Case Presentation on Pneumonia

Group 1 BSN II

OBJECTIVES
Cognitive Associate ideal signs and symptoms with the clients manifestations(differential diagnosis) Determine how different signs, symptoms and laboratory reports resulted to the final diagnosis Discuss the correlation of theoretical and clinical knowledge with present real-life scenarios Evaluate the level of medical treatment

 Affective

Express confidence in independently carrying out nursing interventions Select a course of action based on the ABC(airway, breathing, circulation) prioritization

 Psychomotor

Carry out independent nursing interventions Enact the roles and functions of being a health educator Refine communication skills

CHAPTER I

ASSESSMENT

Nursing Health History

Name Address Age Sex Religion Civil Status Birthdate Weight Chief Complaint Admitting Diagnosis

Baby Cleft Perpetual Help, Iriga City 10 months old Male Catholic Single November 18, 2011 6.3 kg Fever, colds, cough, DOB pneumonia

Dr. orders for U/A September 2,2012 Patient suffers from colds and cough Pt. is confined v/s monitored every 4 hours Medications prescribed September 7, 2012 Pt. is admitted to the ER with cc of colds, cough, DOB, fever Weight-6.3 kg

September 8, 2012 Patient still shows signs of DOB, cough and colds Medications were retained X-ray exam was ordered

5:45 a.m. HEMATOLOGY results showed LOW RBC, hemoglobin, hematocrit, MCV, MCH and neutrophil count

September 9, 2012 Urinalysis results

arrived

September 10, 2012

Assessment includes rales(ALS), and fever of 37.2 C

8 a.m.Cr-110;Rr-28;T-37.1 5 p.m. cr 164; Rr 68;T-37.8

Assessment: patient was positive for rales, nasal flaring , having irregular breathing and restlessness

September 7 8 a.m. Cr 110

September 8 Cr 124

September 9 Cr 126

September 10 Cr 134

Rr
T 1 p.m. Cr Rr T 2 p.m. Cr Rr T 5 p.m. Cr

28
37.1 128 38 37.2 -------164

Rr
T Cr Rr T Cr Rr T Cr

40
36.5 118 28 36.2 ---------

Rr
T --------------

33
36.4 -------------

Rr
T Cr Rr T Cr Rr T Cr

44
36.1 130 54 36.1 134 44 36.1 ---

Rr
T

68
37.8

Rr
T

-----

-----

-----

Rr
T

-----

Vital Signs

X-Ray results

Final Diagnosis

September 11, 2012

Productive Cough

Focused on pulmonary and cardiovascular systems

Pneumonia

Pulmonary Tuberculosis

Lung Cancer

Acute Bronchitis

diaphoresis

All systems

Pneumonia

tuberculosis

MI

Hypoglycemia

fever

infection

Immune complex dysfunction

West Nile Encephalitis

dyspnea

Abdomen, resp., cardiovascular, neurologic Pulmonary embolism Pulmonary edema

Acute asthma

pneumothorax

Pneumonia

s/sx Asthma X-fever; allergy-like symptoms xcyanosis,fe ver, asymmetry of chest Xwheezing *Mucus(gr een or yellow), wheezing, odor Wheezing

morpholog y bronchiole s Air in pleural spaces

Laboratory tests Uses asthma test x_consolidati on; heart size infiltrate infiltrates leukocytosi s Po-low peak flow

Pneumoth orax Cough, colds, fever, DOB, rales

Bronchitis Bronchiect asis

Airways(br onchi) airways(br onchial tree)

Bronchiolit is Pneumonia

Airways(br onchioles) Lung parenchym a Lung parenchym a

infiltrates Sputum testcausative agent Skin testfalse positive if BCG was given Some forms of pneumo-x /increased leukocytosis; lab results

Tuberculos is

X-Ray results

Final Diagnosis

September 11, 2012

Patients Past History

Delivery Medical History natural April 2012-first confinement for UTI September-Second confinement Vitamin C, antibiotics, oregano Medications Childhood illnesses Asthma dust Allergies Incomplete: last shots for Immunization Hepatitis, diphtheria and TB DOTS Surgical History none

The-3 yo Jack-14 yo Hill- 2 yo Up-7 yo And-12 yo Jill-10 yo Went-8 yo MALE FEMALE ASTHMATIC POSITIVE FOR PNEUMONIA

Baby Cleft-10 mo HAS CLEFT LIP HAS CLEFT PALATE

FAMILY HISTORY CHART

Occasional alcoholism and hypertension present

Lifestyle
Diet 10 ounces of fluid a day; breastfed 3 times a day; am am Hospitalization-water given through droppers Fussy during mealtimes; hosp. fussy in the early morning and in the night

ADL

Sleep

Sleeps for 9-11 hours; naps when comfortable

Social Data
Health beliefs Mother
Age Occupation

pilay
37 years old Stay-at-home mother 35 years old Carpenter

Father
Age Occupation

Finances

Environment and housing

alam mo naman pag taghirap, walang pera village with unpaved roads; 3 rooms Baby Cleft and Hill sleeping with parents

