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Christ the King College
9014 Gingoog City
Pediatric Case Study
“Pediatric Community Acquired Pneumonia”
Table of Contents
I. Introduction
II. Nursing Health History
Biographic Data
Family health history
Personal history
Past medical history
Life style
Social history
Physical assessment
Assessment Data
Assessment Vital Signs
III. Laboratory Results
IV. Anatomy and Physiology
V. Pathophysiology
VI. Nursing care plan
VII. Drug study
VIII. Discharge plan
IX. Evaluation
X. Bibliography
I- Introduction:
Pediatric community-acquired Pneumonia is a disease which individuals who have not
recently been hospitalized develop on infection of the lungs. PCAP is a common illness
that affects infants and children. PCAP occurs because the atmosphere or the areas of
the lungs which absorb oxygen from the atmosphere become filled with fluid and cannot
work effectively.
PCAP occurs throughout the world and is a leading cause of illness and death. The
cause of PCAP includes bacteria, viruses, fungi and parasites. PCAP can be diagnosed
by symptoms and physical examination alone, through x-rays, examination of sputum
and other tests are often used. Individuals with PCAP are primarily treated with
antibiotic medication in the hospital some forms of PCAP can be prevented by
vaccination.
PCAP usually acquired via inhalation or aspiration of pulmonary pathogenic organism
into a lung segment or lobe. Less commonly, PCAP results from secondary bacteria
from a distant source, such as Escherichia coli urinary tract infection and or bactericidal.
PCAP is due to aspiration of oro-pharyngeal content is the only form of PCAP involving
multiple pathogens. The proportion of children with pneumonia who are diagnosed with
specific etiology is low. Unlike adults, children usually do not produce adequate sputum
specimens for Gram stain and culture. Blood cultures have a yield of less than 10% in
patients with bacterial pneumonia. “Lung puncture” studies that are conducted in
developing countries are obviously not met with enthusiasm in general pediatric
practices. Prospective studies that have employed sensitive antibody test and
polymerase chain reaction techniques have suggested that in up to 20% of pediatric
community acquired pneumonias, the infection is “mixed” (i.e., both S. Pneumonia and
M. and C pneumonia); in these cases, the primary pathogen is not clear. Authors of
these studies have also suggested that mixed infection with bacteria and respiratory
viruses is likely to become as well.
Many studies have looked at causes of pediatric pneumonia as it relates to
certain readily available laboratory measurements. Many clinicians consider S.
pneumonia to be likely cause of the lower respiratory infection if the picture is
characterized by acute onset of high fever, pneumonia on chest radiograph,
leukocytosis, and a rapid response to B-lactam antibiotics. Numerous studies have
found that chest radiographs do not readily distinguish between bacterial, a typical
bacterial, and viral pneumonia. A variety of laboratory test have been used in attempt to
distinguish bacterial from viral pneumonia, including C-reactive protein and absolute
neutrophil counts. One problem in using “screening” test is that specific cut off levels
have often not been established.
A recent study done in Europe found that although white blood cell count and C-reactive
proteins were statistically higher in patients with pneumococcal infections, other clinical
and laboratory and radiographic studies were of little value. Given the clinical,
epidemiologic, and laboratory difficulties in pinpointing the cause of pediatric
pneumonia, an additional approach is to divide patients by age. The primary bacterial
pathogen in neonatal pneumonia is group B streptococci, although Escherichia coli and
Listeria mono cytogeneses have also been reported
The mechanism is similar to that in neonatal sepsis, where colonization from the mother
results in neonatal colonization and breakthrough infection. Chlamydia trachomatis is
the most common sexually transmitted infection in the United States. The organism may
reside in the genital tract of pregnant women and be transmitted in about 60% of cases
to infants at the time of delivery. About one half of infants who acquire the organism
develop conjunctivitis, and 20% eventually develop lower respiratory disease
REASON FOR CHOOSING THE CASE:
It is due to the motive to learn and apply our knowledge and skills
incaring the patient with pediatric community acquired pneumonia (PCAP).
