Pneumonia |1

OBJECTIVES OF STUDY Our main scheme for this study could be very helpful for everyone potentially at risk to have the disease. What we hope to achieve after this study are the following:

To be able to identify and analyze etiology of the underlying cause of the disease

To be able to give relation between another theoretical framework and the chosen diagnosis; which is Pneumonia.
To discuss Anatomy and Physiology of the of the related disease

To tackle and give classification of drugs being taken by the patient.

To establish essential nursing intervention to be implemented for the patients wellness

and recovery

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INTRODUCTION Background of the Study The group chose Pneumonia as our case to be study out of curiosity. This is our first time to encounter this kind of case and because of that; our group was interested in it. We are willing to do this case to challenge our mind in analyzing the problem and to enhance our hidden knowledge, and also to gain new experiences which would bring new learning for the member of the group.

Significance of the Study The relevance of this study is for the concluding of the prearranged diagnosis. Likewise, it would be a big help in identifying the primary needs for its wellness and recovery. By identifying such needs and health problems, the group will capable of formulating individualized nursing interventions for the patient that would suffice to the clients needs. Effective management of the problems identified will help the patient to recover faster and maintain a holistic sense of wellness within the hospital. This case study would also provide the group with enough knowledge, skills and attitude on how to manage future patients with the same or similar condition.

Scope and Limitations This case study was conducted at Capitol Medical Center in Quezon City to a 1 year and 10 months old Pneumonia patient in cooperation of the patients family. It covers the overview of the disease, causative and related factors, pathophysiology, intervention and management and

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patients health status which includes the health history and present health status. Similarly, this study complies to the chosen diagnosis which is Pneumonia focusing on children. Overview of the Disease Pneumonia is an inflammatory condition of the lungs caused by an infection. It is usually occurs at a rate of 2 to 4 children in 100. It may be of bacterial origin (pneumococcal, streptococcal, staphylococcal, or Chlamydia) or viral in origin, such as RSV (respiratory syncytial virus). Aspiration of lipid or hydrocarbon substances also causes pneumonia. These disease is commonly divided into two types: hospital acquired (pneumococcal or streptococcal pneumonia) and community acquired (Chlamydia, viral pneumonias). It is the most common pulmonary causes of death in infants younger than 48 hours of age. It occurs most often in late winter and early spring. Newborns that are born more than 24 hours after rupture of amniotic membranes and those who aspirated amniotic fluid or meconium during birth are particularly prone to developing pneumonia in their first few days of life. Classification of Pneumonia: Hospital-acquired pneumonia, also called nosocomial pneumonia, is pneumonia acquired during or after hospitalization for another illness or procedure with onset at least 72 hrs after admission. The causes, microbiology, treatment and prognosis are different from those of community-acquired pneumonia. Community-acquired pneumonia (CAP) is infectious pneumonia in a person who has not recently been hospitalized. CAP is the most common type of pneumonia. The most common causes of CAP vary depending on a person's age, but they include Streptococcus pneumoniae, viruses, the atypical bacteria, and Haemophilus influenzae. Overall, Streptococcus pneumoniae is the most common cause of community-acquired pneumonia worldwide. Gram-negative bacteria cause CAP in certain at-risk populations.

Pneumonia |4

There are also types of Community-acquired pneumonia: Pneumococcal Pneumonia is generally abrupt and follows an upper respiratory

tract infection. With this, children may have blood-tinged sputum as exudative serum and red blood cells invade the alveoli.

Chlamydial Pneumonia is most often seen in newborns up to 12 weeks of age

because the chlamydial organism is contracted from the mothers vagina during birth. Laboratory assessment will show an elevated level of immuunoglobulin IgG and IgM antibodies, peripheral eosinophilia and a specific antibody to Chlamydia Trachomatis. Viral Pneumonia caused by the viruses of upper respiratory tract infection: RSVs,

myxoviruses or adenoviruses. Mycoplasma Pneumonia are similar to yet larger than viruses. Mycoplasmal

pneumonia occurs more frequently in older children (over 5 years) and more often during the winter. Lipid pneumonia is caused by the aspiration of an oily or lipid substance. It is

much less common than it once be cause children are not given oil-based tonics. Hydrocarbon Pneumonia caused by products such as furniture polish, cleaning

fluids, turpentine, kerosene, gasoline, lighter fluid and insects spray have hydrocarbon bases. In making diagnosis of pneumonia begins with taking a thorough medical history, including symptoms, smoking history, and exposure to infections and lung irritants. A physical examination is also performed and includes listening with a stethoscope to the sounds that lungs

Pneumonia |5

make during respiration. Lung sounds that may point to a diagnosis of pneumonia include a bubbling or crackling sound and decreased lung sounds. A physician or nurse practitioner will also tap on the chest with the fingers to listen for certain sounds that may also point to a diagnosis of pneumonia. Diagnostic testing generally includes a chest X-ray. Depending on a person's condition and medical history, testing may also include lung function tests, such as a spirometry, which measures how much air is moved in and out of the lungs during breathing. A CT scan of the chest can help to evaluate such factors as the presence of other lung conditions, including COPD and congestive heart failure. A sample of phlegm that is coughed up from the lungs may be tested for the presence of bacteria or other pathogens. The treatment for pneumonia involves a multifaceted approach. Treatment plans vary depending on the cause, the severity of the symptoms, the presence of complications, general health, and an individual's medical history. One goal of treatment of pneumonia is to control symptoms, such as fever, cough, and shortness of breath, until a child recovers. Another goal is to minimize the development of serious complications, such as severe shortness of breath and hypoxia. With treatment, generally healthy children and adults can often recover from bacterial pnemonia or viral pneumonia.

