I.

Introduction
It was September 7,2010 that we started to gather information about our case study and find the most interesting case that will surely captured our minds about it. At OPD ward, weve noticed a mother carrying her baby boy, a 2 months old with a complaint of difficulty of breathing, having a fever, cough and cold for almost 3 days. Weve see the baby boy pale, with mucus secretion on the nose and prolonged coughing. The baby is also suffer from watery stool. Baby boy is diagnosed with pneumonia by his physician. We chose pneumonia as our case to be study out of curiosity. This is also our first time to encounter this kind of case and because of that, we are willing to do this to challenge our minds in analyzing the problem and enhances our hidden knowledge, and also to gain new experiences which would bring new learnings for ourselves. Pneumonia is a general term that refers to an infection of the lungs, which can be caused by a variety of microorganisms, including viruses, bacteria, fungi, and parasites. Often pneumonia begins after an upper respiratory tract infection (an infection of the nose and throat). When this happens, symptoms of pneumonia begin after 2 or 3 days of a cold or sore throat According to the International Union Against Tuberculosis and Lung Disease, Pneumonia kills more than any other condition affecting the lungs; it is a prime cause of death in young children. There are also 10 to 12 million deaths occur annually in children under 5 years of age over 90% are in the developing world. It is small children who are less than one year of age living in the poorest communities who most often suffer and die from this condition. Pneumonia is often a result of other infections such as measles and pertussis. The frequency of pneumonia in children could be reduced by 10- 20% through immunization with these vaccines. Many Developing countries have very low immunization rates due to funding and delivery problems. According to Department of Health, pneumonia is the number one leading cause of morbidity in the Philippines and top 5 leading cause of death in 2009. In the United States, pneumonia is the sixth most common disease leading to death; 2 million Americans develop pneumonia each year, and 40,000-70,000 die from it. Pneumonia is also the most common fatal infection acquired by already hospitalized patients. In developing countries, pneumonia ties with diarrhea as the most common cause of death. Even in nonfatal cases, pneumonia is a significant economic burden on the health care system. One study estimates that people in the American workforce who develop pneumonia cost employers five times as much in health care as the average worker.

II. Objectives
At the end of the case presentation, nursing student will be able to: 1. Understand what is pneumonia all about, 2. Identify the sign and symptoms, causes and the result of pneumonia 3. Discuss how to prevent pneumonia by health teaching and treat of the occurrence of the disease.

III. Nursing Theory

VIRGINIA HENDERSON Nursing theories mirror different realities, throughout their development; they reflected the interests of nurses of that time. The 14 components

Breathe normally. Eat and drink adequately. Eliminate body wastes. Move and maintain desirable postures. Sleep and rest. Select suitable clothes-dress and undress. Maintain body temperature within normal range by adjusting clothing and modifying environment Keep the body clean and well groomed and protect the integument Avoid dangers in the environment and avoid injuring others. Communicate with others in expressing emotions, needs, fears, or opinions. Worship according to ones faith. Work in such a way that there is a sense of accomplishment. Play or participate in various forms of recreation. Learn, discover, or satisfy the curiosity that leads to normal development and health and use the available health facilities.

The first 9 components are physiological. The tenth and fourteenth are psychological aspects of communicating and learning The eleventh component is spiritual and moral The twelfth and thirteenth components are sociologically oriented to occupation and recreation Hendersons theory and the four major concepts 1. Individual :

Have basic needs that are component of health. Requiring assistance to achieve health and independence or a peaceful death. Mind and body are inseparable and interrelated. Considers the biological, psychological, sociological, and spiritual components. The theory presents the patient as a sum of parts with biopsychosocial needs, and the patient is neither client nor consumer.

2.Environment:

Settings in which an individual learns unique pattern for living. All external conditions and influences that affect life and development.

Individuals in relation to families Minimally discusses the impact of the community on the individual and family. Basic nursing care involves providing conditions under which the patient can perform the 14 activities unaided

3. Health:

Definition based on individuals ability to function independently as outlined in the 14 components. Nurses need to stress promotion of health and prevention and cure of disease. Good health is a challenge. Affected by age, cultural background, physical, and intellectual capacities, and emotional balance Is the individuals ability to meet these needs independently?