This is a rare case since the patient is only 3 years old
Family Centered Objectives:
Our family centered objectives would remain to be our most significant motive in
conducting this case study. They are as follows:
• The parents of the patient will be able to understand the causes and
therapeutic management regimen
• The parents will be able to consider and demonstrate the proper way of breastfeeding
and guidelines for the condition.
• The parents will be able to verbalize the importance of increase fluid intake.
• The parents will be able to identify potential complications and how to initiate appropriate
preventive or corrective actions.
II- Nursing Health History:
Biographic Data
Name: Batang X
Address: Barangay 20, Purok 7, Gingoog City
Gender: Male
Status: single/Child
Birthday: April 25, 2009 Age: 3 years and 9 months
Birth place: Cagayan de Oro City
Religion: Roman Catholic
Nationality: Filipino
Room: Pediatric Semi private
Attending physician: Dr. Almero
Chief Complaint: 4 days fever
Date/Time admitted: January 20, 2013
Diagnosis: Pediatric Community acquired pneumonia
Family History:
His paternal side has a genetic history of hypertension, his grandfather
previously Diagnosed for CAP,
One of his aunt in his mother side has DM after pregnancy, no other known
illnesses.
Personal History:
5 days prior to admission the child played under the rain and catches colds afterward, 4
days until Admission the child experienced high fever associated with cough, which
prompted his mother to admit her son to the hospital.
Past medical history:
The mother stated that the patient was hospitalized be fo re s ta ted
D iagnosed Bronco pneumon ia when the ch i ld was s t i l l 4 months o ld
a lso when he was 1 y r . and 5 months he was d iagnosed w i th same
i l l ness . The pa t ien t had no a l le rg ies to d rugs . The mother a lso
claimed that the patient already received complete vaccination
Lifestyle:
They live near the rice field at barangay 20, hot, and humid condition always causes the
cough to her child as the mother stated. The child often plays at the market with the
other kids every time his mother brings him to work.
Social History:
The mother describes her son sociable, and always mingles with other kids much often
plays at the mud bridges on the rice fields. The community knows their family well, they
respect them, and they have a peaceful community, and consider their family at peace
with everyone.
Developmental Task:
Psychosexual Theory
According to Freud’s Psychoanalytic theory the patient is under Anal stage, where he
has a need to control, and his area of pleasure is in the anus or activities related in that
area.
Psychosocial Theory
According to Erickson’s psychosocial theory the patient is under, Autonomy vs. Shame
and doubt, where the child need a degree of freedom inorder to meet his need for
control.
Cognitive Theory
According to Piaget’s cognitive theory the patient is under, Preoperational, the child is
ego centric and relates everything that is presently happening is because of him.
Moral development Theory
According to Kohlberg’s Moral development the child is under pre conventional stage
where in a child will do good inorder to receive reward, and avoid to do wrong action to
avoid punishment.
Physical assessment
Mouth
The lips are pinkish in color and moist. No ulcerations or lesions noted. The tongue
moves freely and not tender. The client possesses pinkgums
INTEGUMENT:
1 . S k i n
The skin of the client is moist, pale and has a good skin turgor.Has a fair skin complexion.
2.Hai r and Scalp
The hair are equally distributed with a thin hair strands; wellkept; no lice or dandruff seen/noted.
3 . N a i l s
Client’s nails are normally transparent and convex. Thesurrounding cuticles are intact and without
inflammations noted. Has anormal capillary refill with 1 to 2 seconds.
THORAX and LUNGS
The chest contour is symmetrical, the spine is vertically aligned. The ches t wa l l i s
in tac t , no tenderness o r no masses no ted . Upon auscultation rales was being
noted.
HEART
There is no presence of abnormal pulsations when the heart was auscultated. No
murmurs and friction rubs heard upon auscultation.
