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Capitol Medical Center Colleges, Inc.

#4 Sto. Domingo Avenue, Quezon City

College of Nursing

A Case Analysis of Pneumonia

In Partial Fulfillment of the Requirements in

Related Learning Experiences of

Nursing Care Management 102

Submitted by:

Level II Group 4 Members:

Misador, Grace

Navarro, Simon

Nery, Francis

Palisoc, Marili

Petrache, Joseph

Poot, Marlen

Punzalan, Archimedes

Ramos, Diane

Submitted to:

Dr. Sherwin Buluran, RN, RMT, MAN, Ph.D

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OBJECTIVES OF STUDY

Our main scheme for this study could be very helpful for everyone potentially at

risk to have the disease. What we hope to achieve after this study are the following:

To be able to identify and analyze etiology of the underlying cause of the

disease.

To be able to give relation between another theoretical framework and the

chosen diagnosis; which is Pneumonia.

To discuss Anatomy and Physiology of the of the related disease

To tackle and give classification of drugs being taken by the patient.

To establish essential nursing intervention to be implemented for the patients

wellness and recovery.

INTRODUCTION

Background of the Study

The group chose Pneumonia as our case to be study out of curiosity. This is our

first time to encounter this kind of case and because of that; our group was interested in

it. We are willing to do this case to challenge our mind in analyzing the problem and to

enhance our hidden knowledge, and also to gain new experiences which would bring

new learning for the member of the group.

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Significance of the Study

The relevance of this study is for the concluding of the prearranged diagnosis.

Likewise, it would be a big help in identifying the primary needs for its wellness and

recovery. By identifying such needs and health problems, the group will capable of

formulating individualized nursing interventions for the patient that would suffice to the

client’s needs. Effective management of the problems identified will help the patient to

recover faster and maintain a holistic sense of wellness within the hospital.

This case study would also provide the group with enough knowledge, skills and

attitude on how to manage future patients with the same or similar condition.

Overview of the Disease

Pneumonia is an inflammatory condition of the lungs caused by an infection. It is usually

occurs at a rate of 2 to 4 children in 100. Between 5 and 10 million people get

pneumonia in the United States each year, and more than 1 million people are

hospitalized due to the condition. As a result, pneumonia is the fourth most frequent

cause of hospitalizations. Although the majority of pneumonias respond well to

treatment, the infection kills 40,000 - 70,000 people each year. Men with community-

acquired pneumonia tend to fare worse than women. Men are 30% more likely than

women to die from the condition, even if the severity of the illness is the same.

Researchers say there may be some genetic reason for the disparity.

It may be of bacterial origin (pneumococcal, streptococcal, staphylococcal, or

Chlamydia) or viral in origin, such as RSV (respiratory syncytial virus). Aspiration of lipid

or hydrocarbon substances also causes pneumonia. These disease is commonly

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divided into two types: hospital acquired (pneumococcal or streptococcal pneumonia)

and community acquired (Chlamydia, viral pneumonias). It occurs most often in late

winter and early spring.

Classification of Pneumonia:

Hospital-acquired pneumonia, also called nosocomial pneumonia, is pneumonia

acquired during or after hospitalization for another illness or procedure with onset

at least 72 hrs after admission. The causes, microbiology, treatment and

prognosis are different from those of community-acquired pneumonia.

Community-acquired pneumonia (CAP) is infectious pneumonia in a person who

has not recently been hospitalized. CAP is the most common type of pneumonia.

The most common causes of CAP vary depending on a person's age, but they

include Streptococcus pneumoniae, viruses, the atypical bacteria, and

Haemophilus influenzae. Overall, Streptococcus pneumoniae is the most

common cause of community-acquired pneumonia worldwide. Gram-negative

bacteria cause CAP in certain at-risk populations.

There are also types of Community-acquired pneumonia:

Pneumococcal Pneumonia is generally abrupt and follows an upper respiratory

tract infection. With this, children may have blood-tinged sputum as exudative

serum and red blood cells invade the alveoli.

Chlamydial Pneumonia is most often seen in newborns up to 12 weeks of age

because the chlamydial organism is contracted from the mother’s vagina

during birth. Laboratory assessment will show an elevated level of

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immuunoglobulin IgG and IgM antibodies, peripheral eosinophilia and a

specific antibody to Chlamydia Trachomatis.

Viral Pneumonia caused by the viruses of upper respiratory tract infection:

RSVs, myxoviruses or adenoviruses.

Mycoplasma Pneumonia are similar to yet larger than viruses. Mycoplasmal

pneumonia occurs more frequently in older children (over 5 years) and more

often during the winter.

In making diagnosis of pneumonia begins with taking a thorough medical history,

including symptoms, smoking history, and exposure to infections and lung irritants. A

physical examination is also performed and includes listening with a stethoscope to the

sounds that lungs make during respiration. Lung sounds that may point to a diagnosis of

pneumonia include a bubbling or crackling sound and decreased lung sounds. A

physician or nurse practitioner will also tap on the chest with the fingers to listen for

certain sounds that may also point to a diagnosis of pneumonia.

Diagnostic testing generally includes a chest X-ray. Depending on a person's

condition and medical history, testing may also include lung function tests, such as a

spirometry, which measures how much air is moved in and out of the lungs during

breathing. A CT scan of the chest can help to evaluate such factors as the presence of

other lung conditions, including COPD and congestive heart failure.

A sample of phlegm that is coughed up from the lungs may be tested for the

presence of bacteria or other pathogens. The treatment for pneumonia involves a

multifaceted approach. Treatment plans vary depending on the cause, the severity of

the symptoms, the presence of complications, general health, and an individual's

medical history. One goal of treatment of pneumonia is to control symptoms, such as

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fever, cough, and shortness of breath, until a child recovers. Another goal is to minimize

the development of serious complications, such as severe shortness of breath and

hypoxia. With treatment, generally healthy children and adults can often recover from

bacterial pnemonia or viral pneumonia.

