KANTIPUR ACADEMY OF HEALTH SCIENCE

Tinkune, Kathmandu, Nepal

Affiliated to Purbanchal University

A REPORT ON CASE STUDY OF PNEUMONIA

Submitted To: Submitted By:

Mrs. Jharana Shah (Coordinator) Dibya Pokhrel
Mrs. Ambika Wagle (Nursing Instructor) Roll No: 13
Mrs. Ishu Yogi PBBN 1st year
Name of Patient: Abhi Acharya
Age: 2 years/ Male
Ward: General Ward
Address: Budanilkantha, Kathmandu
Diagnosis: Bronchiolitis

Chief Complain:
 Fever with temperature 100 0F
 Tachycardia
 Difficulty in Breating
Name of child : Krisham Shrestha
Age : 3 yrs/ Male
Address : Hetauda
Ward : Special Ward
Medical Diagnosis: Acute Meningoencephalitis
Chief complaint (present problem)
According to his Grandmother patient develops fever since 4 days and vomit since 4 days
Past History: According to his grandmother patient was admitted to Patan Hospital due to
meningitis for 1 month.
 Developmental task
My patient is a school age child. School age refers to those years of life span that extends from 6
to 12 years of age which begins to entrance into the wider sphere of influences represented by the
school environment. It has significant impact on development and relationship of children.
According to Erickson, in this age, development of the senses is “Industry vs Inferiority”.
According to him, school age is the period of developing the sense of industry. The successful
achievement in psychosocial development during earlier age namely the development of trust,
autonomy and initiative, enables the child to progress through this development stage with relative
case.
A comparison of development task is done below:
According to Book In my Patient
1. Learning physical skill for ordinary games. 1. Play different game with interest.

2. Building a positive attitude towards 2. Has happier and satisfied behavior.

oneself.

3. Learning to get along with similar age 3. Play and learn with similar age mates.
mates.

4. Learn about sexes, appropriate masculine 4. Has basic concept of male and female.
or feminine social role for social acceptance.

5. Developing Fundamental skills in reading, 5. Read, write and calculate properly.

writing and calculation.

6. Developing conscience morality and 6. Knows difference between right and

values. wrong.

7. Achieving personal independence. 7. Has some sort of independence.

 Prevention on Pneumonia
We can help prevent pneumonia by:
1. Get Vaccinated
 Get a flu shot every year to prevent seasonal influenza. The flu is a common cause of
pneumonia, so preventing the flu is a good way to prevent pneumonia.
 Children younger than 5 and adults 65 and older should get vaccinated against
pneumococcal pneumonia, a common form of bacterial pneumonia. The pneumococcal
vaccine is also recommended for all children and adults who are at increased risk of
pneumococcal disease due to other health conditions. There are two types of pneumococcal
vaccine. Talk to your healthcare provider to find out if one of them is right for you.
 There are several other vaccines that can prevent infections by bacteria and viruses that
may lead to pneumonia, including pertussis (whooping cough), chicken pox and measles.
Please talk to your doctor about whether you and your children are up to date on your
vaccines and to determine if any of these vaccines are appropriate for you.
2. Wash Your Hands
Wash your hands frequently, especially after blowing your nose, going to the bathroom, diapering,
and before eating or preparing foods.
3. Don't Smoke
Tobacco damages your lung's ability to fight off infection, and smokers have been found to be at
higher risk of getting pneumonia. Smokers are considered one of the high-risk groups that are
encouraged to get the pneumococcal vaccine.
4. Be Aware of Your General Health
 Since pneumonia often follows respiratory infections, be aware of any symptoms that
linger more than a few days.
 Good health habits—a healthy diet, rest, regular exercise, etc.—help you from getting sick
from viruses and respiratory illnesses. They also help promote fast recovery when you do
get a cold, the flu or other respiratory illness.
If you have children, talk to their doctor about:
 Hib vaccine, which prevents pneumonia in children from Haemophilus influenza type b
 A drug called Synagis (palivizumab), which is given to some children younger than 24
months to prevent pneumonia caused by respiratory syncytial virus (RSV).
S. Assessment Nursing Nursing Goal Planning Implementation Rational Evaluation
No. Diagnosis
1. Subjective Ineffective Patient will 1) Assess respiratory 1) Assessed respiratory 1) It indicates the Patient
Data airway demonstrate rate, depth rate, depth severity of disease and demonstrate
Mother said clearance airway with degree of lungs airway as
“My child related to normal involvement and evidence by
coughs a lot” increased breathe underlying general decrease in
mucosal sounds and health status wheeze
Objective data secretions absence of sound on
Child was evidence by dyspnea 2) Auscultate the chest 2) Auscultated the chest 2) Crackles wheeze are auscultation
coughing, wheezing to hear the breadth to hear the breadth sounds heard in response to and absence
tachypnea 40 and dyspnea sounds fluid accumulation of dyspnea.
beats/min, thick secretions and Thus my
wheezing airway spasm and goal was
sound on obstruction met.
auscultation
3) Slightly elevate 3) Slightly elevated head 3) Promotes chest
head of bed and change of bed and changed expansion and
position position mobilization
expectoration of
secretions

