T
A B L E
OF
C
ONTE NTS
I. Introduction
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II. Objectives
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3
III. Patient's Data
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4
IV. Ge Geno nogr gram am
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5
V. Health History
i. Pre Prese sent nt Hea Healt lth h Stat Status us ---------------------------------------------------------------------------
6
ii. ii. Past Past Heal Health th Hist Histor ory y ---------------------------------------------------------------------------
6
VI. VI. Phys Physic ical al Asse Assess ssmen mentt
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7
VII. Definition of Terms
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12
VIII. Developmental Task
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13
IX. Anatomy and Physiology --------------------------------------------------------------------------------
14
X. Pathophysiology
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16
XI. XI. Diag Diagno nost stic ic Exam Examss
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20
XII. XII. Labo Labora rato tory ry Exam Examss
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21
XIII. Drug Study
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23
XIV XIV. Nur Nursi sing ng Care Care Plan Plan
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26
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33
XV. Discharge Planning Method XVI. XVI. Prog Progno nosi siss
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35
XVII. Bibliography
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36
University of the Immaculate Conception
In partial fulfillment of the requirements in NCM 101 – RLE 101
A Case Study: Pneumonia
Submitted to: Nena Evangelista, R.N.
Submitted by: Montenegro, Roland Jireh Cabuntalan, Amerah Castillo, Manilyn Masunag, Ronie Cerdina, Jester Pellegas, Chon
August 2009
I. 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 cause of morbidity and mortality in the country. (www.msn.encarta.com/org)
There are many kinds of pneumonia that range in seriousness from mild to life-threatening. In infectious pneumonia, bacteria, viruses, fungi or other organisms attack your lungs, leading to inflammation that makes it hard to breathe. Pneumonia can affect one or both lungs. In the young and healthy, early treatment with antibiotics can cure bacterial pneumonia. The drugs used to fight pneumonia are determined by the germ causing the pneumonia and the judgment of the doctor. It’s best to do everything we can to prevent pneumonia, but if one do get sick, recognizing and treating the disease early offers the best chance for a full recovery. (www.wikipedia,.com/org)
To know the disease, we have to anticipate its warnings. Symptoms would include fever, chills, cough (non-productive or productive), tachycardia, a crackling sound would be noted and some would show labored breathing. These symptoms are common to almost all upper and lower respiratory infections so it is important that we know the diagnosis.
A case with a diagnosis of Pneumonia may catch one’s attention, though the disease is just like an ordinary cough and fever, it can lead to death especially when no intervention or care is done. Since the case is a pre-school, an appropriate care has to be done to make the patient’s recovery faster. Treating patients with pneumonia is necessary to prevent its spread to others and make them as another victim of this illness.
1
The death rate (or mortality) also depends on the underlying cause of the pneumonia. Pneumonia caused by Mycoplasma, for instance, is associated with little mortality. However, about half of the people who develop methicillin-resistant Staphylococcus aureus (MRSA) pneumonia while on a ventilator will die. In regions of the country without advanced health care systems, pneumonia is even deadlier. Limited access to clinics and hospitals, limited access to x-rays, limited antibiotic choices, and inability to treat underlying conditions can leads to higher rates of death from pneumonia. For these reasons, the majority of deaths in children under five due to pneumococcal disease occur in developing countries. (DOH.gov.ph)
In a worldwide aspect of the disease, according to the World Health Organization (WHO) that one in three newborn infant deaths are due to pneumonia and over two million children under five die each year. Mortality from pneumonia generally decreases with age until late adulthood. (www.reuters.com)
Knowing this, it can be safe to say that pneumonia is not ‘just’ a disease but ‘it is’ a disease. It will be a challenge to the group for the client of J.F.G, 5 years old, a Filipino male who was admitted because of cough and fever and was diagnosed of having pneumonia.
This would be a great opportunity for the group to study this case since the concept for this duty is about Oxygenation. This would also present an opportunity in applying the learned skills of giving care to the client and the implications as nurses. We must know our roles efficiently in our chosen field of profession.
2 II. OBJECTIVES
General Objective:
At the end of the rotation, the group will be able to come up with a case presentation aimed to determine the subject’s health concern, underlying causes for the disease and the intervention including medical and nursing interventions for any complications that may arise during the duration and as partial fulfillment of the requirements in Related Learning Experience, B.S. in Nursing, University of the Immaculate Conception, Philippines.
