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I. INTRODUCTION

A distinguishing feature of lower airway and pulmonary vessel disorders is the

presence of dyspnea. Dyspnea (shortness of breath) is a subjective experience that

results when air flow, oxygen exchange, or both are impaired. The sensation of

uncomfortable breathing can be as distressing as pain and can lead to severe functional

disability. The intensity and frequency of dyspnea as well as its association with

specific activities must be assessed to develop realistic expectations of treatment

outcomes. Because the experience of dyspnea is associated with much anxiety, nursing

interventions to relieve this manifestations are essential to the care of clients with

conditions of the lower airways and pulmonary vessels.

Pneumonia (pneumonitis) is an inflammatory process in lung parenchyma usually

associated with a marked increase in interstitial and alveolar fluid. Advances in

antibiotic therapy have led to the perception that pneumonia is no longer a major health

problem in the United States. Among all nosocomial infections (hospital acquired),

pneumonia is the second most common, but has the highest mortality. Pneumonia can

be divided into three groups, which guide management: community acquired, hospital

or nursing home acquired (nosocomial), and pneumonia in an immunocompromised

person.

Complications of pneumonia include pleural effusion, septic shock, pericarditis,

bacteremia, meningitis, delirium, atelectasis, and delayed resolution.

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II. GENERAL DATA:

 Name:  Ms. M.A.C

Address: Ilihan, Toledo City

Gender: Female

Status: Infant

Date of Birth: August 28, 2009

Age: 5 months old

Nationality: Filipino

Religion: Roman Catholic

Father’s Name: Mr. H.C

Father’s Occupation: Laborer

Mother’s Name: Mrs. M.C

Mother’s Occupation: Housewife

Chief Compliant: Cough and LBM

Date of Admission: February 24, 2010

Time Admitted: 12:50 AM

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Room Number: BB

Admitting Diagnosis: Pneumonia, AGE with no Dehydration

Physician: Dr. Egbert Ian Echavez

 III. HISTORY OF PRESENT CONDITION / ILLNESS

The patient’s mother claims that her baby experienced cough for three days.

According to the patient’s mother her child also experienced four episodes of LBM

for one day and two episodes of vomiting prior to admission. The patient’s mother

also claims that the night prior to admission, her child cries after every cough and felt

that her child is hot to touch, which she concluded that her child has fever. With this

situation, she was alarmed and decided to go to the hospital for her child to be

checked upon.

 IV. PAST HEALTH HISTORY

 The patient’s mother claims that this is the first time her child was admitted in

the hospital due to a serious condition. She also mentioned that whenever her child

experiences mild fever and colds, she buys over the counter medications and uses

herbal plants to alleviate the patient’s condition. According to her, her child doesn’t

have any known allergy to any kind of food or drug.

 V. NURSING REVIEW OF SYSTEMS

Nutrition – Metabolic Pattern

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Before Admission:

As stated by the patient’s mother, the patient has good appetite. She drinks

breast milk as often as possible. The patient’s mother also claims that before

admission, the patient is a healthy child.

During Admission:

The patient’s mother claims that her child became thin due to her present

condition. The patient is still able to drink breast milk from her mother despite her

condition.

Elimination Pattern

Before Admission:

According to patient’s mother, her child defecates everyday. Stool is solid and

cylindrical in form. The color of patient’s stool is brownish or yellowish. According

to patient’s mother she changes her child’s diaper 2-3 times a day.

During Admission:

The patient’s mother claims that her child defecates watery ,yellowish to

brownish color of stool. She changes her child’s diaper 3-4 times a day.

Activity – Exercise Pattern

Before Admission:

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According to patient’s mother, her child shows activeness while playing with

her toys and as well as playing with her.

During Admission:

The patient’s mother claims that her child seemed weak and cries upon

coughing.

Sleep – Rest Pattern

Before Admission:

According to patient’s mother, her child most of the time sleeps at home and

wakes up or cries whenever she wants to drink milk.