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NURSING HEALTH HISTORY Patients Profile With abundance of dignity and respect, we have decided to protect the clients identification and call her Patient 73 instead. statement of the patients family. Patient 73, a 1 year and 10 months-old female, infant, born on the 29 th of April 2009 at Capitol Medical Center, residing at Quezon City. Daughter of a Capitol Medical Center Clerk in Laboratory Department for 2 years and a bus driver in Cubao area for 5 years has been diagnosed with Pneumonia. During her first few months, She was breastfed every hour and as time passes by the frequency was decreased to 2-3 hours. After 1 year of breastfeeding, her parents decided to switch to milk formula like Bona and Lactum to support her increasing nutritional needs. All the information below are based from

Past Health History Upon the interview, the patients mother was asked about the past health history of patient 73 and she told us that her daughter had fever and cough for a couple of days and OTC medication was provided. During her first 18 months, all vaccines under the Expanded Program Immunization were given to her and were brought by their Community Health Center. As for now, she had already completed her EPI vaccines. Any form forms of allergies, has not been reported and werent present at all.

Chief Complains

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She has a high fever for almost a week associated with cough and colds as verbalized by her mother. Present Health History Patient brought to CMC ER with cheif complain of fever, cough and colds for 8 days prior to confinement which she was given Amoxicillin for 7 days medications as prescribed and sent her home. After 5 days, patient brought again to CMC still with fever and cough together with productive yellowish sputum. There she was undergone for sputum analysis and urinalysis that revealed a normal result. After prescribing her Disudrin and Paracetamol, she was sent home. 13 Febraury 2011, the day of admission, she still have fever and cough. Then her parents decided for her to be admitted for things might deteriorate if not treated.

Family Health History Patient 73 father who resides in Bulacan together with her Family doesnt have any history of other diseases aside from chicken fox and measles which were treated by medications prescribed by their physician. Similarly, they have also stated that the family is not sportsinclined and has not practiced much of their active lifestyle. Usually they spend their time at work and at home watching television and movies and enjoy occasional drinking. On the other hand, her mother who grew up in Quezon City had a history of Hypertension. Certain supplement which helps boosting up her immune system is taken daily together with her healthy lifestyle consisted of regular exercise and a good balanced diet.

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THEORETICAL FRAMEWORKS Virginia Henderson, 14 Basic Human Needs The nurse is temporarily the consciousness of the unconscious, the love of life for the suicidal, the leg of the amputee, the eyes of the newly blind, a means of locomotion for the infant, knowledge and confidence for the mother, the mouthpiece for those too weak or withdrawn to speak and so on. She defined nursing in functional terms. She articulated that the unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery. On the other hand she has not describe her own definition of health but rather equated health independence. In her sixth edition of the Principles and practice of nursing, she cited several definitions of health from different sources. She viewed health in terms of the patients ability to perform 14 components of nursing care unaided. As for perspective regards to environment she did not convey her own definition of it but used the Websters collegiate dictionary instead and expounded it as the aggregate of all external conditions and influences affecting life and development of organism. In addition she viewed the patient as an individual who requires assistance to achieve health and independence. Lastly she has also identified 14 basic needs which compromise of the component of nursing care She conceptualized the 14 Fundamental Needs of human. These needs are: Breathing normally. Eating and drinking adequately. Eliminating body wastes. Moving and maintaining a desirable position. Sleeping and resting. Selecting suitable clothes.

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Maintaining normal body temperature by adjusting clothing and modifying the environment.

Keeping the body clean and well groomed to promote integument (skin). Avoiding dangers in the environment and avoiding injuring others Communicating with others in expressing emotions, need, fears, or opinions Worshipping according to ones faith. Working in such a way that one feels a sense of accomplishment. Playing or participating in various forms of recreation. Learning, discovering or satisfying the curiosity that leads to normal development and health, and using available health facilities.

The Nurse Patient Relationship Henderson stated that there are three levels compromising the nurse patient relationship: The nurse as a substitute for the patient. In times of illness, when the patient cannot function fully, the nurse serves as the substitute as to what patient lacks such, as knowledge, will and strength in order to make him complete, whole and independent once again. The nurse as a helper to the patient. In situation where the patient cannot meet his basic needs, the nurse serves as a helper to accomplish them. Since these needs are needed to achieve health, the nurse focuses her attention in assisting the patient meet these needs so as to regain independence as quickly as possible. The nurse as a partner with the patient. As partners, the nurse and the patient formulate the care plan together. Both as an advocate and as a resource person, the nurse can empower the patient to make effective decisions regarding his care plan. As the relationship goes on, the patient and

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the nurse see each other as partners whose interest are the same having the patient achieve health and independence.

GORDONS PATTERN OF FUNCTIONING Patterns of Functioning Health perception management pattern Before Hospitalization The patient 73 usually takes OTC drug to treat her sickness. She takes a bath every morning. She already completed her EPI Vaccines. She drinks milk formula (Lactum) 3 4 bottles per day She likes to eat vegetables and fruits lespecially banana. She has no allergies on all foods. She loves to eat jellyace. Her mother insist her to drink water every after bottlefed. She consumes 5 or more diaper per day. She usually defecates twice a day and the color is brown During Hospitalization She takes nebulization very 6 hours as prescribed. During hospitalization, she had difficulty in taking her bath due to fever Patients diet is DFA but after 2 days, it changed in Regular diet. She partially lost her appetite due to her condition Patient method of feeding is bottle feeding and consumes 2-3 bottles of milk a day Patient partially lost her appetite. Analysis/ Interpretation It shows a big difference in her personal hygiene.

