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A CASE STUDY ON PNEUMONIA

Submitted to: Mrs Precy Padilla Submitted by: Lopez, Margarette Mariel G. Vero, Merimel S.

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. 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. Its 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. A case with a diagnosis of Pneumonia may catch ones 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 toddler, an appropriate care has to be done to make the patients recovery faster. Treating patients with pneumonia is necessary to prevent its spread to others and make them as another victim of this illness.

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. 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.

PATHOPHYSIOLOGY

Pneumonia is a serious infection or inflammation of your lungs. The air sacs in the lungs fill with pus and other liquid. Oxygen has trouble reaching your blood. If there is too little oxygen in your blood, your body cells cant work properly. Because of this and spreading infection through the body pneumonia can cause death. Pneumonia affects your lungs in two ways. Lobar pneumonia affects a section (lobe) of a lung. Bronchial pneumonia (or bronchopneumonia) affects patches throughout both lungs. Bacteria are the most common cause of pneumonia. Of these, Streptococcus pneumoniae is the most common. Other pathogens include anaerobic bacteria, Staphylococcus aureus, Haemophilus influenzae, Chlamydia pneumoniae, C. psittaci, C. trachomatis, Moraxella (Branhamella) catarrhalis, Legionella pneumophila, Klebsiella pneumoniae, and other gram-negative bacilli. Major pulmonary pathogens in infants and children are viruses: respiratory syncytial virus, parainfluenza virus, and influenza A and B viruses. Among other agents are higher bacteria including Nocardia and Actinomyces sp; mycobacteria, including Mycobacterium tuberculosis and atypical strains; fungi, including Histoplasma capsulatum, Coccidioides immitis, Blastomyces dermatitidis, Cryptococcus neoformans, Aspergillus fumigatus, and Pneumocystis carinii; and rickettsiae, primarily Coxiella burnetii (Q fever). The usual mechanisms of spread are inhaling droplets small enough to reach the alveoli and aspirating secretions from the upper airways. Other means include hematogenous or lymphatic dissemination and direct spread from contiguous infections. Predisposing factors include upper respiratory viral infections, alcoholism, institutionalization, cigarette smoking, heart failure, chronic obstructive airway disease, age extremes, debility, immunocompromise (as in diabetes mellitus and chronic renal failure), compromised consciousness, dysphagia, and exposure to transmissible agents. Typical symptoms include cough, fever, and sputum production, usually developing over days and sometimes accompanied by pleurisy. Physical examination may detect tachypnea and signs of consolidation, such as crackles with bronchial breath sounds. This syndrome is commonly caused by bacteria, such as S. pneumoniae and H. influenzae.

PATIENTS PROFILE
Name: Baby X Age: 11mos. old Birth date: 09/18/2010 Birth place: Sta. Rosa, Laguna Sex: Male Language: Tagalog Nationality: Filipino Address: Purok 4 Sunduan Ibaba, Sta. Rosa, Laguna Religion: Roman Catholic Civil Status: Single Admitting Weight: Chief Complaint: Difficulty of Breathing / Fever Date and Time of Admission: 08/22/2011 12:46 a.m. Admitting Physician: Miriam Cecilia B. Sales, M.D. Admitting Clerk: Edison Magno Attending Physician: Miriam Cecilia B. Sales, M.D.

HISTORY OF ILLNESS
A. Past Medical History - (-) asthma - (-) allergies - Incomplete vaccinations B. Present Medical History One (1) day prior to admission, patient had experienced fever of 39.5C, cough with phlegm, coryza, and difficulty of breathing.

C. Family Health History PMHx: (+) asthma (mother)

ASSESSMENT [Gordons Functional Health Pattern]

A. Nutritional Metabolic Pattern

Milk formula in bottle. B. Sleep-Rest Pattern

 Sleeping mostly at night and during afternoon Usually wakes up early in the morning (5AM) to be milk fed. C. Elimination Pattern Urinates in her diaper (more than 4 times a day) BM (1-2 times a day) D. Activity-Exercise Pattern

Active, responsive Likes to play with those around her

LABORATORY EXAMS
Hematology Complete Blood Count:

