Pneumonia Case Study

INTRODUCTION
Pneumonia is an inflammation of the lungs caused by an infection. It is also called Pneumonitis or
Bronchopneumonia. Pneumonia can be a serious threat to our health. Although pneumonia is a special
concern for older adults and those with chronic illnesses, it can also strike young, healthy people as well. It
is a common illness that affects thousands of people each year in the Philippines, thus, it remains an
important cause of morbidity and mortality in the country.
There are many kinds of pneumonia that range in seriousness from mild to life-threatening. In infectious
pneumonia, bacteria, viruses, fungi or other organisms attack your lungs, leading to inflammation that makes
it hard to breathe. Pneumonia can affect one or both lungs. In the young and healthy, early treatment with
antibiotics can cure bacterial pneumonia. The drugs used to fight pneumonia are determined by the germ
causing the pneumonia and the judgment of the doctor. It’s best to do everything we can to prevent
pneumonia, but if one do get sick, recognizing and treating the disease early offers the best chance for a full
recovery.
A case with a diagnosis of Pneumonia may catch one’s attention, though the disease is just like an ordinary
cough and fever, it can lead to death especially when no intervention or care is done. Since the case is a
toddler, an appropriate care has to be done to make the patient’s recovery faster. Treating patients with
pneumonia is necessary to prevent its spread to others and make them as another victim of this illness.
ANATOMY AND PHYSIOLOGY
The lungs constitute the largest organ in the respiratory system. They play an important role in respiration,
or the process of providing the body with oxygen and releasing carbon dioxide. The lungs expand and
contract up to 20 times per minute taking in and disposing of those gases.
Air that is breathed in is filled with oxygen and goes to the trachea, which branches off into one of two
bronchi. Each bronchus enters a lung. There are two lungs, one on each side of the breastbone and
protected by the ribs. Each lung is made up of lobes, or sections. There are three lobes in the right lung and
two lobes in the left one. The lungs are cone shaped and made of elastic, spongy tissue. Within the lungs,
the bronchi branch out into minute pathways that go through the lung tissue. The pathways are called
bronchioles, and they end at microscopic air sacs called alveoli. The alveoli are surrounded by capillaries
and provide oxygen for the blood in these vessels. The oxygenated blood is then pumped by the heart
throughout the body. The alveoli also take in carbon dioxide, which is then exhaled from the body.
Inhaling is due to contractions of the diaphragm and of muscles between the ribs. Exhaling results from
relaxation of those muscles. Each lung is surrounded by a two-layered membrane, or the pleura, that under
normal circumstances has a very, very small amount of fluid between the layers. The fluid allows the
membranes to easily slide over each other during breathing.
PATHOPHYSIOLOGY
Pneumonia is a serious infection or inflammation of your lungs. The air sacs in the lungs fill with pus and
other liquid. Oxygen has trouble reaching your blood. If there is too little oxygen in your blood, your body
cells can’t work properly. Because of this and spreading infection through the body pneumonia can cause
death. Pneumonia affects your lungs in two ways. Lobar pneumonia affects a section (lobe) of a lung.
Bronchial pneumonia (or bronchopneumonia) affects patches throughout both lungs.
Bacteria are the most common cause of pneumonia. Of these, Streptococcus pneumoniae is the most
common. Other pathogens include anaerobic bacteria, Staphylococcus aureus, Haemophilus influenzae,
Chlamydia pneumoniae, C. psittaci, C. trachomatis, Moraxella (Branhamella) catarrhalis, Legionella
pneumophila, Klebsiella pneumoniae, and other gram-negative bacilli. Major pulmonary pathogens in infants
and children are viruses: respiratory syncytial virus, parainfluenza virus, and influenza A and B viruses.
Among other agents are higher bacteria including Nocardia and Actinomyces sp; mycobacteria, including
Mycobacterium tuberculosis and atypical strains; fungi, including Histoplasma capsulatum, Coccidioides
immitis, Blastomyces dermatitidis, Cryptococcus neoformans, Aspergillus fumigatus, and Pneumocystis
carinii; and rickettsiae, primarily Coxiella burnetii (Q fever).
The usual mechanisms of spread are inhaling droplets small enough to reach the alveoli and aspirating
secretions from the upper airways. Other means include hematogenous or lymphatic dissemination and
direct spread from contiguous infections. Predisposing factors include upper respiratory viral infections,
alcoholism, institutionalization, cigarette smoking, heart failure, chronic obstructive airway disease, age
extremes, debility, immunocompromise (as in diabetes mellitus and chronic renal failure), compromised
consciousness, dysphagia, and exposure to transmissible agents.
Typical symptoms include cough, fever, and sputum production, usually developing over days and
sometimes accompanied by pleurisy. Physical examination may detect tachypnea and signs of
consolidation, such as crackles with bronchial breath sounds. This syndrome is commonly caused by
bacteria, such as S. pneumoniae and H. influenzae.
NURSING PROFILE
a. Patient’s Profile
Name: R.C.S.B.