Nutritional/Metabolic pattern

Elimination pattern

She consumes 3-4 diaper per day She did not loose her bowel since admitted

The frequency of patients elimination decreased possibly because of decreased food intake

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Activity-Exercise pattern

She wakes up around 7:00 to 9:00 in the morning. She usually fed with milo as her breakfast She usually plays with her stuff toys She likes to watch Dora and Spongebob Her mother bathes her before she goes to bed She wears pajama and sando

She receives her medication whenever she wakes up by 8 and drink her milk She was unable to play with her toys and has lost interest in watching television

Patient daily activity has dratically changed due to her condition

Sleep and rest pattern

She sleeps a lot to gain energy. She has a sleeping disturbance because of her cough She wears pajamas, shirt and jacket. She is conscious about taking up her medicines yet doesnt know its significance She obeys with replacement of jellyace or any foods she like She observes by staring at the visitor in order to build up trust An IV line is an unfamiliar thing to her because of it she ttempted to free herself from it. She wears printed pajama, stripes shirt and pink jacket. Her family supports and monitor her condition

Patient needs to spkeep as much strength by resting and sleeping.

Cognitive and perceptual pattern

Sher parents teaches her to speak short words. She cant pronounce words clearly Objects identification is not yet possible for her as well as distinguishing smell and task

Being admitted in hospital because of her illness actually helped her conscious and awareness develop

Self-perception/selfconcept pattern

Her parents usually decide what kind of clothes she has to wear She is not conscious on her physical image

She protects herself from cold environment by wearing thick clothes and became conscious on herself

Role-relationship pattern

Shes unica iha of the family

Theres no change in her relationship to her parents.

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Coping stress tolerance pattern

She is naughty but sweet daughter She cries when her mother pushes her to sleep Shes irritable when she is lack of sleep or you disturb her from sleeping

She cries during the first insertion of the IV line and whenever there is medication given or even in thermometer They tries to tantalized her in foods she likes

Patient become more irritable and develop trauma due to insertion of IV line

Value-belief pattern

They try to cope up her stress with toys or bottlefed Patients family Unable to attend mass shows strong due to her condition faithfulness to the but still they assure to Lord by attending pray at night together. mass every Sunday. They teach the patient hwo to pray before going to bed.

The patients family still remain faithful and believes in the power of the God Almighty.

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PHYSICAL ASSESSMENT Physical examination follows a methodical head to toe format in the Cephalocaudal assessment. This is done systematically using the techniques of inspection, palpation, percussion and auscultation with the use of materials and investments such as the penlight, thermometer, sphygmomanometer, tape measure and stethoscope and also the senses. During the procedure, we made every effort to recognize and respect the patients feelings as well as to provide comfort measures and follow appropriate safety precautions. This was taken on February 15, 2011 Vital signs Temperature: 36.0 C Respiratory rate: 31 cpm Pulse rate: 120 bpm General Appearance and Mental Status: She wears printed pajama, stripes shirt and pink jacket with a pony tail. She has IV line on her right foot covered with a diaper. She is sitting on her mothers lap because she finds it comfortable according to her mom. She takes a bath 5 days before she was admitted and there is the presence of curiosity. Body Part A.HEAD Skull Techniques used Inspection Palpation Normal Findings Proportional to the body size of the body, round with prominence in the Actual Findings Proportional to the body and face round symmetrical in all planes, Interpretation Normal Weight: 22 lbs. Height: 30 in.

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Scalp

Inspection Palpation Inspection Palpation

Hair

frontal area anteriorly and the occipital area posteriorly symmetrical in all planes gently curve. White clean, free from masses, lumps, scars, nits seborrhea, and lesion Black evenly distributed and covers the whole scalp, thick, shiny, free from split ends

gently curve.

Face

Inspection Palpation

Eyes and Eyebrows

Inspection

Eye lashes Eye lids

Inspection Inspection

Oblong or oval or She has a mole square or heartunder her left eye shaped, symmetrical facial expression that is dependent on the mood or true feelings smooth and free from wrinkles, in involuntary muscle movement Parallel and evenly Parallel and evenly Normal placed symmetrical. placed Non-protruding with symmetrically. scant amount of Both eyes are secretion. Both eyes black and clear. black and clear Black evenly Long and black She has a longa nd distributed and evenly distributed beautiful turned outward eyelashes. Upper lids cover a Covers a small Normal small portion of the portion of the iris iris and the cornea and the cornea and and the sclera when the sclera when the the eyes are closed eyes are closed the the lids meet lids meet

White, free from masses and lumps. Slighty presence seborrhea Slightly presence of oiliness, thin, black hair and evenly distributed and covers the whole scalp with no presence of split ends. There is slighty presence of lice in other part. Round shape of face and has a mole under her left eye

Theres is slighty presence of seborrhea She has an oily hair with slighty presence of lice in other part.

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Sclera Iris and Pupil

Inspection Inspection

completely. Symmetrical color is the same the surrounding skin. White and clear Proportional to the size of the eye round. Black/brown and symmetrical. Constrict with increasing light and accommodation when the light closely constrict the size of the pupil it get smaller than the normal size Parallel symmetrically proportion to the size of the head. Bean-shaped, helix is in line with the outer canthus of the eye, skin is the same color as the surrounding area, clean Pinkish clean with scant amount of cerumen and a few cilia. Able to hear whisper spoken 2 feet away. Midline, symmetrical and patent

completely

Ears

Inspection

White and clear. No presence of dark spot. Dark brown color and both symmetrical. Constricting effect when there is increasing light and accommodation when the light closely constricts the size of the pupil it gets smaller than the normal size. Bean-shaped, symmetrically proportion to the size of head. In line with the outer canthus of the eye and same color.