During Admission:

The patient cries and is not able to sleep properly because of present condition.

Role Relationship Pattern

Before Admission:

The patient’s mother claims that her child is able to interact and play with

people she is familiar with but cries whenever she sees someone unfamiliar to her.

During Admission:

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The patient’s mother claims that her child is still able to interact and play with

people she is familiar with and still cries whenever she sees someone unfamiliar to

her.

VI. FAMILY, PERSONAL, SOCIAL AND ENVIRONMENTAL HISTORY

A. MEMBERS OF IMMEDIATE FAMILY 

NAME AGE

POSITION

IN THE

FAMILY

EDUCATIONAL

ATTAINMENT

OCCUPATION

GENERAL

HEALTH

STATUS

Mr. H.C 29 Father Highschool

Graduate

Laborer Healthy

Mrs.

M.C

28 Mother Highschool

Graduate

Housewife Healthy

B. PERSONAL AND SOCIAL HISTORY

           The patient is the only child of Mr. and Mrs. Castillano. Because she is the only

child, is well loved by her parents as well as her grandparents. The patient also cries upon

seeing an unfamiliar face approaching towards her.  

C. ENVIRONMENTAL HISTORY

            The patient’s mother said that their house is near the road where most vehicles

pass by. She also said that their house is made of cement and wood which is enough for

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her family to live in. According to her, cockroaches and flies are present at their house.

They also own some appliances like television, radio and electric fan. They have an

electric and water connection. They live in a place where houses are near each other.

D. HEREDO – FAMILIAL HISTORY

The patient’s mother claimed that they have a family history of being

hypertensive but does not have any allergy to any kind of food or drug. They do not have

a family history of being asthmatic. On the patient’s father side, there is no known

serious condition. Aside from that, they have no other history of having serious illnesses.

 VII. Physical Assessment: 

GENERAL APPEARANCE

The patient was seen lying on bed, conscious, febrile, with her mother beside

her, with ongoing IVF # 2 D5.3% Nacl infusing well @ 22- 24 micro gtts/min on

right arm. With the following vital signs of:

Temperature – 38.4 ºC

Pulse rate – 168 bpm

Respiratory rate – 64 cpm

Skin

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The patient has brown skin. Skin is smooth and soft to touch when being palpated.

No ecchymoses noted. There are no lesions and masses palpated. Skin is also warm to

touch with good turgor.

  Hair

Patient’s hair is fine, proportionately distributed on the head with no greasy scales

on scalp noted. No presence of infestations noted. No tenderness upon palpation of scalp

noted.

Head

The shape of the patient’s head is symmetrical without depressions or bulging of

fontanel. The head is round in shape. No tenderness upon palpation noted.

Face

Able to smile and frown, face is symmetrical in contour, no masses palpated.

Eyes

Patient’s eyes are positioned symmetrically. Patient can see clearly and reacts on

moving objects. Patient’s eyes are not sunken, sclera is clear and moist.

Ears

Top of the ear is in lined with the imaginary line drawn from the outer cantus.

Both ears are symmetrical to each other. No presence of any drainage and tenderness

noted upon assessment.

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Nose and Sinuses

Nose is symmetrical to both sides. Nasal flaring noted. No tenderness of sinuses

upon palpation. Nostrils are patent.

Mouth and Throat

Patient’s lips are intact and moist. Oral mucosa is moist and reddish in color.

Absence of lesions noted.  

Neck

Able to hold her neck erect and at midline. Able to move neck from side to side

without difficulty. No swelling or masses noted. Trachea is symmetrical and in midline

position. Pulsation is felt in carotid artery. Lymph nodes are non- palpable.

Anterior Chest

Patient experiences tachypnea with respiratory rate of 64 cpm. Chest rises upon

inspiration and falls upon expiration. No tenderness lumps and nodules felt during

palpation. Crackles heard upon auscultation.

Posterior Chest

Posterior chest is symmetrical. No nodules and tenderness felt upon palpation.