4. Nursing

Temporarily assisting an individual who lacks the necessary strength, will and knowledge to satisfy 1 or more of 14 basic needs. Assists and supports the individual in life activities and the attainment of independence. Nurse serves to make patient complete whole", or "independent." Henderson's classic definition of nursing: "I say that the nurse does for others what they would do for themselves if they had the strength, the will, and the knowledge. But I go on to say that the nurse makes the patient independent of him or her as soon as possible." The nurse is expected to carry out physicians therapeutic plan Individualized care is the result of the nurses creativity in planning for care. Use nursing research o Categorized Nursing : nursing care o Non nursing: ordering supplies, cleanliness and serving food.

Comparison with Maslow's Hierarchy of Need Maslow's Henderson Breathe normally Physiological needs Eat and drink adequately Eliminate by all avenues of elimination Move and maintain desirable posture Sleep and rest Select suitable clothing Maintain body temperature Keep body clean and well groomed and protect the integument

Safety Needs

Avoid environmental dangers and avoid injuring other

Belongingness and Communicate with others love needs worship according to one's faith Work at something providing a sense of accomplishment Esteem needs Play or participate in various forms of recreation Learn, discover, or satisfy curiosity

IV. Nursing History

A. Biographical Data Patient Name : Address : Date of Birth : Birth Place : Age : Source of Health Assistance: Religion : B. Chief complaint : Patient J Tondo, Manila July 16,2010 Tondo Manila 2 months old Parents and Hospital Roman Catholic Difficulty of Breathing Fever Watery loose stool

C. History of Present Illness 3 days prior to admission, the patient experienced difficulty of breathing associated with fever , cough and cold. He defecated many times a day and his stool loose and watery. His parents decided to bring him to hospital for observation and proper treatment of his illness. Patient J was admitted on August 29,2010 in Hospital ng Manila and stayed here for 7 days. He was given medications such as ampicillin, paracetamol and salbutamol nebule. He was also undergone CBC. Upon stayed in the hospital, he was getting well and was discharge on September 5, 2010. On September 6,2010, he was cuddled by her mother together with his father came to the hospital for follow-up check-up. D. Past Health History

When the patient was born, he was so very healthy baby. He only experienced fever cough and cold but manageable and treated with over the counter drugs. Upon interview, his mother told me that patient had its immunization like BCG, DPT, and hepatitis B.. E. Family Health History The parents and other members of the family have no known illness.

V. Immunization
Upon interview, his mother told me that patient had its immunization like BCG, DPT, and Hepa B.

VI. Allergies
Patient J has no known allergy.

VII. Home medication/alternative medicine

A lot of time, his mother doing her own diagnoses and self-prescribing of medicine especially over the counter drugs

VIII. Developmental Level

Patient J at 1-2 months old explores the world by using his mouth, especially his tongue. He learned to love and to be loved

IX. Psychosocial History

The baby is often cry and wants to be cuddle a lot. He doesnt have problem feeding and going to sleep if she is well.

X. Pediatric History
The optimal development of children is considered vital to society and so it is important to understand the social, cognitive, emotional, and educational development of children. Increased research and interest in this field has resulted in new theories and strategies, with specific regard to practice that promotes development within the school system. In addition there are also some theories that seek to describe a sequence of states that comprise child development. According to Freuds theory, an infant is categorized in oral phase where a child is seeking pleasure through his mouth. The most powerful urge is to seek immediate satisfaction of impulses such as hunger or discomforts. In relation to the child, When the mother breastfeeds the child, the child experiences oral pleasure and subsequently sucks his or her finger in order to recover this pleasure. The nature of the breast-feeding determines the kind as well as intensity of oral sexuality.

