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Patients Data
Name of Patient: Peach Twinkle T. Abundo
Age: 1
Sex: Female
Address: Calatagan Virac, Catanduanes
Religion: Roman Catholic
Medical Data:
Date of Admission: September 17. 2011
Time of Admission: 12:25 PM
Hospital Number: 557
Attending Physician: Dr. Louie Panti
Chief Complaint: Vomiting
Diagnosis: Pneumonia, Intestinal Parasitism
Health History
Present Health History
Peach Twinkle T. Abundo, 1 years old, female from Calatagan Virac, Catanduanes was admitted at EBMC on September 17,2011 at 12:25 PM with a chief complaint of vomiting.
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Upon admission baby Peach Twinkle T. Abundo is conscious and coherent. Her CR is 101 bpm, RR is 25 bpm and T of 37.1 C.She weighs 8 kg. Upon auscultation fine crackles is noted. Cough and colds are present. She also vomits and her mother claimed thatthere is a change in her bowel habit. Dr. Panti, as an Attending Physician, requested for laboratory examinations such as CBC andStool Examination. The result of the Hematology revealed an increased in WBC counts therefore the patient have an infection.
Past Health History
The patient is born through CS. Her feeding is composed of breastmilk and also formula milk. Her immunization is complete.The patient dont have any past confinement after she was born.
Developmental Task
Autonomy vs. Shame & Doubt is Eriksons second developmental stage, as the child gains control over eliminative functionsand motor abilities, they begin to explore their surroundings. The parents still provide a strong base of security from which the childcan venture out to assert their will. The parents' patience and encouragement helps foster autonomy in the child. Children at this agelike to explore the world around them and they are constantly learning about their environment. Caution must be taken at this agewhile children may explore things that are dangerous to their health and safety. At this age, children develop their first interests. Forexample, a child that enjoys music may like to play with the radio. Children that enjoy the outdoors may be interested in animals andplants. Highly restrictive parents, however, are more likely to instill the child with a sense of doubt and reluctance to attempt newchallenges. As they gain increased muscular coordination and mobility, toddlers become capable of satisfying some of their ownneeds. They begin to feed themselves, wash and dress themselves, and use the bathroom. If caregivers encourage self-sufficient
behavior, toddlers develop a sense of autonomy- a sense of being able to handle many problems on their own. But if caregiversdemand too much too soon, refuse to let children perform tasks of which they are capable, or ridicule early attempts at self-sufficiency; children may instead develop shame and doubt about their ability to handle problems.
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Anatomy and Physiology of the Affected
Organ
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The lungs are paired, cone-shaped organs which take up most of the space in our chests, along with the heart. Their role is to take oxygen
into the body, which we need for our cells to live and function properly, and to help us get rid of carbon dioxide, which is a waste product. We
each have two lungs, a left lung and a right lung. These are divided up into 'lobes', or big sections of tissue separated by 'fissures' or dividers. The
right lung has three lobes but the left lung has only two, because the heart takes up some of the space in the left side of our chest. The lungs can
also be divided up into even smaller portions, called 'bronchopulmonary segments'.
These are pyramidal-shaped areas which are also separated from each other by membranes. There are about 10 of them in each lung. Each
segment receives its own blood supply and air supply.
Air enters your lungs through a system of pipes called the bronchi. These pipes start from the bottom of the trachea as the left and right
bronchi and branch many times throughout the lungs, until they eventually form little thin-walled air sacs or bubbles, known as the alveoli. The
alveoli are where the important work of gas exchange takes place between the air and your blood. Covering each alveolus is a whole network of
little blood vessel called capillaries, which are very small branches of the pulmonary arteries. It is important that the air in the alveoli and the
blood in the capillaries are very close together, so that oxygen and carbon dioxide can move (or diffuse) between them. So, when you breathe in,
air comes down the trachea and through the bronchi into the alveoli. This fresh air has lots of oxygen in it, and some of this oxygen will travel
across the walls of the alveoli into your bloodstream. Travelling in the opposite direction is carbon dioxide, which crosses from the blood in the
capillaries into the air in the alveoli and is then breathed out. In this way, you bring in to your body the oxygen that you need to live, and get rid
of the waste product carbon dioxide.
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Phatophysiology
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Pneumonia is a serious infection or inflammation of your lungs. The air sacs in the lungs fill with pus and other liquid. Oxygenhas trouble reaching your blood. If there is too little oxygen in your blood, your body cells cant work properly. Because of this andspreading infection through the body pneumonia can cause death. Pneumonia affects your lungs in two ways. Lobar pneumoniaaffects 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 Bviruses. Among other agents are higher bacteria including Nocardia and Actinomyces sp; mycobacteria, including Mycobacteriumtuberculosis 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 theupper 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 bypleurisy. Physical examination may detect tachypnea and signs of consolidation, such as crackles with bronchial breath sounds. Thissyndrome is commonly caused by bacteria, such as S. pneumoniae and H. influenzae.