Heart

No pulsations, heave or retractions. No murmurs heard upon auscultation.

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Breast

No tenderness, masses or nodules noted upon palpation.

Abdomen

Abdomen is round and slightly protuberant. No swelling and tenderness noted.

Veins are not visible upon inspection. No abnormal sounds heard on abdomen upon

auscultation.

Female External Genitalia and Anus

No lesions noted. No tenderness noted upon palpation. Anus is patent.

Upper Extremities

Fingers, hands and wrist are straight. Elbows are at the same height and

symmetrical in appearance. Able to move arms and hands without pain. Capillary refill of

2 seconds. Able to grasp objects firmly.

Lower Extremities

     Legs and thighs are slightly curved No lesions or edema noted. Able to move

legs and feet without any pain.

VIII. DEVELOPMENTAL DATA

Traditionally, infancy is designated as the period of time from 1 month to 1

year of age. In these important months, an infant undergoes such rapid development that

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parents sometimes believe looks different and demonstrates new abilities each day.

During this time, an infant triples birth weight and increases length by 50%. A baby’s

senses sharpen and, with the process of attachment to caregivers, she forms a first social

relationship. Because of the growth and learning potential that occurs, this first year is a

crucial one. Without proper nutrition, a baby will not grow and physically thrive, and

without proper stimulation and nurturing care by consistent caregivers, an infant may not

develop a healthy interest in life or a feeling of security essential for future development.

Summary of Infant Growth and Development

Month Motor

Development

Fine Motor

Development

Socialization and

Language

Play

0-1 Largely reflex Keeps hands fisted;

able to follow object

to midline

Enjoys watching

face of primary

caregiver,

listening to

soothing sounds.

2 Holds head up when

prone

Has social smile Makes cooing

sounds;

differentiates cry

Enjoys bright-

colored mobiles

3 Holds head and

chest up when

prone

Follows objects past

midline

Laughs out loud Spends time

looking at hands

or uses them as

toy during the

month(hand

regard)

4 Grasp, stepping,

tonic neck reflexes

are fading

Needs space to

turn

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5 Turns front to back;

no longer has head

lag when pulled

upright; bears

partial weight on

feet when held

upright

Handles rattles

well

IX. A. ANATOMY AND PHYSIOLOGY OF THE SYSTEMS INVOLVED

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The Respiratory system consists of the external nose, the nasal cavity, the

pharynx, the larynx, the trachea, the bronchi and the lungs. Although air frequently

passes through the oral cavity, it is considered to be part of the digestive system instead

of the respiratory system. The upper respiratory tract refers to the external nose, nasal

cavity, pharynx, and associated structures; and the lower respiratory tract includes the

larynx, trachea, bronchi, and lungs. 

Nose

The nose consists of the external nose and the nasal cavity. The external nose is

the visible structure that forms a prominent feature of the face. Most of the external nose

is composed of hyaline cartilage, although the bridge of the external nose consists of

bone. The bone and cartilage are covered by connective tissue and skin.

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The nasal cavity extends from the nares to the choane. The nares or nostrils, are

the external openings of the nose and the choane are the openings into the pharynx. The

nasal septum is a partition dividing the nasal cavity into left and right parts. A deviated

nasal septum occurs when the septum bulges to one side or the other. The hard palate

forms the floor of the nasal cavity, separating the nasal cavity from the oral cavity. Air

can flow through the nasal cavity when the mouth is closed or when the oral cavity is full

of food. Three prominent bony ridges called conchae are present on the lateral walls on

each side of the nasal cavity. The conchae increase the surface of the nasal cavity.

Paranasal sinuses are air-filled spaces within bone. The maxillary, frontal,

ethmoidal and sphenoidal sinuses are named after the bones in which they are located.

The paranasal sinuses open into the nasal cavity and are lined with a mucous membrane.

