CASE CONFERENCE

PEDIATRIC COMMUNITY
ACQUIRED PNEUMONIA
 INTRODUCTION
• Pneumonia is an inflammation of the lungs caused by an infection. It
is also called Pneumonitis or Bronchopneumonia. Pneumonia can be a
serious threat to our health. Although pneumonia is a special concern
for older adults and those with chronic illnesses. It can also strike
young healthy people as well. It is a common illness that affects
thousands of people each year in the Philippines thus, it remains an
important range in seriousness from mild to life-threatening.
Classification of Pneumonia:
• Several systems are used to classify pneumonia. Classically,
pneumonia has been catagorised into one of the four categories:
bacterial or typical, atypical, anerobic/cavitary and opportunistic.
However there is overlap in the microorganism thought to be
responsible for typical and atypical pneumonias. A more widely used
classification schee categorize the major pneumonia as Community
Acquired Pneumonia(CAP). Hospital Acquired (nosocomial)
Pneumonia (HAP), Pneumonia in the Immune-compromised host and
Aspiration pneumonia. There is overlap in how specific pneumonias
are classified because they may occur in the different settings.
Community Acquired Pneumonia (CAP)
• Community Acquired Pneumonia occurs either in the community setting or within the first
48hours after hospitalization or institutionalization mostly by inhalation of infected
droplets. The process may be patchy, involves whole lobes bilaterally or unilaterally. The
causative agents for CAP that requires hospitalization are most frequently S. Pneumonia.
H. Influenza, Legionella, Pseudomonas aeruginosa, and other gram negative rods.
• In the Philippines, pneumonia is one of the leading causes of morbidity, especially <5
years of age. In 2006, there were 670,231 cases of acute lower respiratory infection and
pneumonia(or 828.8 per 100,000 population) in the country, with 393,812 cases (59%)
occurring in the age group of <5 years. In 2010, the total number of cases decreased to
381,123 (or 412.8 per 100,000) with 197,852 cases (52%) occurring in the age group of 1
to 4 years. However, despite this decrease, pneumonia continued to be the leading cause of
mortality among children in this age group in 2001. In addition, in 2010, pneumonia was
the leading cause of mortality among those in the age group of 5 to 14 years.
 Why do we chose this topic?
Why chose this topic mainly because Community Acquired Pneumonia
(CAP) is a common disorder affecting people of all ages. A lot of people
here in our province live in poor environments wherein bacterias that
cause pneumonia thrive. It makes it easy for one to catch the disease
from an affected person due to the disease being contagious. It is also
the most common type of pneumonia which is the leading cause of
illness and death worldwide. We would like to enhance our knowledge
on this disorder to provide better health teachings and nursing
managements to those affected
 HISTORY
• I. PATIENT’S PROFILE
Patient’s mother
Reliability: 99 %
GENERAL INFORMATION
Name: HJ Jr.
Age: 6 months
Address: Tinabangay, Alaska Mambaling, Cebu City
Birthday: September 5, 2018
Birthplace: Vicente Sotto Hospital
Sex: Male
Chief complaint: Producing cough
Admitting Physician: Ivan Lyndyl Miranda
Diagnosis: Pediatric Community Acquired Pneumonia
• II. HISTORY OF PRESENT ILLNESS
• A 6 months old male infant brought with the history of fever since 1 week long, low grade,
wet type cough associated with rapid breathing
• 3 days prior to admission noted onset of producing cough with fever thus consult with a
private physician and was given salbutamol 2ml thrice a day and tempra 1ml every 4–6 hours,
with a 24-hour maximum of 5 doses which altered afforded temporary relief of symptom,
• 2 days prior to admission experiencing colds and nonproductive cough, fever and having
difficulty in breathing
• 1 day prior to admission, persistence of cough with fever noted of 38.3 C associated with
dyspnea. Persistence of symptoms prompted consult and subsequent admission
• 1 hour prior to admission vital signs, T-39.9 C, P-144 bpm, R- 43 cpm, nasal flaring, grunting,
tachypneic, irritable, wheezing rales on both lung field and pallor noted.
• Past Medical History
No accidents or injuries, No known drug and food allergies
Past hospitalization
none other than obstetrical reason
• Family History
• Heridofamilial disease induced hypertension and heart problem on patient
maternal side
• Mother: 22 years old, apparently well, housewife with mini store
• Father 27 years old, apparently well, truck driver
• Sibling: 1 older sister 7 years old,
• Maternal Grandparents:
• Grandmother: 57, induced hypertension and heart problem,
apparently well
• Grandfather: 62 years old, hypertension, apparently well
• Paternal Grandparents:
• Grandmother: 55 years old, apparently well
• Grandfather: 59 years old, apparently well
• SOCIOECONOMIC AND ENVIRONMENT
• Living circumstance
• Patient lives in a cemented bungalow-type house near the road with 3 bed rooms,
well lit, with limited space and ventilation 
• Economic circumstance
• Both Mother and Father are the source of income
• Environmental circumstance
• Patient has no exposure to cigarrete smoke, no factor or ongoing construction nearby,
regular garbage collection twice a week but not segregated. Family’s source of water
is from purified water
• No recent contact with sick person
• Prenatal History
• Patient mother is 22 years old, G3P2. First prenatal checkup was at 20 weeks age of
gestation and is regular thereafter by an obstetrician at Vicente Sotto hospital. No
maternal illness during pregnancy. No exposure to radiation, none smoker, none
alcoholic, Never tried illicit drug use, Ferrous sulphate, Iron, Folic acid supplements
and Anmum milk were taken during pregnancy.