Normal Normal

Normal

Ear canal

Inspection

Presence of cilia, slightly pinkish and scant amount of cerumen. Able to hear whisper Midline, symmetrical and patent. Same color and tender. Presence of small amount fo mucus. Pinkish lip color and symmetrical

Normal

Hearing acuity Nose

Senses Inspection

Normal Presence of small amount of mucus

Mouth

Inspection

Pinkish symmetrical Lip margin well

Normal

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Gums

Inspection

Teeth

Inspection

defined, smooth and moist Pinkish. Smooth. No swelling no retraction, no discharge 32 permanent teeth aligned free from caries or feeling. No halitosis Large medium red or pink slightly rough on top smooth along the lateral margins, moist, shiny, and free movable Midline. Straight. and moist Pinkish, smooth and moist Pinkish, smooth, and moist No hoarseness and well modulate Proportional to the size of the body and head, symmetrical and position The chest is symmetrical and the chest is twice as wide as deep. Bronchial sounds are hallowing high pitched whistling sounds. Pulsation visible and palpable Cardiac rate range

Pink color, smooth and no swelling. Yellowish teeth with no dental carries. 32 Permanent teeth are aligned. Slightly presence of halitosis. Medium sized white color on top and freely movable.

Normal

She has no false teeth and slightly presence of halitosis.

Tongue

Inspection Palpation

She has medium white color tongue and freely movable.

Frenulum Cheeks Soft palate Voice

Inspection Inspection Palpation Inspection Palpation Senses

Midline, straight and moist Pinkish, smooth and moist Pinkish, smooth, and moist Partial modulated. Difficulty to pronounce words Proportion and symmetrical to the head and body. Freely movable without difficulty. The chest is symmetrical, no lamps and masses. Vibrations are prominent and occasional wheezing sound. Cardiac rate range from 120 bpm. Pulsation visible

Normal Normal Normal Partial modulated and she cant pronounce word clearly Normal

Neck

Inspection Palpation

Thorax & Lungs

Inspection Palpation Auscultation

Presence of occasional wheezing sound

Heart

Inspection Palpation Auscultation

Normal

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from 82 beats per/minute Breast/Chest Inspection Palpation Female: variable in size depending on body builds in obese, large and pendulous. Slender- thin and small. In young client firms, Elastic in consistence. Coneshaped, symmetrical skin surface smooth. In older women, breast sag, nipples lower, stringy and nodular. Warm to touch and smooth Round or oval color darker than surrounding skin, symmetrical for dark skinned client color is darker that other skin surfaces. No masses and area of tenderness Skin is unblemished, no scar, color is uniform or scaphoid, symmetrical movement caused by respiration. The umbilicus is flat or concave. Color is the same as the surrounding skin.

and palpable. Positive for two heart sound Warm to touch and smooth. Color of the skin is same with the abdomen. No lumps and masses.

Normal

Areola/Nipples

Inspection Palpation

Small, round darker than surrounding skin, symmetrical. No masses, tenderness and discharges. Skin is unblemished, no scar and lesions. Color is uniform, symmetrical movement due to respiration. Umbilicus is flat, no bulging, masses. Presence of bowel sounds and distention. She has a mole on her right side Same color with the body. Symmetrical and

Normal

Abdomen

Inspection Palpation Auscultation Percussion

Presence of mole on right side of the abdomen, borborygmy, distention.

Arm

Inspection Palpation

Skin color varies Symmetrical fine evenly distributed

She has 2 mole on her left arm.

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Hands and Palm

Inspection Palpation

Nails

Inspection Palpation

Shoulder, Arms, Elbows, Hand and wrists Legs

Inspection Palpation Inspection Palpation

Ankles, toes and nails

Inspection Palpation

moves freely. Absence of scar. Warm and tender. She has a 2 mole on her left arm. Small, soft and pinkish palm. No presence of callus. Presence of 5 fingers on each hand. Nails are transparent Nails are smooth and convex transparent and with pink nail beds smooth. No and white presence of nail translucent polish. Pinkish As pressure applied white translucent to the nail bed, tips. When appears white or pressured is balance and pink applied the color is color returns white and when immediately as released it returns pressure is released. to normal color. Perform on ease Moves freely without difficulty. Uniform color. skin is smooth fine Skin color is hair evenly uniform. distributed absence Symmetrical and of varicose vein muscles are tender muscle symmetrical and warm. No length presence of edema. Muscle appear equal Moves freely warm and with good without difficulty. muscle tone. Five toes in each Pinkish white foot sole and dorsal color of nails with surface is smooth translucent tips. with pink nailbeds No presence of and white nail polish. Five translucent tips. toes in each foot. Range of motion Moves freely without any discomforts.

presence/absence of visible veins. Warm dry and elastic no areas of tenderness. Palm pinkish warm

Normal

Normal

Normal Normal

Normal

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ANATOMY AND PHYSIOLOGY

Nasal Passages The flow of air from outside of the body to the lungs begins with the nose, which is divided into the left and right nasal passages. The nasal passages are lined with a membrane composed primarily of one layer of flat, closely packed cells called epithelial cells. Each epithelial cell is densely fringed with thousands of microscopic cilia, fingerlike extensions of the cells. Interspersed among the epithelial cells are goblet cells, specialized cells that produce mucus, a sticky, thick, moist fluid that coats the epithelial cells and the cilia. Numerous tiny blood vessels called capillaries lie just under the mucous membrane, near the surface of the nasal passages.

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While transporting air to the pharynx, the nasal passages play two critical roles: they filter the air to remove potentially disease-causing particles; and they moisten and warm the air to protect the structures in the respiratory system. Filtering prevents airborne bacteria, viruses, other potentially disease-causing substances from entering the lungs, where they may cause infection. Filtering also eliminates smog and dust particles, which may clog the narrow air passages in the smallest bronchioles. Coarse hairs found just inside the nostrils of the nose trap airborne particles as they are inhaled. The particles drop down onto the mucous membrane lining the nasal passages. The cilia embedded in the mucous membrane wave constantly, creating a current of mucus that propels the particles out of the nose or downward to the pharynx. In the pharynx, the mucus is swallowed and passed to the stomach, where the particles are destroyed by stomach acid. If more particles are in the nasal passages than the cilia can handle, the particles build up on the mucus and irritate the membrane beneath it. This irritation triggers a reflex that produces a sneeze to get rid of the polluted air. In addition to their role in the respiratory system, the nasal passages house cells called olfactory receptors, which are involved in the sense of smell. When chemicals enter the nasal passages, they contact the olfactory receptors. This triggers the receptors to send a signal to the brain, which creates the perception of smell. Oral Cavity The first space of the mouth is the mouth cavity, bounded laterally and in front by the alveolar arches (containing the teeth), and posteriorly by the isthmus of the faces. The oral cavity is also known as the mouth which it swallows food and drinks and goes down to the person's stomach. The mouth plays an important role in speech (it is part of the vocal apparatus), facial expression, kissing, eating, drinking (especially with a straw), and breathing. Pharynx