NURSING HEALTH HISTORY

Patient’s Profile

With abundance of dignity and respect, we have decided to protect the client’s

identification and call her Patient 801 instead. All the information below are based from

statement of the patients’ family.

Patient 801, a 1 year old female, born on the 28 th of August 2009 born at

Greenhills San Juan and now residing at Quezon City.

During her first few months, she was breastfed every hour and as time passes by the

frequency was decreased to 2-3 hours. After 1 year of breastfeeding, her parents

decided to switch to milk formula like Bona and Promil to support her increasing

nutritional needs.

Past Health History

Upon the interview, the patient’s mother was asked about the past health history

of patient 801 and she told us that her daughter had fever and cough for a couple of

days and OTC medication was provided. During her first 14 months, all vaccines under

the Expanded Program Immunization were given to her and were brought by their

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Community Health Center. As for now, she had already completed her EPI vaccines.

When she was 10 months old, she was diagnosed with Bronchoasthma.

C.C.:

“She has a high fever for almost a week associated with cough and colds” as

verbalized by her mother.

Present Health History

6 days PTA, patient was noted to have fever 38C. pt was given paracetamol. 4

days PTA, patient was brought to a private MD where in Erythromycin was given. 2

days PTA, pt was now afrebile but still have an acute cough and colds. On the day of

admission, the pt. had a fever 38C.

Family Health History

Patient 801 father who resides in Quezon together with her Family doesn’t have

any history of other diseases aside from chicken fox and measles which were treated by

medications prescribed by their physician. Similarly, they have also stated that the

family is not sports-inclined and has not practiced much of their active lifestyle. Usually

they spend their time at work and at home watching television and movies and enjoy

occasional drinking.

On the other hand, her mother who grew up in Quezon City had a history of

Hypertension. Certain supplement which helps boosting up her immune system is

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taken daily together with her healthy lifestyle consisted of regular exercise and a good

balanced diet.

THEORETICAL FRAMEWORKS

Self-Care Deficit Nursing Theory of Dorothea Orem

Orem developed the Self-Care Deficit Theory of Nursing, which is composed of three interrelated theories: (1) the theory of Self-Care, (2) the theory of Self-Care Deficit, and (3) the theory of Nursing System.

Theory of Self-Care

Self-care is the performance or practice of activities that individuals initiate and perform on their own behalf to maintain life, health, and well-being.

Self-care agency is a human ability which is “the ability for engaging in self care.”

Therapeutic self-care demand “totality of self-care actions to be performed for someduration in order to meet self care requisites by using various methods and related sets of operations and actions.”

Three Categories of Self-Care Requisites

Universal self-care requisites- are associated with life processes, maintenance of the integrity of human structure and functioning, and with general being.

Developmental self-care requisites- are associated with the developmental processes; derived from a condition or associated with an event (e.g. adjusting to a new job).

Health Deviation self-care requisites- Required in conditions of illness, injury, or disease; includes seeking medical assistance, learning to live with effects of condition, etc.

Theory of Self-Care Deficit

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Self-care deficit is the basic element of Orem’s general theory of nursing because it delineates when nursing is needed. Nursing is required when adults are incapable of or limited in their ability to provide continuous effective self-care.

Five methods of helping

1. Acting for or doing for another2. Guiding and directing3. Providing physical or psychological support4. Providing and maintaining an environment that supports personal

development5. Teaching

Conceptual Framework

C.F.

C.F.

C.F.

Theory of Nursing System

1. Wholly Compensatory Nursing System2. Partly Compensatory Nursing System3. Supportive-Educative System

The wholly compensatory nursing system is selected when the patient cannot or should not perform any self-care actions. The partly compensatory nursing system is selected when the patient can perform some, but not all, self-care actions. The

Self -care

Self-care demands

Self care Agency

Deficit

Nursing Agency

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supportive-educative nursing system is selected when the patient can and should perform all self-care actions.

Basic Nursing System

Wholly Compensatory System

Accomplishes patient’s therapeutic self-care

Compensates for patient’s inability to engage in self-care

Supports and protects patient

Partly Compensatory System

Performs some self-care measures for patient

Compensates for self-care limitations of patient

Assist patient as required

Performs some self-care measures

Regulates self-care agency

Accepts care and assistance from nurse

Supportive-Educative System

Accomplishes self-care

Regulates the exercise and development of self-care agency

Nurse action

Nurse action

Nurse action

Patient action limited

Patient action

Patient action

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In relation to the patient;

In the case of the patient wherein she manifested pneumonia and the fact that she is only 1 year old, Orem’s self-care deficit theory is one of the theories that are suitable to the patient. Since the patient is too young and doesn’t know anything yet, she needs the help of her parents and other health care providers. The parents and the health care providers should be involved in doing the 5 helping methods which are;

1. Acting for or doing for anotherIn this method, we can help the patient in taking her medications.

2. Guiding and DirectingGuide and direct her parents and other health team members to provide

comfort measures such as maintaining a hygienic environment.

3. Providing Physical or Psychological SupportProvide physical and psychological support by attending accordingly to the

patient whenever she needs something physically and/or emotionally.

4. Providing and maintaining an environment that supports personal development

Guide the parents of the child for proper hygiene. Cleanliness must start in their house for her to recuperate continuously. Proper ventilation must be applied for her to breathe fresh air that is very essential. Adequate light is also needed because the light has tangible effects upon the human body. Sufficient warmth, the patient should not be too warm or too cold for this interacts with the environment. Controlling the noise can help through the client’s healing process. Unnecessary noises should be eliminated because it’s irritating to the patient.

5. TeachingHealth teachings such as: increase oral fluid intake, adequate intake of

nutritious foods, and emphasize the importance of proper hygiene to promote optimum wellness.

If the patient is ready for discharge, it is our part to act as an educator. To educate our client in maintaining her health one’s the client is discharged.