According to Ericksons psychosocial trust vs. mistrust which is the foundation of all psychosocial tasks. Because an infant is utterly dependent, the development of trust is based on the dependability and quality of the childs caregivers. If a child successfully develops trust, he or she will feel safe and secure in the world. Caregivers who are inconsistent, emotionally unavailable, or rejecting contribute to feelings of mistrust in the children they care for. Failure to develop trust will result in fear and a belief that the world is inconsistent and unpredictable. In relation to patient, the child develops trust on the day that he was delivered and cuddled by his mother. Until the day that he was took cared. According to Piagets cognitive tasks, he categorized infants in sensory motor where they developed to have object permanence(infants learns that objects has identity of their own). Infants also begins to recognizes familiar faces, objects and sounds. In relation to Patient, he had familiarize faces of his mother and other members of the family. With its motor development, at 1 month old he already lifts head temporarily, but generally, head must be supported, head sags. At 2 months old, he can carry hand or object to mouth at will reaches for objects but misjudges distances, step o dances reflexes fading, grasp, tonic reflexes, Moro reflexes fading.

XI.Gordons Functional Pattern

Before Hospitalization

During Hospitalization

Analysis

SelfConcept SelfPerceptio Pattern

Patient health is managed by her mother and most of the time her health maintenance is home remedy but if it is needed to seen by a doctor ,she is bringing it to the hospital. She has a close relation with her mother since

The patient mother sees her child a total ill person.

Her health is become poorer.

RoleRelationship Pattern

She has more time with her parents in the

She had a close relationship with her parents.

she take care of her most of the time.

hospital since her parents took care of him .Her family gives support when medications are being given. The patient sleep 10 hours at night time but somnetimes interrupted because of V/S taking. Theres a changes of her resrt and activity because during the hospitalization the patient has 10 hrs.of sleep unlikely before she had a 12 hrs.of sleep at night .And she was also interrupted because of V/S taking. The Sexuality and Reproductive Pattern is not applicable for her age. Theres a changes in her elimination pattern because she had a diarrhea.

Rest and Activity

The patient sleep 12 hours at night time.She usually sleep also in the morning and afternoon.

Sexuality and Reproductive Pattern.

Patient J is female ,and yet a 2 months old baby.

During the hospitalization she use about six diapers because she had a diarrhea. During hospitalization she also breastfed and additional the prescribed medication. During hospitalization she also enjoys thumb sucking most of the time.

Elimination Pattern

Normally she defecates twice a day and urinates regularly using about four diapers.

Nutritional Metabolic Pattern

Patient J is a breastfed which provide her complete nutrition.

The nutritional and metabolic pattern had an a additional because she had a prescribed medication for her illness. There are no significant changes in her

Activity-Exercise Pattern

According to the mother patient J enjoys thumb sucking most of the

Also during hospitalization to

time.

cope it the stress tolerance pattern the patient fed or change the diaper and her mother give love and support. Her mother said she usually cry when she is hungry and uncomfortable due to wet diaper ti cope it the baby was being fed or change the diaper by her mother. The baby can do her natural movement such as blink reflexes,raising her hands and sucking her thumb. Family of patient J is a Roman Catholic and sometimes they go to church on Sunday,Her parents wants her daugther to be a God believing child. She is a baby girl and now 2 months old. Theres are no significant changes during hospitalization her cognitive abilities.

activity-exercise pattern.

Coping Stress Tolerance Pattern

The patient had a full love and support by her parents.

Cognitive Perceptual pattern

During hospitalization the family of patient J cannot go to church to attend the mass but her parent is continuous believe in God.

Her cognitive abilities was appropriate for her age.

Value Belief Pattern

The family of patient J was believe in God.

Reproduction

XII. Physical assessment A. Physical Assessment Findings Height: 55cm Age: 2 months Weight: 6 kgs Chest circumference: 36 cm Head circumference: 36.5 cm Abdominal circumference: 36cm B. Vital sign Temperature : Respiratory Rate: Pulse rate: Blood pressure:

