Mariano Marcos State University

College of Health Sciences

CASE ANALYSIS
(Measles, Pneumonia)
SUBMITTED BY:

ABALANZA, JINZEN MAE D.

SUBMITTED TO:

PROF. JULIE C. DAMASO

PROF. MARILYN M. RACCA

PROF. PRECY G. ODUCAYEN

(Clinical Instructors)

Mid-year Affiliation S.Y. 2017-2018

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I. PERSONAL DATA

Name: Noah Vio Lopez Jetajube

Hospital number: 000000001219355

Sex: Male

Age: 9 months old

Date of birth: September 14, 2017

Place of birth: Angono, Rizal

Civil Status: Single

Religion: Roman Catholic

Educational Attainment: None

Occupation: None

Address: Phase 3 Zone 1 Mahabang Parang Angono Rizal

Chief Complaint: persistent fever, productive cough and rashes, 4 days PTA

Date and Time of Admission: June 25, 2018 5:30 PM

Admitting Diagnosis: Measles Pneumonia

Attending Physician: Dr. Edna A. Miranda

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II. PATHOPHYSIOLOGY

Disease Process

When an individual exposed to a person who has measles, there is an increased chance

to acquire the virus which is the Rubeola Virus via coughing and sneezing. With that, there is

now a chance of the Rubeola Virus to enter through respiratory tract. When the virus reaches

the upper respiratory tract, first line of defense will happened wherein there will be an increase

mucous production that may happened. Because of that, there is an increased chance to

develop initial infection in the site where the virus deposits.

After the development of initial infection, hematogenous spread may occur wherein the

virus will gain access to the bloodstream causing the person to develop viremia. Then,

inflammatory process will happened wherein there is a fever and inflamed eyes. Then after that,

the Rubeola Virus will continue to replicate into the epithelial and reticuloendothelial system

tissue. Then, secondary viremia will occur after the virus has replicated to the different tissues in

the body and once the virus re-entered again in the circulation. Then, there will now be an

increased chance of the infection to become established in the skin and other tissues. Then,

production of interleukin will happened which could be the reason why there will be a delayed

hypersensitivity reaction that may also happened along the way. Appearance of Pre-eruptive

Stages may happened followed by the Eruptive Stages. With delayed hypersensitivity reaction,

there is an increased chance now for the Koplik’s Spots to appear on the bucal mucosa causing

now the person to experienced Eruptive Stages. For the Pre-Eruptive Stages, there will be a

feeling of photophobia, catarrhal symptoms, and 3 C’s which are the coryza, conjunctivitis, and

cough.

For the Eruptive Stages, there will be constant sore throat, constant runny nose,

lethargy, and the rashes will come out in the cheek, and in the hairline of the face and temple. If

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left untreated, there is an increased chance that the middle ear, bronchus, nephrons, and the

wall of the small bronchial tubes will become inflamed.

Risk Factors

Non-modifiable

1. Age- Being a young, unvaccinated child is the biggest risk factor for contracting the

measles virus and developing complications.

2. Pregnant Women- Pregnant women who are not vaccinated can become infected with

potentially fatal consequences to the fetus.

Modifiable Risk Factors

1. Immunocompromised individuals- This is true even if they had previously received

the MMR vaccine. Disease like Diabetes, HIV impairs the immune system by reducing

the body to fight against infection.

2. Vitamin A deficiency- This concern makes more likely to contract measles and for the

illness to be more severe.

3. International travel- International travel and choosing not to vaccinate are the two

lifestyle risk factors for contracting measles, and they are significant ones. Those who

are travelling to different countries where measles is prevalent, then they have a higher

chance of contracting the disease.

4. Unimmunization- Individuals who haven't received measles vaccine are more likely to

develop the disease than others.

5. Overcrowded areas- Children residing in crowded areas or in schools are at higher risk

of acquiring measles

6. Malnourishment- Those children who are malnourished can easily acquire the disease

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III. HEALTH HISTORY

A. FAMILY HEALTH HISTORY

The hereditary diseases present in the family are diabetes mellitus and asthma. On the

maternal side, the patient’s grandmother, Maria Elena was diagnosed with diabetes mellitus.

According to the patient’s mother she experienced non healing wound accompanied by pain

and swelling on the affected side which persisted for a few months. This prompted them to seek

for consultation, however the patient’s mother can no longer recall the year she was diagnosed

with diabetes mellitus, procedures done, the medications given as well as the physician who

diagnosed the said disease. After one year the patient’s grandmother was diagnosed with

asthma. The manifestations experienced were difficulty of breathing, coughing, and chest pain.