Specific Objectives:
1. To identify a qualified client to be the subject of this case study. 2. Gather the needed data regarding the subject and the family. 3. Assess the health status of the client, including the past and present illnesses that the subject would have. 4. Review and familiarize the anatomy and physiology of the respiratory system regarding the present complication of the patient. 5. Formulate a relevant Nursing Care Plan with the identified problems of the client. 6. Formulate Drug Studies for all the drugs given to the client and be able to explain why such drug is given to the client; and 7. Provide the subject as well as the family with the support systems, health teaching appropriate to the client’s needs and the family as well including the formulation of discharge plans.
3 III. PATIENT’S DATA
Patient’s name
:
J. J. F. A.
Age
:
5 years old
Sex
:
Male
Religion
:
Roman Catholic
Nationality
:
Filipino
Address
:
San Jose, Digos City
Birth date
:
October 10, 2003
Birth place
:
Digos City
Father’s name
:
J. G. A.
Mother’s name
:
A. A.
Date of Admission
:
August 2, 2009 / 2:45 p.m
Registry Number:
:
3738
Chief complaint
:
fever and cough
Admitting Diagnosis
:
CAP
Attending Physician
:
Dr. Lutero
4 V. HEALTH HISTORY
Present Health Status
The client is a 2-year old female child. Upon admission at Gonzales Maranan Clinic and Hospital, client was complaining of LBM, fever, anorexia and vomiting. Client is having persistent diarrhea and has had fever with 38.3 celcius for temperature when admitted. The client is ambulatory, coherent and v/s results showed an elevated RR of 37 rpm, pulse rate of 84. No intestinal parasite as result for fecalysis on the first day would indicate. Soft diet was prescribed, has a standing order of TSB for fever. Platelet is below normal but WBC count is within range and with a medical diagnosis of Pneumonia.
Past Health Status
Cough and fever has been noted to have onset 4 days prior to admission. Client has history of pneumonia and was admitted to the hospital when he was three years old. By then he was prescribed with Montelukast as his medicine. He was also admitted again 4 months after that with the same prescribed drug. Client has suffered asthmatic attack when he was 3 years old and was admitted to the hospital and was given Ventolin for treatment but has no record of any onset after that. Immunizations were completed when he was one year old. Patient has not yet visited a dentist. Latest medicines prescribed are Cefuroxime, Albuterol, Montelukast, and Naproxen.
6 VI. PHYSICAL ASSESSMENT
Patient:
J.J.F.A.
Unit / ward:
NS 1
Age:
5 years old
Sex:
Male
Civil status:
Child / Single
I. Vital signs: (latest)
Temperature:
36.9 celcius (axilla)
Pulse rate:
115 bpm (radial)
Respiratory rate:
23 rpm
Blood pressure:
100/70 mmHg
103 bpm (apical)
First Day
Second Day
Third Day
Temp.
38.1
36.5
36.9
Respiratory rate
28
24
23
Pulse rate
115
98
115
Blood pressure
110/80
110/70
100/70
II. Integument
Client has fair complexion and is consistent throughout the body. Abrasions were noted at the right outer hip related to bicycle accident 2 months ago. There were no lesions, rashes and lacerations noted. Mucus membranes are intact, moist and has no lesions present. Nails are cleanedshort with no lesions noted on fingers. Hair is colored black and is evenly distributed on the head scalp. No noted parasite on the hair and patient has good grooming.
7
III. HEENT
Head
Head circumference is 52 cm with normocephalic head configuration. No lesions, burns, lacerations and cuts noted. Masses and depressions not noted on head.
Eyes Pupils are black and equally rounded and constricts with light accommodation. Peripheral vision and visual acuity were not assessed.
Ears
Auricle is symmetrical, tenderness were not noted. External surfaces are smooth with discharges noted in small amount. Size of ears are symmetrical and proportional to the head. Ear canal is pinkish in color.
Nose Mucosal condition of nose is fine with pinkish color. No noted lesion but nasal flaring is present. No profuse discharges present. Nose is symmetrical with the nasal septum at the midline and intact with no lesions nor masses noted.
Mouth Lips were pale in color and dry. Few cracks were noted but no lesions, cut nor ulcerations noted. Gums are intact, pink in color and moist.
Pharynx Pharynx located at the midline. Tonsils are non-palpable. No structural abnormalities noted.
8
IV. Neck / Lymph nodes
Trachea is at the midline. Range of motion for neck is normal. No reported stiff neck present and was symmetrical. No signs of lesions, lacerations or pigmentation noted. Thyroid was non-
palpable and no enlargements noted. Carotid pulse is palpated with strong bounding pressure. No distended neck vein noted.
V. Pulmonary breath sounds
Crackling breath sounds were heard with stethoscope when auscultated. Productive cough is observed.