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Air leaves the nasal passages and flows to the pharynx, a short, and funnel-shaped tube about 13 cm (5 in) long that transports air to the larynx. Like the nasal passages, the pharynx is lined with a protective mucous membrane and ciliated cells that remove impurities from the air. In addition to serving as an air passage, the pharynx houses the tonsils, lymphatic tissues that contain white blood cells. The white blood cells attack any disease-causing organisms that escape the hairs, cilia, and mucus of the nasal passages and pharynx. The tonsils are strategically located to prevent these organisms from moving further into the body. One tonsil, called the adenoids, is found high in the rear wall of the pharynx. A pair of tonsils, the palatine tonsils, is located at the back of the pharynx on either side of the tongue. Another pair, the lingual tonsils, is found deep in the pharynx at the base of the tongue. Larynx Air moves from the pharynx to the larynx, a structure about 5 cm (2 in) long located approximately in the middle of the neck. Several layers of cartilage, a tough and flexible tissue, comprise most of the larynx. A protrusion in the cartilage called the Adams apple sometimes enlarges in males during puberty, creating a prominent bulge visible on the neck. While the primary role of the larynx is to transport air to the trachea, it also serves other functions. It plays a primary role in producing sound; it prevents food and fluid from entering the air passage to cause choking; and its mucous membranes and cilia-bearing cells help filter air. The cilia in the larynx waft airborne particles up toward the pharynx to be swallowed. Food and fluids from the pharynx usually are prevented from entering the larynx by the epiglottis, a thin, leaf like tissue. The stem of the leaf attaches to the front and top of the larynx. When a person is breathing, the epiglottis is held in a vertical position, like an open trap door. When a person swallows, however, a reflex causes the larynx and the epiglottis to move toward each other, forming a protective seal, and food and fluids are routed to the esophagus. If a

P n e u m o n i a | 22

person is eating or drinking too rapidly, or laughs while swallowing, the swallowing reflex may not work, and food or fluid can enter the larynx. Food, fluid, or other substances in the larynx initiate a cough reflex as the body attempts to clear the larynx of the obstruction. If the cough reflex does not work, a person can choke a life-threatening situation. The Heimlich maneuver is a technique used to clear a blocked larynx. Trachea, Bronchi, and Bronchioles Air passes from the larynx into the trachea, a tube about 12 to 15 cm (about 5 to 6 in) long located just below the larynx. The trachea is formed of 15 to 20 C-shaped rings of cartilage. The sturdy cartilage rings hold the trachea open, enabling air to pass freely at all times. The open part of the C-shaped cartilage lies at the back of the trachea, and the ends of the C are connected by muscle tissue. The base of the trachea is located a little below where the neck meets the trunk of the body. Here the trachea branches into two tubes, the left and right bronchi, which deliver air to the left and right lungs, respectively. Within the lungs, the bronchi branch into smaller tubes called bronchioles. The trachea, bronchi, and the first few bronchioles contribute to the cleansing function of the respiratory system, for them, too, are lined with mucous membranes and ciliated cells that move mucus upward to the pharynx. Alveoli The bronchioles divide many more times in the lungs to create an impressive tree with smaller and smaller branches, some no larger than 0.5 mm (0.02 in) in diameter. These branches deadend into tiny air sacs called alveoli. The alveoli deliver oxygen to the circulatory system and remove carbon dioxide. Interspersed among the alveoli are numerous macrophages, large white blood cells that patrol the alveoli and remove foreign substances that have not been filtered out earlier. The macrophages are the last line of defense of the respiratory system; their presence

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helps ensure that the alveoli are protected from infection so that they can carry out their vital role. The alveoli number about 150 million per lung and comprise most of the lung tissue. Alveoli resemble tiny, collapsed balloons with thin elastic walls that expand as air flows into them and collapse when the air is exhaled. Alveoli are arranged in grapelike clusters, and each cluster is surrounded by a dense hairnet of tiny, thin-walled capillaries. The alveoli and capillaries are arranged in such a way that air in the wall of the alveoli is only about 0.1 to 0.2 microns from the blood in the capillary. Since the concentration of oxygen is much higher in the alveoli than in the capillaries, the oxygen diffuses from the alveoli to the capillaries. The oxygen flows through the capillaries to larger vessels, which carry the oxygenated blood to the heart, where it is pumped to the rest of the body. Carbon dioxide that has been dumped into the bloodstream as a waste product from cells throughout the body flows through the bloodstream to the heart, and then to the alveolar capillaries. The concentration of carbon dioxide in the capillaries is much higher than in the alveoli, causing carbon dioxide to diffuse into the alveoli. Exhalation forces the carbon dioxide back through the respiratory passages and then to the outside of the body. Lung It is either of a pair of elastic, spongy organs used in breathing and respiration. In humans the lungs occupy a large portion of the chest cavity from the collarbone down to the diaphragm, a dome-shaped sheet of muscle that walls off the chest cavity from the abdominal cavity. Heart In anatomy, hollow muscular organ that pumps blood through the body. The heart, blood, and blood vessels make up the circulatory system, which is responsible for distributing oxygen and nutrients to the body and carrying away carbon dioxide and other waste products. The heart is

P n e u m o n i a | 24

the circulatory systems power supply. It must beat ceaselessly because the bodys tissues especially the brain and the heart itselfdepend on a constant supply of oxygen and nutrients delivered by the flowing blood. If the heart stops pumping blood for more than a few minutes, death will result. Epiglottis It is a thin, lidlike flap of cartilage attached to the base of the tongue of terrestrial vertebrates. The epiglottis is normally pointed upward, but during the passage of solids and liquids from the mouth into the esophagus, the epiglottis is folded down over the glottis, the opening between the vocal cords, to prevent food from passing into the trachea.