She added that there were medications given but she failed to give further information regarding

her mother’s condition.

The patient’s mother Nerlyn Mae was diagnosed with asthma after giving birth to her first

child. She experienced the same manifestations as experienced by the patient’s grandmother

such as difficulty of breathing and chest pain. According to her, there were medications given to

her however, she failed to recall the drug given as well as the physician who diagnosed her

illness. She further added that she stopped taking the medications after the manifestations

disappeared. As claimed by the patient’s mother, her siblings were all alive and well and don’t

experience any hereditary diseases.

On the paternal side, both the patient’s grandparents were deceased however the

patient’s mother doesn’t know the cause of their death. They were blessed with four children, in

which all of them were still alive and well.

There are several childhood illnesses experienced by the family such as chicken pox,

measles and mumps. For the chicken pox, the signs and symptoms were the presence fluid-

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filled blisters particularly on the face abdomen and back. The management done was eating

eggs and corns every meal. It was believed that it can trigger the appearance of the rashes.

They also isolate themselves in order to prevent the spread of the disease. According to the

patient’s mother, the rashes disappear within 7 days and some of the scars remained.

The family also suffered from measles. It was manifested by small red spots scattered all

over the body particularly on the abdomen and back. As claimed by the patient’s mother, they

do the same management with that of the chickenpox. As claimed by the mother, the illness

lasted for about a week.

For mumps, the manifestations felt were pain and swelling on the affected area, difficulty

swallowing, and fever. It was managed by applying 1 tablespoon of anyel (a blue powder)

combined with 1 table spoon of water once a day. The said mixture is applied on the affected

site and after 3 to 5 days, the mumps was healed.

The family also suffered from common illnesses such as fever, cough and colds,

headache and sore eyes. For the fever of the family, they simply managed it by taking over the

counter drug like Paracetamol 500 mg three times a day and they also performed tepid sponge

for about 5-7 times. The patient’s mother claimed that after the said management the fever

usually subsides after 2-3 days.

In managing cough and colds, they boil 3-5 oregano leaves and drink 1 tablespoon of it

for two times a day usually at morning and night. They also managed it by drinking a lot of water

usually 1.5 to 2 liters per day. She said that the cough usually subsides after 3-4 days.

For headache of the family, most of the family members usually felt the pain on the

temporal lobe and managed it by taking OTC drug like Paracetamol 500 mg usually three times

a day as needed. The patient’s mother said that the usual cause of headache is the hot

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weather. They also do bed rest and water therapy to decrease the pain as mentioned by the

patient’s mother. In doing these procedures, the pain is alleviated in 1-3 hours.

For the sore eyes of the family, it occurs usually on both eyes. The manifestations

experienced by the family are redness on the eyes and itchiness. The family managed it by

using over the counter medication, Eye Mo 1-2 drops on each eye for 2 times a day usually

morning and evening.

As verbalized by the patient’s mother, they receive complete vaccination but then failed

to show supporting documentations.

The family is fond of eating pork, chicken and fish. They also like to vegetables such as

horse radish, squash and string beans.

The family is fond of eating vegetables such as squash, horseradish and string beans.

They usually drink 8-10 glasses of water every day. They sleep 7-8 hours a day.The patient

stated that they usually sleep at around 8-9:30 in the evening and wakes up at 4-5:30 o’clock in

the morning. They also take naps during the day usually at 1-2 pm for about 30 minutes to 1

hour. The family has no form of exercise.

In addition, the family takes bath 2-3 times a day, after waking up, at noon and before

going to bed. The patient mentioned that they also brush their teeth 2 times a day. They usually

have their breakfast at 6-6:30 AM, lunch at 11-12 noon and dinner at around 6-6:30 PM.

B. PAST HEALTH HISTORY

The patient first experienced having fever during his first month with a manifestation of

warm to touch skin accompanied by cough and colds that lasts for about 2-3 days. His mother

managed it by taking Paracetamol 0.3 ml every 4 hours prescribed by a physician at their

municipal health center and she also performed tepid sponge bath for about 5-6 times per day.

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During his 6th-month, his mother managed the fever by taking Paracetamol 0.5 ml every 6

hours. According to the patient’s mother the fever usually subsided for 2-3 days.

