PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA

A Case Study Presented to The Faculty of the College of Nursing LORMA COLLEGES City of San Fernando, La Union

In Partial Fulfillment of the Requirements for the Degree of Bachelor of Science in Nursing

By: Abaggo, Hershey Clarisse Agaid, Grethel Joey Aguda, Tia Marie Bautista, Nikkola Cabagbag, Kristel Elumba, Penny Joy Galindo, Ellen Lorie Gaona, Elemyr Laroco, Abegael L. Vendiola, Loryn

August 2010 I. INTRODUCTION

Pediatric community-acquired is diseases in which individuals who have not recently been hospitalized develop on infection of the lungs (pneumonia). PCAP is a common illness that affects infants and children. PCAP often causes problems like difficulty in breathing, fever, chest pain and cough. PCAP occurs because the atmosphere or the areas of the lungs which absorb oxygen (alveoli) from the atmosphere become filled with fluid and cannot work effectively. PCAP occurs throughout the world and is a leading cause of illness and death. The cause of PCAP includes bacteria, viruses, fungi and parasites. PCAP can be diagnosed by symptoms and physical examination alone, through x-rays, examination of the sputum and other tests are often used. Individuals with PCAP are primarily treated with antibiotic medication in the hospital some forms of PCAP can be prevented by vaccination. PCAP usually acquired via inhalation or aspiration of pulmonary pathogenic organisms into a lung segment or lobe. Less commonly, PCAP results from secondary bacteria from a distant source, such as Escherichia coli urinary tract infection and/or bactericidal. PCAP is due to aspiration of oropharyngeal contents is the only form of PCAP involving multiple pathogens. The proportion of children with pneumonia who are diagnosed with a specific etiology is low. Unlike adults, children usually do not produce adequate sputum specimens for Gram stain and culture. Blood cultures have a yield of less than 10% in patients with bacterial pneumonia. Lung puncture studies that are conducted in developing countries are obviously not met with enthusiasm in general pediatric practices. Prospective studies that have employed sensitive antibody tests and polymerase chain reaction techniques have suggested that in up to 20% of pediatric communityacquired pneumonias, the infection is mixed (i.e., both S. pneumoniae and M. pneumoniae or C. pneumoniae); in these cases, the primary pathogen is

not clear. Authors of these studies have also suggested that mixed infection with bacteria and respiratory viruses is likely to be common as well. Many studies have looked at causes of pediatric pneumonia as it relates to certain readily available laboratory measurements. Many clinicians consider S. pneumoniae to be the likely cause of the lower respiratory infection if the picture is characterized by acute onset of high fever, lobar pneumonia on chest radiograph, leukocytosis, and a rapid response to lactam antibiotics. Numerous studies have found that chest radiographs do not readily distinguish between bacterial, atypical bacterial, and viral pneumonia. A variety of laboratory tests have been used in the attempt to distinguish bacterial from viral pneumonia, including the C-reactive protein and absolute neutrophil counts. One problem in using screening tests is that specific cutoff levels have often not been established. A recent study done in Europe found that although white blood cell count and C-reactive proteins were statistically higher in patients with pneumococcal infections, other clinical and laboratory and radiographic studies were of little value. Given the clinical, epidemiologic, and laboratory difficulties in pinpointing the cause of pediatric pneumonia, an additional approach is to divide patients by age. The primary bacterial pathogen in neonatal pneumonia is group B streptococci, although Escherichia coli and Listeria monocytogenes have also been reported. The mechanism is similar to that in neonatal sepsis, where colonization from the mother results in neonatal colonization and breakthrough infection. Chlamydia trachomatis is the most common sexually transmitted infection in the United States. The organism may reside in the genital tract of pregnant women and be transmitted in about 60% of cases to infants at the time of delivery. About one half of infants who acquire the organism develop conjunctivitis, and 20% eventually develop lower respiratory disease.