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Laboratory Results and Diagnostic Exams
CBC Result
Diagnostics Done SI Values Significance
Hematocrit
Hemoglobin
0.40 0.54
120 140 g/L
Increased in: polycythemia, dehydration, Addisons disease,acute thermal injury, Extreme physical exertion, COPD
Decreased in: hemorrhage, anemia, hemolytic anemia, fluid
overload, fluid retention, cirrhosis, leukemia, lymphoma
Increase d in: polycythemia, dehydration, acute thermal injury, COPD
Decreased in: hemorrhage, bleeading, anemia, hemolytic anemia,
fluid overload, fluid retention, pregnancy, cirrhosis of the liver,
hyperthyroidism
Increase indicates presence of systemic infections.
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WBC Count
Segmenters
Lymphocytes
Eosonophil
5.0 10 x 10 /L
0.58 0.66
0.21 0.3
0.02 0.04
Increase indicates presence of bacterial infections.
Increased in: infectious mononucleosis, infectious hepatitis,cytomegalo virus infection, pertussis, brucellosis, tuberculosis,syphilis, lymphocytic leukemia,
Decreased
in: thoracic duct drainage, right-sided heart failure Hodgkins
disease,SLE,aplastic anemia, HIV infection, military TB,renal
failure,Terminal cancer
Increased in: skin diseases, trichinosis, scar let fever,
CML, MPD, Hodgkins disease, malignancy, rheumatoid arthritis,sarcoidosis, allergic reaction to drugs, allergies
Decreased in: pyrogenic infection, shock, postsurgical
response
Stool ExaminationColor:Yellow
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Non-pharmacological Treatment:Health Teachings ImpartedRoutine Nursing Care
Drug StudyName of Drug: Cefuroxime
Dosage: 270 mg
Indications: Listed in Dosage.
Administration: Should be taken with food.
Contraindications: Hypersensitivity to cephalosporins.
Special Precautions: Severe renal impairment; pregnancy, lactation; hypersensitivity to penicillins.
Adverse Drug Reactions: Large doses can cause cerebral irritation and convulsions; nausea, vomiting, diarrhoea, GI disturbances; erythemamultiforme, Stevens-Johnson syndrome, epidermal necrolysis.
Potentially Fatal: Anaphylaxis, nephrotoxicity, pseudomembranous colitis.
MIMS Class: Cephalosporins
Name of Drug:Metronidazole
Dosage: 140mg
Indications: Listed in Dosage.
Administration: Tab: Should be taken with food.Susp: Should be taken on an empty stomach. (Take at least 1 hr before meals.)
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Contraindications: History of hypersensitivity to metronidazole or other nitroimidazole derivatives. Pregnancy (1st trimester) and lactation.
Special Precautions: Patients with CNS diseases; discontinue IV therapy if abnormal neurologic symptoms occur. History of seizure disorder.Evidence or a history of blood dyscrasias; perform total and differential leukocyte counts before and after treatment. Severe hepatic
impairment; monitor plasma levels. Predisposition to oedema (inj contains sodium). Prolonged use may result in fungal or bacterial
superinfection.
Adverse Drug Reactions: GI disturbances e.g. nausea, unpleasant metallic taste, vomiting, diarrhoea or constipation. Furred tongue, glossitis,and stomatitis due to overgrowth of Candida. Rarely, antibiotic-associated colitis. Weakness, dizziness, ataxia, headache, drowsiness,insomnia, changes in mood or mental state. Numbness or tingling in the extremities, epileptiform seizures (high doses or prolonged
treatment). Transient leucopenia and thrombocytopenia. Hypersensitivity reactions. Urethral discomfort and darkening of urine. Raised liver
enzyme values, cholestatic hepatitis, and jaundice. Thrombophlebitis (IV).
Potentially Fatal: Anaphylaxis.
MIMS Class: Other Antibiotics / Antiamoebics / Preparations for Vaginal Conditions / Topical Antibiotics
Name of Drug: Combivent Nebule
Dosage: Neb
Indications: COMBIVENT (ipratropium bromide and albuterol sulfate) Inhalation Aerosol is indicated for use in patients with chronic obstructivepulmonary disease (COPD) on a regular aerosol bronchodilator who continue to have evidence of bronchospasm and who require a second
bronchodilator.
Administration: It is recommended to test-spray three times before using for the first time and in cases where the aerosol has not been usedfor more than 24 hours. Avoid spraying into eyes.