The patient has no allergies. No previous hospitalization.

As claimed by the mother, Noah took his first solid food during his 6th month. Cerelac

was the first solid food introduced to the patient. He also further added that he likes to drink a lot

of water usually 1-2bottles per day and can consume 5-6 bottles of milk each day.

The patient sleeps 4-5 times a day, first 9-11AM, second 1-3PM in the afternoon, third 5-

6PM if he was done and tired of playing then sleeps again at around 7-8 PM. The mother also

stated that, Noah usually wakes up at around 2-3 AM because he was hungry and wakes up

again at around 5-6AM.

The patient received BCG as evidence by the presence of scar on his right deltoid, 1

dose of pentavolent during his 1 ½ month and the second dose on his 3rd month. As claimed by

the patient’s mother the 3rd dose of pentavolent should be given the next month but since the

child has fever, cough and colds, the health care provider refused to administer the vaccination.

As stated by the patient’s mother they decided not to take the third dose because of the issue

about dengvaxia.

C. PRESENT HEALTH HISTORY

On June 22, 2018 in the morning, the patient experienced loose of bowel movement

accompanied by fever. He defecated 5-6 times per day but as claimed by the mother she failed

to quantify the amount of stool. It is characterized as loose watery and yellowish in color. The

only management done was by increasing the patient’s fluid intake and as claimed by the

mother they did not seek for consultation due to lack of money.

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 As to his fever, they manage it through tepid sponge bath and giving paracetamol 0.5ml

every 6 hours. According to his mother, they stopped in giving his paracetamol @ 6 pm the

same day because the patient started to vomit.

On June 23, 2018, the patient was still warm to touch accompanied by productive cough

with white secretion. In the afternoon, the rashes begin to appear as characterized by red spots

scattered on the cheeks and hairline. The mother failed to get his temperature because they

don’t have thermometer, so she just managed it again by tepid sponge bath. Due to the

persistent fever the patient was rushed to Antipolo Hospital at 7PM. The laboratories done were

blood test, fecalysis and urinalysis. For the blood test and fecalysis the result were found normal

but for the urinalysis they found out that the patient has urinary tract infection. The medications

prescribed were Cefuroxime 3.5 ml twice a day, Paracetamol 1.2 ml every 4 hours and

Cetirizine 1 ml once a day. The patient’s mother failed to recall the doctor who prescribed these

medications and further added that there should be taken the next day.

On June 25, 2018 , the fever did not subside, cough was still productive, rashes increase

in number specifically on hairline, cheeks and abdomen. This prompted them to consult at

Children’s Hospital but due to inavailability of rooms they immediately referred the patient to

San Lazaro Hospital with an admitting diagnosis of measles pneumonia.

PHYSICAL ASSESSMENT

Place of Assessment: San Lazaro Hospital

Date of Assessment: June 26, 2018

Time: 9:02 AM

Vital Signs

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 Temperature: 38.7

Cardiac rate: 145 bpm

Respiratory Rate: 85 bpm

General Health Condition

Upon assessment, the patient was seen lying on the bed with his mother, with an

ongoing IV fluid of D5IMB at 500cc level, and also with an oxygen inhalation administered within

nasal cannula regulated at 2-3L/minute. The patient was wearing sleeveless white shirt and

plain green shorts which is appropriate to the weather. His appearance is congruent to his

actual age. He appears clean and well groomed. He has a brown overall skin complexion with a

presence of maculopapular rashes all over his body most especially on the face, trunk abdomen

and back. His body built is Ectomorph.

Head to Toe Assessment

Head

 Head is normocephalic, symmetric and round

 No involuntary movement

 Scalp is pale in color, clean and dry

 Presence of maculopapular rashes on the head

 Hair is black and smooth

 Face is symmetric and brown in color

Eyes

 Eyelids close symmetric

 Eyelashes and eyebrow are well distributed

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  Eyelids close easily and meet completely when closed

 Presence of redness on the sclera

 Presence of swelling in the upper and lower eye lid

Ears

 Ears are symmetric

 Lobules are elongated and attached

 The auricle aligns with the corner of each eye

 Presence of maculopapular rashes on the ears

Nose and Sinuses

 With yellowish nasal discharges noted

 Nasal mucosa is dark pink

 Nose and nasal passages are not inflamed

Mouth

 Lips are dry and reddish in color, with a presence of lesions

 Gums are pinkish and moist no lesions or masses

 Buccal mucosa is smooth and moist without lesions

 Tongue is pink, moderate in size

 Tongue has no lesions

 No unusual odor

 Throat is pink, without exudate or lesions

Neck

 Both sides of neck are symmetrical

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  Presence of maculopapular rashes on the neck