Pneumonia caused by bacteria such as group B streptococcus typically occurs in the first weeks of life, presenting with fever, increased work of breathing, and hypoxia. C. trachomatis infection usually occurs between 2 and 19 weeks after birth. The infants are afebrile, have increased respiratory rate, and cough. Children with chlamydial pneumonia often have hyperinflation, and bilateral infiltrates on chest x-ray, eosinophilia, and elevated serum immunoglobulin levels. Cultures of the blood, urine, and even cerebrospinal fluid are often obtained and intravenous antibiotic started. C. trachomatis can be diagnosed by culture or direct fluorescent antibody staining of nasopharyngeal secretions. The management of the febrile tachypneic neonate suspected of having pneumonia is similar to that of neonatal fever. Empiric intravenous antibiotics are started until culture results are final. Empiric treatment usually consists of ampicillin combined with gentamicin or a third-generation cephalosporin. Treatment of C. trachomatis is with oral erythromycin, 50 mg/kg per day in four divided doses for 2 weeks. In the past, erythromycin was given to neonates exposed to C. trachomatis at the time of delivery. Recently, there has been an association reported between oral erythromycin and the subsequent development of hypertrophic pyloric stenosis in infants younger than 6 weeks of age. The current recommendation is to treat with oral erythromycin, 50 mg/kg per day in four divided doses for 14 days all infants with chlamydial conjunctivitis and pneumonia. Patients who are exposed at the time of delivery are not presumptively treated, but rather monitored closely for the development of disease. Routine screening of all pregnant women for sexually transmitted disease is helpful in reducing disease by C. trachomatis. The peak incidence of this viral pathogen is in the first 6 months of life. Respiratory syncytial virus (RSV) typically occurs annually during the winter months. The spectrum of disease includes significant bronchiolitis and

pneumonia in infants and younger children to a mild upper respiratory infection in older children. Patients with underlying conditions such as bronchopulmonary dysplasia, congenital heart disease, or underlying immunodeficiency are at risk for a more severe course. RSV is diagnosed rapidly using a direct fluorescent antibody on nasal secretions. An aerosolized antibiotic agent, ribavirin, has been used in the treatment of RSV disease in infants. The use of ribavirin remains the subject of continuing debate. Citing new evidence, the American Academy of Pediatrics changed its recommendation in the 1990s regarding the use of ribavirin and now has a less stringent may be considered recommendation for its use in RSV infections in children with underlying conditions such as immunodeficiency, congenital heart disease, or chronic lung disease. Children with less serious disease need only supportive treatment. Pneumonia in children 4 months to 5 years of age was caused by viral pathogens again predominate in this age group, with RSV, parainfluenza, influenza, and adenovirus being common pathogens. The primary bacteria causing pneumonia in infants and children remains S. pneumoniae. Some studies also report M. catarrhalis, and nontypeable H. influenzae as pathogens. STATISTICS: World Wide According to WHO and BTS criteria, severe CAP was present in 57 (50%) and in 96 (85%) cases, respectively; 29 (26%) were aged less than 1 year. The median age (months) was 22 (mean 24 14, range 2-58). Overall, radiographic finding was right-sided in 77 (68%) cases and the upper lobe was compromised in 36 (32%) cases. By analyzing data stratified to age, the frequency of upper lobe involvement was significantly higher among severe cases (WHO criteria) only for those patients aged 1 year (13/35 [37%] vs. 7/45 [16%], P = 0.03, OR [95% CI] 3.2 [1.1-9.2]). The specificity and positive predictive value of

upper lobe involvement for severity among the latter group of patients were 84% (95% CI 70-93%) and 65% (95% CI 41-84%), respectively. No association was found by using the BTS criteria. The admission chest radiography was useful to predict severity of children aged 1 year hospitalized with CAP. Pediatr Pulmonol. 2009; 44:249-252. 2009 Wiley-Liss, Inc. National

Regional 1= Lorma Medical Center =

REASON FOR CHOOSING THE CASE: It is due to the motive to learn and apply our knowledge and skills in caring the patient with pediatric community acquired pneumonia (PCAP). This is a rare case since the patient is only 6 month old. Family Centered Objectives: Our family centered objectives would remain to be our most significant motive in conducting this case study. They are as follows: The parents of the patient will be able to understand the causes and therapeutic management regimen

The parents will be able to consider and demonstrate the proper way of breastfeeding and guidelines for the condition.