40 C 50bpm 90bpm N/A

IPPA ( inspection, palpation, percussion, and auscultation) Body Part Findings Analysis Nursing Alert
A Appearance and mental status a. Body built, height and weight in relation to clients age b. overall hygiene and glooming His weight is proportion to his height Not neat and unclean normal

c. body odor and breath odor in relation to activity level d. skin color

No body odor, no breath odor

Parents has no enough time for her baby and lack of financial support normal

Advice parents to give enough time to their baby( health teaching)

e. edema f. skin lesion g. skin moisture h. skin temperature

The color of his skin is brown There is no skin discoloration on his body There is no presence of edema No abrasion or lesion It is moist in skin folds His body is warm to touch, flushed skin

normal

Normal Normal Normal Not normal

i. Skin turgor

Poor skin turgor

Not normal

Due to increased body temperature. Render tepid sponge bath . Advise the patients

significant others to increase fluid intake or breastfeeding as possible. j. nails His nail has a convex curvature His fingernails are smooth and it is not dirty His nail bed is pink and it is highly vascular normal

B. Head and neck a.skull

His skull is rounded and has smooth skull contour There is no masses and nodules on his skull His scalp in white in color There is no tenderness The anterior and posterior fontanelles are still soft His hairs are evenly distributed, thick and resilient He has proportional face even to his body Hairs in the eyebrows are evenly distributed, skin intact, it is symmetrically aligned Has discoloration and sunken eyeball

normal

b. fontanelles

normal

c. hairs

normal

d. face f. eyes

normal Normal

Not normal

Teach the mother continue breastfeed her baby

e. ear

His auricle is the same as his facial skin, it is symmetrical to his face

normal

g. nose

Nasal flaring

Due to difficult of breathing

Notify doctor for treatment Have nebulizer

h. mouth

His tongue is in central position, pink in color Dry lips and mucus membrane

Normal

Not normal

Teach the mother continue breastfeed her baby

i. oropharynx and tonsil

C. Thorax and lungs

D.Heart and central vessels E.Abdomen

The color of his oropharynx is pink and it is smooth on posterior wall Adventitious breath sounds such as wheeze and crackles Chest in drawing

normal

Not normal

Notify doctor for treatment Position the baby in a comfortable position

Not normal

Unblemished, uniform in color, Rounded and tend to protrude Hyperactive bowel sound Equal in size on both sides of the body Firm,no tremors, smooth coordinated movement No deformities, no tenderness or swelling He can perform range of motion using his elbows, hands and ankles Moves smoothly and with coordination Presence of reflex Penile skin intact No tenderness and no swelling Slightly more pigmented than the skin of the buttoks Hairless

Normal

Not normal normal

Notify the doctor

F.Musculoskeletal system

a.bones and joints

normal

b.range of motion

normal

G.Neurological system H.Genital and inguinal I.Rectum and anus

normal

Normal

normal

XIII.Diagnostic/Laboratory Exam Laboratory Test : Test Pneumonia-sputum tests Indication Chronic respiratory infections Physiology Staphylococcus pneumoniae causes pnuemonia. The sputum sample is the most reliable sample. Normal Range negative Interpretation Presence of blood and the yellow or brown colour of the sputum indicates positive test.

Sputum Tests. The color of the mucus (sputum) sample coughed up from the lungs can reveal the severity of the disease. Only a sputum sample will reveal the organism causing the infection. The patient coughs as deeply as possible to bring up mucus from the lungs, since a shallow cough produces a sample that usually only contains normal mouth bacteria. Some people may need to inhale a saline spray to produce an adequate sample. In some cases, a tube will be inserted through the nose into the lower respiratory tract to trigger a deeper cough. The physician will check the sputum for:

Blood, which means an infection is present. Color and consistency: If it is yellow, green, or brown, an infection is likely.

The sputum sample is sent to the laboratory, where it is analyzed for the presence of bacteria and to determine whether the bacteria are Gram-negative or Gram-positive. Blood Tests. The following blood tests may be performed:

White blood cell count (WBC). High levels indicate infection.

Normal levels: The normal range for WBC count is 4,300 to 10,800 cells per cubic millimeter (cmm) or 4.3 to 10.8 x 109 cells per liter. A range of 11 to 17 x 109/L may be considered mild to moderate leukocytosis, and a range of 3.0 to 5.0x109/L may be considered mild leukopenia.

