1

I. INTRODUCTION

CAP is a common illness in all parts of the world. It is a major cause of death among all age
groups. In children, the majority of deaths occur in the new born period, with over 2 million world
wide deaths a year. In fact, the WHO estimates that 1 in 3 new born infant deaths are due to
pneumonia. Mortality decreases with age until late adulthood.

More cases of CAP occur during cold months than during other times of the year. CAP occurs
more commonly in males than females and in blacks than Caucasians.

Community acquired pneumonia (CAP) is disease in which individuals who have not recently
been hospitalized developed an infection of the lungs (pneumonia). CAP is a common illness and can
affect people of all ages. CAP often cause problems like difficulty in breathing, fever, chest pains, and a
cough. CAP occurs because the areas of the lung which absorb oxygen (alveoli) from the atmosphere
become filled with fluid and cannot work effectively.

CAP occurs throughout of the world and is a leading cause of illness and death. Causes include
bacteria, viruses, fungi, and parasites. CAP can be diagnosed by symptoms and physical examination
alone, though x-rays, examination of the sputum, and other tests are often used. Individual with CAP
sometimes require treatment in a hospital. CAP is primarily treated with antibiotic medication. Some
forms of CAP can be prevented by vaccination.

Symptoms of CAP commonly include:

• Problems of breathing
• coughing that produces greenish or yellow sputum.
• A high fever that maybe accompanied with sweating chills and uncontrollable shaking.
• Sharp or stubbing chest pain
• Rapid, Shallow breathing that is often painful

Less common symptoms Include:

• The coughing up of blood (hemoptysis)

• Headache (including migraine headaches)
• Loss of appetite
• Excessive Fatigue
• Blueness of the skin (cyanosis)
• Nausea
•vomiting
•diarrhea
•joint pain (arthralgia)
• Muscle aches (myalgia)
• For the most part, children older than one month of life are at risk for the same
microorganisms as adult. However, children less than five years are much less likely to have
pneumonia caused by Mycoplasma Pneumoniae, chlamydophila pneumoniae. In contrast, all
their children and teen agers are more likely to acquire mycoplasma pneumoniae and
chlamydophila pneumoniae than adults.
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• Individuals with symptoms of CAP require further evaluation. Physical examination by a
health provider may reveal fever, an increase respiratory rate (tachypnea), Low blood pressure
(hypotension), a fast heart rate (tachycardia), and /or changes in the amount of oxygen in the
blood. Feeling the way the chest expands (palpation) and tapping the chest wall (percussion) to
identify dull areas which do not resonate can identify areas of the lung which are stiff and full
of fluid (consolidated). Examination of the lungs with the aid of stethoscope can reveal several
things. A lack of normal beath sounds or the presence of crackling sounds (rales) when the
lungs are listened to (auscultated) can also indicate consolidation. Increased vibration of the
chest when speaking (tactile fremitus) and increased volume of whispered speech during
auscultation of the chest can also reveal consolidation.

Treatment of CAP in children depends on both the age of the child and the severity of his/her
illness. Children less than five do not typically receive treatment to cover atypical bacteria. If a child
does not need to be hospitalized, amoxicillin for seven days is a common treatment. However, with the
increasing prevalence of DSRP, other agents such as in the future. Hospitalized children should receive
intravenous ampicillin, ceftraxione, or cefatoxime. According to a recent meta-analysis a 3 days course
of antibiotics seems to be sufficient for most cases of mild to moderate CAP in children.

Individuals who are treated for CAP outside for the hospital have a mortality rate less than 1% . Fever
typically responds in the first two days of therapy and other symptoms resolve in the first week. The x-
ray, however, may remain abnormal for at least a month, even when CAP has been successfully treated.
Among individuals who require hospitalization, the mortality rate averages 12% overall, but is as much
as 40% in people who have bloodstream infections or require intensive care.

In addition to treating any underlying illness whicn can increase a person’s risk for CAP, there are
several addition ways to prevent CAP. Vaccinaion is important in both children and adults. Vaccinations
against Haemophilus influanze and Streptococcus penumoniae in the first year of life have greatly
reduce the role in CAP children.

II. GENERAL DATA

Patient’s Name: TPJK

Age : 4 years old
Birthdate : March 04, 2006
Birthplace : Cebu
Address : DR. 9 Fontanar Mandaue Cebu
Sex : Male
Status : Single
Religion : Baptist
Race : Asian
Citizenship : Filipino

III. HEALTH ASSESSMENT

A. HEALTH HISTORY
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A.1 Biological data

In keeping safe the private life of our patient and in maintaining confidentiality, let us hide for
with the pseudonym of patient TPJK. He is the only child.

A.2 Reason for seeking Consultation

he patient was brought to hospital due to high fever and a productive cough. Patient’s mother
Verbalized “ wala gyuy wala-wala ang iyang ubo din taas sad iyang hilanat.”

A.3 Current Health Status

days prior to consultation, onset of productive cough and coryza, complain headache thus
sought consult to Dr. Sanchez’s Clinic and was given loratidi plus phenyleptin 2.5 ml twice a day and
salbutamol 2.5 ml twice a day.

Morning prior to consultation, onset of fever 37.8oC and persistent of cough and coryza. Patient
experience 4 episodes of soft tarry stool and decrease or loss in appetite.

A.4 Past Health History

Patient’s general state of health is good. Patient TPJK received vaccination such as:
1ST dose 2nd dose 3rd dose 1st booster 2nd booster
BCG √
DTP √ √ √ √
OPV/ IPV √ √ √ √
Hib
Hep B √ √ √ √
Pneumoccocal √ √ √
Rotavirus √ √
Flu
Varicella
AMV √
MMR √ √

Last 2008 patient was hospitalized and admitted at Chung Hua Hospital due to epistaxis and in
Benedecto Hospital for acute Gastroenteritis. December of 2009 patient was also admitted at CHH due
to food poisoning.