The parents will be able to verbalize the importance of increase fluid intake.

The parents will be able to identify potential complications and how to initiate appropriate preventive or corrective actions.

II. NURSING HEALTH HISTORY: A. BIOGRAPHIC DATA Client MT is a 6 month old, female, was born January 28, 2010 in Biday, San Feranando City La Union. She is the youngest daughter of Mr and Mrs NT. She is a Roman Catholic. She was admitted on July 31, 2010 9:40 PM at Lorma Medical Center by Dr. Rapisura, Carie Q.,MD and Dr. Orlindo, Maria Teresa V.,MD as her attending physician. B. CHIEF COMPLAINT The patient was admitted due to the chief complaint of high grade fever, 38.6 C via axilla, productive cough and difficulty of breathing. C. HISTORY OF PRESENT ILLNESS The present condition started 3 days prior to admission when the patient had dry cough with associated difficulty of breathing. No other associated signs and symptoms such as diarrhea and vomiting. No consultation done or medication taken. 2 days prior to admission, the above condition persisted associated with neither fever, still no consultation done nor medication taken.

Few hours prior to admission, due to persistence of the above condition, she was then brought in the institution and was then admitted on July 31, 2010 at 9:40PM with the vital signs of T-38.6C, PR-135bpm, RR68bpm, O2sat-98%, weight-6.4kg, height-58.5cm and a BMI of 18.90 kg/m2 (healthy weight) 22 as ideal with a range of 18.5-25 D. PAST MEDICAL HISTORY The mother stated that the patient was not hospitalized nor had illnesses before. The patient had no allergies to drugs. The mother also claimed that the patient already received her BCG and Hepa B vaccines, 1 dose each, 1 week after her birth at the health center, and had her vaccines in DPT and OPV with 1 dose each when she was 6th week old. E. PEDIA HISTORY The patient was born to a 33 year old mother with a 38-39 weeks age of gestation via NSD at home. The mother stated that there were no complications happened nor the mother acquired illnesses during her pregnancy period. F. FAMILY HEALTH HISTORY The mother of the patient claimed that both sides of the patient has history of asthma. And no other hereditary illnesses present such as diabetes, cancer and hypertension. G. LIFESTYLE In an interview, mother said that their house is a concrete bungalow, located along the highway and near to other houses. The patient is a pure breastfed baby, the mother verbalized that she didn't introduced any solid foods yet. The family is using firewood in cooking their foods. While their drinking water comes from a well which the mother

boils before giving to her children. They are also using dipper in taking a bath and flushing their toilet. The mother also claimed that the patient's uncle who lives with the family is an active smoker. And this can one of the precipitating factors that contributed on the patients case for her lungs are still sensitive since patient is still 6 month old. Health teaching was done to the mother by encouraging the mother to advice the uncle to minimize smoking and not to smoke near their house. H. SOCIAL HISTORY The mother also claimed that, their family are active and concern citizen of the community, they also mingles with their neighbors and always active participates in activities, education in their community. Just like a typical family relationships, there are some

misunderstanding experienced by the family but usually it only lasted for a day, they fix the problem in a calm manner. The patient's mother described their family as a traditional Filipino family, wherein they eta together, live together and giving respect with one another. I. EALTH PRACTICES When a member of the family got sick, they always consult to a medical doctor. They don't have any private family physician. They also believe in hilot but they never use any herbal medicines that were being prescribed to them, they only taking medicines which are prescribed only by a physician. J. DEVELOPMENTAL TASK