The nursing system that can be applied based on Orem’s Theory is supportive-educative. We should refer the patient to her attending physician for the follow-up check up, prescribed diet and take home medications. We are also responsible to teach the significant others on the prevention of re-occurrence of pneumonia, advice to increase the immune system of the child by taking vitamin supplements, explaining foods that are

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rich in vitamin C and proper intake of take home medications so that the health continuum of the client is moving forward further to wellness.

GORDON’S PATTERN OF FUNCTIONING

Pattern of Functioning

Normal

Findings

Before Hospitalization

During Hospitalization

Analysis / Interpretation

Health Perception – Health Management Pattern

Regular exercise, regular check-ups, regular maintenance visit for screening examination.

The client‘s mother verbalized that she experienced cough and fever.

She had a regular check-ups with her pediatrician

The client’s health is good the fever resided, but she experienced difficulty in expectorating cough. The mother informed the nurse on duty if her temperature increased.

The client manages her health well, she informed the nurse whenever she feels something wrong, and it really helps the medical staffs to treat her.

Nutritional - Metabolic Pattern

Eat 3 meals per day, need protein rich food and breakfast to sustain the prolonged physical and mental effort. Drink 6-8 glasses of water.

The was fed 8-10 bottles of milk amounting up to 2500 Kcal per day and drink up to 4 glasses of water per day.

She’s on DFA (Diet for age). She had an on-going IV fluid. She lost her appetite and was only consuming 4-5 bottles of milk per day

The client’s appetite decreased due to her condition.

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Elimination Pattern

The client’s usual defecating pattern is 1 – 2 times a day and voiding pattern 3 – 4 times a day.

The client defecated once a day and voided 2-3 times a day.

The Clients defecating pattern decreased due to her decreased oral fluid intake and physical activity.

Activity-Exercise Pattern

Moves freely, easily, rhythmically, and purposely in the environment.

The client usually stays at home while being watched by her guardian. She plays with her toys and interacts with the people around her surroundings.

The client was not allowed to mobilize as much due to the fact that her IV was inserted at her lower extremities. She was usually carried around by her guardian.

The client must have enough rest so she’s not allowed her usual activities.

Sleep-Rest Pattern

Most healthy child needs 8 to 12 hours of sleep.

The client sleeps when she felt tired or full. She was given time for afternoon naps and put to bed around 9pm.

During hospitalization, the client’s mother stated her baby lacked sleep due to her cough and the change in environment. She was only able to sleep for 5 hours the most.

There is a change in sleeping pattern due to nursing rounds and environment.

Cognitive-Perceptual Pattern

Alert, oriental in time, place, person, understand verbal and written words.

The Client is in her developmental age. She watches TV, and plays with

The client showed no change in her patterns, she still did the same activities

Having an intact cognition and perception could help the client in participating in

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books and toys. while being hospitalized

health related activities that could enhance his condition.

Role-Relationship Pattern

Family roles, work roles, student roles and social roles.

She is the youngest of the 2 children, she stays at home with her mother, or other guardians that are available

The client is visited and taken care of by her relatives most especially by her mother.

Her roles did not changed, she is still the dependent person that is still being taken care of.

Sexuality – Reproductive

Sexual activity is common. Establishes own lifestyle and values.

Client is raised as a normal baby girl, she is provided with feminine toys and clothed as a young lady.

There is no change in sexual patterns

There is no change in her sexual lifestyle and values.

Self-Perception – Self-Concept Pattern

Establishing priority of needs, recognizing both self and others.

As being the youngest member of the family, the family views her as their baby and every member of the family perceives her as well

The family participated in accompanying her so she can maintain the same perception

Nothing changed with the clients perception and self-concept pattern

Coping and Stress Tolerance

Maintaining social status and standard of living.

The client has a history of fear when being hospitalized due to her prior admission. She is scared of any

In relation to the past encounters with the patient, the client is still scared of interacting with the health team

The client is working on overcoming her fear and stress factors when being hospitalized.

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health team members that are wearing white.

member, which created stress and discomfort for her. Her family provided her with toys that resemble medical equipment to help her deal with her fear and stress

Values and Beliefs

New found appreciation for the pas; increased respect for inner voice.

The client is raised as a Catholic girl. They hope to provide her with the proper values and beliefs so she can grow up to be a proper and good citizen

It was difficult to show her that she will be okay, but their beliefs still have not changed, they want to provide her with the best and hopefully help her turn into a wonderful person.

Nothing changed with the family’s methods, she is still taught the same values and hope that she picks op on the values that her parents have showed her

PHYSICAL ASSESSMENT

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Physical examination follows a methodical head to toe format in the

Cephalocaudal assessment. This is done systematically using the techniques of

inspection, palpation, percussion and auscultation with the use of materials and

investments such as the penlight, thermometer, tape measure and stethoscope and

also the senses.

During the procedure, we made every effort to recognize and respect the patient’s

feelings as well as to provide comfort measures and follow appropriate safety

precautions.

Vital signs:

Temperature: 36.0 C Weight: 22 lbs.

Respiratory rate: 31 cpm Height: 30 in.

Pulse rate: 120 bpm

General Appearance and Mental Status: She wears printed pajama, stripes shirt and

pink jacket with a pony tail. She has IV line on her right foot covered with a diaper. She

is sitting on her mother’s lap because she finds it comfortable according to her mom.

She takes a bath 5 days before she was admitted and there is the presence of curiosity.

Body Part Techniques used

Normal Findings Actual Findings Interpretation

A.HEADSkull Inspection Proportional to the Rounded Normal

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Palpation body size of the body, round with

prominence in the frontal area

anteriorly and the occipital area

posteriorly symmetrical in all

planes gently curve.

Hair is black

Evenly distributed hair

Thick and slight curly hair

No infestation/lice and dandruff

Scalp InspectionPalpation

White clean, free from masses,

lumps, scars, nits seborrhea, and

lesion

White, free from masses and

lumps. Slighty presence seborrhea

Theres is slighty presence of seborrhea

Hair InspectionPalpation

Black evenly distributed and

covers the whole scalp, thick, shiny,

free from split ends

Slightly presence of

oiliness, thin, black hair and

evenly distributed and

covers the whole scalp with no

presence of split ends.

