De La Salle Health and Sciences Institute College of Nursing

NURSING CASE STUDY

Submitted by: Maria Nia Aerolyn B. Obbania, SN13 BSN 23

Submitted to: Prof. Lindsay Camet, RN

I.

ADMISSION/FINAL DIAGNOSIS: Pediatric Community Acquired Pneumonia HEALTH HISTORY AND PHYSICAL EXAMINATION A. Demographic (Biographical Data) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Client s Initial - A.J.A.G. Gender - Male Age, Birth date and Birthplace - 6 months old; Aug.20, 2010 ;TreceMartirez City Marital (Civil) Status - Married Nationality - Filipino Religion - Roman Catholic Address and Telephone Number - Blk 1, Lot 19 Educational Background - College Graduate Occupation (usual and present) - welder Usual Source of Medical Care - Barangay Health Center Date of Admission - Feb.22,2011

II.

B. Source and Reliability of Information The patient is not yet able to provide information; data had to be obtained from the parents. C. Reason for Seeking Care or Chief Complaints persistent cough and colds for two weeks D. History of Present Illness or Present Health Two weeks prior to confinement, patient had productive cough with whitish phlegm. Patient had a consult and was then diagnosed with bronchopneumonia. The patient was advised to take Cefaclor 2ml every 8 hours for 7 days. After a week, the patient s condition worsened and was accompanied with a low grade fever and was then given Disudrin and Ambroxol. After 3 days of persistent cough and colds, the patient was referred to the hospital for admission. E. Past Medical History or Past Health a. Pediatric/Childhood Illnesses The patient have not experienced any illnesses. b. Injuries or Accidents The patient have not experienced any injuries or accidents.

c. Hospitalizations and Operations The patient have not undergone any hospitalization and operations. d. Immunization BCG: ( / ) At Birth ( ) School Entrance DPT: ( / ) 1st dose ( / ) 2nd dose ( ) 3rd dose OPV: ( / ) 1st dose ( ) 2nd dose ( ) 3rd dose AMV: ( ) 1st dose TT: ( ) 1st dose ( ) 2nd dose ( ) 3rd dose ( ) 4th dose HBV: ( ) 1st dose ( ) 2nd dose () 3rd dose Others: Based on the information obtained, the patient isnot fully immunized. e. Allergies The patient does not have any allergies. f. Medications The patient has taken Cefuroxime, Salbutamol, and Paracetamol.

( ) 5th dose

F. Family History

A&W,67A&W,58

A&W,63

A&W,60

A&W,29A&W,29

A&W,1yrA&W,6 mos.

-Male

-Female

-Patient

Based on the genogram, the client is not at risk of any hereditary diseases.

G. Socio-Economic History FAMILY MEMBER / RELATIONSHIP TO PATIENT C.G./mother

OCCUPATION / SOURCE OF INCOME welder

MONTHLY INCOME (optional) Not disclosed

The mother of the patients is the sole earner. H. Psychosocial Assessment Patient s Age: 6 mos. old Developmental Stage: Infancy Developmental Task: Trust vs. Mistrust The first stage of Erik Erikson's theory centersaround the infant's basic needs being met by the parents. The infant depends on the parents, especially the mother, for food, sustenance, and comfort. The child's relative understanding of world and society come from the parents and their interaction with the child. If the parents expose the child to warmth, regularity, and dependable affection, the infant's view of the world will be one of trust. Should the parents fail to provide a secure environment and to meet the child's basic need a sense of mistrust will result. According to Erik Erikson, the major developmental task in infancy is to learn whether or not other people, especially primary caregivers, regularly satisfy basic needs. If caregivers are consistent sources of food, comfort, and affection, an infant learns trust- that others are dependable and reliable. If they are neglectful, or perhaps even abusive, the infant instead learns mistrust- that the world is in an undependable, unpredictable, and possibly dangerous place. As for the patient, the most significant relationship is with the maternal parent, or whoever is his most significant and constant caregiver. I. Review of Systems and Physical Examination SYSTEM 1. General R.O.S. P.E. >Received patient out of bed, awake and conscious, with IVF of #5 D5IMB 500 cc at an IV level of 100 cc infusing @RMCV running at 38-39 micro gtts/min, not in cardiorespiratory distress, well developed, well nourished >T= 37.t C >PR= 132bpm >RR= 40cpm