VI. Breast and Axillary Areas
Breast were normal and symmetrical with no lesion or masses noted. It has a lighter color compared to face. Axillas does not have hair and is dry. Axillary lymph nodes were not palpable.
VII. Cardiovascular
The PMI (point of maximal impulse) was at the 5 th intercostals space, left mid claviclar line with cardiac rhythm as normal. Cardiac rate is 103 at apical pulse and 115 bpm for the radial. Heart sounds are normal with S1 and S2 sounds heard. No murmurs noted.
9
VIII. Peripheral / Vascular
Pulse
Grade
Equal or not equal
Temporal
2+
equal
Carotid
3+
equal
Radial
2+
equal
Peripheral pulses are strong and are equal. Varicosities, rashes and edemas were not noted.
IX. Abdomen
Skin integrity is normal, color is fair, masses and pulsation were not noted. Bowel sounds were not assessed. Tenderness were not noted.
X. Musculoskeletal / Extremities
Range of motions was normal. Shoulders and arms were free from deformities. Nail beds are pink in color with capillary refill of 2 seconds.
XI. Genitalis
Urinates 5 times a day with amber yellow and sometimes clear white urine. Appearance of genitals was not assessed.
10
XII. Neuro-assessment
Refer legend at last page of case study.
Eyes are open spontaneously.
5 pts.
Verbal response is Alert and oriented
5 pts.
Motor response is withdraws from pain
4 pts.
Result
14 pts.
Patient’s neuro-assessment is lethargic.
11 VII. DEFINITION OF TERMS
There were several words whose definitions are vague that it needs to be defined in order for the reader to understand the case study. The following are words used in this case study whose definition has been provided for easier comprehension on the reader ’s part.
Pneumonia
- inflammation of the one or both lungs usually caused by an infection from a bacteria, virus or from a parasite
Tachycardia
- increase in heart rate. An elevated heart / cardiac rate from the normal.
Palpitations - fast or irregular beating that can be felt by the patient
Bronchus - a tube leading from the windpipe to the lungs which provide passage of air
Contractions
- reduction in size
Pleura - a thin transparent membrane that lines the chest wall and doubles back to cover the
lungs thus closing the narrow pleural cavity.
Dyspnea
- difficulty in breathing usually caused by a heart o r lung disease
12
VIII. DEVELOPMENTAL TASK
Stages Erik Erikson's Psychosocial Crisis:
Developmental Task Goals: •
Evaluation
Patient has partially established what is Learning to do things on their expected at her age.
Initiative vs. Guilt •
•
own Patient is able to Begins to evaluate their own stand, eat, play and behaviours take a bath on their Do things for a purpose own with any assistance from his parents and guardians. Patient is establishing his own behaviours by applying or doing what he wants, saying what he thinks and play what he likes.
Freud’s Stages of Development Phallic Stage
Child’s genitals are the center for The child seeks pleasure. Activities would include immediate pleasure and fantasy, experimentation with other gratification by means peers. of his mother’s attention and comfort. Major conflict: Has identified his Oedipus complex father as his significant person.
13 IX. ANATOMY AND PHYSIOLOGY
The lungs constitute the largest organ in the respiratory system. They play an important role in respiration, or the process of providing the body with oxygen and releasing carbon dioxide. The lungs expand and contract up to 20 times per minute taking in and disposing of those gases.
The first line of defense includes the hair in the nostrils, which serves as a filter for larger particles. The epiglottis is a trap door of sorts, designed to prevent food and other swallowed substances from entering the larynx and then trachea. Sneezing and coughing, both provoked by the presence of irritants within the respiratory system, help to clear such irritants from the respiratory tract.
Mucous, produced throughout the respiratory system, also serves to trap dust and infectious organisms. Tiny hair-like projections (cilia) from cells lining the respiratory tract beat constantly, moving debris, trapped by mucus, upwards and out of the respiratory tract. This mechanism of protection is referred to as the mucociliary escalator.
14
Cells lining the respiratory tract produce several types of immune substances which protect against various organisms. Other cells (called macrophages) along the respiratory tract actually ingest and kill invading organisms.
Air that is breathed in is filled with oxygen and goes to the trachea, which branches off into one of two bronchi. Each bronchus enters a lung. There are two lungs, one on each side of the breastbone and protected by the ribs. Each lung is made up of lobes, or sections. There are three lobes in the right lung and two lobes in the left one. The lungs are cone shaped and made of elastic, spongy tissue. Within the lungs, the bronchi branch out into minute pathways that go through the lung tissue. The pathways are called bronchioles, and they end at microscopic air sacs called alveoli. The alveoli are surrounded by capillaries and provide oxygen for the blood in these vessels. The oxygenated blood is then pumped by the heart throughout the body. The alveoli also take in carbon dioxide, which is then exhaled from the body.