There is slighty presence of lice

in other part.

She has an oily hair with slighty presence of lice

in other part.

Face InspectionPalpation

Oblong or oval or square or heart-

shaped, symmetrical facial expression that is dependent on the

mood or true feelings smooth and free from wrinkles, in

involuntary muscle movement

Round shape of face and has a mole under her

left eye

She has a mole under her left

eye

Eyes and Eyebrows

Inspection Parallel and evenly placed

symmetrical. Non-

Parallel and evenly placed symmetrically.

Normal

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protruding with scant amount of secretion. Both eyes black and

clear

Both eyes are black and clear.

Eye lashes Inspection Black evenly distributed and turned outward

Long and black evenly

distributed

She has a longa nd beautiful eyelashes.

Eye lids Inspection Upper lids cover a small portion of the iris and the cornea and the sclera when the eyes are closed

the lids meet completely.

Symmetrical color is the same the

surrounding skin.

Covers a small portion of the iris and the cornea and the sclera when the eyes are closed the

lids meet completely

Normal

Sclera Inspection White and clear White and clear. No presence of

dark spot.

Normal

Iris and Pupil Inspection Proportional to the size of the eye

round. Black/brown and

symmetrical.Constrict with

increasing light and

accommodation when the light

closely constrict the size of the

pupil it get smaller than the normal

size

Dark brown color and both

symmetrical. Constricting effect when

there is increasing light

and accommodation when the light

closely constricts the size of the

pupil it gets smaller than the

normal size.

Normal

Ears Inspection Parallel symmetrically

proportion to the size of the head.

Bean-shaped, helix is in line with the outer canthus of the eye, skin is the same color as the surrounding

Bean-shaped, symmetrically

proportion to the size of head. In

line with the outer canthus of

the eye and same color.

Normal

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area, cleanEar canal Inspection Pinkish clean with

scant amount of cerumen and a

few cilia.

Presence of cilia, slightly pinkish and

scant amount of cerumen.

Normal

Hearing acuity Senses Able to hear whisper spoken 2

feet away.

Able to hear whisper

Normal

Nose Inspection Midline, symmetrical and

patent

Midline, symmetrical and patent. Same

color and tender. Presence of

small amount fo mucus.

Presence of small amount of

mucus

Mouth Inspection Pinkish symmetrical Lip

margin well defined, smooth

and moist

Outer lips is pink color

Symmetry of contour

Lips is slightly dried

Lips os slightly dried

Gums Inspection Pinkish. Smooth. No swelling no retraction, no

discharge

Pink color, smooth and no

swelling.

Normal

Teeth Inspection 32 permanentteeth aligned free

from caries or feeling.

No halitosis

Yellowish teeth with no dental

carries. 32 Permanent teeth

are aligned. Slightly

presence of halitosis.

She has no false teeth and

slightly presence of

halitosis.

Tongue InspectionPalpation

Large medium red or pink slightly rough on top

smooth along the lateral margins,

moist, shiny, and free movable

Medium sized white color on top and freely

movable.

She has medium white color tongue

and freely movable.

Frenulum Inspection Midline. Straight. and moist

Midline, straight and moist

Normal

Cheeks Inspection Pinkish, smooth Pinkish, smooth Normal

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Palpation and moist and moistSoft palate Inspection

PalpationPinkish, smooth,

and moistPinkish, smooth,

and moistNormal

Voice Senses No hoarseness and well modulate

Partial modulated. Difficulty to pronounce

words

Partial modulated and

she can’t pronounce word

clearlyNeck Inspection

PalpationProportional to the

size of the body and head,

symmetrical and position

Proportion and symmetrical to the head and body. Freely

movable without difficulty.

Normal

Thorax & Lungs

InspectionPalpation

Auscultation

The chest is symmetrical and the chest is twice as wide as deep.Bronchial sounds are hallowing high pitched whistling

sounds.

The chest is symmetrical, no

lamps and masses.

Vibrations are prominent and

occasional wheezing sound.

Presence of occasional

wheezing sound

Heart InspectionPalpation

Auscultation

Pulsation visible and palpable

Cardiac rate rangefrom 82 beats

per/minute

Cardiac rate range from 120 bpm. Pulsation

visible and palpable.

Positive for two heart sound

Normal

Breast/Chest InspectionPalpation

Female: variable in size depending on body builds in obese, large and

pendulous.Slender- thin and small. In young client – firms,

Elastic in consistence.

Cone-shaped, symmetrical skin surface smooth.In older women,

breast sag, nipples lower, stringy and

nodular.

Warm to touch and smooth.

Color of the skin is same with the

abdomen. No lumps and masses.

Normal

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Warm to touch and smooth

Abdomen InspectionPalpation

AuscultationPercussion

Skin is unblemished, no

scar, color is uniform or scaphoid,

symmetrical movement caused by respiration. The umbilicus is flat or concave. Color is the same as the surrounding skin.

Skin is unblemished, no scar and lesions. Color is uniform,

symmetrical movement due to respiration.

Umbilicus is flat, no bulging,

masses. Presence of

bowel sounds and distention.She has a mole on her right side

Presence of mole on right

side of the abdomen,

borborygmy, distention.

Arm InspectionPalpation

Skin color variesSymmetrical fine evenly distributed presence/absence

of visible veins.Warm dry and

elastic no areas of tenderness.

Same color with the body.

Symmetrical and moves freely.

Absence of scar. Warm and

tender. She has a 2 mole on her

left arm.

She has 2 mole on her left arm.

Hands and Palm

InspectionPalpation

Palm pinkish warm Small, soft and pinkish palm. No

presence of callus. Presence of 5 fingers on

each hand.

Normal

Nails InspectionPalpation

Nails are transparent smooth and

convex with pink nail beds and

white translucentAs pressure

applied to the nail bed, appears

white or balance and pink color

returns immediately as

pressure is released.