They reduce the weight of the skull, produce mucus, and influence the quality of the

voice by acting as resonating chambers. The nasolacrimal ducts, which carry tears from

the eyes, also open into the nasal cavity. Sensory receptors for the sense of smell are

found in the superior part of the nasal cavity. Air enters the nasal cavity through the

nares. Just inside the nares the epithelial lining is composed of stratified squamous

epithelium containing coarse hairs. The hairs trap some of the large particles of dust

suspended in the air. The rest of the nasal cavity is lined with pseudostratified columnar

epithelial cells containing cilia and many mucus-producing goblet cells. Mucus produced

by the goblet cells also traps debris in the air. The cilia sweep the mucus posteriorly to

the pharynx, where it is swallowed. As air flows through the nasal cavities, it is

humidified by moisture from the mucous epithelium and is warmed by blood flowing

through the superficial capillary networks underlying the mucous epithelium.

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Pharynx  

The pharynx is the common passageway of both respiratory and digestive

systems. It  receives air from the nasal cavity and air, food, and water from the mouth.

Inferiorly, the pharynx leads to the rest of the respiratory system through the opening into

the larynx and to the digestive system through the opening into the larynx  and to the

digestive system through the esophagus. The pharynx can be divided into three regions:

the nasopharynx, the oropharynx, and the laryngopharynx.

 The nasopharynx is the superior part of the pharynx. It is located posterior to the

choaneae and superior to the soft palate, which is an incomplete muscle and connective

tissue partition separating the nasopharynx from the oropharynx. The uvula is the

posterior extension of the soft palate. The soft palate forms the floor of the nasopharynx.

The nasopharynx is lined with pseudostratified ciliated columnar epithelium that is

continuous with the nasal cavity. The auditory tubes extend form the middle ears open

into the nasopharynx. The posterior part of the nasopharynx contains the pharyngeal

tonsil, which aids in defending the body against infection.  The soft palate is elevated

during swallowing, this movement results in the closure of the nasopharynx, which

prevents food from passing from the oral cavity into the nasopharynx.

The oropharynx extends from the uvula to the epiglottis, and the oral cavity opens

into the oropharynx. Food and drink all passes in the oropharynx. The laryngopharynx

passes posterior to the larynx and extends from the tip of the epiglottis to the

esophagus.The larynx (plural larynges), colloquially known as the voicebox, is an organ

in the neck of mammals involved in protection of the trachea and sound production. The

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larynx houses the vocal folds, and is situated just below where the tract of the pharynx

splits into the trachea and the esophagus. Sound is generated in the larynx, and that is

where pitch and volume are manipulated. The strength of expiration from the lungs also

contributes to loudness.The trachea, or windpipe, is the bony tube that connects the nose

and mouth to the lungs, and is an important part of the vertebrate respiratory system.

When an individual breathes in, air flows into the lungs for respiration through the

windpipe. Because of its primary function, any damage incurred to the trachea is

potentially life-threatening.The bony skeletal trachea is comprised of cartilage and

ligaments, and is located at the front of the neck. The trachea begins at the lower part of

the larynx and continues to the lungs, where it branches into the right and left bronchi. It

measures 3.9 to 4.7 inches (10-12 cm) in length, and .62 to .7 inches (16-18 mm) in

diameter. The trachea is composed of 16 to 20 “c” shaped rings of cartilage connected by

ligaments, with a  ciliated-lined mucus membrane. It is this structure that helps push

objects out of the airway should something become lodged.

Larynx

The larynx is the portion of the breathing, or respiratory, tract containing the

vocal cords which produce vocal sound. It is located between the pharynx and the

trachea. The larynx, also called the voice box, is a 2-inch-long, tube-shaped organ in the

neck.

We use the larynx when we breathe, talk, or swallow. Its outer wall of cartilage

forms the area of the front of the neck referred to as the "Adams apple". The vocal cords,

two bands of muscle, form a "V" inside the larynx.