4) Encourage mother 4) Encouraged mother to 4) Helps in

to feed baby as warm feed baby as warm liquid mobilization
liquid fluid fluid expectoration of
secretion making them
easier to expectorate

5) Provide chest 5) Provided chest 5) Helps in

physiotherapy physiotherapy Assessed Mobilization of
respiratory rate, depth Secretion
S. Assessment Nursing Nursing Goal Planning Implementation Rational Evaluation
No. Diagnosis
2. Subjective Elevated To maintain 1) Access the general 1) Accessed the general 1) Provides baseline Goal was
Data body normal body condition and monitor condition and monitor data for nursing fully met as
Mother said temperature temperature vital signs vital signs interventions patient
“My child is related to within one temperature
getting hot” infectious hour 2) Keep room free 2) Kept room free from 2) Well ventilated was reduced
process in from crowdedness, crowdedness, open the room may reduce to 98.6 0F
Objective data lungs open the door and door and window temperature through
On manifested window evaporation
examination by increased
temperature temperature 3) Encourage mother 3) Encouraged mother to 3) Basic measure
was 1000 F, 1000 F, to put off heavy cloths put off heavy cloths brings down
tachycardia tachycardia temperature by
148 beat/min convection
and
respiration 38 4) Monitor vital signs 4) Monitored vital signs 4) It helps to access the
beat/min every 30 mins and as every 30 mins and as rate of alteration of
needed needed vitals and helps to
conform steps of
increasing and
decreasing

5)Administer 5) Administered 5) It helps to block the

antipyretic drug as antipyretic drug as temperature regulating
prescribed prescribed center and
hypothalamus and
hence decrease the
elevated body
temperature
S. Assessment Nursing Nursing Goal Planning Implementation Rational Evaluation
No. Diagnosis
3. Subjective Intake of patient will 1) Access the general 1) Accessed the general 1) To obtain baseline My set
Data nutrient be increase condition and condition and nutritional data for further objective
Mother said insufficient appetite nutritional status of status of patient intervention has met as
“He did not to meet within patient evidence by
want to eat metabolic hospitalizati the
anything needs, on 2) Provide nutritious 2) Provided nutritious 2) To maintain verbalizatio
unwilling to food food rich in vitamin, nutritional status n on the
Objective data eat protein to prevent patient
Patient looks malnutrition mother that
lethargy does he was
not show 3) Encourage him to 3) Encouraged him to 3) To maintain fluid taking food
interest to eat take plenty of fluids take plenty of fluids and electrolyte balance in time.
food