• Neonatal History
• Patient was born on September 5, 2018 (30 weeks) with a birth rank of 414.
Delivered at VSMMC via Caesarian Section. No complications and injuries.
 
• Postnatal History
• Patient is exclusively breastfed by his mother with no medical problems noted.
Breastfeeding was every 2-3 hours for 30 minutes to 1 hour. Multivitamins once
daily
• Growth and development
• Regard: 2 months, Social smile: 2 months, Turned over: 5 months

• Immunization
• Patient is up to date with his immunization as claimed by mother

• Nutritional history
• Patient was breastfed until his 1st month. Milk formula (Bonakid) from
1st month until present
 ASSESSMENT
• I. HEAD TO TOE ASSESSMENT
• HEAD, SCALP, AND HAIR
Patient head circumference is 42cm,round in shape, posterior fontanelle is not palpable,
frontal fontanelle appeared to be sunken. Hair in back portion was coiled and unevenly
distributed. Scalp is moist, no scars noted, free from lice, and dandruff. No lesions and
tenderness palpated.
• EYES, EYEBROWS AND EYELASHES
Eyes are symmetrical, not in strabismus and telecanthus, both eyes blinked at the same time.
Conjunctiva is pink and sclera is white. Cornea is clear and properly aligned when corneal
test done. Eyebrows symmetrical and inline with each other. Eyelashes turned outward
• EARS
Ears Earlobes are parallel and symmetrical, aligned with the outer canthus of the eye. Skin
color is the same with the face. No lesions noted on inspection. Earcanal has some cerumen but
no discharges noted. The baby will divert attention when someone make noise or sounds.
• NOSE
Nose is symmetrical. Septum in midline and not perforated. Both nares are patent. No
tenderness at sinuses. It has the same color with the face. Small amount of clear mucus
discharges with no unusual odor.
• MOUTH AND THROAT
Lips is moist and pinkish in color. Teething start developing but not yet erupted. Buccal
mucosa is moist and pinkish. No gum bleeding noted. Tongue is soft, pinkish with visible veins
in ventral part. Palate is intact and pinkish in color. Present of gag reflex also noted.
• NECK
Neck is not yet elongated. Neck muscles and head control is strong and
steady. Has a good ROM in rotation. Negative torticollis noted upon
observation. No masses or nodules noted on palpation.
• THORAX
Chest is symmetrical with no abnormal structures noted. Chest wall
configuration is 46cm. Abdominal breathing noted with 44CPM.
Audible stridor sounds during inspiration. Breath sounds, rales/crackles
heard upon auscultation.
• UPPER EXTREMITIES
Hand and arms warm to touch. No edema and lesions noted. Skin color is light brown with
no unusual discoloration noted. Nailbed regained color immediately on capillary refill
time. The patient can also hold feeding bottle during feeling time.
• ABDOMEN
Abdominal circumference is 47cm. Patient has slightly protuberant abdomen. Warm to
touch, light brown in color the same with the hands and face, no other unusual
discoloration noted. No lesions and swelling, no scars and no venous engorgement noted.
Upon inspection, umbilical hernia was seen and noted umbilicus free from infection. Skin
turgor slow, skin fold visible for less than 2 seconds. Upon auscultation, 22 bowel sounds
per minutes noted. Liver, spleen, kidney is nonpalpable. No tenderness upon palpation.
• Lower Extremities
• Skin color is the same with upper extremities, skin is warm to touch, no edema, no scars,
and no deformities noted. Mongolian spot seen over the sacrum area. Bow leg is also
noted when the mother assisted the baby to stand. Capillary refill time is immediate in 2
seconds.
 ASSESSMENT
• II. SYSTEMS ASSESSMENT
• CARDIOVASCULAR SYSTEM
Inspected the neck veins and all other upper and lower extremities of patient
and has no bulging of veins. Nail color is pinkish. CRT on both right and
left extremity is immediate to 2 seconds. Apical impulse auscultated in the