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PATHOPHYSIOLOGY
Contributing Factor Bacteria Viruses Mycoplasma Other Pathogens Inhalation of infectious and irritating agents Microbial invasion (organisms penetrate the airway mucosa & multiply in alveolar spaces)

Predisposing Factor 2 y/o

Inflammation in interstitial spaces, alveoli, and/or bronchioles

Lung become stiff Reduced lung compliance and vital capacity decrease Alveolar collapse (atelectasis)

RBC and fibrin moves in alveoli Capillary leaks spread the infection to other areas of the lung

WBC migrates to the area of infection Capillary leak, edema, exudates Fluids collect in and around the alveoli

Organisms move into the bloodstream Sepsis

Infection extends into the pleural cavity Emphysema

Ability of the lungs to oxygenate blood decrease Arterial tension falls

Excess fluid in the lungs

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Alveolar walls thicken

Gas exchange is reduced

Hypoxemia

If treated:

If untreated:

Analgesics to relieve pleuratic chest pain. Antitussives Bed rest Bronchodilator therapy Chest physiotherapy Postural drainage High-calorie diet Adequate fluid intake Humidified oxygen therapy for hypoxia Mechanical ventilation for respiratory failure Recovery

Lung abscess

Pleural effusion

Meningitis

Pericarditis

Metastatic infection such as brain abscess

Emphysema

Diffuse brain swelling Death

Pericardial effusion Death

Death Death

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LABORATORY AND DIAGNOSTIC EXAMINATIONS Test Total WBC Segmenters Lymphocytes Normal values 5 10 x 109/I 0.55-0.65 0.25 0.40 Results 9.9 x 109/I 0.41 0.47 Interpretation Normal Normal Increased - TB, hepatitis, infectious mononucleosis, mumps, rubella, thyrotoxicosis, lymphocytic leukemia Increased - TB, malaria, hepatitis, SLE, RA, carcinoma, monocytic leukemia, lymphomas Normal Normal Normal Normal

Monocytes

0.02 0.06

0.10

RBC Count Hemoglobin Hematocrit Platelet CT Implications: WBC

M: 3.5-5.5 x 1012/L F: 4.3 -5.9 1012/L M: 135 160 g/I F: 120 150 g/I M: 0.40 -0.48 F: 0.37 0.45 150 130 x 109/I

5.0 1012/L 126 0.39 464 x 109/I

Increased infection, leukemia, tissue necrosis Decreased bone marrow depression, influenza, typhoid fever, measles, infectious hepatitis, mononucleosis, rubella Segmenters (Neutrophils) Increased infection, ischemic neurosis, metabolic disorders, RA, acute gout Decreased bone marrow depression, typhoid, hepatitis, influenza, measles, mumps, rubella, hepatic disease, SLE, vit. B12 deficiency Lymphocytes Increased TB, hepatitis, infectious mononucleosis, mumps, rubella, thyrotoxicosis, lymphocytic leukemia

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Monocytes Increased TB, malaria, hepatitis, SLE, RA, carcinoma, monocytic leukemia, lymphomas Eosinophils Increased asthma, hay fever, parasitic infections, chronic myelocytic leukemia, Hodgkins disease, metastasis Decreased Cushings Syndrome Basophils Increased chronic myelocytic leukemia, Hodgkins disease, ulcerative colitis Decreased hyperthyroidism, ovulation, pregnancy RBC Increased absolute/relative polycythemia Decreased anemia, fluid overload of >24 hrs. Hemoglobin Increased polycythemia or dehydration Decreased anemia, recent hemorrhage, fluid retention Hematocrit Increased polycythemia, hemoconcentration Decreased anemia, hemodilution Platelet Count Increased hemorrhage, iron deficiency anemia, inflammatory disease, primary trombocythemia, myeloid metaplasia, polycythemia vera, chronic myelogenous leukemia Decreased aplastichypoplastic bone marrow, leukemia, vit. B12 deficiency, immune disorders

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DEVELOPMENTAL MILESTONE CHART Child's Age 1 month Normal Findings Lifts head when lying on tummy Responds to sound Stares at faces Follows objects briefly with eyes Vocalizes: oohs and aahs Can see black-and-white patterns Vocalizes: gurgles and coos Follows objects across field of vision Notices his hands Holds head up for short periods Smiles, laughs Holds head at 45-degree angle Makes smoother movements Recognizes your face and scent Holds head steady Visually tracks moving objects Squeals, gurgles, coos Blows bubbles Recognizes your voice Does mini-pushup Smiles, laughs Can bear weight on legs Coos when you talk to him Can grasp a toy Rolls over, from tummy to back Distinguishes between bold colors Plays with his hands and feet Recognizes own name Turns toward new sounds Rolls over in both directions Turns toward sounds and voices Imitates sounds Rolls over in both directions Is ready for solid foods Sits without support Actual Findings Positive reflex movements Brings hands to face Lifts head briefly Stares at faces

2 months

Lifts head Hands in fist Smiles Ah & Ooh sounds

3 months

Cries to communicate hunger, fear, discomfort Anticipates being lifted Turns toward colors Turns prone to supine Supports upper body with arms in prone Holds head erect Makes consonant sounds Laughs Turns supine to prone Plays with toes Bears partial weight on feet when held upright Reaches/grasps objects Helps hold bottle Moves toys between hands Pulls up to sit Sits with UE support