According

to

Erik

Erikson's

Psychosocial

Theory

of

Human

Development, the patient is under Trust vs. Mistrust Stage. Wherein the patient always depend all her needs on her mother, which is the main caregiver of the child. When trust did not develop well it will result to mistrust which can be developed when the needs of the patient were not given attention. From Freuds Psychosexual Theory, the patient is under Oral stage. Wherein, the child cries when she needs something. And during also this stage that mouth or oral is only the means of her satisfaction. According to Piagets Cognitive Theory, she is under the Preoperational Stage. The id personality dominates during this age. The infant only wanted to be supplied with all her pleasures like attending and pampering her all the time.

III. PHYSICAL ASSESSMENT Date examined: August 3, 2010 Time Examined: 12:30 PM I. GENERAL STATISTICS A Filipino female client, conscious and with a normal body built. A. Vital signs RR: 60 bpm

TEMP: 36.5 C CR: 142 bpm OXYGEN SAT: 99% B. Height and weight: Height 58.5 cm Weight- 6.4kg BMI- 18.90 kg/m2 (healthy weight) 22 as ideal with a range of 18.5-25 II. HEAD AND NECK A. Head The head is round with no nodules or masses and depressions. B. Eyes The eyes are symmetrically aligned and eyebrows are evenly distributed with no discharge or discoloration on the eyelids. Conjunctiva on both eyes is pinkish in color, and the sclera is normal in color. The pupils are black round and equal in size and are reactive to light and accommodation. C. Ears The ears are symmetrically aligned and the color is same as the facial skin, it is firm and not tender. No serum and discharges noted. D. Nose The nose is symmetrically aligned with the face, no discharges, with flaring nares. It is the same color with the face. It is not tender and no lesions present. The mucosa is pink. The sinuses are not tender when palpated.

E.

Mouth

The lips are pinkish in color and moist. No ulcerations or lesions noted. The tongue moves freely and not tender. The client possesses pink gums with no teeth yet. III. INTEGUMENT: 1. Skin The skin of the client is moist, pale and has a good skin turgor. Has a fair skin complexion.

2. Hair and Scalp The hair are equally distributed with a thin hair strands; well kept; no lice or dandruff seen/noted. 3. Nails Clients nails are normally transparent and convex. The surrounding cuticles are intact and without inflammations noted. Has a normal capillary refill with 1 to 2 seconds. IV. THORAX and LUNGS The chest contour is symmetrical, the spine is vertically aligned. The chest wall is intact, no tenderness or no masses noted. Upon auscultation rales was being noted. V. HEART There is no presence of abnormal pulsations when the heart was auscultated. No murmurs and friction rubs heard upon auscultation. VI. BREAST

The breasts are even with the chest wall, skin is smooth and intact. Areola is round and bilaterally the same. The nipples are round and equal in size, no discharge noted. The breast are not tender, no masses or nodules noted. VII. ABDOMEN The abdomen is intact, round and with normal bowel sound heard upon auscultation. Has a darken umbilicus. No deformities seen. VIII. EXTREMITIES: On the upper extremities no deformities noted. The has a D5IMB L at the left hand. While on the lower extremities, no deformities were noted. IX. GENITAL AND RECTAL: Upon inspection there were no deformities, no rashes, no abnormal secretions were present.