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Each time we inhale (breathe in), air goes into our nose or mouth, then through

the larynx, down the trachea, and into our lungs. When we exhale (breathe out), the air

goes the other way. When we breathe, the vocal cords are relaxed, and air moves through

the space between them without making any sound.

When we talk, the vocal cords tighten up and move closer together. Air from the

lungs is forced between them and makes them vibrate, producing the sound of our voice.

The tongue, lips, and teeth form this sound into words.

The esophagus, a tube that carries food from the mouth to the stomach, is just

behind the trachea and the larynx. The openings of the esophagus and the larynx are very

close together in the throat. When we swallow, a flap called the epiglottis moves down

over the larynx to keep food out of the windpipe.

Trachea

A tube-like portion of the breathing or "respiratory" tract that connects the "voice

box" (larynx) with the bronchial parts of the lungs.

Each time we inhale (breathe in), air goes into our nose or mouth, then through

the larynx, down the trachea, and into our lungs. When we exhale (breathe out), the air

goes out the other way.

The esophagus, the tube that carries food from the mouth to the stomach, is just

behind the trachea and the larynx. The openings of the esophagus and the larynx are very

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close together in the throat. When we swallow, a flap called the epiglottis moves down

over the larynx to keep food out of the windpipe.

The trachea is also called the windpipe, weasand (sometimes written wesand or

wezand) or wesil. "Cut his weasand with thy knife." The Tempest, Shakespeare.

Bronchi

 The trachea divides into left and right main (primary) bronchi. Each of which

connects to a lung. The left main bronchus is more horizontal than the right main

bronchus because of it is displaced by the heart. Foreign objects that enter the trachea

usually lodge in the right main bronchus, because it is more vertical than the left main

bronchus and threfore more in direct line with the trachea. The main bronchi extend from

the trachea to the lungs. Like the trachea, the main bronchi are lined with pseudostratified

ciliated columnar epithelium and are supported by C- shaped pieces of cartilage.

The large air tubes leading from the trachea to the lungs that convey air to and

from the lungs. The bronchi have cartilage as part of their supporting wall structure. The

trachea divides to form the right and left main bronchi which, in turn, divide to form the

lobar, segmental, and finally the subsegmental bronchi.

Bronchi is the plural of bronchus from the Greek word bronchos, a conduit to the lungs.

  Lungs

The lungs are the principal organs of respiration. Each lung is cone-shaped, with

its base resting on the diaphragm and its apex extending superiorly to a point about 2.5

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cm above the clavicle. The right lung has three lobes called the superior, middle and

inferior lobes. The left lung has two lobes called the superior and inferior lobes. The

lobes of the lungs are separated by deep, prominent fissures on the surface of the lung.

Each lobe is divided into bronchopulmonary segments separated from one another by

connective tissue septa, but these separations are not visible as surface fissures. There are

9 bronchopulmonary segments in the left lung and 10 in the right lung. The main bronchi

branch many times to form the tracheobronchial tree. Each main bronchus divides into

lobar bronchi as they enter their respectibe lungs. The lobar (secondary) bronchi, two in

the left and three in the right lung, conduct air to each lobe. The lobar bronchi in turn give

rise to segmental (tertiary) bronchi, which extends to the bronchopulmonary segments of

the lungs. The bronchi continue to branch many times, finally giving rise to bronchioles.

The bronchioles also subdivide numerous times to give rise to terminal bronchioles,

which then subdivide into respiratory bronchioles. Each respiratory bronchiole subdivides

to form alveolar ducts, which are like long, branching hallways with many open

doorways. The doorways open into alveoli which are small air sacs become so numerous

that the alveolar duct wall is little more than a succession of alveoli. The alveolar ducts

end as two or three alveolar sacs, which are chambers connected to two or more alveoli.