4 months

5 months

6 months

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7 months

8 months

Mouths objects Passes objects from hand to hand Sits without support Drags objects toward herself Lunges forward or starts crawling Jabbers or combines syllables Starts to experience stranger anxiety Says "mama" and "dada" to both parents Passes objects from hand to hand Stands while holding onto something Crawls Points at objects Searches for hidden objects Stands while holding onto something Jabbers or combines syllables Understands object permanence Cruises while holding onto furniture Drinks from a sip cup Eats with fingers Bangs objects together Waves goodbye Picks things up with pincer grasp Crawls well, with belly off the ground Says "mama" and "dada" to the correct parent Indicates wants with gestures Says "mama" and "dada" to the correct parent Plays patty-cake and peek-aboo Stands alone for a couple of seconds Cruises Understands "no" and simple instructions

Rolls over Bounces in standing Opens mouth for spoon Babbles Laughs Smiles in mirror First tooth Fear of strangers Responds to expressions Tracks moving object Says tata & mama Pulls to stand Sits without support Explores with hands & mouth Raking grasp Drinks from cup Attempts to feed self Looks for hidden object Cruises along furniture Well-developed craw

9 months

10 months

Pulls self to standing Use pincer to grasp objects

11 months

Knows familiar faces Plays peak-a-boo Cries when parent Leaves

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12 months

Puts objects into a container Imitates others' activities Indicates wants with gestures Takes a few steps Says one word besides "mama" and "dada"

13 months

Uses two words skillfully Bends over and picks up an object Enjoys gazing at his reflection Holds out arm or leg to help you dress him

14 months

15 months

16 months

17 months

Eats with fingers Empties containers of contents Imitates others Toddles well Initiates games Points to one body part when asked Responds to instructions Plays with ball Uses three words regularly Walks backward Scribbles with a crayon Runs Adopts "no" as his favorite word Turns the pages of a book Has temper tantrums when frustrated Becomes attached to a soft toy or other object Discovers the joy of climbing Stacks three blocks Uses spoon or fork Learns the correct way to use common objects Uses six words regularly Enjoys pretend games

Drinks well from cup Apprehensive with strangers Cries when parent leaves Says dada & mama Responds to music with motion Walks alone or 1 hand held Falls frequently when walking Points with 1 finger Pulls off socks Crawl forward on belly Creeps on hand/knees Assumes quadruped Responds to simple instructions. Uses trial-anderror to learn about objects Demonstrate affection. Participate in nursery rhymes Turns pages in a book Carries a doll Stacks 2 blocks Scribbles with crayons Runs clumsily Jumps in plac Looks for hidden objects Follows 1-step directions 810 word vocabulary Scribbles with crayons Runs clumsily Jumps in place Points/asks for things Helps with dressing Indicates soiled or

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Likes riding toys Feeds doll Speaks more clearly Throws a ball underhand 18 months Will "read" board books on his own Scribbles well Strings two words together in phrases Brushes teeth with help Stacks four blocks Uses a spoon and fork Runs Throws a ball underhand Enjoys helping around the house Understands as many as 200 words Recognizes when something is wrong Feeds doll Takes off own clothes Dumps an object in imitation, such as throwing garbage away Learns words at a rate of ten or more a day Can walk up stairs (but probably not down) Can walk up stairs Able to set simple goals Throws a ball overhand Kicks ball forward Stacks six blocks Kicks ball forward Follows two-step requests Does simple puzzles Draws a straight line Names several body parts

19 months

wet paints Emotionally dependent on familiar adult Likes to play a lot Very curious. Drinks without spilling Picks up toy without falling over Shows preference for one hand Gets up/down stairs holding onto rail Enjoys simple picture books Explores environment Knows the names of parts of his body

20 months

Can crawl down stairs backwards Builds 2 block tower Can place objects precisely Turns pages of picture book

21 months

22 months

Can kick large ball Squats with ease Rises without using hands Builds tower of six cubes Able to run Walks up and down stairs 2 feet per step Recognizes details in pictures Uses own name to refer to self Starts to draw simple shapes with pattern

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DRUG STUDY Generic Name Cefuroxime Classification: Antibiotic Antiinfective Brand Name Ceftin Dosage 125 mg/5ml Mechanism Indication Contraindications Hypersensitivity to Cefuroxime or related to component of formula or other cephalosporins Adverse Reaction Diarrhea Nausea/Vomitting Abdominal pain Pseudomembrano us colitis Rashes Thrombocythope nia Nursing Responsibility Assess for allergy Monitor I/O Report onset of loose stools

Procaterol HCL Classification: Bronchodilator Salbutamol Classification: Bronchodilator

Meptin Syrup

2.5 ml

Ventolin

Inhalation: 0.25mg/kg

Inhibits bacterial Treat cell wall synthesis susceptible by binding 1 or infections of the more of the URTI/LRTI penicillin binding Gonorrhea proteins which in Otitis Media turn inhibit the final Sinusitis transpeptidation Other skin step of infections peptidoglycan synthesis Cost-effective and Relief of promotes dyspnea compliance among Bronchial asthma patients asthma Pulmonary emphysema Activate of beta 2Treat severe adrenergic breathing receptors on airway problems smooth muscle leads to relaxation of bronchioles and bronchodilation

Hypersensitivity to any of the ingredients of this drug. Hypersentivity to soy lecithin or foods related products

Shock Anaphylactic reaction Decreases in serum potassium levels Tachycardia Stomach upset Dry mouth Flusing Dizziness Cough Nasal stiffiness

Assess for allergy Monitor S/sx of shock Assess allergy Assess breath sounds Monitor for the characteristics and frequency of sputum production

NURSING CARE PLAN

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Assessment Subjective: Nahihirapan syang huminga as verbalized by the mother Objective: Adventitious breath sounds (crackles & wheeze) RR: 28 34 cpm Restlessness wide-eyed ineffective cough

Diagnosis Ineffective airway clearance related to accumulation of secretion as evidenced by coughing.