Blood cultures. Cultures are done to determine the specific organism causing the pneumonia, but they usually cannot distinguish between harmless and dangerous organisms. They are accurate in only 10 - 30% of cases. Their use is generally limited to severe cases. Detection of antibodies to S. pneumoniae. Antibodies are immune factors that target specific foreign invaders. One type of immunohistochemical test for S. pneumoniae is showing tremendous promise. The presence of antibodies that are responding to mycoplasma or chlamydia infection are not present early enough in the course of pneumonia to allow for prompt diagnosis and treatment. Polymerase Chain Reaction (PCR). In some difficult cases, PCR may be performed. The test makes multiple copies of the genetic material (RNA) of a virus or bacteria to make it detectable. PCR is useful for identifying certain atypical bacteria strains, including mycoplasma and Chlamydia pneumoniae, and possibly, Haemophilus influenzae type b, but it is expensive. One study found that using a real-time PCR test may help quickly diagnose Pneumocystitis pneumonia in HIV-positive patients.

Urine Tests. Urine antigen tests for Legionella pneumophila (Legionnaires' disease) and Streptococcus pneumoniae may be performed in patients with severe CAP. The S. pneumoniae test takes only 15 minutes and may identify up to 77% of pneumonia cases and rule out S. pneumoniae infection in 98% of patients. It may not be useful in children. Invasive Tests. In critically-ill patients with ventilator-associated pneumonia, physicians have tried sampling fluid taken from the lungs or trachea. These techniques enabled the physicians to identify the pneumonia-causing bacteria and start the appropriate antibiotics. However, this made no difference in the length of stay in the ICU or hospital, and there was no significant difference in outcome Chest X-Rays and Other Imaging Techniques X-Rays. A chest x-ray is nearly always taken to confirm a diagnosis of pneumonia.

X-rays are a form of electromagnetic radiation (like light). They are of higher energy, however, and can penetrate the body to form an image on film. Structures that are dense (such as bone) will appear white, air will be black, and other structures will be shades of gray depending on density. X-rays can provide information about obstructions, tumors, and other diseases, especially when coupled with the use of barium and air contrast within the bowel. A chest x-ray may reveal the following:

Complications of pneumonia, including pleural effusions and abscesses White areas in the lung called infiltrates, which indicate infection

XIV. Medical Diagnosis

Pneumonia

XV. Anatomy and Physiology

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. How do the lungs normally work? The chest contains two lungs, one lung on the right side of the chest, the other on the left side of the chest. Each lung is made up of sections called lobes. The lung is soft and protected by the ribcage. The purposes of the lungs are to bring oxygen (abbreviated O2), into the body and to remove carbon dioxide (abbreviated CO2). Oxygen is a gas that provides us energy while carbon dioxide is a waste product or "exhaust" of the body. Nostrils/Nasal Cavity During inhalation, air enters the nostrils and passes into the nasal cavities which the foreign are removed, the air is heated and moisturized before it is brought further into the body. It is the part of the body that houses the sense of smell.

Sinuses It is a small cavities that lined the mucous membrane within the bones of the skull. Pharynx It is a throat carries foods and liquids into the digestive tract and carries air into the respiratory tract. Larynx It is also called voice box located between the pharynx and trachea. It is the location of the adams apple, which in reality a thyroid gland and houses the vocal cords. Trachea The trachea begins immediately below the larynx (voicebox) and runs down the center of the front part of the neck ends behind the upper part of the sternum. Here it divides to form two branches which enter the lung cavities. The trachea (windpipe) forms the trunk of an upsidedown tree and is flexible, like a vacuum tube, so that the head and neck may twist and bend during the process of breathing. The trachea, or windpipe, is made up of fibrous and elastic tissues and smooth muscle with about twenty rings of cartilage, which help keep the trachea