 Thyroid cartilage, cricoid move upward symmetrically upon swallowing

 No swelling, no hardness is present on the lymph nodes

 Trachea is midline

 Thyroid gland is positioned midline and not bulging

Chest

 Regular breathing pattern

 Presence of maculopapular rashes on the chest

 Use of accessory muscles when breathing

 No masses noted on the each sites upon palpation

 Presence of abnormal lung sound upon auscultation (crackles)

 Breast is slightly lighter than the rest of the body; smooth with no edema, masses

 Areolas are round,

 Nipples are equal bilaterally in size

 No extra heart sounds

Abdomen

 Abdominal skin is appropriate with the general skin tone

 Presence of maculopapular rashes on the abdomen

 Umbilicus is inverted

 Umbilicus is in midline

 Abdomen is flat and round, non-tender

 Presence of maculopupular rashes on the abdomen

Upper Extremities

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  Nails are clean

 Nail plate is attached to nail bed

 Presence of maculopapular rashes on the upper extremities

 Good capillary refill: pink tone returns in 1 second when pressure is released

 Hands, arms, and fingers are warm to touch bilaterally from fingertips to upper arms

Lower Extremities

 Skin is smooth brown in color with evenly distributed hair

 Presence of maculopapular rashes on the lower extremities

IV. MEDICAL MANAGEMENT

LABORATORY MANAGEMENT:

Routine health examination

 CBC

Measures several components and features of the blood including red blood cells which

carry oxygen, white blood cells which fight infection, hemoglobin; the oxygen-carrying protein in

red blood cells, hematocrit; the proportion of red blood cells to fluid component, and platelet

which help with blood clotting

 Urinalysis

Used to detect and manage a wide range of disorders. A urinalysis involves checking the

appearance, concentration and content of urine. Abnormal urinalysis may point to a disease or

illness.

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  Potassium Test

This test measures the amount of potassium in the fluid portion of the blood. Potassium

help nerves and muscles communicate. It also helps move nutrients into cells and waste

products out of cells

 Sodium Test

This test is used to determine whether sodium level is within normal limits; to help

evaluate electrolyte balance and to help determine the cause of and monitor the treatment for

illnesses associate with abnormal sodium levels in the body.

DIAGNOSTIC PROCEDURES

 Measles specific IgM titers

Measles antibodies are virus-specific proteins produced by the immune system in

response to an infection by the measles virus. There are two types of antibodies produced, IgM,

IgG. These tests are used to diagnose measles.

 X-ray

X-ray is a common imaging test that is used to diagnose pneumonia. Pneumonia is a

lung infection associated on X-ray with consolidation. Consolidation refers to all lung

abnormalities which increase density and show as opacities.

SUPPORTIVE MANAGEMENT

 Oxygen Therapy

The patient is on oxygen supplementation through nasal cannula. This was prescribed

by his attending physician, Edna A. Miranda on June 26, 2018. Pneumonia is an inflammatory

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condition of the lungs. Oxygen supplementation is one way to help patients who cannot breathe

adequately on their own.

NURSING CARE PLAN

NURSING CARE PLAN NO. 1

Nursing Diagnosis: Ineffective airway clearance related to poor cough effort possibly

evidenced by presence of crackles upon auscultation, use of accessory muscles in breathing

and a verbalization of the mother “para po siyang hinihingal”.

Nursing Inference: Organs have an effective cleaning system known as mucociliary clearing.

Due to ciliary breathing, secretions produced in the airways transport possible contaminants

from the peripheral airways to the main and upper airways, hence they are unconsciously

swallowed.

Changes in the ability to cough, understood as the inability to expel secretions effectively or

finding it difficult to do so, may precede alterations in alveolar ventilation, thus ineffective airway

clearance.

Coughing is a mechanism for clearing secretions. An ineffective cough compromises

airway clearance and prevents mucus from being expelled.

Nursing Goal: After 3-4 hours of rendering appropriate nursing intervention:

 the patient will be able to show signs of improved airway.

 The mother will be able to verbalize understanding of health teachings

Nursing Intervention Rationale

1) Maintain oxygen inhalation regulation To help and aid with the patients breathing

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 as prescribed.