Nails are transparent and

smooth. No presence of nail polish. Pinkish

white translucent tips. When

pressured is applied the color

is white and when released it returns to normal

color.

Normal

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Shoulder, Arms, Elbows,

Hand and wrists

InspectionPalpation

Perform on ease Moves freely without difficulty.

Uniform color.

Normal

Legs InspectionPalpation

skin is smooth fine hair evenly distributed absence of

varicose vein muscle

symmetrical lengthMuscle appear equal warm and

with good muscle tone.

Skin color is uniform.

Symmetrical and muscles are tender and warm. No

presence of edema. Moves freely without

difficulty.

Normal

Ankles, toes and nails

InspectionPalpation

Five toes in each foot sole and

dorsal surface is smooth with pink

nailbeds and white translucent tips.Range of motion

Pinkish white color of nails

with translucent tips. No

presence of nail polish. Five toes

in each foot. Moves freely without any discomforts.

Normal

ANATOMY AND PHYSIOLOGY

Functions of the Respiratory System:

Respiration is necessary because all living cells of the body require oxygen and produce carbon dioxide. The respiratory system assists in gas exchange and performs other functions as well:

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1. Gas exchange. The respiratory system allows oxygen from the air to enter the blood and carbon dioxide to leave the blood and enter the air. The cardiovascular system transports oxygen from the lungs to the cells of the body to the lungs. Thus, the respiratory and cardiovascular system work together to supply oxygen to all cells and remove carbon dioxide.

2. Regulation of blood pH. The respiratory system can alter blood pH by changing blood carbon dioxide levels.

3. Voice production. Air movement past the vocal folds make sound and speech possible.

4. Olfaction. The sensation of smell occurs when airborne molecules are drawn into the nasal cavity.

5. Protection. The respiratory system provides protection against some microorganism by preventing their entry into the body and by removing them from respiratory surfaces.

Gross Anatomy:

1. NoseThe nose is a prominent feature of the face composed mostly of cartilage, except for the bridge which is a bone. Externally, it is covered with the skin containing large sebaceous glands and small hairs.

2. Nasal cavityA cavity that extends from the nares to the choanae, it is lined mostly by pseudostratified columnar epithelium with cillia and goblet cells. It serves to humidify and filter the air coming int the body, and to produce thick mucus that traps dust, microorganisms, and foreign bodies carried by the air flowing in.

• Nares- the external openings into the nasal cavity, which are lined by stratified squamous epithelium with coarse hairs that trap large particles of dust. The flow of air from the atmosphere begins its journey into the body through the nares.

• Choanae- the opening at the posterior end of the nasal cavity leading to the pharynx.

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• Nasal septum- a partition dividing the nasal cavity into the right and left cavities.

3. PharynxThe pharynx is a funnel-shaped passageway that connects the respiratory and digestive system. It houses the tonsils, which are lymphatic tissues that attack any disease-causing organisms that escapes the hairs, cilia, and mucus of the nasal cavity. The pharynx consist of three regions:

• Nasopharynx- which extends from the choanae to the level of the uvula. This is where the auditory tubes open into the pharynx, and where the pharyngeal tonsils are located.

• Oropharynx- which extends from the uvula to the epiglottis and is lined by stratified squamous epithelium since food, drink, and air all pass through this region. This is also where the palatine and lingual tonsils are located.

• Laryngopharynx- which passes posterior to the larynx and extends from the tip of the epiglottis to the esophagus and is lined by stratified squamous epithelium.

4. Trachea

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Commonly called the “windpipe”, the trachea is a tube that stretches from the inferior end of the larynx, then projects through the mediastenum and divides into the right and

left primary bronchi at the level just above the heart .

5. BronchiA passage of airway in the respiratory tract that conducts air into the lungs. The bronchus branches into smaller tubes, which in turn become bronchioles.

6.Lungs

In humans, the trachea divides into the two main bronchi that enter the roots of the lungs. The bronchi continue to divide within the lung, and after multiple divisions, give rise to bronchioles. The bronchial tree continues branching until it reaches the level of terminal bronchioles, which lead to alveolar sacs. Alveolar sacs are made up of clusters of alveoli, like individual grapes within a bunch. The individual alveoli are tightly wrapped in blood vessels and it is here that gas exchange actually occurs. Deoxygenated blood from the heart is pumped through the pulmonary artery to the lungs, where oxygen diffuses into blood and is exchanged for carbon dioxide in the hemoglobin of the erythrocytes. The oxygen-rich blood returns to the heart via the pulmonary veins to be pumped back into systemic circulation.

Human lungs are located in two cavities on either side of the heart. Though similar in appearance, the two are not identical. Both are separated into lobes by fissures, with three lobes on the right and two on the left. The lobes are further divided into segments

P n e u m o n i a | 26

and then into lobules, hexagonal divisions of the lungs that are the smallest subdivision visible to the naked eye. The connective tissue that divides lobules is often blackened in smokers. The medial border of the right lung is nearly vertical, while the left lung contains a cardiac notch. The cardiac notch is a concave impression molded to accommodate the shape of the heart.

Air flow into the Alveoli:

The volume and pressure changes responsible for one cycle of the inspiration and expiration can be described as follows:

1. At the end of expiration, the alveolar pressure, which is the air pressure within the alveoli, is equal to atmospheric pressure, which is the air pressure outside the body. There is no movement of air into or out of the lungs because alveolar pressure and atmospheric pressure are equal.

2. During inspiration, contraction of the muscles of inspiration increases the volume of the thoracic cavity. The increased thoracic volume causes the lungs to expand, resulting in an increase in alveolar volume. As the alveolar volume increases, alveolar pressure becomes less than the atmospheric pressure, and air flows from outside the body through the repiratory passage to the alveoli.

3. At the end of inspiration, the thorax and alveoli stop expanding. When the alveolar pressure and atmospheric pressure become equal, airflow stops.