fifth ICS at the MCL with no trill. Apical heart rate auscultated 149 BPM
regular / rhythm noted. Auscultated carotid pulse, patient had negative bruits
sounds. Palpated the peripheral pulses; upper extremities carotid, radial, and
brachial was rhythmic. Lower extremities femoral, tibialis, popliteal and
dorsalis pedis are weak. Oxygen saturation by pulse oximeter was 97% on
room air.
• RESPIRATORY SYSTEM
The patient has a respiratory rate of 44 breathes per minute. Lung
expansion is symmetrical upon expansion. Patient has wheezing and
crackling lung/breathe sounds. Audible non-productive cough noted
with nasal discharges. Chest measurement is 46cm
• MUSCULOSKELETAL SYSTEM
There is absence of musculoskeletal deformities, patient can turn from
supine to prone position without S.O assistance. He can sit with support
and can hold feeding bottle. Sacral dimple seen upon inspection, bow-
legs is also observed.
• SENSORY PERCEPTION
The patient’s eyebrows and eyelashes are symmetrically aligned and has equal
movement. Conjunctiva appears pinkish and sclera appears white, pupils are
round and black. The ears are symmetrical with a shape and size proportion to
the face, there are some cerumen and no discharges noted. Patient reacts or
reactive to sounds, nose is proportion to the face and has minimal clear mucus
discharges on both nostrils. Patient is responsive to peekaboo.
• INTEGUMENTARY SYSTEM
Patient has light brown skin color, skin is warm to touch, has a good skin
turgor. Patient has diaper rash, no birthmarks upon inspection, no lesions or
any discolorations in the upper extremities.
• GASTROINTESTINAL SYSTEM
Patient can consume 80-120ml of bottle milk three times a day, oral mucosa
is uniformly pink in color, teeth has not yet erupted or developed, stool
output: 2-3 diapers/day, color of the stool is yellow
• NEUROLOGICAL SYSTEM
Patient is fully conscious and alert, he can sit with support and can hold
their feeding bottle, very reactive to peekaboo. Baby’s toes faming out when
Babinski reflex is done
• LYMPHATIC SYSTEM
Absence of lymph nodes upon palpations
• GENITO-URINARY SYSTEM
There's no unusual discharges in genitalia. Checking for any genito-
urinary disorders and it's negative from hydrocele and cryptorchidism.
Upon inspection, blisters or impetigo was noted on baby's buttocks.
Patient consumed 3 diapers/day for urine and weighs 50grams/diaper.
Urine color is light yellow without unusual odor noted. 2-3 diapers
consumed for stool, stool's color is yellow, slightly runny and bubbly or
jelly-like in appearance.
ANATOMY AND PHYSIOLOGY
PATHOPHYSIOLOGY
LABORATORY TESTS AND
DIAGNOSTICS TEST
 HEMATOLOGY SECTION
Test Name
Complete Blood Count Result Unit Reference range
WBC Count 10.24 x10^9/L 6.0-14.0
RBC Count 4. 34 x10^12/L 3.4-5.2
Hemoglobin 116.00 g/L 105-140
Hematocrit 34.100 % 32-42
MCV 78.60 fl 72-88
MCH 26.70 pg/cell 24-30
MCHC 34.00 % 32-36
RDW-C 14.60 H % 11.50-14.50
Platelet Count 465.00 H x10^9/L 150-450
Differential Count
Neutrophil 16.10 L % 54-62
Lymphocyte 67.70 H % 25-33
Monocyte 12.70 H % 3-11
Eosinophil 3.00 % 1-3
Basophil 0.50 % 0-1
 OUTLINE NURSING MANAGEMENT
• To Improve Airway Clearance
• Maintain adequate hydration
• Nebulize as ordered
• Suctioning of secretions as needed
• Auscultate breath sounds
• Assess vital signs
• Improving Gas Exchange
• Assess respirations
• Monitor body temp
• Suctioning of secretions
• Monitor body temperature
• Monitor vital signs
• Promoting Skin Integrity/ To Prevent Infection
• Instruct S/O keep the affected area clean dry
• Instruct S/O to remove wet linens, monitor diaper and change
immediately when soaked
• Recommend use of ointment for rash
• Instruct S/O to bathe child regularly
• Instruct S/O not to use tight/heavy clothing
• IDEAL MANAGEMENT ACTUAL MANAGEMENT
A.Laboratory Test
• Complete Blood Count CBC done on
• Sputum and Blood Cultures