Patient TPJK was born and delivered via NSVD, full term and in cephalic presentation. He was
the only Child in the family. He used to be an active and playful. He is usually given 10 glasses of milk
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per day by her mother. Patient TPJK had low appetite with meals. Patient together with his family is
living on a rented house just near at the road. They usually used mineral as their source for drinking
water. Patient experienced minor injury due to childhood play. He usually sleeps 2-3 hours on a day
and 7-10 hours at night.

A.5 Family History

Mother/Maternal Father/Paternal
Hypertension: √ X
Diabetes : √ √
Cancer : X X
Heart Disease: X √
Ulcer : X √
Kidney Failure: X X
Asthma : √ X
Flu : √ X

A.6 Review of Systems

“Gordon’s Functional of Health Pattern Assessment”

1. Health Perception- Health Management Pattern

Patient’s mother said that TPJK had an excellent health prior to his illness. He is an active and
playful child. Periodical check-ups and immunization serve as her mother’s means of keeping him
healthy. When the patient got sick his mother always provides him home remedy medications such as:
Pracetamol tempra and do tepid sponge bath for fever and if still symptoms persist he is brought to
clinic for consultation. Patient’s mother always follows prescribed instruction in giving medication to
her child. At this time though, it is considered that the patient’s health status is poor and he is weak and
irritable due to his condition or illnesses. He was admitted to hospital because patient’s parent believe
that patient TPJK health status will improve and be better if he is treated will in the hospital for close
monitoring of his condition. He was admitted due to persistent cough for 5 days and fever and was
considered as pediatric community acquired pneumonia.

2. Nutritional-Metabolic Pattern

Patient was usually given 10 glasses of milk per day by her mother. He had low appetite with
meals and always request chukie to drink. He loves to eat fried chicken, hotdogs but rarely eat
vegetables. He was given daily vitamins for supplementation especially vitamin C. Patient’s mother
said that her child gain weight from the last six months passed due to proper nutrition given to him. At
this point of his hospitalization patient cannot anymore consume 10 glasses of milk per day due to loss
of appetite he can only consume 3-5 glasses a day and he still request chukie and consumed 3-5 pack a
day. He doesn’t have the urge to eat. He only ate when he was forcedly feed by her mother.
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3. Elimination Pattern

Prior to admission patient was able to void without any difficulty for at least 6 times a day, urine
is light yellow in color and no unusual odor noted. Bowel movement is regular at least 2 times a day
with yellowish brown color and semisolid consistency. While on his hospitalization period or merely at
his illness period he void more than 8 times a day on the same color. And noticed to had a bowel
movement of 4 times of soft tarry stools a day.

4. Activity- Exercise Pattern

Prior to illness patient was active and playful. Most of his activities consist of play together with
his friend and classmates in the nursery 2. Patient was ambulatory without limitations on his
movements. While during his illness stage patient was already weak, irritable, in guarded behavior and
displays fear to strangers. He complains difficulty in breathing due to excessive production of mucus.

5. Sleep-Rest Pattern

Before the patient become ill he usually sleeps 2-3 hours at day and 7-10 hours at night without
any problem experienced. But when he was already sick he can no longer sleep at day and only had 6-8
hours of sleep during at night due to discomfort felt. He is already restless.

6. Cognitive- Perceptual Pattern

Patient doesn’t have any problems in seeing and hearing during his pre illness stage and up until
to his illness stage.

7. Self-Perception Pattern

N/A

8. Role- Relationship Pattern

Since patient was still a 4 years old, he only utters some words perfectly such as: no, mommy
and daddy and he even utter the word goodbye as ”gohbye” He is able to express himself and able to
understand what other is saying to him.

9. Sexuality and Reproductive Pattern

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N/A

10. Coping-Stress Management Pattern

N/A

11. Value-Belief System

N/A

A.7 Psychosocial Profile

Patient was the only Child in the family. He used to be an active and playful. Most of his
activities consist of play together with his friend and classmates in the nursery 2. He is usually given 10
glasses of milk per day by her mother. Patient TPJK had low appetite with meals.

Patient was a Baptist and according to her mother they usually attend mass or prayer meetings.
Patient is a current nursery 2 pupil. Together with his family is living on a rented house just near at the
road. They usually used mineral as their source for drinking water.

Their means of transportation is through riding a jeepney. Patient experienced minor injury due
to childhood play. He usually sleeps 2-3 hours on a day and 7-10 hours at night.

B. PHYSICAL EXAMINATION

General Observation:

Receive patient sitting on bed with mother at the side. He appears weak but awake, coherent,
febrile, irritant, and displays fear to strangers and health providers as evidenced of crying everytime
someone enters the room. A D5IMB 500 runs at 75-80 ml per hour was on his right arm. he is in active
mobilization. Clear watery discharge on his nasal cavity and a cough was noted. His lip is relatively
dry.