There are about 300 million alveoli in the lungs. As the air passageways of the lungs

becomes smaller, the structure of their walls changes. The amount of cartilage decreases

and the amount of smooth muscle increases, until at the terminal bronchioles, the walls

have a prominent smooth muscle layer, but no cartilage. Relaxation and contraction of

the smooth muscle within the bronchi and bronchioles can change the diameter of the air

passageways. For example, during exercise the diameter can increase, thus increasing the

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volume of air moved. During an asthma attack, however, contraction of the smooth

muscle in the terminal bronchioles can result in greatly reduced air flow. In severe cases,

air movement can be so restricted that death results. As the air passageways of the lungs

become smaller, the lining of their walls also changes. The trachea and bronchi have

pseudostratified ciliated columnar epithelium, the bronchioles have ciliated simple

cuboidal epithelium. The ciliated epithelium of the air passageways functions as mucus-

cilia escalator, which traps debris in the air and removes it from the respiratory system.

The respiratory membrane of the lungs is where gas exchange between the air and blood

takes place. It is mainly of the alveoli and surrounding capillaries but there’s some

contribution by the alveolar ducts and respiratory bronchioles it is very thin to facilitate

the diffusion of gases.

Pleural cavity

In human anatomy, the pleural cavity is the body cavity that surrounds the lungs.

The pleura are a serous membrane which folds back upon itself to form a two-layered,

membrane structure. The thin space between the two pleural layers is known as the

pleural cavity; it normally contains a small amount of pleural fluid. The outer pleura

(parietal pleura) is attached to the chest wall. The inner pleura (visceral pleura) covers the

lungs and adjoining structures, viz. blood vessels, bronchi and nerves.

The pleural cavity, with its associated pleurae, aids optimal functioning of the

lungs during respiration. The pleural cavity also contains pleural fluid, which allows the

pleurae to slide effortlessly against each other during ventilation. Surface tension of the

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pleural fluid also leads to close apposition of the lung surfaces with the chest wall. This

physical relationship allows for optimal inflation of the alveoli during respiration. The

pleural cavity transmits movements of the chest wall to the lungs, particularly during

heavy breathing. This occurs because the closely opposed chest wall transmits pressures

to the visceral pleural surface and hence to the lung itself.

  IX. B. CONCEPTUAL FRAMEWORK ON THE CONDITION /

PATHOPHYSIOLOGY

PneumoniaEtiologic/ risk factors

Non infectious causes

Aspirati-on of food and water

Inflammation

Organisms penetrate airway mucosa

WBC migrate

Causes exudates collect in/ around alveoli

Organisms

Immune system unable to fight

From environ- ment and other people

Such as fungi, viruses & bacteria

Signs and symptoms

FatigueChillsFeverCough

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Alveolar walls thicken

Hypoxemia Reduced gas exchange

Chest pain Sputum Production Dyspnea Tachypnea Crackles in lungs

IX. C. DISCUSSION ON THE CONDITION / PATHOPHYSIOLOGY

Upper airway characteristics normally prevent potentially infectious particles

from reaching the sterile lower respiratory tract. Pneumonia arises from normal flora

present in patients whose resistance has been altered or from aspiration of flora present in

the oropharynx; patients often have an acute or chronic underlying disease that impairs

host defenses. Pneumonia may also result from blood borne organisms that enter the

pulmonary circulation and are trapped in the pulmonary capillary bed. Pneumonia affects

both ventilation and diffusion. An inflammatory reaction can occur in the alveoli,

producing an exudate that interferes with the diffusion of oxygen and carbon dioxide.

White blood cells, mostly neutrophils, also migrate into the alveoli and fill the normally

air-containing spaces. Areas of the lung are not adequately ventilated because of

secretions and mucosal edema that cause partial occlusion of the bronchi or alveoli, with

a resultant decrease in alveolar oxygen tension. Bronchospasm may also occur in patients

with reactive airway disease. Because of hypoventilation, a ventilation-perfusion

mismatch occurs in affected area of the lung. Venous blood entering the pulmonary

circulation passes through the underventilated area and travels to the left side of the heart

poorly oxygenated. The mixing of oxygenated and unoxygenated or poorly oxygenated

blood eventually results in arterial hypoxemia. If a substantial portion of one or more

lobes is involved, the disease is refers to as “lobar pneumonia”. The term

“bronchopneumonia” is used to describe pneumonia that is distributed in patchy fashion,

having originated in one or more localized areas within the bronchi and extending to the

adjacent surrounding lung parenchyma. Bronchopneumonia is more common than lobar

pneumonia.