B.Diagnostic Test
• Physical Examination Physical Examination
• Chest X-ray Chest X-ray done on March 9, 2019
C. Treatment
• Oxygen, Therapy Oxygen therapy done on March 11, 2019
• Nebulizer Nebulizer started on March 9, 2019
D. Medication
• Antibiotics 
E.Diet
• Increase fluid intake
• Nutrition supplements 
F.Activity./ Exercise
• Proper positioning
G.Referral
DRUG SUMMARY
 Name of drug Date Dose, frequency, Specific Classification Mechanism of Side Effects Nursing Responsibilities
Generic and ordered route and time Indication action
Brand name

Before:
       
     
-check the doctor’s order
Respiratory Anti-infective Bacterial action -nausea
-skin test is done to determine signs and
Generic: 3/9/19 380mg
tract infection Bactericidal against sensitive -vomiting symptoms of hypersensitivity

Ampicillin     During:
    organisms -diarrhea
-verify the patients name
  q6   -abdominal
-administer the right dose, frequency,

pain route and time

Brand:  
After:
-headache
Omnipen IVTT -Advise the SO to inform the nurse if
-urinary
adverse effects are present
   
retention -document and record

 
  8A  
 Name of drug Date ordered Dose, frequency, Specific Classification Mechanism of action Side Effects Nursing Responsibilities
Generic and route and time Indication
Brand name

              Before:

Generic: 3/9/19 76mg Primarily for Anti-infective Inhibit protein CNS: -check the physician’s order

Amikacin     short term   synthesis in bacterial -weakness -educate the SO the importance of

  q2 treatment of cell and is usually -tremor the medication

    serious infection bactericidal -convulsion During:

  IVTT of respiratory   GI: -administer the right dose,

Brand:   tract -nausea frequency, route, and time

Amikin 4:30 A   -vomiting -assess patient for sign and

    -hepatoxicity symptoms of the medication

  Skin: After:

  -skin rash -Instruct the SO to report if any

-urticaria manifestations occur

-rednessa -document and record

 Name of drug Date ordered Dose, frequency, Specific Classification Mechanism of action Side Effects Nursing Responsibilities
Generic and route and time Indication
Brand name

Before:
             