FINDINGS
SKIN: Throughout the entire head-to-toe assessment, inspect the skin for the following
characteristics:
1. Color white Fair complexion with flushed skin
noted
2. Bleeding No bleeding is noted
3. Ecchymosis No ecchymosis noted
4. Vascularity No pulsation is noted
5. Lesions No lesions noted
Throughout the head-to-toe assessment, palpate the skin for:
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6. Moisture Skin is relatively dry with minimal amount
of perspiration
7. Temperature Warm to touch
8. Texture Smooth and intact
9. Turgor Good turgor, goes back to position less than
2 seconds
10. Edema No edema noted
HEAD AND FACE
11. Inspect head and face for size, shape Head and face are symmetrical and
and symmetry in proportion to the body. proportional to the body.
12. Inspect scalp for scaliness and scars Scalp is shiny, no scaliness nor scars is
noted.
13. Inspect the color and distribution of the Hair color is black, evenly distributed; no
hair. Note any infestations; palpate the hair. infestations noted and had a fine hair.
14. Inspect the face for expression, shape, Eyes, eyebrows, ears, nose and mouth are
symmetry (CN VII), symmetry of eyes, symmetrical; can project appropriate
eyebrows, ears, nose and mouth. expressions.
Assess CN VII: Instruct the Patient to:
15. raise the eyebrows able to raise the eyebrows without
tenderness felt
16. frown Able to frown without pain felt
17. smile Able to smile without any pain felt
18. wrinkle the forehead Able to wrinkle his forehead
19. show the teeth Has a complete white teeth; able to show
teeth without problems
20. purse the lips Able to purse lips
21.puff the cheeks Able to puff the cheeks without pain felt
22. whistle Doesn’t know how to whistle
Palpation:
23. Palpate the temporal pulses Temporal pulse is palpable
24. Palpate and auscultate the No crepitus sound heard
temporomandibular joints.
25. Palpate the masseter muscles (CN V). No tenderness noted
26. Assess joint mobility and motor Proper alignment with o visible deformity
function of CN V.
27. Test motor function CN VII and CN V. Able to produce motion
28. Assess light touch CN V. Able to feel the light touch
29. Assess superficial pain CN V. Able to feel pain
EYES
Inspection:
30. Inspect the eyelids, eyebrows, palpebral Symmetrical; no drooping present; no
fissures, and position of eyes, lacrimal enlargement, swelling or edema noted.
meatus.
31. Inspect the pupils’ size Patient pupil size is 4 mm
32. Inspect the conjunctiva Conjunctiva is clear and shiny.
a.) Palpebral Pinkish and moist
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b.) Bulbar Transparent with small amount of blood
vessels
Palpation:
33. Palpate the eyelids for tremors and No tremors and tenderness noted.
tenderness CN III.
34. Palpate the lacrimal meatus. No enlargement or swelling noted.
Assess extraocular muscle mobility &
Cranial Nerves:
35. cover-uncover test, corneal light reflex Eyes are aligned
36. Six cardinal field of gaze ( CNs III, IV, Able to follow the object without moving
VI). the head
37. perform the corneal sensitivity test Able to blink
38. Test papillary light reflex CN III Pupils constrict when hit by the light
39. Test corneal light reflex. Light falls at the same spot of the cornea
40. test for accommodation Able to see things behind him while
focusing on an object.
41. Test visual fields via confrontation (CN Patient was able to see stimulants
II).
Visual Acuity
42. far vision Snellen chart- 20/40
43. Near vision can identify figures
44. color vision Able to identify but not all colors
45. Conduct fundoscopic assessment:
a.) Red Light reflex N/A
b.) Retinal Structures N/A
c.) Macula N/A
EARS
Inspection:
46. Inspect and Palpate the external ear. No discharges or lesions noted.
47. Assess ear alignment. Ear is symmetrically aligned.
Palpation:
48. Palpate external ear for masses, No masses and tenderness noted.
tenderness, etc.
49. Palpate the mastoid process. No masses noted.
Test for Gross Hearing:
50. Voice-whisper test or watch-tick test Able to hear but can’t fully utter the words
(CN VIII).
51. Weber test N/A
52. Rinne Test N/A
Conduct Otoscopic assessment:
53. Assess the external ear canal and No redness, swelling or discharges noted.
tympanic membrane.
NOSE AND SINUSES:
Inspection
54. Inspect the external surface of the nose. No perforation or lesion noted.
55. Inspect nasal cavity with the nasal Redness and clear watery discharge is
55.speculum or with the use of the
penlight.
56. Assess nostril patency.
57. Test olfactory nerve (CN I).
Palpation
58. Palpate the nasal sinuses
Percussion:
59. Percuss the nasal sinuses.
MOUTH AND THROAT:
Inspection:
60. Inspect the lips, buccal mucosa, gums,
and hard and soft palates.
61. Test gag reflex (CNs IX, X).
62. Test hypoglossal nerve.
63. Test taste sensation (CN VII)
Palpation:
64. Palpate the lips using the thumbs and
index finger.
65. Using gauze pad hold tongue to one
side and palpate the side of the mouth.
NECK:
Inspect, Palpate and Ausculatate
66. Inspect the musculature and symmetry
of the neck.
67. Inspect range of motion
Test for muscle strength
68. Strength of sternocleidomastoid and
trapezius muscles (CN XI).
69. Shoulder shrug
70. Palpate the musculature of the neck.
71. Inspect and palpate the trachea.
72. Palpate the carotid arteries (one at a
time).
73. Assess jugular veins for distention;
estimate jugular venous pressure (JVP) if
indicated.
74. Inspect and palpate the thyroid (use
only one approach, either anterior or
posterior).
75. Auscultate the thyroid and carotid
arteries.
76. Inspect and palpate the lymph nodes.
UPPER EXTREMITIES:
77. Inspect the nailbed color, shape and
configuration; Palpate nailbed texture.
78. Blanch test
9
noted
Left side of his nostril is obstructed.
Able to smell and identify odors.
Felt comfort and ease during palpation
Resonant sound
Lip is pink but relatively dry. buccal
mucosa and gums are pinkish; no signs of
inflammation noted.
Nauseated or gag
Hypoglossal nerve is normal
Able to identify taste
No tenderness felt
Free from lesions, smooth, and moist
Symmetrical without masses or spasms
noted.
move head side to side without pain felt.
Able to resist against force
Able to shrug shoulder
No tenderness or masses noted.
Trachea is in the midline.
Felt pulses
No jugular vein distention noted; but if
patient uses strength there’s a trace noted
No enlargement and masses noted.
No bruits heard
Lymph nods are not visible or palpable.
Nailbed is pinkish in color and oval in
shape.
Returns within less than 2 seconds.
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79. Inspect muscle size and palpate muscle Muscle size are symmetrical, no
tone of hands, arms and shoulders. involuntary movements and no tenderness
felt.
80. Palpate the joints of fingers, wrists, Joints are smooth and strong.
elbows, and shoulders.
Assess range of motions:
ARMS
81. Flexion Able to flexed fully without tenderness felt
82. Extension Able to extend
83. Hyperextension Can hyperextend without complaining pain
84. Abduction Can move 180o
85.Adduction Can move 50o
86. Cirumduction Able to move 360o
ELBOW
87. Extension Able to extend 180o without pain
88. Flexion Able to flexed 180o without pain
HANDS
89. Pronation Able to position w/o pai at 90o
90. Supination Position for about 90 o
91. Inversion Perform well
92. Eversion Perform well
93. Flexion Flexed well
94. Extension Extend well
95. Hyperextension Hyperextend w/o complaining pain
Test and grade muscle strength.
96. Deltoid Moderate resistance
97. Biceps Complete ROM against gravity
98. Triceps Able to resist
99. Wrists an finger muscles Complete ROM joint motion against
capacity
100. grip strength Complete ROM joint motion against
capacity
Assess sensory function
101. Assess light touch Able to feel light touch
102. Assess pain sensation Able to feel pain
103. Test temperature Able to identify warm and cold
104. Test vibration Able to feel vibration
105. Test proprioception N/A
Test fine touch discrimination
106. Stereognosis N/A
107. Grapethesia Cannot identify yet what is being written
on his palm.
108. two-point discrimination Able to identify 2 points
Assess Motor function
109. Finger-to-Nose Able to perform on coordinated manner
110. Finger-to-Nose to nurse’s finger Able to perform in coordinated manner
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111. Fingers to thumb Able to perform but not alternating manner.
112. fingers to fingers Able to perform but not alternating manner.
113. Rapid alternating hand movements Cant perform rapid alternating hand
movement.
Assess Deep Tendon Reflexes
114. Biceps N/A
115. Triceps N/A
116. Brachioradialis N/A
BACK, POSTERIOR & LATERAL
THORAXES
117. Palpate the thyroid (posterior No masses noted; have normal swallowing
approach0. movement.
118. Assess the shape and symmetry Note Shape is symmetrical; no signs of distress
rate and rhythm and respiration movement
of chest wall with deep inspiration and full
expiration and signs of distress.
119. Estimate the antero-posterior diameter. Approximately 4 inches
120. Palpate spinous processes N/A
121. Palpate the posterior thorax and lateral No tenderness and crepitus noted.
thorax.
122. Assess respiratory expansion. Expand symmetrically
123. assess tactile fremitus Vibration is felt
124. Percuss posterior thorax in a Dull sound is heard
systematic manner.
125. Percuss for diaphragmatic excursion Omits dull sound
126. Percuss the costo-vertebral angle Produces flat sound
127. Auscultate for breath sounds Crackles is heard
Move in front of the patient and drape the patient at waist level (female may cover their
breasts).
ANTERIOR THORAX:
128. Inspect shape of the thorax, symmetry Symmetrical with normal angle
of the chest wall, presence of superficial
veins, costal angle, angle of ribs,
intercostals spaces, muscles of respirations,
and sputum.
129. Palpate the anterior thorax No pulsation noted
130. Perform anterior thoracic expansion. Symmetrical and equally expanded
131. Perform tactile fremitus. Vibration was felt.
132. Percuss the anterior thorax. Produce a wheezing sound
133. Auscultate the anterior thorax; Sound is heard equally
perform voice sounds if indicated.
HEART
134. Have the client assume supine No pulsation noted
position and inspect the pericardium area.
Note Pulsations, heaves or retractions
135. Inspect and palpate cardiac landmarks Visible pulsation in all landmarks
for apical impulses.
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136. Auscultate for the cardiac Rhythmic auscultation (pulsation)
Cover the patient’s anterior thorax with the gown and cover the abdomen from the
symphysis pubis to the costal margin.
BREAST
Inspection and Palpation
Female and Male Breast:
Note: for male breast exam repeat the sequence for female breast exam but having the
patient lean forward is usually unnecessary unless gynecomastia is present.
Inspect the breast for color, vascularity, Flat contour; no edema, no discharges.
thickening or edema, size symmetry,
contour, lesions or masses, and discharge
with the patient in these positions:
137. arms at the side N/A
138. Arms raised over the head. N/A
139. hands pressed into hips N/A
140. Patient leaning forward N/A
While the client sits with arms abducted N/A