4) Educate and 4) Educated and 4) To stimulate the

encourage the patient encouraged the patient appetite
visitor to serve food in visitor to serve food in
attractive way in small attractive way in small
and continuous amount and continuous amount
S. Assessment Nursing Nursing Goal Planning Implementation Rational Evaluation
No. Diagnosis
4. Subjective Activity Progressive 1) Access the degree of 1) Accessed the degree of 1) Provide information
Goal was
Data intolerance improvemen weakness and fatigue weakness and fatigue about fatigue and partially
Mother said related to t activities tendency of lying in achieved as
“He can’t fatigue tolerance prone position patient
Sleep well” returned to
2) Encourage 2) Encouraged alternating 2) Promotes activity limited self-
Objective data alternating activity activity with rest and exercise care
Patient look with rest activities
like restless and looks
and fatigued 3) Inform child to rest 3) Informed child to rest 3) Reduce fatigue and some relief
when feel tired when felt tired conserves energy

4) Assess self-care 4) Assessed self-care 4) permits patients to

activities where patient activities where patient is participate extent
is fatigue fatigue possible in self-care
activities
S. Assessment Nursing Nursing Planning Implementation Rational Evaluation
No. Diagnosis Goal
1. Subjective Altered Temperatur 1) Assess the patient 1) Assessed the patient 1) To find out baseline My goal was
data: body e will be general condition general condition data. achieved as
I am feeling temperature reduced up the
cold. related to to 98 oF 2) removed all the 2) Removed all the extra 2) Heat loss through temperature
Objective disease within a 2 extra clothes and clothes and blanket from radiation. decreased
data: process as hours of blanket from the body the body up to 98 oF
Patient evidence by nursing
temperature increased intervention. 3) Maintain cross 3) Maintained cross 3) Heat loss through
rise up to temperature ventilation. ventilation by opening convection
101.2 oF of patient is doors and windows.
Pulse: 120 101.2 oF
b/m 4) Encourage to drink 4) Encouraged to drink 4) Replace the fluid
oral fluid as much as oral fluid as much as loss in the body.
possible. possible fluid such as
adequate water, milk etc.

5) Compress warm 5) Compressed water on 5) Heat loss through

water on the forehead the forehead and axilla. conduction.
and both axilla.

6) Give antipyretic 6) Provided antipyretic 6) To stimulate

drugs (syrup drugs (syrup paracetamol hypothalamus to
paracetamol) 7.5 ml po stat) reduce the
according to doctor temperature.
order.
S. Assessment Nursing Nursing Planning Implementation Rational Evaluation
No. Diagnosis Goal
2. Subjective Parental Visitors will 1) Assess the level of 1) Assessed to level of 1) To provide Goal was
data: deficit be able to knowledge and knowledge and information met as
We are knowledge verbalize understanding of the understanding of parents accordingly. parents
unknown related to understandi parents verbalize
about the disease ng of disease understandi
disease condition of process, 2) Provide complete 2) Provided complete and 2) It helps patient ng of disease
condition of patient prognosis and correct correct information about visitor know about condition of
my grandson treatment and information about disease condition its patient disease baby,
regimen and treatment disease condition and causes sign and condition and preventive
Objective prevention regimen and treatment. symptoms treatment and treatment protocol. measures of
data: visitor of prevention. management. acute
exhibiting reoccurrenc 3) Emphasize 3) Emphasized necessary 3) It helps to recover meningoenc
feelings and e necessary for for continuing antibiotic the condition and early ephalitis and
being containing antibiotics therapy for prescribed discontinuation of express to
overwhelmed therapy for prescribed period. antibiotics may result do continue
period in failure toete ly follow up.
resolve infectious
process.