P n e u m o n i a | 27

4. During expiration, the thoracic volume decreases, producing a decrease in alveolar volume. Consequently, alveolar pressure increases above the air pressure outside the body, and air flows from the alveoli through the respiratory passages to the outside.

As expiration ends, the decrease in the thoracic volume stops and the process repeats.

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PATHOPHYSIOLOGY

Inhalation of infectious and irritating agents

Microbial invasion (organisms penetrate the airway mucosa & multiply

in alveolar spaces)

Inflammation in interstitial spaces, alveoli, and/or bronchioles

WBC migrates to the area of infection

RBC and fibrin moves in alveoli

Lung become stiff

Reduced lung compliance and vital capacity decrease

Alveolar collapse (atelectasis)

Ability of the lungs to oxygenate blood decrease

Capillary leaks spread the infection to other areas of the lung

Organisms move into the bloodstream

Infection extends into the pleural cavity

Sepsis Emphysema

Capillary leak, edema, exudates

Fluids collect in and around the alveoli

Excess fluid in the lungs

Arterial tension falls

Predisposing Factor1 y/o

Contributing FactorBacteriaViruses

Mycoplasma Other Pathogens

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Alveolar walls thicken

Gas exchange is reduced

Hypoxemia

If untreated:If treated:

Analgesics to relieve pleuratic chest pain. Antitussives Bed rest Bronchodilator therapy Chest physiotherapy Postural drainage High-calorie diet Adequate fluid intake Humidified oxygen therapy for hypoxia Mechanical ventilation for respiratory failure

Recovery

Lung abscess

Metastatic infection such as brain abscess

Death

Pleural effusion

Death

Meningitis

Diffuse brain swelling

Death

Emphysema Pericardial effusion

Death

Pericarditis

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LABORATORY AND DIAGNOSTIC EXAMINATIONS

Test Normal values Results InterpretationTotal WBC 5 – 10 x 109/L 9.9 x 109/L Normal Segmenters 0.55-0.65 0.31 Normal Lymphocytes 0.25 – 0.40 0.64 Increased - TB, hepatitis,

infectious mononucleosis, mumps, rubella,

thyrotoxicosis, lymphocytic leukemia

Monocytes 0.02 – 0.06 0.04 Increased - TB, malaria, hepatitis, SLE, RA,

carcinoma, monocytic leukemia,

lymphomasRBC Count M: 3.5-5.5 x 1012/L

F: 4.3 -5.9 1012/L5.0 1012/L Normal

Hemoglobin M: 135 – 160 g/LF: 120 – 150 g/L

123 Normal

Hematocrit M: 0.40 -0.48F: 0.37 – 0.45

0.38 Normal

Platelet CT 150 – 130 x 109/L 464 x 109/L Normal

Implications:

WBC

Increased – infection, leukemia, tissue necrosis

Decreased – bone marrow depression, influenza, typhoid fever, measles, infectious

hepatitis, mononucleosis, rubella

Segmenters (Neutrophils)

Increased – infection, ischemic neurosis, metabolic disorders, RA, acute gout

Decreased – bone marrow depression, typhoid, hepatitis, influenza, measles, mumps,

rubella, hepatic disease, SLE, vit. B12 deficiency

Lymphocytes

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Increased – TB, hepatitis, infectious mononucleosis, mumps, rubella, thyrotoxicosis,

lymphocytic leukemia

Monocytes

Increased – TB, malaria, hepatitis, SLE, RA, carcinoma, monocytic leukemia,

lymphomas

Eosinophils

Increased – asthma, hay fever, parasitic infections, chronic myelocytic leukemia,

Hodgkin’s disease, metastasis

Decreased – Cushing’s Syndrome

Basophils

Increased – chronic myelocytic leukemia, Hodgkin’s disease, ulcerative colitis

Decreased – hyperthyroidism, ovulation, pregnancy

RBC

Increased – absolute/relative polycythemia

Decreased – anemia, fluid overload of >24 hrs.

Hemoglobin

Increased – polycythemia or dehydration

Decreased – anemia, recent hemorrhage, fluid retention

Hematocrit

Increased – polycythemia, hemoconcentration

Decreased – anemia, hemodilution

Platelet Count

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Increased – hemorrhage, iron deficiency anemia, inflammatory disease, primary

trombocythemia, myeloid metaplasia, polycythemia vera, chronic myelogenous

leukemia

Decreased – aplastichypoplastic bone marrow, leukemia, vit. B12 deficiency, immune

disorders

ROENTGENOLOGICAL EXAMINATION

Examination:

Chest AP/LAT

Roentgenological Findings:

Streaky densities are noted in both perihilar regions with confluent infiltrates in the left.

Some tracheobronchial lymph nodes are enlarged

Heart is not enlarged

Pulmonary vascularity is within normal limits

Diaphragm and costophrenic sulci are intact

Impression:

Bilateral pneumonia w/ lymphadenopathy

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DEVELOPMENTAL MILESTONE CHART

Child's Age Normal Findings Actual Findings

1 month • Lifts head when lying on tummy

• Responds to sound• Stares at faces

• Follows objects briefly with eyes

• Vocalizes: oohs and aahs• Can see black-and-white

patterns

Positive reflex movements

Brings hands to faceLifts head brieflyStares at faces

2 months • Vocalizes: gurgles and coos• Follows objects across field

of vision• Notices his hands

• Holds head up for short periods

• Smiles, laughs• Holds head at 45-degree

angle• Makes smoother movements

Lifts headHands in fist

Smiles“Ah” & “Ooh” sounds

3 months • Recognizes your face and scent

• Holds head steady• Visually tracks moving

objects• Squeals, gurgles, coos

• Blows bubbles• Recognizes your voice

• Does mini-pushup

Cries to communicatehunger, fear,discomfort

Anticipates being liftedTurns toward colors

4 months • Smiles, laughs• Can bear weight on legs

• Coos when you talk to him• Can grasp a toy

• Rolls over, from tummy to back

Turns prone to supineSupports upper body

with arms in proneHolds head erectMakes consonant

soundsLaughs

5 months • Distinguishes between bold colors

• Plays with his hands and feet

• Recognizes own name• Turns toward new sounds

Turns supine to pronePlays with toes

Bears partial weight on feet when held upright

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• Rolls over in both directions6 months • Turns toward sounds and

