Professional Documents
Culture Documents
Case Study
Case Study
Case Study
Case Study on
Pediatric Community Acquired
Pneumonia and
Urinary Tract Infection
Submitted by:
Chara Marie N. De dios
Kashmira P. Canda
Submitted to:
Ma. Hazel D. Cayena, RN, MAN
CLIENTS HISTORY
PATIENT'S PROFILE
NieroRainiel Gomez, is a 2 years old male, residing at Purok 1, Rosary Heights 9,Cotabato City.
Her mother is Lorina Gomez, 36 y/o, works as a cashier teller and her father is Roni Gomez, 37
y/o, works as a security guard. Niero was born on November 2, 2012 and was born at Notre
Dame Hospita, Cotabato City. Their whole family is Filipino in nationality and Roman Catholic
in religion. He was admitted on February 16,2015 at the Pedia Respiratory Ward at
CotabatoRegiona and Medical Center with the chief complaint of cough and fever threedays
prior to admission. Hewas diagnosed with Pediatric Community Acquired Pneumonia and
Urinary Tract Infection.
PHYSICAL ASSESSMENT
Neurological Assessment
Orientation
Not applicable
Appropriate behavior/communication
Crying
Level of Consciousness
Conscious
Emotional State
Anxious
Skin
General Color
Light brown
Texture
Smooth
Turgor
Temperature
Warm
Moisture
Dry
Head
Facial Movements
Symmetrical
Fontanels
Closed
Hair
Fine
Scalp
Clean
Eyes
Lids
Symmetrical
Conjunctiva
Pale
Sclera
White
Reaction to light
R- Brisk
L- Brisk
Reaction to accommodation
Nose
Uniform constriction
Septum
Midline
Mucosa
Pinkish
Sinuses
Non-tender
Ears
External Pinnae
Symmetrical
Hearing acuity
Normal
Mouth
Lips
Tongue
Midline,slightlyrough,pinkish
Teeth
No missing noted
Gums
Pinkish
Uvula
Midline
Tonsils
Not Inflamed
Neck
Trachea
Midline
Thyroids
Non-palpable
Abdomen
General
Configuration
Symmetrical
Bowel Sounds
Normoactive
Normal
Fair
Spine
Midline
Cardiovascular Status
Point of Maximal Impulse (PMI)
Heart Sounds
Regular
Peripheral Pulses
Regular
Capillary Refill
2 seconds
Respiratory Status
Breathing Pattern
Irregular
Shape of Chest
Lung Expansion
Symmetrical
Percussion
Resonant
Breath Sounds
Cough
Non-productive
GENERAL ASSESSMENT
The patient is crying and irritable upon observation he was also anxious. Fast breathing
is observed when doing inspection with an RR of 54 bpm. There is crackles sound heared upon
auscultation when the patient is inhaling and exhaling. The patienthas a pale conjunctiva and has
a crack and dry lips. The skin tone is evenly colored without unusual or prominent discoloration
in all parts of the body. Nailbeds are pinkish in color with a 160-degree angle between the base
and the skin.
ANATOMY AND PHYSIOLOGY
(Pneumonia)
Respiratory System
The respiratory system includes tubes that remove particles from incoming air and
transport air to and from lungs and the air sacs where gases are exchange.Respiratory is the
entire process of gas exchange between the atmosphere andbody cells.
Respiratory is biological system for all organisms that involve gas exchange. Body
tissues received the oxygen by respiratory system and the rate of oxygen is increased during
exercise.
Organs of the Respiratory System.
The organs of the respiratory system can be divided into two groups. The upper
respiratory tract includes the nose, nasal cavity, and pharynx and the lower respiratory tract
includes the larynx, trachea, bronchial tree and lungs.
NOSE
Bone and cartilage support nose internally. Its two nostrils are openings through which
air can enter and leave the nasal cavity. Many internal hairs guard the nostril for preventing entry
large particles carried in the air.
NASAL CAVITY
The nasal cavity is a hollow space behind the nose. The nasal septum, composed of bone
and cartilage, divides the nasal cavity into right and left portions. Nasal conchae are bones that
curl out from the lateral walls of the nasal cavity on each side, dividing the cavity into
passageways. Nasal conchae also support the mucous membrane that line the nasal cavity and
help increase its surface.The mucous membrane filters, warms, and moistens incoming air.
Ciliary action carries particles trapped in mucus to the pharynx, where they are swallowed.
PHARYNX.
The pharynx or throat is behind the oral cavity, the nasal cavity and the larynx. It is a
passageway for food travelling from the oral cavity to the esophagus and for air passing between
the nasal cavity and the larynx. It also helps produce the sounds of speech.Pharynx are consists 3
parts. Those are nasopharynx, oropharynx and laryngopharynx.
LARYNX.
The larynx is an enlargement in the airway at the top of the trachea and below the
pharynx. It is composed of muscles and cartilages and is lined with mucous membrane.The
larynx contains the vocal cords, which vibrate from side to side and produce sounds when air
passes between them. Inside the larynx, two pairs of horizontal vocal folds. The upper folds are
called false vocal cords and the lower folds are called true vocal cords. The glottis and epiglottis
help prevent foods and liquids from entering the trachea.
TRACHEA.
The trachea is a flexible cylindrical tube about 2.5 cm in diameter and 12.5cm in length.
It extends downward anterior to the esophagus and into the thoracic cavity, where it splits into
right and left bronchi.A ciliated mucous membrane with many goblet cells lines the tracheas
inner wall. This membrane filters incoming air and moves entrapped particles upward into the
pharynx, where the mucus can be swallowed. The cartilaginous rings prevent the trachea from
collapsing and blockingthe air-way. The soft tissues that complete the rings in the back allow the
nearby esophagus to expand as food moves through it to stomach.
BRONCHIAL TREE.
The bronchial tree consists of branched airways leading from the trachea to the
microscopic air sacs in the lungs. Its branches begin with the right and leftprimary bronchi,
which arise from trachea at the level of fifth thoracic vertebra. Each primary bronchus divides
into secondary bronchi, which in turn branch into tertiary bronchi and then into finer and finer
tubes.Among the smaller tubes are bronchioles that continue to divide, giving rise to terminal
bronchioles, respiratory bronchioles and finally to very thin tubes called alveolar ducts. These
ducts lead to thin-walled outpouchings called alveolarsacs. Alveolar sacs lead to smaller
microscopic air sacs called alveoli.The branches of the bronchial tree air passages whose mucous
membranes filter incoming air and distribute the air to alveoli throughout the lungs. The alveoli
provide a large surface area of thin simple squamous epithelial cells through which gases can
easily be exchanged.
LUNGS
The lungs are soft, spongy, and cone-shaped in the thoracic cavity. The mediastinum
separates the right and left lungs medially and diaphragm and thoracic cage enclose
them.Visceral pleura firmly attach to each lung surface and folds back to become the parietal
pleura.A major branch of the bronchial tree supplies each lobe. A lobe also has connections to
blood and lymphatic vessels and lies within connective tissues. Thus, a lung includes air
passages, alveoli, blood vessels, connective tissues, lymphatic vessels and nerves.
PATHOPHYSIOLOGY
PRECIPITATING FACTORS
>sweat dries in his body
>organisms from environment & other
people
Z
PREDISPOSING FACTORS
>AGE
>GENDER
>EXPOSURE
>Lost of
appetite
>Sputum
production
>Fever
Occurrence of
Bronchopneumonia
Bacteria
invades
Inhalation
localized of
alveolar
cell
inorganism
the
Mucus
production
pathological
inflammation
>Fast breathing
the lungs
Airway
SIGNS &
obstruction
SYMPTOMS