Inhaling is due to contractions of the diaphragm and of muscles between the ribs. Exhaling results from relaxation of those muscles. Each lung is surrounded by a two-layered membrane, or the pleura, that under normal circumstances has a very, very small amount of fluid between the layers. The fluid allows the membranes to easily slide over each other during breathing.
15
X. PATHOPHYSIOLOGY
Predisposing factors
Precipitating factors
Patient is 5 years old where pneumonia
Lifestyle factors: Exposed to second-hand smoke (uncles and aunties).
.
is more common to these ages
Does not wash hands unless father is present Only eats meat and does not prefer eating vegetables nor fruits.
Weakened immune system
Aspiration of organism inhabiting the upper airways
Organisms invade the lungs and co nducts bacterial growth
Inflammation of the lungs
Mucus production is increased and plugs the alveoli and is further filled with fluid and debris from WBC’s produced to fight the infection
16
Fever
The alveoli (air sacs) of the lungs becomes blocked with mucus secretions.
Crackling breath 16 sound
If not treated....
If treated .......
The alveoli (air sacs) of the lungs becomes blocked with mucus
Administration of anti-infectives and bronchodilators to inhibit bacterial growth and promotes dilation of the bronchi
Less functional are for oxygencarbon dioxide exchange
Infection is stopped and inflammation is resolved.
Patient becomes oxygen deprived and retention of Carbon dioxide Patient becomes oxygen deprived and retention of Carbon dioxide
Mucus secretions are loosened and will be expectorated
Consolidation occurs
Alveoli will be clear from secretions
Atelectasis
Lung activity will return to normal
Respiratory failure
Death 17 Narrative
A picture of a lung with pneumonia with close-up for alveolar sac filler with mucus secretions
The lung is sterile. It is part of the lower respiratory tract. The upper respiratory tract has bacteria for its normal flora. Factors such as being 5 years old increases that risk for pneumonia (WHO) as well as exposure for second hand smoking, also not washing of hands and the imbalanced nutrition increases the risk for the child to have pneumonia.
The bacteria in the upper respiratory tract gets aspirated in the lungs where it grows in number and thus results in the inflammation of the lungs. This inflammation causes the body to increase its temperature as it compensate in fighting for the infection. Mucus secretion is then increased. Fluids and debris from WBC’s sent to fight the infection also invades the alveolar sac. The alveoli then is plugged and blocked with secretions which causes the crackling breath sound. If it is treated with anti-infectives to inhibit the bacterial growth and bronchodilators to dilate the bronchi and for loosening the secretions, the infection is stopped and inflammation is resolved. This results in secretion of the mucus and lungs will return to normal state.
18
If untreated on the other hand, the child becomes oxygen-deprived and retention of CO2 will result. After that, consolidation will occur which is when the alveoli becomes solid due to the quantities of the fluids, debris and mucus secretions in it. (www.science.jrank.org)
When the alveoli becomes solid, this will cause lung collapse (atelectasis) which would later then result to respiratory failure and when it is not treated immediately can cause death.
A comparison between clear alveoli and alveoli with mucus secretions caused by pneumonia
19
XI. DIAGNOSTIC TESTS
A chest x-ray is a routine radiographic method for evaluating the heart, lungs and other organs found on and in the chest area. Since this case is about the lungs, A CXR would be appropriate. It is an important test for pneumonia in unclear situations. CXR can reveal areas of opacity which would represent consolidation.
Patient's radiology result showed heart normal in size, infiltrates on both upper and lower lobes.
20 XII. LABORATORY EXAMS
Several laboratory examination was done to the patient which the results are shown below with their significances on her disease and condition.
Laboratory
Result
Examination
Normal Values
It is used to determine the packed-
Hematocrit test
Packed-cell volume
Significance
cell volume which would indicate the 42%
37 – 49 %
hemoglobin
in
the
blood.
Any
increase in Hct will show a decrease in volume plasma. An elevated Hct will signify increase In Hgb. If Hgb is elevated, that means that the body is creating more Hgb to accommodate the low level of oxygen in the body.
No intestinal
Fecalysis
Pneumonia can be caused by several
parasite
factors, parasitic is one of them. This test is done to check if there are presence of parasites which would cause the pneumonia.
Urinalysis 8.
pH
6.0
slightly acidic
Check the hydration status of the patient, if it is highly acidic – dehydrated, if it is alkalinic – over hydrated.