DRUG STUDY
Name of the Drug Generic Name: Amikacin (amikacin sulfate) Brand Name: Amikacide Dosage Frequency Preparation 120mg OD Classification Mechanism of Actions Amikacin binds to 30S ribosomal subunits of susceptible bacteria, thus inhibiting its protein synthesis. Distribution: D etected in body tissues and fluids after inj; crosses the placenta but does not readily penetrate the CSF. Significant amounts penetrate the blood-brain barrier in children with meningitis. Excretion: Via the urine by glomerular filtration (within 24 hr); 2-3 hr (elimination half-life). Paracetamol exhibits analgesic and antipyretic activity by inhibiting prostaglandin synthesis. It produces analgesia by elevating the pain threshold and antipyresis through action on the hypothalamic heat-regulating center. Adverse Reactions Tinnitus, vertigo; ataxia and overt deafness. Potentially Fatal: Ototoxicity, nephrotoxicity, neuromuscular blockade. Actual Adverse Reactions None was observed. Nursing Considerations - Discontinue if signs of ototoxicity, neurotoxicity or hypersensitivity occurs; lactation. Safety has not been established for treatment period >14 days. Monitor renal function before and during treatment.

Aminoglycosid es

Generic Name: Paracetam ol 25mg/5ml Brand Name: Naprex

25ml Q 4 T=37.8C

Analgesics (Non-Opioid) & Antipyretics

Oral Hematological , skin & allergic reactions, GI upsets. Inj Neutrop enia & thrombocytopenic purpura; rarely, laryngeal edema & anaphylactoid reactions, leukopenia, agranulocytosis, & pancytopenia in prolonged use.

None was observed.

- Administer with caution in patients with preexisting anemia since cyanosis may not be apparent despite dangerously high blood concentrations of methemoglobin. Administration to patients with renal or hepatic impairment may result in accumulation of hepatotoxic conjugates.

Generic Name: Ipratropium Bromide + Salbutamol Sulfate

nebule Q 6

Antiasthmatic & COPD Preparations

Ipratropium bromide is an anticholinergic agent that inhibits vagallymediated reflexes by antagonising the action of acetylcholine. It prevents the increases in intracellular concentration of cyclic guanosine monophosphat e (cyclic GMP) which are brought about by interaction of acetylcholine with the muscarinic receptors on bronchial smooth muscle. Salbutamol is a direct-acting 2-adrenergic agent. It acts on the airway smooth muscle resulting in bronchodilation. Distribution: Ip ratropium: Minimally bound to plasma proteins. Excretion: Ipra tropium: Elimination halflife: About 2 hr (after IV or inhalational admin). Plasma half-life of salbutamol: About 4-6 hr.

Bronchitis, respiratory tract infections. Chest pain, arrhythmia, oedema, hypertension, hypokalaemia, palpitation, tachycardia. Headache, dizziness, fatigue, insomnia, tremor, nervousness. GI symptoms e.g. nausea, vomiting, diarrhoea, dyspepsia and constipation. Potentially Fatal: Anaphylacti c reactions such as angioedema of tongue, lips or face and laryngospasm.

None was observed.

- Patient may have hypersensitivity to soy lecithin or related food products e.g. peanuts. - May cause paradoxical bronchospasm. Caution when used in patients who are sensitive to sympathomimetic agents. Not for treatment of acute episodes of bronchospasm. Caution when used in patients with CV disease as agonists may increase BP, heart rate and risk of arrhythmias. Monitor blood glucose in diabetics. Monitor serum potassium levels especially in patients who are on concurrent treatment with xanthine derivatives, steroids or diuretics. Caution when used in patients with narrow angle glaucoma, hyperthyroidism, prostatic hyperplasia, bladder neck obstruction, seizure disorders, renal or hepatic impairment. Safety and efficacy have not been established in children <12 yr. Increased risk of GI motility disturbance in patients with cystic fibrosis. Pregnancy and lactation.

NURSING CARE PLAN

Assessment Nursing Diagnosis Scientific Explanation of the Problem
Bacterial microorganism enter the airways Inflammation of the lung/s Air sacs filled with pus & other liquids Presence of obstructions in the airways Inability to breathe properly

Planning

Interventions

Rationale

Evaluation

Subjective: Nahihirapan yata syang huminga saka lagi na lang sumusuka ng plema, as verbalized by the Pts Grandmother. Objective: (+) sputum production Rapid, shallow breathing (+) crackles, gargles

Ineffective Airway Clearance related to inability to maintain clear airway as characterized by (+) sputum, (+) crackles, rapid & shallow breathing

After 8 hours of Nursing Intervention, the Pts breathing will have no more adventitious sounds present (crackles/gargl es) when auscultated

> Monitor respiratory patterns, including rate, depth, and effort. > Assist with clearing secretions from pharynx by offering tissues and gentle suction of the oral pharynx if necessary > Provide postural drainage, percussion, and vibration as ordered > Administer medications such as bronchodilators or inhaled steroids as ordered.