2. Integument

Skin: >smooth and soft >good skin turgor; no swelling >no pitting or edema noted Hair and scalp: >black, smooth, fine hair >normal hair distribution >no parasites present >scalp symmetrical, smooth and firm Nails: nails are round, hard and immobile >nail beds are smooth, firm, clean and pink with a normal angle of 160 degrees Head: >Symmetrical, smooth,firm >(-) lesions on the scalp Face: >Symmetrical, centered head position >no involuntary movements on facial muscles

3. Head

4. Eyes

Eyelids and eyelashes: >Lid margins pale >blinking symmetrical >eyelids evenly distributed along lid margins on both sides Conjunctiva: >Pale palpebral conjunctiva Iris and pupil:

5. Ears

>(+) PERRLA >non tender lacrimal apparatus >anicteric sclera External Ear: >(-) discharges >(-)tenderness >equal size and similar appearance bilaterall >non-tender auricle and tragus >movable and firm pinna Mastoid process: >warm, non-tender and easily palpated External nose: Color is same as face, and smooth >symmetrical in shape >(-) lesions in turbinates and septum >(+) nasal flaring >(-) hoarseness >dry lips >(-) lesions on lips, mouth and throat >Smooth, symmetrical neck >smooth, firm, non tender thyroid >Full ROM on neck >Midline, symmetrical trachea >no swollen lymph nodes and tenderness

6. Nose and Sinuses

7. Mouth and Throat

8. Neck

9. Breast and Axilla

10. Respiratory

Breast: >symmetrical, flat breast >light brown areola >(-) lesion and discharges >(-) swollen lymph nodes >no rashes on both axilla >pinkish brown colored lips >(-) tenderness >bronchial sounds heard over

11. Cardiac

trachea >no chest pain >trachea in midline >equal chest expansion >(-) wheezes >(-) crackles on both lung fields >no heaves, murmurs, and thrills >(-) crepitus >shallow breathing >normal heart sounds >rhythm is regular; radial and apical pulse are identical; no extra heart sounds identified

12. Gastrointestinal

Abdomen: >no visible dilated veins >normal bowel sounds heard >(-) mass

13. Urinary 14. Genitalia

>(-) bladder distention > No PE

15. Peripheral Vascular >(-) ecchymoses >weak apical pulse

16. Musculoskeletal 17. Neurologic 18. Hematologic

>No PE >No PE >pale palpebral conjunctiva >pinkish nail beds >no swelling of lymph nodes

19. Endocrine

20. Psychiatric

>Even hair distribution >no visible enlargement of the thyroid gland >(+)excessive sweating > No PE

III.

LABORATORY STUDIES AND DIAGNOSTICS Procedure/Date Indications Normal Values/Findings Actual Findings/ Interpretation Nursing Responsibilities (pre,intra,post) Pre: - Instruct the client about the requirements and restriction. - Provide information about what the client may feel - Inform the client from time to time period before the results will be available. - Prepare the equipments and supplies needed. Intra: - Use standard precaution and apply sterile technique in holding materials and while performing the test. - Provide emotional and physical support while monitoring the client as needed. - Provide privacy for the patient. Post: - Observe and monitor the client. - Compare the previous, if any,

Complete Blood Count (02-21-11)

Hemoglobin Hematocrit WBC Segmenters Lymphocyte

Platelets

Hematology test is done for clients with or are candidate to have: - Anemia - Hemorrhage - Abnormal destruction of erythrocytes - Bone marrow suppression - Acute Myocardial Infarction - Acute Cerebrovascular Disease - Muscular Dystrophy - Renal failure - Kidney disease

124 0.37 12.4 0.35 0.62

11.9 35.9 15.9 76 21

464

Adequate

and current test results. - Modify nursing interventions as needed. - Report significant results to health care provider.

IV.