1) Assess airway for patency. Maintaining patent airway is always the first

priority, especially in cases like trauma, acute

neurological decompensation, or cardiac

arrest.

2) Auscultate lungs for presence of Abnormal breath sounds can be heard as fluid

normal or adventitious breath sounds, and mucus accumulate. This may indicate

as in the following: airway is obstructed.

 Decreased or absent breath These may indicate presence of a mucous

sounds plug or other major obstruction.

 Wheezing This may indicate partial airway obstruction or

resistance.

 Coarse crackles This may indicate presence of secretions

along larger airways.

3) Assess respirations. Note quality, rate, A change in the usual respiration may mean

pattern, depth, flaring of nostrils, respiratory compromise. An increase in

dyspnea on exertion, evidence of respiratory rate and rhythm may be a

splinting, use of accessory muscles, compensatory response to airway obstruction.

and position for breathing.

4) Note for changes in mental status. Increasing lethargy, confusion, restlessness,

and/or irritability can be initial signs of cerebral

hypoxia. Lethargy and somnolence are late

signs.

5) Note for changes in HR, BP, and Increased work of breathing can lead to

temperature tachycardia and hypertension. Retained

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 secretions or atelectasis may be a sign of an

existing infection or inflammatory process

manifested by a fever or increased

temperature.

6) Note cough for efficacy and Coughing is a mechanism for clearing

productivity. secretions. An ineffective cough compromises

airway clearance and prevents mucus from

being expelled. Respiratory muscle fatigue,

severe bronchospasm, or thick and tenacious

secretions are possible causes of ineffective

cough.

7) Use pulse oximetry to monitor oxygen Oxygen saturation should be maintained at

saturation; assess arterial blood gases 90% or greater. Alteration in ABGS may result

(ABGs) Pulse oximetry is used to in increased pulmonary secretions and

detect changes in oxygenation. respiratory fatigue.

8) Assess hydration status: skin turgor, Airway clearance is impaired with poor

mucous membranes, tongue. hydration and subsequent secretion

thickening.

9) Check for peak airway pressures and Increases in these parameters signal

airway resistance(since patient has O2 collection of secretions or fluid and likely for

inhalation). ineffective ventilation.

Nursing Evaluation: After 3-4 hours of rendering appropriate nursing intervention:

 the patient was able to show signs of improved airway.

 The mother was able to verbalize understanding of health teachings

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Nursing Care Plan No. 2

Nursing Diagnosis: Hyperthermia related to inflammatory process as manifested by body

temperature of 38.7ºC, warm and flushed skin.

Nursing Inference: The inflammatory process causes increase in body temperature

Nursing Goal: After 15-30 minutes of rendering appropriate nursing interventions, the patient’s

body temperature will be on normal range (36.6ºC – 37.2ºC) and warm and flushed skin will

disappear.

Nursing Interventions Rationale

1. Provide tepid sponge bath To enhance heat loss by evaporating

2. Remove excess clothing and covers To decrease warmth and increase evaporative

cooling

3. Promote a well-ventilated environment To promote heat loss

4. Advise SO to increase patient’s oral To help prevent elevated temperature

fluid intake associated with dehydration

5. Administer antipyretics as ordered To lower down body temperature

6. Administer antibiotic as ordered To treat underlying cause

Nursing Evaluation: After 20 minutes of rendering appropriate nursing interventions, the

patient’s body temperature is 36.8ºC and warm and flushed skin disappeared.

Nursing Care Plan No. 3

Nursing Diagnosis: Risk for impaired skin integrity related to raking pruritus

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Nursing Inference: Presence of maculopapular rashes as a manifestation of measles can cause

itchiness/ pruritus

Nursing Goal: After 2 hours of appropriate nursing interventions, the mother will able to perform

health teachings that will able to maintain patient’s intact skin

Nursing Interventions Rationale

1. Encouraged SO to keep patient’s nails To minimize trauma and secondary infection

short and clean.

2. Advised mother to let patient wear To prevent scratching

mittens

3. Give clothes that are thin, loose and To prevent excessive heat that can increase

not irritating. itching

4. Avoid exposure to sunlight or heat To prevent itching and further development of

rashes.

Nursing Evaluation: After 2 hours of appropriate nursing interventions, the patient’s mother

was able to perform health teachings and the patient was able to maintain intact skin.

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