voices• Imitates sounds

• Rolls over in both directions• Is ready for solid foods

• Sits without support• Mouths objects

• Passes objects from hand to hand

Reaches/grasps objectsHelps hold bottle

Moves toys betweenhands

Pulls up to sitSits with UE support

Rolls overBounces in standing

7 months • Sits without support• Drags objects toward herself

• Lunges forward or starts crawling

• Jabbers or combines syllables

• Starts to experience stranger anxiety

Opens mouth forspoon

BabblesLaughs

Smiles in mirrorFirst tooth

8 months • Says "mama" and "dada" to both parents

• Passes objects from hand to hand

• Stands while holding onto something• Crawls

• Points at objects• Searches for hidden objects

Fear of strangersResponds toexpressions

Tracks moving objectSays tata & mama

Pulls to standSits without support

Explores with hands &mouth

Raking grasp9 months • Stands while holding onto

something• Jabbers or combines

syllables• Understands object

permanence• Cruises while holding onto

furniture• Drinks from a sip cup

• Eats with fingers• Bangs objects together

Drinks from cupAttempts to feed self

Looks for hiddenobject

Cruises along furnitureWell-developed craw

10 months • Waves goodbye• Picks things up with pincer

grasp• Crawls well, with belly off the

ground• Says "mama" and "dada" to

the correct parent

Pulls self to standingUse pincer to grasp

objects

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• Indicates wants with gestures

11 months • Says "mama" and "dada" to the correct parent

• Plays patty-cake and peek-a-boo

• Stands alone for a couple of seconds• Cruises

• Understands "no" and simple instructions

• Puts objects into a container

Knows familiar facesPlays “peak-a-boo”Cries when parent

Leaves

12 months • Imitates others' activities• Indicates wants with

gestures• Takes a few steps

• Says one word besides "mama" and "dada"

Drinks well from cupApprehensive with

strangersCries when parent

leavesSays “dada” &

“mama”Responds to music

with motion13 months • Uses two words skillfully

• Bends over and picks up an object

• Enjoys gazing at his reflection

• Holds out arm or leg to help you dress him

Walks alone or 1 handheld

Falls frequently whenwalking

Points with 1 fingerPulls off socks

Crawl forward on bellyCreeps on hand/kneesAssumes quadruped

14 months • Eats with fingers• Empties containers of

contents• Imitates others• Toddles well

• Initiates games• Points to one body part

when asked• Responds to instructions

Responds to simple instructions. Uses trial-and-error to learn about

objectsDemonstrate affection. Participate in nursery

rhymes

15 months • Plays with ball• Uses three words regularly

• Walks backward• Scribbles with a crayon

• Runs• Adopts "no" as his favorite

word

Turns pages in a bookCarries a doll

Stacks 2 blocksScribbles with crayons

Runs clumsilyJumps in plac

P n e u m o n i a | 36

16 months • Turns the pages of a book• Has temper tantrums when

frustrated• Becomes attached to a soft

toy or other object• Discovers the joy of climbing

• Stacks three blocks• Uses spoon or fork

• Learns the correct way to use common objects

Looks for hiddenobjects

Follows 1-stepdirections

8–10 word vocabularyScribbles with crayons

Runs clumsilyJumps in place

Points/asks for things

17 months • Uses six words regularly• Enjoys pretend games

• Likes riding toys• Feeds doll

• Speaks more clearly• Throws a ball underhand

Helps with dressingIndicates soiled or

wet paintsEmotionally dependent

on familiar adultLikes to play a lot

Very curious.18 months • Will "read" board books on

his own• Scribbles well

• Strings two words together in phrases

• Brushes teeth with help• Stacks four blocks

Drinks without spilling Picks up toy without

falling overShows preference for

one handGets up/down stairs

holding onto rail19 months • Uses a spoon and fork

• Runs• Throws a ball underhand• Enjoys helping around the

house• Understands as many as

200 words• Recognizes when something

is wrong

Enjoys simple picture books

Explores environmentKnows the names of

parts of his body

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DRUG STUDY

Generic Name Brand Name

Dosage Mechanism Indication Contraindications Adverse Reaction

Nursing Responsibility

Cefuroxime

Classification:Antibiotic

Ceftin 125 mg/5ml Inhibits bacterial cell wall synthesis

by binding 1 or more of the

penicillin binding proteins which in

turn inhibit the final

transpeptidation step of

peptidoglycan synthesis

Treat susceptible infections of

the URTI/LRTIGonorrheaOtitis Media

SinusitisOther skin infections

Hypersensitivity to Cefuroxime or

related to component of

formula or other cephalosporins

DiarrheaNausea/Vomitting

Abdominal painPseudomembra

nous colitisRashes

Thrombocythopenia

Assess for allergy

Monitor I/O

Report onset of loose stools

Paracetamol

Classification:Antipyretic

Tempra 2.5 ml Inhibits prostaglandin synthesis that

possesses anti-inflammatory, anti

pyretic and analgesic effect.

Normalize the body

temperature

Ulceration or chronic

inflammation of GIT, and

hypersensitivity to the drugs

ShockAnaphylactic

reactionDecreases in

serum potassium

levels

Assess for allergy

Reasses the pt’s vital signs

Salbutamol

Classification:Bronchodilator

Ventolin Inhalation: 0.25mg/kg

Activate of beta 2-adrenergic

receptors on airway smooth muscle leads to

relaxation of bronchioles and bronchodilation

Treat severe breathing problems

Hypersentivity to soy lecithin or foods

related products

TachycardiaStomach upset

Dry mouthFlusing

DizzinessCough

Nasal stiffiness

Assess allergyAssess breath

sounds

Monitor the characteristics

and frequency of sputum

production

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NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:“Nahihirapan syang huminga” as verbalized by the mother

Objective:• Adventitious

breath sounds (crackles & wheeze)

• RR: 28 – 34 cpm

• Restlessness• wide-eyed• ineffective

cough

Ineffective airway clearance related to accumulation of secretion as evidenced by

coughing.