4) Encourage parents 4) Encouraged parents to 4) Helps to increase

to provide balance diet. provide balance diet with natural defense, limits,
increasing carbohydrate, exposure to pathogens.
protein, and vitamins, and
provide adequate rest to
the patients.
5) Provide health 5) Provided health 5) It may help to
education about education about continual prevent reoccurrence
continual medical medical follow up and of ac
follow up and give give medicine according meningoencephalitis
medicine according to to doctor order. and related
doctor order. complications.
S. Assessment Nursing Nursing Planning Implementation Rational Evaluation
No. Diagnosis Goal
3. Subjective Anxiety Anxiety will 1) Assess the child 1) Assessed the child 1) To provide After 1 day
data: I don’t related to be level of anxiety level of anxiety information about of nursing
want to stay hospital stay decreased understanding of understanding of illness sources and level of intervention
here .I want to within 1 day illness and reason for and reason for anxiety associated to patient
go home hospitalization hospitalization illness and experienced
hospitalization. of reduced
Objective 2) Provide orientation 2) Provided orientation to 2) To familize child anxiety and
data: patient to hospital hospital environment and with the hospital was relaxed.
seems so environment and rooms, routines, environment develop
nervous and rooms, routines, medications and play security and decrease
cry. medications and play time, introduction to staff fear of unknown.
time, introduction to and others patients.
staff and others
patients.

3) Maintain quiet 3) Maintained quiet 3) To decrease stimuli

environment, control, environment, control, that increase anxiety.
visitors and visitors and interactions.
interactions.

4) Provide support to 4) Provided support to 4) It will eliminate

child during anyt child during anyt anxiety and fear.
procedures or procedures or distressing
distressing features features

5) Provide play 5) Provided play material 5) It will divert mind of

material to patients to patients like ball and the patient.
like ball and other other recreational
recreational activities. activities.
S. Assessment Nursing Nursing Planning Implementation Rational Evaluation
No. Diagnosis Goal
4. Subjective Altered Patient will 1) Identify the sleeping 1) Identified the sleeping
1) to determine usual My goal was
data: Patient sleep pattern report sense pattern and changes of pattern and sleeping
sleep pattern and meet as
says “I can’t related to of wellbeing the patient, pattern and changes of the
appropriate evidenced
sleep well." hospital stay and feeling patient. intervention by patient
as evidence rested. slept well
Objective by 2) Provide comfort 2) Provided comfort 2) To increase after nursing
data: on irritability. measures such as measures such as warm relaxation and improve intervention
observation he warm bath, back rub bath, back rub etc. the sleeping pattern.
looks etc.
lethargic.
3) Encourage the 3) Encouraged the patient 3) Milk helps in
patient to drink milk to drink milk 1 glass induced and
before sleep. maintained sleep.

4) Reduced 4) Reduced 4) Provide a situation

environmental environmental distraction conductive to sleep.
distraction such as such as noise and lights
noise and lights.

5) Limit fluid intake 5) Limited fluid intake 5) Minimize the need

during night time during night time. to urinate in the night.

6) Reassess the patient 6) Reassessed the patient 6) It helps in

sleeping pattern. sleeping pattern. evaluation
S. Assessment Nursing Nursing Planning Implementation Rational Evaluation
No. Diagnosis Goal
5. Subjective Fluid After 2 days 1) Assess patient 1) Assessed the fluid 1) To monitor for After 2 days
data: I am volume of nursing conditions. status. others sign and
of nursing
feeling weak .I deficit intervention symptoms. intervention
vomit 2-3 related to patient will 2) Assess likes and 2) Assessed likes and 2) To promote
patient fluid
times in a day. active fluid be stable and dislikes .provide dislikes provided favorite hydration. intake
loss and fluid intake favorite foods. foods like egg, fruits increased
Objective decrease will be ,and weight
data: he seems fluid intake increased. 3) Take patient weight 3) Taken patient weight 3) Changes in weight was
weak. as evidence daily daily. can provide maintained
by general information in fluids
body balance and the
weakness adequacy of fluid
and volume replacement
vomiting.
4) Encourage to eat 4) Encouraged to eat food 4) To maintain fluid
food with high fluid with high fluid content electrolyte balance for
content such as grapes. such as grapes. hydration

5) Encourage increase 5) Encouraged increase 5) To maintain fluid

fluid intake providing fluid intake providing electrolyte balance for
adequate liquids adequate liquid of water, hydration
juice, milk.