open during extreme movement of the neck. The lining includes cells that secrete mucus along with other cells that bear very small hairlike fringes. This mucus traps tiny particles of debris, and the beating of the fringes moves the mucus up and out of the respiratory tract, keeping the lungs and air passages free. Bronchi The bronchus is the air passage into the lungs. Each lung has one main bronchus, which begins at the end of the trachea or windpipe. The bronchus divides into smaller branches known as segmental bronchi, which then divide into bronchioles. (See "Bronchial Bulbs") Bronchioles The small airways of the lung extending from the bronchi to the alveoli. The bronchioles become inflamed and constricted in asthma, causing breathing difficulties. Alveoli The alveoli are the final branchings of the respiratory tree and act as the primary gas exchange units of the lung. The gas-blood barrier between the alveolar space and the pulmonary capillaries is extremely thin, allowing for rapid gas exchange. To reach the blood, oxygen must diffuse through the alveolar epithelium, a thin interstitial space, and the capillary endothelium; CO2 follows the reverse course to reach the alveoli. There are two types of alveolar epithelial cells. Type I cells have long cytoplasmic extensions which spread out thinly along the alveolar walls and comprise the thin alveolar epithelium. Type II cells are more compact and are responsible for producing surfactant, a phospholipid which lines the alveoli and serves to differentially reduce surface tension at different volumes, contributing to alveolar stability.

XVI. Pathophysiology
Virulent Microorganism

Streptococcus Pneumoniae

Microorganism enters the nose( nasal passages)

Passes through the larynx, pharynx, trachea

Microorganism enters and affects both airway and lung parenchyma

Airway damage

Lung invasion

Infiltration of bronchi

flattening of epithelial cells

Infectious organism lodges

macrophages and leukocytes

Stimulation in bronchioles

necrosis of bronchial tissues

mucus and phlegm production

Alveolar collapse

narrowing of air passage

COUGHING

Increase pyrogen in the body

DIFFICULTY OF BREATHING

Productive/non-productive

FEVER

Necrosis of pulmonary tissue

Overwhelming sepsis

DEATH

XVII. Medical/ Surgical Management

Nebulization Nebulization is similar to vaporization and involves a piece of equipment called a nebulizer. The nebulizer creates a mist of fine fluid droplets which can be combined with antibiotics or airway dilators. Unlike vaporized droplets, though, these droplets are small enough to penetrate down into the lung. (Vaporizers make larger droplets which mostly penetrate to the sinuses only. They are used to moisten upper airway secretions while nebulizers moisten lower airway secretions). Nebulized saline or water may carry antibiotics with it thus providing an additional source of moisture and antibiotic for the sick lung thus deeply treating the infection.

Physical Therapy A technique called coupage is helpful at mobilizing respiratory secretions. The therapists hand is cupped and gently but rapidly taps the patients chest wall repeatedly. This loosens some of the deeper secretions and helps them move into airways. Material in the airway generates coughing which removes these materials from the body. Coupage should be performed at least four times daily and should be continued at home as long as the patient has a cough. Light exercise is also helpful in mobilizing the respiratory secretions. The patient should not be over-exerted as he/she does not have normal lung capacity but one can use ones judgment as to what level of exercise is tolerated by the patient. Oxygen Therapy In most cases, oxygen therapy is not necessary but when a pneumonia patient simply cannot move enough air, there is no substitute for oxygen. Room air is 20% oxygen. An oxygen cage typically is set to deliver 40% oxygen (higher percentages over long term are actually toxic to lung cells), and special oxygen-delivery hoods are also popular. A patient who requires this level of support is extremely sick.

XVIII. Drug Study

Name of Drug
1.Salbutamol

Brand name: albuterol

Mechanism of action relaxes bronchial and uterine smooth muscle by acting on beta2adrenergic receptor

Dosag e nebule + 1 ml NSI q 4

Indication To prevent or treat bronchospasm in patient with reversible obstructed airway disease

Contraindication Contraindicat ed to patients with hypersensitivity to drug or any components of formulation.

Adverse reaction Tremors, headache, dizziness. tachycardia, nasal congestion, nausea, vomiting cough,

Nursing alert Patient Teaching: -Instruct the mother of patients to perform oral inhalation correctly For IV use, do not administer drug without delusion. Do mix with other medication. Discard unused diluted solution after 24 hours. Use cautiously in patient with other allergies, especially to cephalosporin For I.V use:Do not mix with solution containing dextrose or fructose because these solution prompted rapid breakdown of ampicillin Tell to the mother of patient to notify doctor if rash, chills

2. Ampicillin

An 250 mg aminopenicil TIV q 6 lin that inhiblits cell wall synthesis during microorgani sm mutiplication

Systemic infections and acte and chronic urinary tract infections caused by susceptible strains of grampositive and gramnegative organism

Contraindicat ed to patent with hypersensitivit y to to the drug or other penicillin

CNS: Lethargy, hallucination, seizure, dizziness GI: nausea, vomiting, diarrhea, abdominal pain HEMATOLOGIC: anemia,

3.
Paracetamol

Brand name: tempra

Thought to produce analgesia by blocking generation of pain impulse , probably by inhibiting prostaglandi n synthesis in the CNS. It is thought to relived fever by central action in the hypothalami c heat regulating center.