Planning Short term: After 8 hours of nursing intervention patient will be able to maintain airway patency

Intervention Independent: Monitor breath sounds by auscultations Evaluate clients gag/cough reflex and swallowing ability Elevate head of bed/change position every 2 hours and PRN

Rationale Indicative of respiratory distress To determine ability to protect own airway To take advantage of gravity decreasing pressure on the diaphragm Maximize effort

Evaluation Patient maintained airway patency and had successfully demonstrated reductions of secretions with breath sounds clear

Long term: After 2 days of nursing intervention the patient will demonstrate reduction of secretions with breath sounds clear

Encourage deep breathing exercises

Increase fluid intake at least Hydration may help secretions Dependent: Administer medication as prescribed by the Physician Helps clear secretions and Administer mobilize Nebulization as ordered Intervention Rationale Evaluation

Assessment

Diagnosis

Planning

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Subjective: Nilalagnat po ang anak ko as verbalized by the mother Objective: T: 38.3 C RR: 28 bpm Skin Warm to touch Dry mucous membrane

Hyperthermia related to viral infection as manifested by increase body temperature above normal range of 36.5 to 37.5

Short term: After 30 minutes of Nursing Intervention, patients temperature will decrease from 38.3 C to 37.5 C

Independent: Provide Tepid Sponge bath Assess fluid loss and facilitate oral intake Promote bed rest Monitor vital signs

Enhances heat loss by conduction and evaporation. Increase metabolic rate and diaphoresis Reduces body heat production To note changes that can affect the patients condition Reduces fever

Patient had successfully decreased his temperature from 38.3 to 37.5 C

Long term: After 2 hours of nursing intervention, patient will maintain normal body temperature ranges from 36.5 to 37.5 C

Dependent: Administer Antipyretic medications as ordered by physician Maintain IV fluids ordered by physician

Patient had successfully maintained normal body temperature of 37.5 C Prevents dehydration

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

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Subjective: Ilang araw na syang hindi nadudumi as verbalized by the mother Objectives: Borborygmy Distended abdomen Severe flatus

Constipation related to decrease motility of Gastrointestinal Tract as manifested by altered bowel sound

Short term: After 8 hours of nursing intervention, patient will be able to establish normal pattern of bowel functioning Long term: After 1 day of Nursing interventions, patient will be able to demonstrate behaviors or change of lifestyle changes to prevent recurrence of problem

Independent: Review daily dietary regimen, noting if the diet is deficient in fiber. Note activity level and exercise pattern.

To evaluate whether the patient has deficient fiber intake It may affect elimination patterns To promote passage of soft stool

Patient verbalized that she has no problem in defecating anymore and she also demonstrated lifestyle change.

Encourage increase fluid intake including high fiber, fruit juices; suggest drinking warm, stimulating fluids such as pineapple juice, warm water. Encourage the patient exercises that may improve abdominal muscle tone.

To promote peristalsis

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Increase intake of fibers in diet like fruits, vegetables and wheat Discuss rationale for and encourage continuation of successful interventions. Dependent: Administer stool softerner or mild stimulants as prescribed by the Physiccian

To improve consistency of stool

To maintain normal bowel movements

To passage of stool

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Assessment Objective: Physical unsecure side rails Due to the change of side of bed Insomnia leading to moving from one side of the bed to the other

Diagnosis Risk for injury (fall)

Planning Mother will be encourage to keep an eye on the babys movement Baby will be free from injury will make sure side rails are in proper position

Intervention Mother was encourage to keep an eye on the baby by making sure baby is not left alone in bed Baby was monitored regularly to make sure she was free from injury Side rails was checked and make sure it was raised up to prevent fall Stress importance of monitoring condition/risk that may contribute to occurrence of falls

Rationale Prevent from injury

Evaluation Patient had successfully displayed appropriate range of feelings and lessened fear and demonstrated understanding through use of effective coping behaviors and resources

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DISCHARGE PLANNING The final discharge was on 16 February 2011 at 6:35 P.M. Medication Cefuroxine Procaterol (Meprin) syrup Salbutamol Nebulization Exercise Parents were advised to conserve the childs strength. Encourage to turn and reposition the childs frequently to avoid pooling of secretions. Chest physiotherapy was taught to parent (by clapping the back of the baby) to encourage the movement of mucus and prevent obstructions. Treatment Parent was taught on how to administer the medications to the child as noted above and also to give the right dose at the right time. Encourage to note the day of the medication and when it supposed to be stopped. Health Teaching Parents were advised to care for the child and also make sure the child is well covered and not exposed to the electric fun and air condition for a long period of time. Encourage also to increase the fluid intake of the child because the child feels weak in sucking or to request for water so given enough water to the child achieves a good oral intake. Encourage to make sure that the environment is free from pollution and other allergens. Daily cleaning in the room and the surroundings was advised, proper hand washing by parent was encouraged to prevent infections. 125mg/5ml BID until 19 Feb 2011 (8am, 8pm) 2.5ml BID until 20 Feb 2011 (8am, 8pm) 1cc NSS TID until 20 Feb 2011 (8am, 2pm, 8pm)

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Outpatient Note the time and date of follow up to: Dra. Rodelia G.Lacson Capitol Medical Center Sct. Magbanua St. cor. Panay ave., Quezon City Room 1108/1109 From Monday Saturday except Wednesday; 3:00 to 6:00 PM Contact nos.: 372 3825 to 44 loc 5708/5709 Diet Parents were advise encourage on frequent small feeding and food served should contain all the six essential food nutrient carbohydrates, proteins, fat, vitamins and minerals. Encourage to increase the fluid intake too as well. Avoid junk foods and chocolates that may stimulate cough. Spiritual Maintain patients good relationship to God and encourage to ask help and guidance in every circumstances occurred.