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D. SYMPTOMATOLOGY

fever

chills

cough

tachypnea

breathing with grunting or wheezing sounds

labored breathing that makes a child's rib muscles retract (when muscles under the

rib cage or between ribs draw inward with each breath)

vomiting

chest pain

abdominal pain

decreased activity

poor feeding (in infants)

X. MEDICAL MANAGEMENT

   A. TREATMENT AND PROCEDURES

Chest X-Ray –PA -A chest X-ray is a test that uses a small amount of radiation to

create an image of the structures within the chest, including the heart, lungs, blood

vessels and bones. A chest X-ray may be used to help diagnose and plan treatment

for various conditions, including lung disorders such as pneumonia.

Nebulization - To deliver medication by a fine mist that is inhaled directly into the lungs.

Medication used is Salbutamol which dilates bronchioles of patients having bronchospasm.

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   B. MEDICATIONS

Cefuroxime (Zinacef) – 180 g IVTT every 8 hrs.

Salbutamol (Ventolin)- 6 mc ½ nebule every 6 hrs.

Paracetamol (Calpol)- .8 ml every 4 hrs. for temperature >38ºC

Zinc Sulfate- 2ml OD

Protexin Balance- 1 cap BID mixed with 5ml H20

C. DIAGNOSTIC PROCEDURES

Complete Blood Count- An individual's white blood cell count can often give a hint

as to the severity of the pneumonia and whether it is caused by bacteria or a virus.

An increased number of neutrophils, one type of WBC, are seen in bacterial

infections, whereas an increase in lymphocytes, another type of WBC, is seen in

viral infections.

Urinalysis - The urinalysis is used as a screening and/or diagnostic tool because it

can help detect substances or cellular material in the urine associated with different

metabolic and kidney disorders. It is ordered widely and routinely to detect any

abnormalities that require follow up.

Stool exam- To determine whether you have pathogenic bacteria in your

gastrointestinal tract.

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Diagnostic exam Result Normal valuesFecalysis Macroscopic

Cellular finding

color yellow soft in consistency Fat globules- moderate Bacteria – abundant

Hematology Hgb Hematocrit WBCWBC Differential Count Stab - Segmenter -

Lymphocyte Monocyte Eosinophil Basophil

Platelete

123g/L - .3720.30 x 10 /L

.14

.23

.63

000_1.0307 x 10 /L

120-160g/L0.37-0.495-10x 10 /L

150-400 x 10 /L

D. DIET

The patient is breastfed by mother which is her only source of nutrition. The

patient is breastfed as often as necessary.

XI. NURSING MANAGEMENT

A. ACTUAL CARE GIVEN

Care given to patient includes nebulization. Performed tepid sponge bath. Also

instructed SO to give paracetamol to patient when pt’s temperature is above normal

limits. Provided a clean environment for the patient to prevent exacerbation of patient

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condition. . Frequent breastfeeding and promoting fluid intake was very much

encouraged because labored breathing may lead to insensible fluid loss that would lead

to dehydration if not monitored. Vital signs taking was also monitored every 4 hours. I

and O taken every shift.

B. PROBLEMS ENCOUNTERED DURING THE IMPLEMENTATION OF

NURSING CARE

I haven’t encountered any problem in implementing nursing care to the patient

because the patient’s mother was very cooperative. Even though the patient cries

whenever I get her vital signs, her mother was always there to help me that is why I

was able to manage taking care of the patient.