240mg TIV every 4 hours

Mild to moderate pain and fever

Contraindicated in patient with hypersensitivity to paracetamol

HEMATOLO GIC: hemolytic anemia HEPATIC: jaundice, severe liver damage GI: hepatic; necrosis SKIN; rashes

and fever develop Instruct patient to report discomfort at I.V injection site. Tell to the parent of patient to consult a doctor before giving this drug to child under 2 years Tell to the parent not to use for selfmedication of marked fever. Liquid form is recommended for children and for all patients who have difficulty swallowing.

XIX. Nursing Care Plan

Assessment Nursing diagnosis
Ineffective breathing pattern related airway obstruction as manifested by adventitious breath sound dyspnea and nasal faring

Rationale/ analysis
Inability to clear secretions from the respiratory tract to maintain a clear airway.

Planning

Nursing intervention
Independent 1.Place the client position comfortable in a upright or semi-upright position 2.Provide for a period of rest 3. provide reassurance when the client experiencing respiratory distress 4. auscultate chest 5. evaluate cough

Rationale

Evaluation

1. Subjective: The mother saidnahihirapan huminga ang anak ko Objective: Adventitious breath sound such as crackle Dypnea Nasal flaring Vital sign: PR: 190bpm RR: 50breath/minute

Short Term Goal: After 15 minutes of nursing intervention, the client condition will improve by breathing without obstruction Long Term Goal: After 3 hours of nursing intervention, the patient condition will

1.This position promote lung expansion and ventilation as well as comfort 2.Rest is important to reduce fatigue and the work of breathing 3..hypoxia and respiratory distress produce high level of anxiety in the client which tends to further increase tachypnea, fatigue and decrease ventilation 4. to evaluate presence and charater of breath

After 15 minutes of nursing intervention, the patient condition was improved by breathing normally without difficulty

back to normal by breathing normally without difficulty

Dependent 1.Suction aiyway as possible 2.. administer oxygen as orderd 4. Provide analgesic as ordered

5. presence of secraetion indicates possible obstruction Dependent 1. to clear secretion 2..supplemental oxygen reduces hypoxia and associated anxiety 3.Adequate pain relief minimizes splinting and promotes adequate ventilation 1.To determine if After 2 hours rendering nursing intervention, the patients body temperature was subsided from 40 C to 37.5 C After 3 hours of nursing intervention, the patient temperature was maintained in normal ranged of 36.5-37.5 C

2. Subjective: The mother said mainit ang anak ko Objective: Skin is flushing and warm to touch Tachypnia Vital sign: 40 C

Hyperthermia is related to infection as manifested by high body temperature of 40 C, flushed skin and warm to touch

Elevated temperature that results of depresses the hypothalamu s. As a result of soaring body temperature increases the metabolic rate, which in turn, increases heat production.

Short Term Goal: After 30 minutes of nursing intervention, the patient temperature will decrease from 40 C to 37.5 C Long Term Goal: After 3 hours of nursing intervention, the patient temperature will maintain in normal range of 36.537.5 C

.1 Monitor patients temperature. 2 Determine the recent environmental exposure of the patient. 3. Render Tepid Sponge Bath to the patient. 4.Instruct the patients significant others to let the baby wear loose clothing 5 Encourage the patients significant others to avoid the baby in noisy environment. 6. Advise the patients

theres any alteration of the temperature. 2.May help identify causative environmental factors. 3.May help to lower down temperature by conduction 4.To prevent from feeling cold and shivering. 5.To have adequate rest and sleep. 6.To meet the increased metabolic demands and prevent dehydration. 7.Used to reduce fever.