and supported on the nurse’s forearm,
palpate for the lymph nodes
Instruct client to place arms at the side
and palpate breast using
141. Sweeping manner (bimanual) N/A
One-handed palpation
142. concentric N/A
143. wedge N/A
144. Parallel N/A
145. Teach breast self examination N/A
Assist the patient into a supine position with the chest uncovered, Drape the abdomen and
legs. Stand on the right side of the patient.
146. Jugular Veins Not distended
As the patient changes from sitting to a supine position for the remainder of the breast
assessment, observe the jugular veins when the patient is at a 45 degree angle. Assess
again when the patient is supine.
ABDOMEN
Inspection
147. Inspect contour, symmetry, Abdomen contour is flat; no scars, masses
pigmentation, and color. and pulsations noted.
Note scars, striae, visible peristalsis,
masses and pulsations.
148. Inspect the rectus abdominis muscles Slightly visible
(supine and with head raised) and
respiratory movement of the abdomen.
149. Inspect the umbilicus. Medially located without discharges.
Auscultation
149. Auscultate bowel sounds. Gurgling sounds
Auscultate for bruits, venous hum, and
friction rub.
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Percussion
150. Percuss all quadrant in a systematic N/A
fashion
151. Percuss liver span and liver descent; N/A
percuss live with the fist if indicated.
Percuss:
152. Spleen N/A
153. Stomach N/A
154. Urinary bladder N/A
Palpation
155. Perform light palpation to all four N/A
quadrants
Palpate:
156. Liver N/A
157.spleen N/A
158. kidney N/A
159.urinary bladder N/A
160. Assess superficial abdominal reflexes N/A
INGUINAL AREA
161. Inspect and Palpate the inguinal N/A
lymph nodes
162. Palpate the femoral pulses N/A
163. Auscultate the femoral pulses for N/A
bruits.
Cover the exposed abdomen with the gown. lift the drape from the bottom to expose the
lower extremities.
LOWER EXTREMITIES: Inspection
and Palpation
164. Inspect for color, capillary refill, White fair skin complexion, CRT less than
edema, ulcerations, hair distributions, and 2 seconds, no edema and varicose veins
varicose veins. noted. Hair is evenly distributed.
165. Blanch test CRT less than 2 seconds
166. Inspect muscle size and palpate No tenderness or pain noted.
muscle tone of the legs and feet.
167. Palpate for temperature, edema, and Warm, no edema and non-tender.
texture.
168. Palpate the joints of the hips, knees, Smooth, non-tender, no pain felt.
ankles, and feet
169. Palpate pulses Pulsations noted
Assess muscle strength:
170. HIP No involuntary muscle movements
Assess Cerebellar Function (Balance and
Movement)
171. Evaluate balance and coordination Able to balance and coordinate well
172. Walking gait N/A
173. Romberg test N/A
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174. Standing on one foot with eyes closed N/A
175. Heal-to-toe walking N/A
176 Toe or heel walking N/A
Assess Sensory Function
177. Temperature Able to identify hot and cold
178. Vibration Able to feel vibration
179. Light touch Able to feel Light touch
180. Pain sensation Able to feel pain
Assess Deep Tendon Reflexes
181. Patellar Reflex N/A
182. Achilles N/A
183. Plantar Reflex N/A
184. Babinski Reflex N/A
Assess Range of Motion
185. TRUNK Movement is done with ease
186. HIP Movement is done with ease
187. KNEE/LEG Movement is done with ease
188. ANKLE Movement is done with ease
189. Assess mobility Movement is done with ease without
assistance.
Assess the female patient back to the examination table. Ask her to assume the lithothomy
position. Drape the patient. Sit on a stool in front of the patient’s legs.
FEMALE GENITALIA, ANUS, AND
RECTUM:
190. Inspect the pubic hair and skin color N/A
and condition: mons pubis, vulva, clitoris,
urethral meatus, vaginal introitus,
sacrococcygeal area, perineum, and anal
mucosa.
191. Palpate the labia, urethral meatus, N/A
Skene’s glands, vaginal intoitus, and
perineum.
192. Insert vaginal speculum. N/A
193. Inspect the cervix: color, position, N/A
size, surface characteristics,discharge, and
shape of cervical os; inspect the vagina.
194. Collect specimens for cytological N/A
smears and cultures.
Stands in front of the patient’legs. N/A
195. Perform bimanual assessment of the
vagina, cervix, fornices, uterus, and
adnexa.
196. Perform rectovaginal assessment N/A
197. Palpate the anus ant the rectum. N/A
198. If stool is on the glove, save it to test N/A
for occult blood.
Assist the patient to a sitting position. Offer 15
her some tissues to wipe the Perineal area. N/A
Ask her to redress. You can answer her
questions when she is dressed. Ask the
male patient to stand. Sit on a stool in front
of the patient. Have the patient lift the
gown to expose the genitalia.
MALE GENITALIA
199. Inspect hair distribution, penis, Patient doesn’t have pubic hair yet.
scrotum, and urethral meatus.
200. Palpate the penis, urethral meatus, and N/A
scrotum
201. Palpate the inguinal areas for hernias. N/A
202. Auscultate the scrotum if indicated. N/A
203. Teach testicular self-examination. N/A
Ask the patient to bend over the examination table. If the patient is bedridden, the knee-
chest or left lateral position may be used. Expose the buttocks. Stand behind the patient.
MALE ANUS, RECTUM, AND
PROSTATE:
204. Inspect the perineum, sacrococcygeal N/A
area, and anal mucosa.
205. Palpate the anus and rectum N/A
206. Palpate the prostate N/A
207. If stool is on the glove, save it to test N/A
for occult blood.
Re-cover the buttocks. Ask the patient to
stand up and redress. Offer him some
tissues to wipe the rectal area. Ask her to
redress. You can answer his questions when
he is dressed.