Contraindications:Combivent Inhalation Aerosol is contraindicated in patients with a history of hypersensitivity to soya lecithin or related foodproducts such as soybean and peanut. Combivent Inhalation Aerosol is also contraindicated in patients hypersensitive to any other
components of the drug product or to atropine or its derivatives
Special Precaution: Effects Seen with Anticholinergic Drugs: Combivent Inhalation Aerosol contains ipratropium bromide and, therefore, should
be used with caution in patients with narrow-angle glaucoma, prostatic hyperplasia, or bladder-neck obstruction.
Adverse Drug Effects: Additional adverse reactions, reported in less than two percent of the patients in the Combivent Inhalation Aerosoltreatment group include edema, fatigue, hypertension, dizziness, nervousness, paresthesia, tremor, dysphonia, insomnia, diarrhea, dry
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mouth, dyspepsia, vomiting, arrhythmia, palpitation, tachycardia, arthralgia, angina, increased sputum, taste perversion, and urinary tract
infection/dysuria.
Name of Drug: Metoclopramide
Dosage: 1 ml
Indications:Disturbances of GI motility Relief of symptoms of acute andrecurrentdiabeticgastroparesis Nausea and vomiting Metabolicdiseases Short-term therapy for adults with symptomatic gastroesophageal reflux who fail to respond to conventional therapy. Prophylaxis
of postoperative nausea and vomiting when nasogastric suction is undesirable.
Contraindications:Contraindicated with allergy to metoclopramide GI hemorrhage Mechanical obstruction or perforation Epilepsy Usecautiously with previously detected breast cancer, lactation, pregnancy, fluid overload, renal impairment
Side Effects:CNS: restlessness, drowsiness, fatigue, Insomnia, dizziness, anxiety CV: transient hypertension GI: nausea and diarrhea
Name of Drug: Paracetamol
Dosage: 4ml
Indications: Mild to moderate pain and fever.
Administration: May be taken with or without food
SpecialPrecautions: Renal or hepatic impairment; alcohol-dependent patients; G6PD deficiency.
AdverseDrugReactions: Nausea, allergic reactions, skin rashes, acute renal tubular necrosis.PotentiallyFatal: Very rare, blood dyscrasias (e.g. thrombocytopenia, leucopenia, neutropenia, agranulocytosis); liver damage.
MIMSClass: Analgesics (Non-Opioid) & Antipyretics
Name of Drug: Efamed Plus
http://www.mims.com/USA/diagnoses/info/1692http://www.mims.com/USA/diagnoses/info/849http://www.mims.com/USA/Browse/Classification/http://www.mims.com/USA/Browse/Classification/http://www.mims.com/USA/Browse/Classification/http://www.mims.com/USA/drug/search/Analgesics%20(Non-Opioid)%20%26%20Antipyreticshttp://www.mims.com/USA/diagnoses/info/1692http://www.mims.com/USA/diagnoses/info/849http://www.mims.com/USA/Browse/Classification/http://www.mims.com/USA/drug/search/Analgesics%20(Non-Opioid)%20%26%20Antipyretics8/2/2019 Case Study Pneumoni
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Dosage:3ml
Indications: Resp disorders complicated by bronchospasm & excessive secretion of tenacious mucus, bronchial asthma, chronicbronchitis & emphysema.
Administrations:Should be taken on an empty stomach (Take on an empty stomach 1 hr before or 2 hr after meals.).
Contraindications: -blocker therapy, thyrotoxicosis. Pregnancy
Adverse Drug Reactions: Efamed syr Fine tremor, tension, angioedema, urticaria, bronchospasm, hypertension, collapse. Efamed Plus tab &syr Confusion, irritability, tremor, insomnia & restlessness; loss of appetite, nausea & vomiting, feeling of tension, peripheral vasodilation,
slight increase in heart rate, headache, transient muscle cramps, hypersensitivity reactions, hyperactivity in childn, risk of dental caries.
MIMS Class: Cough & Cold Preparations
Nursing Care Plan
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIO
N
RATIONALE EVALUATION
Subjective:
Nasakitan pa siyamakahangos asclaimed by mother
Ineffecti
ve
breathi
ngpattern
Excess of fluidin the lungs
Short term goal:
After 3-4 hours ofnursinginterventions, the
patients respirationwill improve anddifficulty of breathing
Independent:
Establish
rapport topatient
andwatcher
Independent:
To gain the
trust andcooperation
Short term
goal:
After 3-4 hours ofnursing
interventions, thepatientsrespiration was
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Objective:
- (+) DOB
- Cracklesnoted
- (+)Wheezing
- V/S taken:
T: 37.2
P: 100
R: 39
related
to
pulmon
ary
infectio
n
Resulting froman inflammatory
process
Inflammation istriggered by
many infectiousorganisms and
inhalation ofirritating agents
Alveolar wallsthickened and
become irritated
will be relieved.