BREAST
The b reas ts a re even w i th the ches t wa l l , sk in i s smooth and intact.
Areola is round and bilaterally the same. The nipples are round and equal in size, no
discharge noted. The breast are not tender, no masses or nodules noted.
ABDOMEN
The abdomen is intact, round and with normal bowel sound heard upon auscultation. No deformities
seen.
EXTREMITIES:
On the upper extremities no deformities noted. Has a D5IMB½ L at the left hand. While on the lower
extremities, no deformities were noted.
GENITAL AND RECTAL:
Upon inspection there were no deformities, no rashes, no abnormal secretions were present.
Admission data:
Client came from home to the hospital ambulatory, accompanied by his mother, with
fever and productive cough noted.
Assessment vital signs:
Temperature: 38.6
Pulse: 120 bpm
Respiratory Rate: 26cpm
Height: 3’2”
Weight: 12 klg
Allergies: No known allergy
III. Laboratory Assessment
Components Normal Values Result Clinical Significance
WBC 4,500–11,000/mm3 9.6 normal
Hemoglobin 12-16 g/dL 14.1 Normal
Hematocrit 36-46 % 42.4 Normal
Platelet 150,000-350,000/
mm3
234, 000
Differential Count:
Normal Values Result
Segmenters 45% - 70% 53
Lymphocytes 18%-45% 39
Monocytes 4-8% 8
IV. Anatomy & Physiology of the Respiratory System
The respiratory system is situated in the thorax, and is responsible for gaseous
exchange between the circulatory system and the outside world. Air is taken in via the
upper airways (the nasal cavity, pharynx and larynx) through the lower airways (trachea,
primary bronchi and bronchial tree) and into the small bronchioles and alveoli within the
lung tissue.
Move the pointer over the coloured regions of the diagram; the names will appear at the
bottom of the screen)
The lungs are divided into lobes; The left lung is composed of the upper lobe,
the lower lobe and the lingula (a small remnant next to the apex of the heart), the right
lung is composed of the upper, the middle and the lower lobes.
Mechanics of Breathing
To take a breath in, the external intercostal muscles contract, moving the ribcage up
and out. The diaphragm moves down at the same time, creating negative pressure
within the thorax. The lungs are held to the thoracic wall by thepleural membranes, and
so expand outwards as well. This creates negative pressure within the lungs, and so air
rushes in through the upper and lower airways.
Expiration is mainly due to the natural elasticity of the lungs, which tend to collapse if
they are not held against the thoracic wall. This is the mechanism behind lung collapse
if there is air in the pleural space (pneumothorax).
Physiology of Gas Exchange
Each branch of the bronchial tree eventually sub-divides to form very narrow terminal
bronchioles, which terminate in the alveoli. There are many millions of alveloi in each
lung, and these are the areas responsible for gaseous exchange, presenting a massive
surface area for exchange to occur over.
Each alveolus is very closely associated with a network of capillaries containing
deoxygenated blood from the pulmonary artery. The capillary and alveolar walls are
very thin, allowing rapid exchange of gases by passive diffusion along concentration
gradients.
CO2 moves into the alveolus as the concentration is much lower in the alveolus than in
the blood, and O2 moves out of the alveolus as the continuous flow of blood through the
capillaries prevents saturation of the blood with O2 and allows maximal transfer across
the membrane.
Significant Parts and organs involved:
The nose consists of the visible external nose and the internal nasal cavity. The
nasal septum divides the nasal cavity into right and left sides. Air enters two
openings, the external nares (nostrils; singular, naris), and passes into the
vestibule and through passages called meatuses. The bony walls of the
meatuses, called concha, are formed by facial bones (the inferior nasal concha
and the ethmoid bone). From the meatuses, air then funnels into two (left and
right) internal nares. Hair, mucus, blood capillaries, and cilia that line the nasal
cavity filter, moisten, warm, and eliminate debris from the passing air.