IV. ANATOMY AND PHYSIOLOGY

Anatomically, the respiratory system structures are divided into: Upper respiratory tract and Lower respiratory tract The upper respiratory tract is located in the head and neck and consists of the: Nose Pharynx Larynx

NOSE: Regions of the nose include the external nose and the nasal cavity. Air moves from the nostrils to the back of the nasal cavity where it exits through the posterior nares. The function of the nasal cavity is to clean, warm and dampen the air that enters so that it can travel throughout the body. REGIONS OF THE PHARYNX: Air moves into the nasal cavity through the nostrils (nasopharynx). The oropharynx opens into the oral cavity which encloses the lips, teeth, cheek, hard and soft palates, tongue and tonsils. Extending from the tip of the epiglottis to the glottis and the esophagus is the laryngopharynx and positioned in the anterior neck is the larynx. LARYNX The larynx is a passageway between the pharynx and the lower airway structures. It is a short tube made up of supportive cartilage, ligaments, muscle and mucosal lining. The supportive cartilage prevents food and drink from entering the larynx while swallowing. The lower respiratory tract is located in the chest and makes up the: Trachea Bronchial tree Lungs Air passes from the larynx to the lungs (trachea).The trachea divides into the right and left primary bronchi (bronchial tree) and the large pair of spongy organs (lungs) are used for respiration. TRACHEA: Also known as the windpipe, the trachea is a 10-12cm tube that runs through the lower neck and chest. The wall of the trachea is made of hyaline cartilage which enables the trachea to stay open so that air can be

conducted between the larynx and primary bronchi.

BRONCHIAL TREE The bronchial tree consists of a primary, secondary (lobar) and tertiary bronchi (segmental bronchi). The trachea splits into the right and left bronchi at the level of the sternal angle. The secondary bronchi forms when the primary bronchus enters the lung; and conducts air directly to one of the five lobes within the lung. Tertiary bronchi derive from the secondary bronchi and conduct air to and from the bronchial segment. There are 8 bronchial segments in the left lung and 10 in the right lung. LUNGS: The lungs are paired cone-shaped organs which take-up most of the space in the chest with the heart. Their role is to take oxygen into the body, which we need for the cells to live and function properly, and to help us get rid of carbon dioxide, which is a waste product. There are two division of the lungs, the left and the right lung. These are divided up into lobes or big secretions of tissues separated by fissures or dividers. The right lung has three lobes but the left lung has only two, it is because the heart takes up some of the space in the left side of the chest. The lungs can also be divided up into even smaller portions, called bronchopulmonary segments. These are pyramidal-shaped areas which are also separated from each other by membranes. There are about 10 of them in each lung. Each segment receives it's own blood supply and air supply. Air enters the lungs through a system pipes called the bronchi. Theses pipe start from the bottom of the trachea as the left and right bronchi and branch many times through out the lungs, until they eventually form little thin-walled air sacs or bubbles, known as the alveoli. The alveoli are important in the gas exchange where it takes place between the air and the blood. Covering alveolus is a whole network of

little blood vessel called capillaries, which are very small branches of the pulmonary arteries. It is important that the air in the alveoli and the blood in the capillaries are very close together, so that oxygen and carbon dioxide can diffuse between them. Mechanics of Breathing To take a breath in, the external intercostals muscles contract, moving the ribcage up and out. The diaphragm moves down at the same time, creating negative pressure within the thorax. The lungs are held to the thoracic wall by the pleural membranes, and so expand outwards as well. This creates negative pressure within the lungs, and so air rushes in through the upper and lower airways. Expiration is mainly due to the natural elasticity of the lungs, which tend to collapse if they are not held against the thoracic wall. This is the mechanism behind lung collapse if there is air in the pleural space (pneumothorax). Physiology of Gas Exchange

Each branch of the bronchial tree eventually sub-divides to form very narrow terminal bronchioles, which terminate in the alveoli. There are many millions of alveloi in each lung, and these are the areas responsible for

gaseous exchange, presenting a massive surface area for exchange to occur over. Each alveolus is very closely associated with a network of capillaries containing deoxygenated blood from the pulmonary artery. The capillary and alveolar walls are very thin, allowing rapid exchange of gases by passive diffusion along concentration gradients. CO2 moves into the alveolus as the concentration is much lower in the alveolus than in the blood, and O2 moves out of the alveolus as the continuous flow of blood through the capillaries prevents saturation of the blood with O2 and allows maximal transfer across the membrane.