IV. ANATOMY AND PHYSIOLOGY OF THE RESPIRATORY SYSTEM

Nostrils/Nasal Cavities
-during inhalation, air enters the nostrils and passes into the nasal cavities where foreign bodies are
removed, the air is heated and moisturized before t is brought further into the body. It is this part of the
body that houses our sense of smell.

Sinuses
-The sinuses are small cavities that are lined with mucous membrane within the bones of the skull.

Pharynx
-the pharynx or throat carries foods and liquids into the digestive tract and also carries into the
respiratory tract.
 16
Larynx
-the larynx or voice box is located between the pharynx and trachea. It is the location of the Adam’s
apple, which in reality is the thyroid gland and houses the vocal cords.

Trachea
-the trachea or windpipe is a tube that extends from the lower edge of the larynx to the upper part of the
chest and conducts air between the larynx and the lungs.

Lungs
-the lungs are the organ in which the exchange of gasses takes place. The lungs are made up of each
lung.

Alveoli
-the alveoli are tiny air sacs that are enveloped in a network of capillaries. It is here that the air we
breathe is diffused into the blood, and waste gasses are returned for elimination.

V. CONCEPTUAL FRAMEWORK OF THE PATHOPHYSIOLOGY OF THE DISEASE

CONDITION

VI. THEORITICAL FRAMEWORK OF THE PATHOPHYSIOLOGY OF THE DISEASE

CONDITION

S. pneumoniae, H. influenzae, C. pneumoniae, and M. pneumoniae are the most common

bacterial causes. Pneumonia caused by chlamydia and mycoplasma are often clinically
indistinguishable from pneumonias with other causes. Common viral agents include respiratory
syncytial virus (RSV), adenovirus, influenza viruses, metapneumovirus, and parainfluenza viruses.
Bacterial superinfection can make distinguishing viral from bacterial infection difficult.
C. pneumoniae accounts for 2 to 5% of community-acquired pneumonia and is the 2nd most common
cause of lung infections in healthy people aged 5 to 35 yr. C. pneumoniae is commonly responsible for
outbreaks of respiratory infection within families, in college dormitories, and in military training
camps. It causes a relatively benign form of pneumonia that infrequently requires hospitalization.
Chlamydia psittaci pneumonia (psittacosis) is rare and occurs in patients who own or are often exposed
to birds.
A host of other organisms cause lung infection in immunocompetent patients, although the term
community-acquired pneumonia is usually reserved for the more common bacterial and viral etiologies.
The symptoms of CAP are the result of both the invasion of the lungs by microorganisms and the
immune system's response to the infection. The mechanisms of infection are quite different for viruses
and the other microorganisms.
 17
•Viruses
Viruses must invade cells in order to reproduce. Typically, a virus will reach the lungs by traveling in
droplets through the mouth and nose with inhalation. There, the virus invades the cells lining the
airways and the alveoli. This invasion often leads to cell death either through direct killing by the virus
or by self-destruction through apoptosis. Further damage to the lungs occurs when the immune system
responds to the infection. White blood cells, in particular lymphocytes, are responsible for activating a
variety of chemicals (cytokines) which cause leaking of fluid into the alveoli. The combination of
cellular destruction and fluid-filled alveoli interrupts the transportation of oxygen into the bloodstream.
In addition to the effects on the lungs, many viruses affect other organs and can lead to illness affecting
many different bodily functions. Viruses also make the body more susceptible to bacterial infection; for
this reason, bacterial pneumonia often complicates viral CAP.

•Bacteria and fungi

Bacteria and fungi also typically enter the lung with inhalation, though they can reach the lung through
the bloodstream if other parts of the body are infected. Often, bacteria live in parts of the upper
respiratory tract and are constantly being inhaled into the alveoli. Once inside the alveoli, bacteria and
fungi travel into the spaces between the cells and also between adjacent alveoli through connecting
pores. This invasion triggers the immune system to respond by sending white blood cells responsible
for attacking microorganisms (neutrophils) to the lungs. The neutrophils engulf and kill the offending
organisms but also release cytokines which result in a general activation of the immune system. This
results in the fever, chills, and fatigue common in CAP. The neutrophils, bacteria, and fluid leaked from
surrounding blood vessels fill the alveoli and result in impaired oxygen transportation. Bacteria often
travel from the lung into the blood stream and can result in serious illness such as septic shock, in
which there is low blood pressure leading to damage in multiple parts of the body including the brain,
kidney, and heart.

•Parasites
There are a variety of parasites which can affect the lungs. In general, these parasites enter the body
through the skin or by being swallowed. Once inside the body, these parasites travel to the lungs, most
often through the blood. There, a similar combination of cellular destruction and immune response
causes disruption of oxygen transportation.

VII. CLINICAL MANAGEMENT

A. MEDICAL MANAGEMENT

A.1 LABORATORY AND DIAGNOSTIC EXAMINATIONS

X-RAY REPORT 8/01/2010 13:34

EXAMINATION CHEST X-RAY-PA AND LATERAL/ AP AND LATERAL CLINICAL DATA

Reports
There are nodular densities associated with perivascular haziness in both lower lobes. The rest
 18
of the lung fields are clear. Heart is not enlarged. Both hemidiaphragms and costophrenic sulci are
intact. The tracheal air column is fairly situated at the midline. No discrete adenopathy is identified.
The visualized bony structures are unremarkable.

---------- [Conclusions] -----------

MILD INFLAMMATORY PROCESS IN BOTH LOWER LOBES.

HEMATOLOGY REPORT 8/01/2010 02:27 PM

COMPLETE BLOOD COUNT RESULT REFERENCE UNIT

BLOOD COUNT
White blood cell 15.50 ↑ 4.8-10.8 10^3/ul
Red blood cell 5.12 4.7-6.1 10^3/ul
Hemoglobin 13.5 ↓ 14.0-18.0 g/dl
Hematocrit 41.2 ↓ 42.0-52.0 %
Platelet 36 130-400 10^3/ul
BLOOD INCICES
MCV 80.0 80-94 Fl
MCH 26.3 ↓ 27.0-31.0 Pg
MCHC 32.8 ↓ 33.0-37.0 g/dl
RDW 11.4 11-16 %
PDW 7.5 ↓ 9.0-14.0 %
MPV 7.0 ↓ 7.2-11.1 Fl
RELATIVE DIFFERENTIAL COUNT
Neutrophil (%) 73.3 40-74 %
Lemphocytes (%) I6.3 ↓ 19-48 %
Monocytes (%) 9.0 3.4-9.0 %
Eosinophils (%) 1.0 0.0-7.0 %
Basophils (%) 0.4 0.0-1.5 %
ABSOLUTE DIFFERENTIAL COUNT
Neutrophil (#) 11.39 ↑ 1.9-8.0 10^3/ul
Lemphocytes (#) 2.53 0.9-5.2 10^3/ul
Monocytes (#) 1.40 ↑ 0.16-1.0 10^3/ul
Eosinophils (#) 0.16 0.0-0.8 10^3/ul
Basophils (#) 0.06 0.0-0.7 10^3/ul
 19
URINALYSIS REPORT 8/2/2010 05:56 AM

FULLY AUTOMATED ROUTINE U/A SI

UNCENTRIFUGED SPECIMEN RESULT REFERENCE UNIT
PHYSICAL CHARACTERISTICS
Color Light yellow
Transparency clear
Ph 5.0 5-6
Specific Gravity 1.005 1.003-1.035
Random
CHEMICAL CHARACTERISTICS
Protein negative NEGATIVE Mg/dl
Glucose negative NEGATIVE Mg/dl
Ketone negative NEGATIVE Mg/dl
Urobilinogen normal Up to 2 Mg/dl
Leukocytes negative NEGATIVE WBC/ul
Blood negative NEGATIVE Mg/dl
Bilirubin negative NEGATIVE Mg/dl
Nitrite negative NEGATIVE
Ascorbic acid negative * Mg/dl
MICROSCOPIC FINDINGS
RBC 1 1-16 /ul
WBC 2 1-8 /ul
BACTERIA NONE * /ul

A.2 TREATMENT AND PROCEDURES

Treatment according to Doctors order:

*Intravenous Fluid

-5% Dextrose in 0.33% Sodium Chloride (fluids bag D5 0.3 NaCl 500 ml Viaflex (Baxter))
To run at ordered rate: 75-80 cc/hr
Rationale: To replenish electrolytes and fluid volume

-Balance Multiple Maintenance Solution

( fluids bag D5 plasmalyte 500ml Viaflex(Baxter)
To run at ordered rate: 75-80 ml/hr
Rationale: Indicated for parenteral maintenance of routine daily fluid and electrolytes requirements
with minimal carbohydrate calories from dextrose.