The pharynx (throat) consists of the following three regions, listed in order through
which incoming air passes:
The nasopharynx receives the incoming air from the two internal nares. The
two auditory tubes that equalize air pressure in the middle ear also enter
here. The pharyngeal tonsil (adenoid) lies at the back of the nasopharynx.
The oropharyrnx receives air from the nasopharynx and food from the oral
cavity. The palatine and lingual tonsils are located here.
The laryngopharynx passes food to the esophagus and air to the larynx.
The larynx receives air from the laryngopharynx. It consists of several pieces of
cartilage that are joined by membranes and ligaments, shown in Figure 2:
The epiglottis, the first piece of cartilage of the larynx, is a flexible flap that
covers the glottis, the upper region of the larynx, during swallowing to
prevent the entrance of food.
The thyroid cartilage protects the front of the larynx. A forward projection of
this cartilage appears as the Adam's apple (anatomically known as the
laryngeal prominence).
The paired arytenoid cartilages in the rear are horizontally attached to the
thyroid cartilage in the front by folds of mucous membranes. The upper
vestibular folds (false vocal cords) contain muscle fibers that bring the folds
together and allow the breath to be held during periods of muscular pressure
on the thoracic cavity (straining while defecating or lifting a heavy object, for
example). The lower vocal folds (true vocal cords) contain elastic ligaments
that vibrate when skeletal muscles move them into the path of outgoing air.
Various sounds, including speech, are produced in this manner.
The cricoid cartilage, the paired cuneiform cartilages, and the paired
corniculate cartilages are the remaining cartilages supporting the larynx.
The trachea (windpipe) is a flexible tube, 10 to 12 cm (4 inches) long and 2.5 cm
(1 inch) in diameter (Figure 2).
The mucosa is the inner layer of the trachea. It contains mucus-producing goblet
cells and pseudostratified ciliated epithelium. The movement of the cilia sweeps
debris away from the lungs toward the pharynx.
The submucosa is a layer of areolar connective tissue that surrounds the mucosa.
Hyaline cartilage forms 16 to 20 C-shaped rings that wrap around the submucosa.
The rigid rings prevent the trachea from collapsing during inspiration.
The adventitia is the outermost layer of the trachea. It consists of areolar
connective tissue.
The primary bronchi are two tubes that branch from the trachea to the left and
right lungs.
Inside the lungs, each primary bronchus divides repeatedly into branches of
smaller diameters, forming secondary (lobar) bronchi, tertiary (segmental)
bronchi, and numerous orders of bronchioles (1 mm or less in diameter),
including terminal bronchioles (0.5 mm in diameter) and microscopic
respiratory bronchioles. The wall of the primary bronchi is constructed like
the trachea, but as the branches of the tree get smaller, the cartilaginous
rings and the mucosa are replaced by smooth muscle.
Alveolar ducts are the final branches of the bronchial tree. Each alveolar
duct has enlarged, bubblelike swellings along its length. Each swelling is
called an alveolus. Some adjacent alveoli are connected by alveolar pores.
The respiratory membrane consists of the alveolar and capillary walls. Gas
exchange occurs across this membrane. Characteristics of this membrane follow:
Type I cells are thin, squamous epithelial cells that constitute the primary cell
type of the alveolar wall. Oxygen diffusion occurs across these cells.
Type II cells are cuboidal epithelial cells that are interspersed among the
type I cells. Type II cells secrete pulmonary surfactant (a phospholipid bound
to a protein) that reduces the surface tension of the moisture that covers the
alveolar walls. A reduction in surface tension permits oxygen to diffuse more
easily into the moisture. A lower surface tension also prevents the moisture
on opposite walls of an alveolus or alveolar duct from cohering and causing
the minute airway to collapse.
Alveolar macrophage cells (dust cells) wander among the other cells of the
alveolar wall, removing debris and microorganisms.
A thin epithelial basement membrane forms the outer layer of the alveolar
wall.