Assess
patientscondition
Monitor
and recordV/S
Auscultate
lung fields,notingareas of decreased/absentairflow andadventitious breathsounds
Assist
patient tochangeposition
To know and
determinepatientsneeds
To establish
base linedata
To identifyareas of consolidation anddeterminepossiblebronchospasm orobstruction
able to improveand difficulty ofbreathing wasrelieved.
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Accumulation of
mucus andinflammatory
cells
Leads to
Pneumonia
every 30minutes
Encourage
to increase
fluidintake.
To mobilize
secretions
To liquefy
secretions
Impaired
gas
exchang
e r/t
collectio
n of
secretio
ns
affecting
Short term goal:
After 2-4 hours ofnursinginterventions, thepatient will achievetimely resolution ofcurrent infection
withoutcomplications.
Independent:
Assess
respiratoryrate, depthand ease.
Independent:
Manifestatio
n ofrespiratorydistress isdependenton
indicative ofthe degreeof lung
Short term
goal:
After 2-4 hours ofnursinginterventions,the patient was
able to achievetimely resolutionof current
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oxygen
exchang
e across
alveolar
membra
ne.
Monitor
bodytemperature
Dependent:
Administer
antimicrobi
als asprescribed
involvementandunderlyinggeneralstatus.
High fever
greatlyincreasesmetabolicdemandsand oxygenconsumption and alterscellularoxygenation
.
Dependent:
These drugs
are used tocombatmost of themicrobialpneumonias
.
infection withoutcomplications.
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Administer
nebulizertreatmentasprescribed
Facilitates
liquefactionand removalofsecretions.
Ineffecti
ve
airway
clearanc
e related
to
excessiv
e,
thickene
d mucus
secretio
ns
Short term goal:
After 4 hours ofnursing interventionsthe patient will :
Demonstrateimprovedventilationand adequateoxygenation.
Arterial blood
gases (ABGs)within normalrange.
No signs ofrespiratory
Independent:
Assess
respiratoryrate,depth.Note use
ofaccessorymuscles,pursed lipbreathing.
Routinely
monitorskin andmucus
membranecolor.
Independent:
Useful in
evaluatingthe degreeorrespiratory
distress andchronicity ofthe diseaseprocess.
Cyanosis
may beperipheral
in nail bedsor central inlips or
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distress.
Long term:
After months of
nursinginterventions, thepatient:
Ventilation or
oxygenation isadequate tomeet self careneeds.
Evaluate
sleeppatterns,note reportofdifficultiesandwhetherpatient
feels wellrested.
Collaborative:
Administer
supplemental oxygenasindicated
by ABGresults andpatients
earlobes.Duskinessand centralcyanosisindicateadvance
hypoxemia.
Multiple
externalstimuli andpresence ofdyspneamaypreventrelaxation
and inhibitsleep.
May correct
or preventworseningof hypoxia.
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tolerance.
Nursing Implications
Nursing Practice
It is essential to be able to understand contemporary nursing practice, which looks at the overall aspects of the nursingprofession. This study enhances the quality and effectiveness of nursing care that will rendered to the clients with similar condition.Nursing practice itself could also be evaluated in this case
This case study will be beneficial to nursing practices. This implies that the health care providers must become more dedicatedin rendering nursing care but there must be no exceptions upon rendering services regardless of the case handled by the caregiver.The greatest impact of the implication is the equality in treatment upon rendering nursing care, that all patients must be entitled to aquality and effective care regardless of who they are and what their health problem is.
Nursing Research
This case study is equipped with useful information, ample opportunities and responsibilities to the nurses, not exempting theaffiliating student nurses in order for them to be well-informed and competitive in this field. Research findings will provide them abroader knowledge of the said case and will enhance their skills for them to be globally competitive in the profession.
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Nursing Education
Education is one of the important processes of learning because it is continuous and it can help achieve the optimum level ofknowledge to every individual in all aspects of life not just in the field of nursing.
This case study is accomplish through the thorough research and studies made intentionally for other proponents who willhandle same case for them to be encouraged and aim for the best to further go through series of studies.
This will also be beneficial to other case studies related or similar to this. The case study could serve as a guide in making moreimproved and comprehensive study about the case.
Catanduanes State Colleges
College of Health Sciences
Department of Nursing
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Case Study of Pneumonia
Submitted by:Carmina A. Aguilar
BSN-2B
Submitted to:
Marilou Lopez, RN, MANClinical Instructor