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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
P n e u m o n i a | 30
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
P n e u m o n i a | 31
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
P n e u m o n i a | 32
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
P n e u m o n i a | 33
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
P n e u m o n i a | 35
• 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
P n e u m o n i a | 37
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
P n e u m o n i a | 39
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.
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