PHARMACOTHERAPEUTICS Generic name Classification Stock Dose Cefuroxime Indication Dosage Frequency Cefuroxime is indicated in the treating of a large number of infections. 300mg q8 It is suitable for the treatment of pains of all kinds (headaches, dental pain, postoperative pain, pain in connection with colds, posttraumatic muscle pain). Migraine headaches, dysmenorrhea and joint pain can also be influenced advantageously. 1 gtt/ml q4 if T>37.8C Nursing Responsibilities/ Implications it should be taken by meals to prevent GI disturbances.

Paracetamol

Salbutamol

Salbutamol has a pronounced bronchodilatatory effect on all forms and degrees of severity of bronchial asthma. It is therefore very well suited for the acute treatment of bronchospasms, even if the attacks are severe. *3

Use liquid form for children and patients who have difficulty swallowing. In children, dont exceed five doses in 24 hours. Warn patient that high doses or unsupervised long term use can cause liver damage. position patient on high back rest position.. dobacktapping after you nebulize the patient. do not give a food immediately it can cause vomiting

V.

PATHOPHYSIOLOGY

CAUSES: -viruses -bacteria and fungi -parasites Organism enters the airway through inspiration passes through theupper respiratory tract and blood circulation

Inflammation and edema of lung parenchyma

organism releases toxins

organism enters lungs and multiplies

accumulation of cellular debris and exudes

consolidation

PNEUMONIA

The causative agent or organism gains entry into the body through the respiratory tract by way of inspiration or aspiration of oral secretions. The organisms that can reach the lungs through blood circulation are staphylococcus and gram negative bacilli. The invading organism starts to multiply and release damaging toxins that cause inflammation and edema of the lung parenchyma. This is often due to the migration of white blood cells in the area to fight off the infection. The alveoli then becomes filled with pus and fluid resulting in the manifestations of fever, cough, breathing problems and chills. This action leads to accumulation of cellular debris and exudes within the lungs. Soon the airless state of the lungs is changed to a consolidated state due to the fluid and exudate filling up. The function of the lungs become affected, and oxygen exchange may be reduced and becomes inadequate for the need of the body.

VI.

NURSING CARE PLAN CUES NURSING DIAGNOSIS Innefective Airway Clearance r/t increased secretions OBJECTIVES OF CARE Short Term: y The patient will expectorate secretions adequately. Long Term: y The patient will maintain patent airway. PLAN OF INTERVENTIONS Diagnostic: y Conduct y assessments every 4 hours of respiration rate, temperature, and signs of airway effectively. y Note chest y movement, watching for symmetry, use of accessory muscles, and supraclavicular and intercostal muscle retractions. y Auscultate breath y sounds, noting areas of decreased or absent ventilation and presence of adventitious sounds. RATIONALE EVALUATION SCHEME y Patient expectorates secretions without undue stress and fatigue. Respiratory Status: Airway Patency as evidenced bynot compromise d respiratory rate, moved sputum out of airway, and no adventitious breath sound.

Objective:

Provides a basis for evaluating adequacy of ventilation.

y Presence of nasal flaring and use of accessory muscles of respirations may occur in response to ineffective ventilation As fluid and mucus accumulate, abnormal breath sounds can be heard including crackles and diminished breath sounds owing to fluidfilled air spaces and diminished lung volume A variety of respiratory therapy treatments may be used to open constricted airways and liquefy

Institute respiratory therapy treatments (e.g., nebulizer) asneeded.

secretions y Monitor for increased restlessness, anxiety, and air hunger. y These clinical manifestation s would be early indicators of hypoxia.

Therapeutic: y y Give Oxygen moist, review the effectiveness of therapy. y Give appropriate y antibiotics and antipyretics order, review the effectiveness and side effects (rash, diarrhea). y Perform y percussion, vibration and postural drainage. y Perform a y gradual suction. Educational: y Provide patient s y relative a health teaching on chest physiotherapy.

Increased lung tissue oxygen supply Eradication of the bacteria as a factor of disturbance

To facilitate drainage of secretions

Helping clean the airway

To help the patient have a patent airway.