Professional Documents
Culture Documents
CASE STUDY
ON
PNEUMONIA
Submitted by:
GARCIA, Neil A.
BSN-3E
Group 6
Submitted to:
Ms. Joann Guzman, RN
Clinical Instructor
September, 2009
I. PATIENT ASSESSMENT DATA BASE
A. GENERAL DATA
1. Patient’s Name: K. I.
2. Address: Sison, Pangasinan
3. Age: 1 y/o & 1 mo.
4. Sex: Female
5. Birth Date: July 18, 2008
6. Rank in the Family: 1st child
7. Nationality: Filipino
8. Civil Status: Single (child)
9. Date of Admission: August 30, 2009
10. Order of Admission:
> Please admit order re service of Dr. Callanta
> secure consent
> I & O every shift & record
> Monitor VS q 4° & record
> DAT with SAP
> Dx with CBC, CXR
> IVF D5 0.3 NaCl 500cc X 37-38 ugtts/min
> Cefuroxime 250mg IVP q 8° ANST (-)
> Pediatapp drops 1ml TID
> Salbutamol + Ipratopium ½ neb q 6°
> Paracetamol drops 100mg/ml 1ml q 4° prn for fever
> E-zinc drops 1ml OD
> refer accordingly
11. Attending Physician: Dr. Callanta, MD
B. CHIEF COMPLAINT
E. FAMILY ASSESSMENT
Attainment
4th Year
Highschool
Marilyn Oligo Mother 23 Female none
G. HEREDO-FAMILIAL ILLNESS
H. DEVELOPMENTAL HISTORY
for
children
I. PHYSICAL ASSESSMENT
A. General Survey
B. Vital Signs
T: 37.2 °C
RR: 56 bpm
CR: 140 bpm
C. Regional Exams
Skin
> color inspection fair-skinned, no
discoloration and
hyperpigmentations
> texture palpation smooth, soft
> temperature palpation warm to touch
> moisture palpation moist due to perspiration
Nails
> color of nailbed inspection pink and clean
> texture palpation smooth
> shape inspection convex curvature
> nail base inspection firm
Hair
> color inspection black
> distribution inspection evenly distributed
> moisture inspection not excessively dry or oily
> texture inspection fine, silky, resilient
Eyes
> eyebrows inspection symmetrically aligned,
equal movement
> eyelashes inspection slightly curved upward
> eyelids inspection smooth, pink, close
symmetrically
> ability to blink inspection blinks voluntarily and
bilaterally
> ocular movement inspection eyes move freely
> size inspection medium
> texture palpation mobile, firm, not tender
> conjunctiva inspection transparent with light
color, shiny and smooth, no
lesions
> cornea inspection clear, shiny, smooth,
transparent
> pupils inspection equal size, round and
constricts briskly, equally
reactive light,
Nose
> symmetry, shape, inspection
size and color symmetrical, smooth and
> mucosa color inspection fair
> nasal septum inspection pinkish
> nasal discharge inspection oval and symmetrical nares
> sinuses palpation with clear discharges
not tender
Mouth
> lips inspection pinkish, symmetrical, soft
and moist
> gums inspection pinkish and moist
> buccal mucosa inspection pinkish, soft, moist
> tongue inspection pinkish, small, symmetrical
> uvula inspection at the midline
> teeth inspection 6 milk teeh
Heart
> heart rate auscultation 140 bpm
> heart sounds auscultation clear
Upper Extremities
> skin color inspection fair
> size inspection equal and appropriate for
her body
> symmetry inspection symmetrical
Lower Extrremities
> skin color inspection fair
> size inspection equal and appropriate for
her body
> symmetry inspection symmetrical
Neurologic
> level of interview responds quickly when name
consciousness was being called
> behavior and interview makes eye contact, normal
appearance behavior of a toddler
> mood interview irritable
> mannerisms and interview likes to cuddle to her
actions mother
B. Mother
Complications of delivery: there were no complications as
recalled by the mother
Anesthesia: no anesthesia
Exposure to teratogens: none
V. INTRODUCTION
Causes of Pneumonia
• Bacteria
• Viruses
• Mycoplsmas
• Other infectious agents such as fungi – including
pneumocystis
• Various chemicals
Symptoms
• Headache
• Excessive sweating and clammy skin
• Loss of appetite
• Excessive fatigue
• Confusion in older people
• Chest x-ray
• Gram’s stain and culture of the sputum for the organism
causing the symptoms
• CBC to check white blood cel count; if high, this
suggests bacterial infection
• CAT scan on the chest
• Pleural fluid culture if there is fluid in the space
surrounding the lungs
Treatment
Complications
Prevention
II. PATHOPHYSIOLOGY
DIFFICULTY OF BREATHING
necrosis of pulmonary
tissue
overwhelming sepsis
DEATH
Hematology Report
Differential Count
Chest X-ray
Impression : Pneumonia
September 1, 2009
It was being recommended by the attending physician that
the patient needs to stay at the hospital for further
observations since it was seen that the disease at this point
of the treatment process still cannot be managed at home by
medications only.