Age: 1 yr,1 mo.
Weight:10 kgs
Religion: Roman Catholic
 Mother: C.B.
Address: Valenzuela City
b. Chief Complaint: Fever
Date of Admission: 1st admission
Hospital Number: 060000086199
c. History of Present Illness
2 days PTA – (+) cough
(+) nasal congestion, watery to greenish
(+) nasal discharge
Tx: Disudrin OD
Loviscol OD
Few hrs PTA - (+) fever, Tmax= 39.3 C
(+) difficulty of breathing
(+) vomiting, 1 episode
Tx: Paracetamol
Sought consultation at ER: Rx=BPN, Salbutamol neb.
IE: T = 38.3C, CR= 122’s, RR= 30’s
(+) TPC
SCE, (-) retractions, clear BS, (-) cyanosis, (-) edema
d. Past Illness
(-) asthma
(-) allergies
e. Family History
PMHx: (+) asthma (mother)
f. Activities of Daily Living
• Sleeping mostly at night and during afternoon
• Usually wakes up early in the morning (5AM) to be milkfed.
• Eats a lot (hotdogs, chicken, crackers, any food given to her)
• Active, responsive
• BM (1-2 times a day)
• Urinates in her diaper (more than 4 times a day)
• Likes to play with those around her
g. Review of Systems
Neuromuscular: weakness of muscles
Integumentary: (-) cyanosis
Respiratory: tavhypnea; (+) DOB; (+) coarse crackles, (+) wheezes,
Digestive: food aversion, vomits ingested milk
DRUG STUDY
View NCP
NURSING ACTIONS
INDEPENDENT
 positioning of the patient with head on mid line, with slight flexion
rationale: to provide patent, unobstructed airway , maximum lung excursion
 auscultating patient’s chest
rationale: to monitor for the presence of abnormal breath sounds
 provide chest and back clapping with vibration
rationale: chest physiotheraphy facilitates the loosening of secretions
 considering that the patient is an infant, and has developed a strong stranger anxiety
as manifested by “white coat syndrome” , it is a nursing action to play with the patient.
rationale: to establish rapport, and gain the patients trust
DEPENDENT
 administer due medications as ordered by the physician, bronchodilators, anti pyretics and anti
biotics
 rationale: bronchodilators decrease airway resistance, secondary to bronchoconstriction,
anti pyretics alleviate fever, antibiotics fight infection
 placing patient on TPN prn
rationale: to compensate for fluid and nutritional losses during vomiting
COLLABORATIVE
 assist respiratory therapist in performing nebulization of the patient
rationale: nebulization is a favourable route of administering bronchodilators
and aid in expectorating secretions, hence patient’s breathing
PHYSICIAN’S ORDER SHEET
11/19/06
Admit patient to ROC under the service of Dr. Vitan secure consent for admission and management, TPR
every shift then record. May have diet for age with strict aspiration precaution, IVF D5 0.3NaCl 500cc to run
at 62-63mgtts/min.May give paracetamol 125mg 1supp/rectum if oral paracetamol is not tolerated.
11/20/06
For urinalysis, IVF to follow D5 0.3 NaCl 500 at SR (62-63mgtt/m Use zinacef brand of cefuroxine 750mg-
given ½ vial 375mg every 8hours, nebulize (Ventolin 1 nebule) every 6 hours, paracetamol drugs prn
every 4hours (Temp 37.8).
11/21/06
Continue cefuroxine and nebulizer every 6 hours. May not reinsert IVF, revise Cefuroxine IV to Cefuroxine
500mg via deep Intramuscular BID,continue management.
11/22/06
Continue management and refer.
DISCHARGE PLANNING
 Take the entire course of any prescribed medications. After a patient’s temperature returns to
normal, medication must be continued according to the doctor’s instructions, otherwise the pneumonia
may recur. Relapses can be far more serious than the first attack.
 Get plenty of rest. Adequate rest is important to maintain progress toward full recovery and to
avoid relapse.
 Drink lots of fluids, especially water. Liquids will keep patient from becoming dehydrated and
help loosen mucus in the lungs.
 Keep all of follow-up appointments. Even though the patient feels better, his lungs may still be
infected. It’s important to have the doctor monitor his progress.
 Encourage the guardians to wash patient’s hands. The hands come in daily contact with germs
that can cause pneumonia. These germs enter one’s body when he touch his eyes or rub his nose.
Washing hands thoroughly and often can help reduce the risk.
 Tell guardians to avoid exposing the patient to an environment with too much pollution (e.g.
smoke). Smoking damages one’s lungs’ natural defenses against respiratory infections.
 Give supportive treatment. Proper diet and oxygen to increase oxygen in the blood when needed.
 Protect others from infection. Try to stay away from anyone with a compromised immune
system. When that isn’t possible, a person can help protect others by wearing a face mask and always
coughing into a tissue.

Source: http://nursingcrib.com/case-study/pneumonia-case-study/