*Medications
fluids :
-Cefuroxime Sodium
(Zinacef 750 mg vial) 20
(Give 500 mg IV push every 8 hours after negative skin test)
Rationale: hinders or kills susceptible bacteria, including many gram-positive microorganisms and
enteric gram-negative organisms.

-Nebulize with Salbutamol (Ventolin)/ nebuli of 2cc PNSS every 8 hours

Rationale: Improve ventilation

-Sodium Chloride (Salinase Drops) gives 1-2 drops on each nostril three times a day. Suction after.
Rationale: Restores sodium and chloride levels.

Oral:
-Ibuprofen 100mg/5ml 6.5mg/vial
As needed for headache and or fever. May use patient’s stock
Rationale: May relieve pain, fever, and inflammation

-Paracetamol (opigesic) 250mg suppository. 1 suppository per rectum for temperature less than or equal
to 38oC every 4 hours.
Rationale: Relieves pain and reduces fever.
 A.3 MEDICATIONS (Drug study format)

IVF STUDY

TYPE OF CLASSIFICATION CONTENT MECHANISM INDICATION CONTRAINDICATIONS HOW DOSE NURSING

SOLUTION OF ACTION SUPPLIED RESPONSIBILITY

D5 0.33% ►Parenteral fluid; Fluid bag When ►Electrolyte Hypersensitivity to can Intravenous 45-50 ►do not administer
NaCl 500 non hydrogenic dextrose of administered and caloric products or any infusion cc/hr unless solution is
ml 0.33% intravenously, water components. Baxter 500 clear and container
►Hypotonic NaCl dextrose hydration. ml is undamaged.
(viaflex) injection
►Electrolyte and Baxter provides water ►management ►Contents must be
nutrient replinisher and electrolyte of sodium exposed of giving
56 Na+ for chloride parenteral fluids.
mEq/L maintenance depletion.
56 Cl- and daily fluid ►Perform time
mEq/L and electrolyte ►management taping
50 requirements. of symptom of
Dextrose The dextrose hyperthermia ►use sterile
(g/L) composition including infusion set
170 approaches seizures.
Calories that of the ►monitor IVF
kcal/L principal ions frequently
Osmolality of normal
365 plasma and
mosm/L electrolyte
concentration.

2
 Drug Study

Generic/ Dose, Strength Indication/Mechanism of Adverse/Side Effects Nursing Rationale Client

Brand Name & & formulation Drug Action Drug Interaction Responsibilities (10%) Teaching
Classification (10%) (15%) (15%) (20%) (20%)
(10%)
Adverse and side Effects: Assessment:
Generic: Ordered: Indications: CNS: dizziness, fever,
= Serious Lower respiratory tract headache Assess patients To have baseline data Tell patient to
Cefuroxime Cefuroxime infection, UTI, skin or skin- GI: diarrhea, dysgeusia, infection before promptly report
sodium Sodium structure infections, bone or joint nausea, therapy ang regularly adverse reaction and
infections, septicemia, meningitis, pseudomembraneous thereafter signs and symptoms
and gonorrhea colitis, vomiting of super infection.
=perioperative prevention GU: Genetal Pruritus and Before giving 1st monitor client health
Timing: =bacterial excacerbation of candidiasis dose, obtain specimen status Instruct patient to
chronic bronchitis or secondary Hematologic: eosonophilia, for culture and have baseline data report pain a e I.V.
Brand: Every 8 hours bacterial infection of acute leucopenia,thrombocytosis sensitivity test. begin site
ANST bronchitis Skin: pain, induration, and therapy pending test
ZInacef =acute bacterial maxillary sinusitis tenderness at injection site; results Tell patient to notify
= pharyngitis and tonsilits phlebitis;rash prescriber if loose
=otitis media Other: Before giving 1st dose, prevent severe stools or diarrhea
=early lyme disease hypersensitivityreaction ask ptient about adverse reactions occur
Duration: =empitego prvious reactions to occurrence
Interaction: cephalosporines os
Classification: 7-10 dys Drug-drug. penicillin Encourage patient
aminoglycosides; may have and family to
Pharmacoogic adetive effects. Be alert for advere identify perform good
Class: second Calcium, Products reactions and sdrug precatiounary hygiene
generation Mechanism of Actions: containing calcium: may interactions measures
cephalosporin Other Forms: cause fatal recipitate.
Chemical effect: inhibit cell-wall Probenecid; may shorten Encourage client to
Therapeutic Infusion: 1g,2g synthesis, promoting osmotic half life of cefttriaxone If adverse GI reaction to monitor health comply in treatment
Class: Injection: instability; usually bactericidal enlarge doses occur, monitor status of the client regimen.
Antibiotic 250mg, 500mg, Quinolones; may have patients hydration
1g, 2g Therapeutic effect: Hinders or synergistic effect against promote cooperation
kills susceptible bacteria S.pneumoniae Assess patient’s and in clients care
family’s knowledge of
Drug-lifestyle. Alcohol use; drug therapy
may cause disulfiram-like
reaction.[

2
 NURSING
DIAGNOSIS:

Ineffective protection
r/t bacteria susceptible
to drug

Risk for deficient fluid

volume r/t drug-
induced adverse GI
reactions

Deficient knowledge
r/t drug therapy

2
 Drug Study

Generic/ Dose, Strength Indication/Mechanism of Adverse/Side Effects Nursing Rationale Client

Brand Name & & formulation Drug Action Drug Interaction Responsibilities (10%) Teaching
Classification (10%) (15%) (15%) (20%) (20%)
(10%)