-check the doctor’s order
Generic: 3/9/19 100mg Relief mild pain Analgesic Relieve fever by -liver damage
-assess patient’s temperature
Paracetamol     or fever   central action in the -jaundice During:
-verify the patient’s name
  PO   Antipyretic hypothalamic heat- -hypoglycemia
-administer the drug at right dose,
    regulating center -rash
frequency, route, and time
Brand: PRN   -urticaria -monitor for signs and symptoms
of side effects.
Tylenol    
After:
  q6
-instruct the SO to report if any
    hypersensitivity occurs
-document and record for future
 
purposes
 
 Name of drug Date Dose, frequency, Specific Classification Mechanism of Side Effects Nursing Responsibilities
Generic and ordered route and time Indication action
Brand name
Before:
             
-check the doctor’s order
Generic: 3/9/19 Neb To control and Bronchodilator Relieves nasal CNS: -assess lung sounds and pulse
-educate the SO the importance of the
Sulbutamol     prevent congestion and -restlessness
medication
  q6 reversible reversible -tremor During :
-verify the patient’s name
    airway bronchospasm by -headache -administer the medication at right

Brand: obstruction relaxing the smooth CV: dose, frequency, route, and time
-instruct the SO to take the missed dose
Ventolin caused by muscles of the -chest pain directly
After:
  asthma or bronchioles -palpitations
-inform the mother to rinse the child’s
  chronic GI: mouth with water after each inhalation
dose to minimize dry mouth
  obstructive -nausea
-document and record
  pulmonary -vomiting

  disorder  

  (COPD)

 
NURSING CARE PLAN
 Assessment Nursing Diagnosis Client Goal Nursing Intervention Rationale Outcome Criteria Actual Evaluation
 
      Independent:      
  Impaired skin integrity Presence of rash 1.To prevent After 4-8 hours of Goal partially met
Subjective Cues: r/t alteration in skin subsides and   further invasion of rendering
  1.Instruct S/O to  
appearance as patient feels more microorganism
“Naa siyay talipaso sa manifested by
comfortable. keep the affected   student-nurse to - Patient was seen
iyang bugan ug lubot presence of rashes
  are clean and dry   patient care, the sleeping w/o
dapit” as verbalized   2.To prevent
by the S/O (Mother)  
 
patient will be interruption
2.Instruct S/O to further invasion of  
 
remove wet linens microorganism or able to:
 
Objective Cues: Scientific Basis:   - Presence of rash
      to prevent infection - Reduce presence
-Diaper rash is a 3.monitor diaper   noticeably
 Presence of of skin rash in the
rashes common form of of and change   subsiding
inflamed immediately
  affected area  
 Restlessness 3.Moisture
noted skin(dermatitis) that      
appears as a potentiates skin -make the patient  
 Cries when 4.Instructed S/O breakdown
affected is patchwork of bright not to use feel at ease and  
red skin on usually at    
touched tight/heavy 4.Can help in comfortable
  the babies buttocks or  
  somewhere near the clothing promote fast    
  area, Diaper rash is   healing of the rash - patient will rest  
 
  most commonly 5.Recommend use   w/o interruption  
  related to wet or of ointment for 5.Promotes good from discomfort of  
  infrequently changing rash hygiene to the child condition  
  if diapers in babies. It
 
   
  usually affects babies 6.Instruct S/O to  
  but anyone who wears bathe child  
  diaper regularly can  
  regularly
  develop the condition.    
     
 
 Assessment Nursing Diagnosis Client Goal Nursing Rationale Outcome Criteria Actual Evaluation
  Intervention
      Independent: Independent    
  Ineffective airway After nursing     After 4 hours of Goal partially met
Subjective Cues: clearance related to interventions, the 1. Assess vital signs 1. To have baseline nursing interventions,  
  increased sputum patient will manifest 2. Monitor breath data the patient will be - Secretions have been
"Way undang ubo sa production secondary behaviors to improve sounds 2. To note presence able to: loosened, and airway
akong anak" as to pneumonia airway clearance 3. Suction of abnormal   clearance has been
verbalized by the   secretions as breath sounds ⁃ Secretions will be improved as evidenced
patient's SO Scientific Basis: needed 3. To remove and loosened by the patient being
    4. Maintain loosen sputum   able to cough out the
Objective Cues: Due to infected lungs, adequate and mucus ⁃ Airway clearance sputum
  a substance are nutrition 4. To avoid will be maintained  
 Coughing formed and   dehydration free from obstructions  
  discharged by cells  
   