significant others to increase fluid intake or breastfeeding as possible. Dependent: 7. Administer antipyretic as possible 3. Subjective data: The mother said maraming beses dumudumi yong anak ko sa isang araw Objective; -Sunken eyeball -Watery stool 5 times a day -poor skin turgor -lips and mucus membrane are dry Diarrhea related to loose bowel movement secondary to dehydration as manifested by dry lips and mucus membrane and sunken eyeball Decreased intravascular , interstitial and/or intracellular fluid. This condition might be result dehydration thats why it need immediate treatment or intervention Short term Goal: After 1 day of nursing intervention, there will be an improvement in the condition of the patient by defecating soft formed stool. Long term Goal: After 3 day of nursing intervention, the patient condition will back to normal by defecating twice a day of solid formed stool. 1. Evaluate diet history and note nutritional/fluid and electrolyte status. 2.detremine recent exposure to different and foreign environment 3.auscultate the abdomen 4. weigh infant diapers 5. provide prompt diaper change and gentle cleansing 6..Increase oral fluid intake 7.monitor I/O balance 8. Provide for a period of rest Dependent: Administer antidiarrheal medication 1. to assess causative factors 2. that may help identify causative environmental problem Infant/young and other nonverbal persons cannot describe thirst 3. for the presence, location, and characteristics of bowel sounds 4.to determine amount of output and fluid replacement needs 5. because skin breakdown can occur quikly when diarrhea is present 6. to maintain fluid status and it will help to solidify the stool 7. to maintain fluid status 8. Rest is important to reduce fatigue Afte 1 day of nursing intervention, the patient condition was improved due to the passage of soft formed stool.

After 3 day of nursing intervention, the patient defecated twice a day of solid formed stool and his condition was back to normal.

To decrease gastrointestinal motility and minimize fluid looses

XXII. Discharge Plan

M (MEDICATION)

Take the entire course of any prescribed medications. After a patients temperature returns to normal, medication must be continued according to the doctors instructions, otherwise the pneumonia may recur. Relapses can be far more serious than the first attack. E (EXERCISE & ACTIVITY) Get plenty of rest. Adequate rest is important to maintain progress toward full recovery and to avoid relapse. Instruct the parent to monitor the clients position, she must be in moderate high back rest and change position every two hours. T (TREATMENT) Give supportive treatment. Proper diet and oxygen to increase oxygen in the blood when needed. Treatment is one of the main factors in restoration of health and curing of the failure in the body system. Treatments are given to the patient for a specific time until treatment is not more needed by the patient. H (HOME TEACHING IN REACTION TO DISEASE, ETIOLOGY & HYGIENE MEASURES) Encourage the parent to wash or wipes patients hands. The hands come in daily contact with germs that can cause pneumonia. These germs enter ones body when he touch his eyes or rub his nose. Washing hands thoroughly and often can help reduce the risk. Tell guardian to avoid exposing the patient to an environment with too much pollution (e.g. smoke). Smoking damages ones lungs natural defenses against respiratory infections. Protect others from infection. Try to stay away from anyone with a compromised immune system. When that isnt possible, a person can help protect others by wearing a face mask and always coughing into a tissue. O (OUT PATIENT FOLLOW UP) Keep all of follow-up appointments. Even though the patient feels better, his lungs may still be infected. Its important to have the doctor monitor his progress. D (DIET) Drink lots of fluids, especially water. Liquids will keep patient from becoming dehydrated and help loosen mucus in the lungs. Controlled diets are designed to avoid excessive sodium retention. S (SPIRITUALITY) Advise the mother of patient to join the church activities. Keeping faith in God and believing in him can uplift some distress.

CASE PRESENTATION
ABOUT

PNEUMONIA
SUBMITTED BY:

BSN III-10 GROUP 40

WILLIAMS,JANICE E. RUIZ,EMERSON VILLANUEVA, DAVID BATOON,VANESSA EDROSO,GELLIE ORVILLE,ELLO BASAL, KEVIN EUSTAQUIO,SHERRY ANN SUMANG,FRANCES IVAN
SUBMITTED TO:

PROFESSOR ROGELYN EDRADA CLINICAL INSTRUCTOR