CBC - Thrombocytes
Used to determine the platelet count
281 g / L
and the coagulation time of the patient’s blood. This test was done to know if there is a need for platelet transfusion.
5.0 – 10.0
- WBC
When WBC is above normal, this indicates that an infection is present in
12.4 k/uL
the body because it will try to fight the foreign organism by creating more WBC’s.
250 - 400
- Platelet
Test is done to indicate if there is the need for platelet transfusion.
244 k/uL
22 XV. DISCHARGE PLANNING METHOD
I. Medication
Before the patient is discharged, the mother must be encouraged to follow the prescribed medications of her child with the right dose at the right time. This could be also enhanced by explaining to the mother the reason why the drug is given and the possible effects that may occur. It would also minimize the chances of stopping the medication once the mother understands them. Also teach the mother that even if the child's symptoms have been relieved, medications must still be continued according the doctor's instruction, otherwise pneumonia may recur and it will be worse than the previous attack.
II. Exercise
Encourage the mother to let the child have frequent exercises such as walking, arm raising, to enhance the lung function but inform the mother to avoid places that are prone to pollution, dust and infections such as smoking places to prevent straining the child's lungs. Advise the mother to balance the child's daily physical activities and provide adequate rest periods. Encourage the mother to reposition the child from side to side turning into a favorable and comfortable position to promote good circulation in the body.
III. Teaching
Inform the mother that the child needs to have adequate rest because it is important to maintain progress toward full recovery. Ask the parents to have the child washed his hands frequently to avoid further infections brought by other microorganisms. Ask the parents not to expose the child in places with too much pollutions. Define the importance of increasing the oral fluid intake of the child in his recovery as well as adequate rest. These are needed by the child to maintain his optimum level of health.
33
IV. Out-patient instructions
Remind the family to have follow-up check-ups with the doctor. Inform for any appointments they may have and request the parents to bring the child to a health care facility as soon as any problems will occur. Even though the patient may feel and look better, his lungs may still be infected and it is important that the physician monitors the child.
V. Diet
Tell about the importance of eating a well-balanced diet. If asked if multivitamins can be given, refer it to the physician. Remind about the increased fluid requirements and advise foods that are rich in natural vitamins such as fruits.
34
XVI. PROGNOSIS
J. J. F. A. was admitted due to fever and cough. He had a fever with a temperature of 38.1 celcius which was later resolved and lowered to 36.9. The patient is ambulatory, coherent and has an IV tube inserted on his right arm. Current medicines are Cefuroxime = 750 mg, IVTT, Albuterol = 1 neb + 2cc NSS, q4 and Montelukast = 4mg O.D., HS, PO. The vital signs: Temperature is 36.9, pulse rate is 115 bpm, respiratory rate is 23 rpm and Blood pressure is 100/70. Productive cough is still noted but with fewer secretions expectorated. The patient is lethargic according to the neuroassessment, no noted abnormalities in physical assessment regarding the patient’s present condition. Nasal flaring is reduced, the patient is currently on moderate high back rest position. Thus patient is showing a good prognosis.
35 XVII. BIBLIOGRAPHY
Books
Carpenito-Moyet, L.J., Handbook of Nursing Diagnoses; (12 ed.), Philadelphia, 2008.
Corbett, J.V., Laboratory Tests and Diagnostic Procedures with Nursing Diagnoses ; (7 th ed.), San Francisco, California, 2008. Doenges, M.E., et.al., Nurse's Pocket Guide; (11 ed.), California, 2007. Deglin, J.H. & Vallerand, A.H.; Davis' Drug Guide for Nurses; (20 ed.), F.A. Davis Company, Philadelphia, 2009.
Elsevier, M., Mosby's Pocket Dictionary of Medicince, Nursing and Health Professions ; (5th ed.), Elsevier Incorporated, Singapore, 2006.
Johnson, J.Y., Textbook of Medical-surgical nursing ; (11 ed.), 2008.
Compilations, articles and etc.
Rosalejos, I.L., Growth and Development handouts ; NCM 101, Davao City, 2009
Internet sites
www.scribd.com www.wikipedia.com/org www.nursingcrib.com www.wrongdiagnosis.com www.encarta.msn.com www.medscape.com/nurse/Amoeba www.science.jrank.org/pages/529/ /Diagnosis www.reuters.com/org 41
IV. GENOGRAM
Paternal
Maternal
L. A.
R.F.
V.A
C.F.
J. A A.F. (client’s mother)
(client’s father)
Legends: Asthma
J. J. F. A. (client)
Hypertensive
4
J. F. A. (client’s brother)