Generic: Ordered: Indications: Adverse Reactions: Assessment: ►Warn patient to stop

drug immediately if
Salbutamol Nebulize with ►to prevent exercise- induced CNS: dizziness, ►Obtain baseline ►to have baseline paradoxical
sulfate Salbutamol bronchospasm headache, insomnia, assessment of data and prevent bronchospasm occurs.
(Ventolin)/ nebuli nervousness, tremor. patient’s respiratory complications
of 2cc PNSS every ►to prevent or treat CV: hypertension, status, and assess ►Give this
Brand: 8 hours bronchospasm in patients with palpitations, patient often during instruction for using
reversible obstructive airway tachycardia. therapy. metered-dose inhaler:
Ventolin Timing: disease. EENT: drying and clear nasal passages
irritation of nose and ►Be alert for adverse ►to establish and throat. Breath out,
Every 8 hours ►Solution for Inhalation throat. reactions and drug precautionary expelling as much air
8 am- 7 pm- 12mn GI: heartburn, nausea, interactions. measures. from lungs as
vomiting. possible. Place
Classification: Duration: Metabolic: ►Assess patient’s and ►To promote mouthpiece well into
Mechanism of Actions: hypokalemia, weight family’s knowledge of cooperation in client’s mouth, and inhale
Pharmacologic 8 days loss. drug therapy. care. deeply as dose is
class: adrenergic Chemical Effect: Relaxes Musculoskeletal: released. Hold breath
Other Forms: bronchial and uterine smooth muscle cramps. ►Administer ►to avoid error on for several seconds,
Therapeutic muscle by acting on beta2- Respiratory: medication observing medication remove mouthpiece,
class: Aerosol Inhaler: adrenergic receptors. Bronchospasm. the 5 rights in administration. and exhale slowly.
Bronchodilator 90mcg/metered administering drugs.
spray, Therapeutic Effect: Improve ►advise patient to
100mcg/metered ventilation. Interactions: ►provide client’s ►to uphold his wait at least 2 minutes
spray privacy. dignity. before repeating
Solution for Drug-drug. CNS procedure if more
Inhalation: stimulants; may NURSING than one inhalation is
0.083%, 0.5%, increase CNS DIAGNOSIS ordered.
0.63% mg/3 ml, stimulation. ►Impaired gas
1.25 mg/3 ml Levodopa; May exchange r/t ►warn patient to
Syrup: 2 mg/5 ml increase risk of underlying respiratory avoid accidentally
Tablets: 2 mg, 4mg arrhythmias. condition. spraying inhalant into
Tablets (extended MAO inhibitors, eyes, which may
release): 4 mg, tricyclic ►Risk for injury r/t cause temporary

2
8mg. antidepressants; May drug induced adverse blurred vision.
increase adverse CV reaction
effects ►tell patient to
Propranolol, other beta ►deficient reduce intake of foods
blockers: May knowledge r/t drug and herbs containing
antagonize each other. therapy. caffeine, such as
coffee, cola, and
Drug-herb. Herbs chocolate, when using
containing caffeine; a bronchodilator.
May have additive
adverse effects. ►show patient how to
Discourage use take his pulse. Instruct
together. him to check pulse
Drug-Food. Caffeine; before and after using
May increase CNS bronchodilator and to
stimulation. call prescriber if pulse
Discourage use rate increases more
together. than 20-30 beats per
minute.

DRUG STUDY

2
 Generic/ Dose, Strength Indication/Mechanism of Adverse/Side Effects Nursing Rationale Client
Brand Name & & formulation Drug Action Drug Interaction Responsibilities (10%) Teaching
Classification (10%) (15%) (15%) (20%) (20%)
(10%)

Generic: Ordered: Indications: Adverse Reactions: Assessment: ►tell patient to

CV: aggravation of report adverse
Sodium chloride Sodium Chloride ►fluid and electrolyte replacement heart failure, edema, if ►obtain history of ►to monitor drug reaction promptly.
(Salinase Drops) in hyponatremia cause by severe given too rapidly or in patient’s sodium and effectiveness.
Brand: gives 1-2 drops electrolyte loss, severe salt excess, chloride levels before ►Instruct to
on each nostril depletion or dehydration. thrombophlebitis. starting therapy and perform proper
Salinase Drops three times a day. Metabolic: aggravation reassess regularly there hygiene.
Suction after. of existing metabolic after.
Mechanism of Actions: acidosis with excessive ►
Timing: infusion, electrolyte ►monitor other ►to ensure
Classification: Chemical effects: replaces and disturbances, electrolyte levels. electrolyte balance.
Three times a maintains sodium and chloride hypernatremia,
Pharmacologic day levels. hypokalemia. ►Asses patient’s fluid ►to ensure adequate
Class: 8 am- 1pm- 7 pm Respiratory: pulmonary status. hydration
Electrolyte Therapeutic effects: restores normal edema if given too
sodium and chloride levels. rapidly or in excess. ►Be alert for adverse ►to establish
Therapeutic Duration: Skin: Abcess, local reactions. precautionary
Class: Chloride tenderness, tissue measures.
and sodium 3-4 days necrosis at injection
replacement site. ► Assess patient’s and ►To promote
Other Forms: family’s knowledge of cooperation in client’s
drug therapy. care.
Injection: half- Interactions:
normal saline
solution: 25ml, Non significant Nursing Diagnosis:
50ml, 150ml,
250ml, 500ml, ►Imbalanced
1000ml. Nutrition: Less than
Normal saline body requirements r/t
solution: 2ml, subnormal levels of
3ml, 5ml, 10ml, sodium and chloride.
20ml, 25ml,
30ml, 50ml, ►Excess fluid volume
100ml, 150ml, r/t the saline solutions
250ml, 500ml, water-drawing power.

2
1000ml.
3% saline ►deficient knowledge
solution: 500ml. r/t drug therapy.
5% saline
solution: 500ml
14.6% saline
solution: 20ml,
40ml, 200ml.
23.4% saline
solution: 30ml,
50ml, 100ml,
200ml
Tablets (enteric-
coated): 650mg.,
1 g, 2.25g
Tablets (slow-
release): 600mg