Patients Present History

Present History On September 2, 2012(5 days PTA), Baby Cleft suffered from colds, cough, and intermittent fever; his mother decided to seek medical help due to continued dyspnea and recurrent fever. Patients mother states kapag may pilay at hindi napahilot, nagkakasipon and believes this may have caused the disease It was on 5:30 a.m. that Baby Cleft was September 7, brought to the Emergency Room 2012

Head to Toe Assessment

General Survey
Body Behavior Distress Symmetrical, poor hygiene Responsive Irregular respiration, restless Even color Intact; no lesions returns to original position when pinched Nails are not well groomed; dirt wedged in Color refill returns after a second Normal 180 degree angle

Skin, Hair and Nails

Color Integrity Mobility and turgor Nail grooming

Nail shape

 Ears

Nose

Arms, Hands and Fingers

No irritations or discharge PERRLA Discharge of white mucus Respiratory distress apparent(patency not tested) Even skin coloration, no lesions or masses Moderately fast radial pulse

 Anterior Chest

Legs, Feet and Toes

Rales present in both lungs Skin is mobile and turgid No discolorations, turgid and mobile skin

CHAPTER II

DEFINITION OF THE DISEASE

What is it?
Lung parenchymal infection Caused by viruses bacteria or intake of lipid or hydrocarbon substances

What are its divisions

Durational Clinical Etiological morphologic
Pneumonia

CHAPTER III

ANATOMY AND PHYSIOLOGY

CHAPTER IV

LABORATORY RESULTS

URINALYSIS

COMPLETE BLOOD COUNT

XRAY REPORT

CHAPTER V

DRUG STUDY

1. This drug relaxes the smooth muscle in the lungs and opens airways to improve breathing. It is used to treat asthma, chronic bronchitis, emphysema and to prevent exercise-related asthma.
SPECIAL CONCERNS Hypersensitivity to adrenergic amines Hypersensitivity to fluorocarbons Use cautiously in patients with cardiovascular disorders. DOSAGE PO (Adults and Children more than 12 years): 2-4 mg 3-4 times a day or 4-8 mg of extended dose tablets twice a day. PO (Geriatric Patients): initial dose should not exceed 2 mg 3-4 times a day and may be increased carefully up to 32 mg/day PO (Children 6-12 years old): 2 mg 3-4 times a day or 4 mg as extended-release tablets twice a day; may be carefully increased as needed but not to exceed 24 mg/day PO (Children 2-6 years old): 0.1 mg/kg 3 times a day Inhalation (Adults and children more than 4 years of age): 2 inhalations every 4-6 hours Inhalation (Children 2-12 years old): 0.1-0.15 mg/kg/dose 3-4 times a day

Uses: 1. Control of pain due to headache, earache, dysmenorrhea, arthralgia, myalgia, musculoskeletal pain, arthritis, immunizations, teething, tonsillectomy 2. Reduce fever in viral and bacterial infections 3. As a substitute for aspirin in upper GI disease, bleeding disorders clients in anticoagulant therapy and gouty arthritis Special Concerns: Liver toxicity (hepatocyte necrosis) may occur with doses not far beyond labeled dosing. If 3 or more alcoholic drinks per day is consumed, consult a physician prior use. Dosage: Per Orem: 325-650mg q4h up to a maximum of 1 gram q6h. Suppositories: 650mg q4h not to exceed 4 grams a day for up to 10 days.

CHAPTER VI

NURSING CARE PLAN

CHAPTE VII

DISCHARGE PLANNING

Medication
Advice/instruct the mother to give all the medications exactly as indicated. Do not skip doses. Advice/instruct the mother to complete the medication as dictated by the doctor. Instruct the mother that she should not give her child cough medicine or cold medicine unless the doctor says so. Childs coughing helps them get rid of mucus from their lungs. Explain each medicines different side effects

Exercise
Allow the baby to crawl, pull up and assist when the infant is trying to walk. Instruct the mother that playing is normal but that it should be restricted to 15-30 minutes to prevent shortness of breathing. Encourage the mother to stick to a consistent bedtime routine(allowing for about 12-14 hours of sleep, and naps during the afternoon and morning);have the baby sleep in supine position to avoid sudden infant death syndrome

Therapy
Instruct the mother to continue medication. Allow for soothing music; encourage the mother to talk to her child

Health Teaching
Instruct the mother to increase the childs fluid intake. Instruct and advice the mother the importance of proper hygiene to prevent infection. Instruct the mother to bath her baby daily. Advice the mother that she should minimize exposing her child in open, dusty environments. Encourage completion of oral antibiotics at home as prescribed. Advice the mother to have a complete immunization of her child.

Outpatient care

Instruct the mother to have a regular check up with the physician. Ensure the mother knows when her follow up appointments with the physician are and that she knows clinical manifestations that require immediate interventions. Advice the mother to have her child vaccinated with flu shots every year. Inquire if the mother knows and understand safety measures as well as how to operate and disinfect nebulizers. Never leave the child alone. Encourage the mother to do chest vibration to facilitate mobilization of secretion.

Diet
Instruct the mother to give nutritious foods. Emphasize breast feeding. Advice the mother to offer small amount of foods, with increased frequency. Reiterate that the child should increase fluid intake. Advice intake of vitamin C and multivitamins to be taken.

Spiritual Counseling
Encourage the mother to continue praying in God and to attend mass every Sunday.