Resource: An Online Examination of Human Anatomy and Physiology. GetBodySmart:Interactive by ConceptCreators Inc

V. DISEASE ENTITY/ PATHOPHYSIOLOGY

Predisposing Factor AGE (6months old)

Precipitating Factor ENVIRONMENT LIFESTYLE

Streptococal Infection

Enters through nose or mouth by Inhalation

Passes to the pharynx, larynx & trachea

Microorganisms enters the affects both the lung parenchyma Lung invasion

Infection lodges and stimulates in the parenchyma

Lung Invasion Leukocytes increased

Narrowing of air passage Mucus and phlegm

DIFFICULTY BREATHING

COUGHING INEFFECTIVELY

VI. DIAGNOSTIC EXAMINATION / LABORATORY RESULTS

LORMA MEDICAL CENTER HEMATOLOGY SECTION July 31, 2010

RESULT Hemoglobin 105

NORMAL 127-183 g/L

INTERPRETATIO N -Decrease hemoglobin indicates anemia

Hematocrit

0.31

0.40-0.50

-Decreased hematocrit indicates anemia, such as that caused by iron deficiency -it may also indicate that the patient has vitamin or mineral deficiency

White Blood Cell

11.1

5-10 x 10^9 g/L

-Increase WBC may be due to inflammation

-bands

-segmenters -eosinophils -basophils -lymphocytes -monocytes Platelet count

0.56 0.05

0.50-0.70 0.00-0.05 0.00-0.01 0.20-0.40 0.00-0.07 150-400 x 10^9/L

Normal Normal

0.32 0.07 402

Normal normal -high platelet count is a reaction to inflammation, infection, anemia,

Irene J. Frigillana, RMT Medical Technologist

LORMA MEDICAL CENTER CHEST X-RAY

Chest x-ray including the anterior, posterior, and lateral was conducted last July 31, 2010. The result indicates opacities on the both lung fields. Notably the upper lobes and paracardiac areas. The heart is not enlarged. And the diaphragm and bony thorax are intact. The impression of the above results indicates that the patient has a bilateral pneumonia.

IMPRESSION: BILATERAL PNEUMONIA

Robert Rana, MD, FPOR (Radiologist)

IX. EVALUATION Good adherence to health care teachings provided to our client and parents became the reason of meeting our family centered objectives.

Before any nursing intervention, we made it a point that we were able to understand the disease itself and its proper management. Rendering health teaching is one of the important tools to help promote the health of the patient. We established a trusting relationship with the parents especially the mother which enable us to provide efficient nursing care. A good nursepatient interaction plays a vital role in meeting the objectives. This is met through creating an environment of trust in listening to the mother of the patient concern and being available to clients side. This enables us to established rapport and respect needed before the mother of the patient will be willing to take part in the learning process. We the student discussed about the disease of the patient to the mother and how it is acquired. Maybe, caused by their environment, lifestyle and also hereditary. To prevent such disease, the parents or the family should clean their surroundings and before handling the baby they must do handwashing to prevent spread of microorganism. Most important thing is for them to give vitamin C to protect her immune system and the importance of completing all the immunizations provided by the Department of Health especially the DPT vaccine which helps the child to prevent in having pneumonia. Certain health teaching was discussed to the mother like the importance of adhering therapeutic management regimens like taking the medications and knowing its advantages or benefits and the effects and adhering to proper hygiene like cleaning the breast with water before the baby will suck and washing the hands before handling the baby. We also imparted to them knowing the potential complications and how to initiate appropriate preventive or corrective action. Lastly we were able to encourage the patients mother on the proper positioning while breast feeding or when propping up the baby in order to increase its intake and prevent aspirations and to help immobilizing secretions. The patient is still confine in the 3B- pedia at Lorma Medical Center.