 
 Nasal flaring and tissues in the Dependent
     
 
lungs which obstruct Dependent - To determine the  
 Stuffy nose the passageway of   progression of the  
  oxygen. Since the -Administer disease process  
 Stridor oxygen cannot medications as  
  properly pass and prescribed by the - Administer
  enter, this results for physician medications in the
 Wheezing the patient to   form of a mist inhaled
 
experience difficulty - Nebulize as ordered to the lungs
 Dyspnea
 
in breathing and to
  have an ineffective
  airway clearance due
  to the presence of
  secretions and mucus
  obstructing the path.
 
 
 
 
 
 Assessment Nursing Diagnosis Client Goal Nursing Intervention Rationale Outcome Criteria Actual Evaluation
 
 
 
    Independent: Independent    
Subjective Cues:
Impaired gas After nursing  
After 4 hours of Goal partially met
exchange related to interventions, the 1.Monitor Vital sign 1.To have baseline
 
collection and     nursing  
"Nag lisod man gud ni patient will be able
siya ug ginhawa" as obstruction of mucus
to manifest
2.Oxygen therapy 2.To have patent interventions, the - Gas exchange
verbalized by the in the secondary to   airway patient will be has been improved
patient's SO pneumonia behaviors of 3.Assess respiration  
    improved gas    
able to: in the body as
Objective Cues:
 
Scientific Basis: exchange in the 4.Assess skin color 3.To note the severity   evidenced by the
- Pneumonia is an body and improve   of the disease ⁃ Improve patient who has
 Presence of rashes
excess of fluid in the 5.Monitor body  
 
lungs resulting from
breathing pattern ventilation been breathing
 Restlessness noted temperature 4.To note presence of
  an inflammatory   cyanosis
  better and
  process. The 6.Suction secretions as   ⁃ Have adequate coughing less
 Cries when affected inflammation is needed
is touched 5.High fever greatly oxygenation  
triggered by many   increases metabolic
 
infectious organisms  
   
  demands and oxygen  
  and by inhalation if   consumption ⁃ Have lessened
  irritating agents.   the secretion in  
 
Infectious pneumonias    
  Dependent 6. Mechanically clears the airways
  are categorized as airway in patient who  
  community acquired  
  Administer
is unable to cough  
(CAP) or hospital  
medications as  
acquired (nosocomial)  
depending on where prescribed by the  
the patient was physician Dependent  
exposed to the These drugs are used  
to combat most of the
infection.
microbial pneumonia
 
 DISCHARGE PLAN
• Take the entire course of any prescribed medications.
-after a patient’s return to normal, medication must be continued
according to the doctor’s instructions, otherwise the pneumonia may
reccur. Relapses can be far more serious than the first attack.
• Get plenty of rest.
-adequate rest is important to maintain progress toward full recovery
and to avoid relapse.
• Drink lots of fluid, especially water.
-liquids will keep patient from becoming dehydrated and help loosen mucus in the lungs.

• Keep all of follow-up appointments.

-even though the patient feels better, his lungs may still be infected. It’s important to have the
doctor monitor his progress.

• Encourage the guardians to wash patient’s hands.

-the hands come in daily contact with germs that can cause pneumonia. These germs enter one’s
body when he touch his eyes or rub his nose. Washing hands thoroughly and often can help reduce
the risk.

• Tell guardians to avoid exposing the patient to an environment with too much pollution (e.g.
smoke)
-smoking damage one’s lungs natural defenses against respiratory infections.

• Protect others from infection

-try to stay away from anyone with a compromised immune system. When that isn’t possible, a
person can help protect others by wearing a face mask and always coughing into a tissue.