> With secretions in the airway, the respiratory rate will increase > It is preferable for the client to cough up secretions. Gentle suctioning of the posterior pharynx may stimulate coughing and help remove secretions > Chest physical therapy helps mobilize bronchial secretions > Bronchodilato rs decrease airway resistance secondary to bronchoconstr iction

After 8 hours of

Nursing Intervention, the Pts breathing had no more adventitious sounds (crackles/gargl es) present when ausultated.

Assessment

Nursing Diagnosis

Scientific Explanation of the Problem Bacterial microorganis ms (e.g. pulmonary pathogens) enter the airway These bacteria/virus es infects the lung/s Inflammation of the lung/s Signs and symptoms of Pneumonia (e.g.temperat ure may be greater than 37.5C), tachypnea, coughs with greenish secretions

Planning

Interventions

Rationale

Evaluation

Subjective:

May lagnat po yata ang anak ko, as verbalized by the Pts mother.
Objective:

febrile moist skin tachypnea, RR= 33 cpm (+) crackles Age: 11mos.old

Altered body temperature related to bacterial invasion in the lungs as manifested by body temperature higher than normal, tachypnea, (+) crackles

After 2 hours of Nursing Intervention, the Pts temperature will decrease from 39.8 C to normal range (36.6 - 37.5 C) After 2 hours of Nursing Intervention, the Pts skin will cool off

> Monitor Pts temperature q1 hr > Encourage Pt to rest > Encourage Pt to increase fluid intake > Encourage the Pts guardian to do tepid sponge bath > Administer antipyretic medications as prescribed

> To determine if the Pts temperature is above the normal body temperature > Allows the patient to recuperate physical strength > To maintain hydration status and increased fluid intake helps lessen febrility > Sponge bath with warm water evaporates off his skin, thus, cooling off the Pt > Promotes return of body temperature to normal

After 2 hrs of Nursing intervention, the Pts temperature had decreased from 39.8 C to 37.4 C After 2 hrs of Nursing Intervention, the Pts skin has cooled off a bit

Assessment

Nursing Diagnosis

Scientific Explanation of the Problem Bacteria or virus attacks the lung/s weakened immune systems Pneumonia Symptoms of Pneumonia: nausea or vomiting, may experience profound weakness w/c lasts for a long time.

Planning

Interventions

Rationale

Evaluation

Subjective:

Ayaw nyang kumain, yung gatas sinusuka lang naman nya, and Mas payat sya ngayon, dati ang lakas naman kumain as verbalized by the Pts grandmother.
Objective:

Vomits ingested milk Food aversion Decreased wt. weakness

Imbalanced Nutrition due to frequent vomiting and not eating the usual foods taken as manifested by decreased weight, food aversion, and weakness.

After 4 hours of Nursing Intervention, the Pt will start taking foods which he usually eat (rice, crackers, chicken breast,etc) After 4 hours of Nursing Intervention, the Pt will not vomit anymore the ingested milk

> Assess for recent changes in physiological status that may interfere with nutrition > Provide companionshi p at mealtime to encourage nutritional intake > Determine healthy body weight for age and height > Assess client's ability to obtain and use essential nutrients.

> The consequence s of malnutrition can lead to a further decline in the patient's condition that then becomes selfperpetuating if not recognized and treated. > Often toddlers will eat more food if other people are present at mealtimes. > Proteincalorie malnutrition most often accompanies a disease process > Cases of vitamin D deficiency have been reported among darkskinned toddlers who were exclusively breast fed and were not given supplemental vitamin D.

After 4 hours of Nursing Intervention, the Pt started taking foods which he usually eat (crackers) After 4 hours of Nursing Intervention, the Pt didnt vomit anymore the ingested milk

VII.

DISCHARGE PLANNING
Take the entire course of any prescribed medications. After a patients temperature returns to normal, medication must be continued according to the doctors instructions, otherwise the pneumonia may recur. 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 fluids, 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. Its important to have the doctor monitor his progress. Encourage the guardians to wash patients hands. The hands come in daily contact with germs that can cause pneumonia. These germs enter ones 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 damages ones lungs natural defenses against respiratory infections. Give supportive treatment. Proper diet and oxygen to increase oxygen in the blood when needed. Protect others from infection. Try to stay away from anyone with a compromised immune system. When that isnt possible, a person can help protect others by wearing a face mask and always coughing into a tissue.