A dense network of capillaries surrounds each alveolus. The capillary walls
consist of endothelial cells surrounded by a thin basement membrane. The
basement membranes of the alveolus and the capillary are often so close
that they fuse.
V. Pathophysiology of PCAP
Predisposing Precipitating
Age, weather, genetics Environment
Aspiration of microbes
Failure of Defenses
Invasion of lower respiratory tract
Activation of b-cells
Release of antibodies
Antigen- Antibody Reaction
Antigen Antibody Complex Adhere to the Mucosal Lining of the lower respiratory tract
Initiation of Immune system
Mucosal Irritation
Vasodilation
Increase blood flow
Vaso-congestionIncrease mucus production
Accumulation of mucus
Productive Cough
Increase plasma Hydrostatic Pressure
Increase capillary permeability
Ineffective airway clearance
Escape of plasma Escape of RBC Serum and Fibrin
Transportation of phagocyting cells
Edema
Narrowing of airways
Exudate formation
Filling of bronchi and alveoli
Consolidation of lung
Decrease lung inflation
Use of accessory muscles
Increase respiration
Asymmetrical chest expansion
Ineffective Breathing pattern
Engulfing of Antigen
Cell becomes infected
Detection of the infected cell by the T-cells
Effector T-cells destroys antigen
Regulatory T-cell Strengthen Act of effector
cells
Effector and Regulatory Cells Synthesize and release cytokinase
Altered Temperature Regulating Mechanism in
the Hypothalamus
Hyperthermia
VIII. Discharge Planning
Medication Advise patient to take home medication
Encourage patient S.O to continue
medication Salbutamol syrup, 5 ml TID, as
prescribed
Exercise Instruct and teach client to exercise as can
be tolerated.
Health teaching Eat nutritious food (green leafy
vegetables).
Encourage ambulation and adequate fluid
intake.
Diet Advise the client to eat nutritious food
especially those have vitamin C (for fast
healing against infection.)
Advise the client drink plenty of water and
limit caffeine.
Spiritual Encourage the client to continue religious
activity( e.g. Attending mass)
Outpatient ( checkup) •Advice to make follow-up one week after
or when the medication is stopped, report
for any unusalities,
Treatment •Instruct the client to do the following
measures.
Observing hand hygine
Avoiding playing under the rain or under
the heat of the sun
Diet Analysis
Food Group
Meat, Fowl, or Fish
Vegetables
Fruits
Breads, Cereals, Rice, Pasta
Milk
Fats, Oils, Sweets
Additional Fluid
Quantities
2-3 servings daily
3 servings daily
2 servings daily
4-7 servings daily
2-5 glasses (8-oz) daily
1 serving daily
3-4 glasses daily
IX. Evaluation
Time consuming, Energy draining, brain busting, this is how I describe a Case Study.
For a novice point of view it is very hard to make such work, though we have complete
sources of information, we still learning how to get the right information out of those
sources.
But such task worth such effort, the knowledge and experience I gained was worth it. I
learned time management, that is very important in my course.
By doing this Case study It gave me more understanding about the disease process by
which was a very big question mark back when I was still on my fresh years.
Time worth Spent, Energy drained reasonably, and Brain busted in exchange for a
better one, this is what this case study left me,
XI. Bibliography
1) Blackwell’s Nursing Dictionary Second Edition (2005), Blackwell’s Publishing Ltd.
2) Maternal & Child Health Nursing Sixth Edition (2010),Adele Pillitteri, Lippincott
Williams & Wilkins
3) Fundamentals of Nursing Eight Edition, Kozier & Erb’s, Pearson, Prentice Hall
4) Nurses Pocket Guide, Diagnoses Prioritized Interventions, and rationales,
Marilynn E.Doenges,Mary Frances Moorhoouse,Alice C. Murr, 12th edition.
5) Lippincott’s Nursing Drug Guide, Amy M. Karch, 2011