C. RESTORATIVE MEASURES USED

I was able to perform tepid sponge bath whenever the patient’s temperature is

above normal limits. I also assisted in nebulization of patient which promotes

bronchodilation. Thus, facilitates proper breathing. I also provided a clean and safe

environment for the patient.

D. EVALUATION

I think, what I have done is partially effective because patient’s condition was

slightly reduced to normal. Patient also has a certain time to rest to conserve energy.

Activities were limited and asked to adhere on a complete bed rest all the time with the

help of the significant others. Hydration is good as evidenced by an adequate fluid intake

and urine output and with a normal skin turgor. Patient’s complies with all management

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strategies and also complies with treatment protocol and prevention strategies for her

sake.

E. PATIENT TEACHING

Patient education is crucial regardless of the setting and the proper administration

of antibiotics is important. In this case in which the patient is still 5 months old, she is

still dependent on her parents especially her mother to care for her.

In these instances, the patient is initially treated with intravenous antibiotics in

the hospital or may be in home setting. It is important that a seamless system of care be

maintained for the patient from hospital to home, this induces communication between

the nurses caring for this patient in both settings. In addition, oral antibiotics are

prescribed, the importance to teach the patient’s mother about proper administration and

potential side effects was greatly taught. Patient’s mother was also advised to avoid

exposing the patient to sudden changes in temperature that will further lower her immune

system. Adequate nutrition was greatly emphasized to patient’s mother to boost the

immune system.

XII.A. CONCLUSION

At first I was hesitant to approach the patient, but when I came to know her

significant others, especially her mother, my anxiety decreased and was able to mingle

with them accordingly. I never thought that family members of the patient would be that

warm and cooperative to me. With this study I have, I learned a lot of things in life.

Confidence in dealing with difficult situations, although encountered many times, will

still bother you. Because of the fact that different situation have different results, you tend

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to be anxious of the outcome. As a student nurse, we should be flexible in dealing with

situations so as to have a positive result. We should be responsible enough in any actions

that we do. We can be successful by our own little way with guidance from God. A

patient should always be treated well whatever the patient’s status might be. Perseverance

and determination will help us to succeed. Serving the needs of the ill is the primary role

of a nurse and that shall be enhanced as we go along our journey in life.

B. RECOMMENDATION

This case study promotes the growth and wellness of the patient and her parents,

as well as the nurse. Current trends and issues should be examined and undergo specific

observations to enlighten the minds of students in understanding an infant with

pneumonia. This case study is focused more especially as to with health care providers,

that would serve as a guideline on how to render effective nursing care to patients having

pneumonia. This would be of great help on how to manage those infant patients with

pneumonia who are physically not in a healthy state.

XIII. IMPLICATIONS OF THE STUDY TO:

A. NURSING EDUCATION

Aspiration is a common problem that can lead to Severe Pulmonary

complications, potential complications of aspiration include obstruction, inflammation

and infection. Nursing assessment and knowledge of risk factors are key in evaluating

patient at risk for potential aspiration problems and preventing this complication. The

focus of this study is in the optimal health of the patient and to know the complications it

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may lead. As a student nurse, it is very important in our field that we both have

knowledge and competent skills that we may apply in the near future.

B. NURSING PRACTICE

            Nursing is the diagnosis and treatment of human responses to health and illness

and therefore, focuses on a broad array of any phenomena. Knowledge, skills and ability

should always come together. Knowledge alone is not enough neither skills nor ability is

not enough. It is an important factor that we perform nursing actions considering its

rationale and principles for it guides us in the care that we give to our patients. Skill

needs to be mastered as we go through the journey of the field we choose to have.

C. NURSING RESEARCH

Nursing research is designed to help solve particular, existing problems so there

is a much larger audience eager to support research that is likely to be profitable or solve

problems of immediate concern. Much medical research on pneumonia with considerable

impact is a good example. Some sort of research is required to support normal decision-

making. Just as nursing is dynamically changing, so is with the nursing research. We

should be updated in laboratory test and procedures that are constantly changing over

time.

 

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