Short term:After 8 hours of

nursing intervention

patient will be able to maintain airway patency

Long term:After 2 days of

nursing intervention the

patient will demonstrate reduction of

secretions with breath sounds

clear

Independent:Monitor breath

sounds by auscultations

Evaluate clients gag/cough reflex and swallowing

ability

Elevate head of bed/change position every 2 hours and

PRN

Encourage deep breathing exercises

Increase fluid intake at least

Dependent:Administer

medication as prescribed by the

PhysicianAdminister

Nebulization as ordered

Indicative of respiratory

distress

To determine ability to protect

own airway

To take advantage of

gravity decreasing

pressure on the diaphragm

Maximize effort

Hydration may help secretions

Helps clear secretions and

mobilize

Patient maintained

airway patency and had

successfully demonstrated reductions of

secretions with breath sounds

clear

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Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:“Nilalagnat po ang anak ko” as verbalized by the mother

Objective:• T: 38.3 C• RR: 28

bpm• Skin Warm

to touch• Dry

mucous membrane

Hyperthermia related to viral

infection as manifested by increase body temperature

above normal range of 36.5 to

37.5

Short term:After 30 minutes

of Nursing Intervention,

patients’ temperature will decrease from

38.3 C to 37.5 C

Long term:After 2 hours of

nursing intervention, patient will

maintain normal body temperature ranges from 36.5

to 37.5 C

Independent:Provide Tepid Sponge bath

Assess fluid loss and facilitate oral

intake

Promote bed rest

Monitor vital signs

Dependent:Administer Antipyretic

medications as ordered by physician

Maintain IV fluids ordered by physician

Enhances heat loss by conduction and evaporation.

Increase metabolic rate and

diaphoresis

Reduces body heat production

To note changesthat can affect thepatients’ condition

Reduces fever

Prevents dehydration

Patient had successfully

decreased his temperature from

38.3 to 37.5 C

Patient had successfully

maintained normal body temperature

of 37.5 C

P n e u m o n i a | 40

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:“Ilang araw na syang hindi nadudumi” as verbalized by the mother

Objectives:• Borborygmy• Distended

abdomen• Severe flatus

Constipation related to decrease

motility of Gastrointestinal

Tract as manifested by altered bowel

sound

Short term:After 8 hours of

nursing intervention,

patient will be able to establish normal pattern of bowel functioning

 Long term:

After 1 day of Nursing

interventions, patient will be

able to demonstrate behaviors or

change of lifestyle changes

to prevent recurrence of

problem

Independent:Review daily

dietary regimen, noting if the diet is deficient in fiber.

Note activity level and exercise

pattern.

Encourage increase fluid intake including high fiber, fruit juices; suggest

drinking warm, stimulating fluids

such as pineapple juice, warm water.

Encourage the patient exercises that may improve abdominal muscle

tone.

To evaluate whether the patient has

deficient fiber intake

It may affect elimination

patterns

To promote passage of soft

stool   

To promote peristalsis

Patient verbalized that

she has no problem in defecating

anymore and she also

demonstrated lifestyle change.

P n e u m o n i a | 41

Increase intake of fibers in diet like fruits, vegetables

and wheat

Discuss rationale for and encourage

continuation of successful

interventions.

Dependent:Administer stool softerner or mild

stimulants as prescribed by the

Physiccian

To improve consistency of

stool

To maintain normal bowel movements

To passage of stool

P n e u m o n i a | 42

Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective:• Physical

unsecure side rails

• Due to the change of side of bed

• Insomnia leading to moving from one side of the bed to the other

Risk for injury(fall)

Mother will be encourage to

keep an eye on the baby’s movement

Baby will be free from injury

will make sure side rails are in proper position

Mother was encourage to

keep an eye on the baby by

making sure baby is not left alone in

bed

Baby was monitored

regularly to make sure she was free

from injury

Side rails was checked and

make sure it was raised up to prevent fall

Stress importance of

monitoring condition/risk that may contribute to

occurrence of falls

Prevent from injury

Patient had successfully

displayed appropriate

range of feelings and lessened

fear and demonstrated understanding through use of effective coping behaviors and

resources

P n e u m o n i a | 43

DISCHARGE PLANNING

Medication

Cefuroxime 250mg 15ml, 3ml 2x a day until March 8, 2011

Salbutamol Nebulization 2ml 3x day

Exercise

Parents were advised to conserve the child’s strength. Encourage to turn and reposition

the child’s frequently to avoid pooling of secretions. Chest physiotherapy was taught to

parent (by clapping the back of the baby) to encourage the movement of mucus and

prevent obstructions.

Treatment

Parent was taught on how to administer the medications to the child as noted above

and also to give the right dose at the right time. Encourage to note the day of the

medication and when it supposed to be stopped.

Health Teaching

Parents were advised to care for the child and also make sure the child is well covered

and not exposed to the electric fun and air condition for a long period of time.

Encourage also to increase the fluid intake of the child because the child feels weak in

sucking or to request for water so given enough water to the child achieves a good oral

intake. Encourage to make sure that the environment is free from pollution and other

allergens. Daily cleaning in the room and the surroundings was advised, proper hand

washing by parent was encouraged to prevent infections.

P n e u m o n i a | 44

Outpatient

Note the time and date of follow up on Friday March 11, 2011

Diet

Parents were advised encourage on frequent small feeding and food served should

contain all the six essential food nutrient carbohydrates, proteins, fat, vitamins and

minerals. Encourage to increase the fluid intake too as well. Avoid junk foods and

chocolates that may stimulate cough.

Spiritual

Maintain patients’ good relationship to God and encourage to ask help and guidance in

every circumstances occurred.