TITLE

CASE STUDY for “PEDIATRIC COMMUNITY ACQUIRED PNEUMONIAE” with complications of

Urinary Tract Infection (UTI) and Moderate Dehydration

SUBMITTED BY:
ABAD, ARLLY FAENA A.

SUBMITTED TO:
MA’AM KARISHA ARTIGAS

DATE OF ROTATION
FEBRUARY 18-20, 2021

AREA OF ROTATION
OB WARD

DATE SUBMITTED
FEBRUARY 25, 2021

I. INTRODUCTION
 Community-Acquired Pneumonia is defined as pneumonia that is acquired outside the hospital. It is a
disease which individuals who have not recently been hospitalized develop an infection of the lungs.
Pediatric Community-Acquired Pneumonia (PCAP) is a common illness that affects infants and children.
PCAP occurs because the atmosphere or the areas of the lungs which absorb oxygen from the atmosphere
become filled with fluid and cannot work effectively.
Among children under five years old, pneumonia is still one of the leading cause of mortality globally
(Mampusti, 2018). According to the United Nations Children’s Fund (UNICEF), Pediatric Pneumonia is
responsible for the deaths of more than 800,000 young children worldwide each year. These deaths occur
almost exclusively in children with underlying conditions, such as chronic lung disease of prematurity,
congenital heart disease, and immunosuppression. Although most fatalities occur in developing countries,
pneumonia remains a significant cause of morbidity in industrialized nations (Waseem, 2020).
Many organisms cause community-acquired pneumonia, including bacteria, viruses, and fungi (Sethi,
2020). Pathogens vary by patient age and other factors, for children aged two years and below viruses are
the most common cause of CAP. After two years, bacteria such as Streptococcus pneumoniae,
Mycoplasma pneumoniae, and Chlamydia pneumoniae become more frequent (Davies, 2003). Symptoms
of Community-Acquired Pneumonia include malaise, chills, rigor, fever, cough, dyspnea, and chest pain.
Cough typically is productive in older children and adults and dry in infants, young children and older
adults (Sethi, 2020). Gastrointestinal symptoms like nausea, vomiting and diarrhea are also common.
Signs include tachypnea, tachycardia, crackles, wheezing, and dullness to percussion. PCAP can be
diagnosed through these signs and symptoms and through physical examination or laboratory test alone.
Laboratory tests include Chest x-ray, blood cultures, sputum tests, urine tests, and pneumococcal antigen
test.
Community Acquired Pneumoniae is usually acquired via inhalation or aspiration of pulmonary
pathogenic organism into a lung segment or lobe. For children, bacteria and viruses living in the nose,
sinuses or mouth may spread to the lungs and/or they may breathe these pathogens directly into the lungs
(Medline Plus, n.d). Individuals with PCAP are primarily treated with antimicrobial therapy with
supportive care in the hospital. Some forms of PCAP can be prevented by vaccination. Heamophilus
influenza type b and Streptococcus pneumoniae conjugate vaccines are currently available against the
leading CAP. Current treatment guidelines also suggest several interventions to prevent CAP. These
include frequent handwashing, avoiding tobacco smoke, promoting breastfeeding and reducing exposure
to other children.

II. CASE STUDY

A. PATIENT PROFILE
a. Name: Patient X
b. Age: 1 y/o
c. Sex: Male
d. Occupation: N/A
e. Chief Complaint: Fever for 2 days
f. Admitting diagnosis: PCAP- C, UTI with moderate signs of dehydration
 g. Final Diagnosis:

B. HEALTH HISTORY
a. History of Past Illnesses (Data Not Available)
b. History of Present Illnesses
- Patient X was admitted on February 18 in the ER cuddled by mother with chief complaint
of fever for 2 days. Episodes of LBM and vomiting is also noted upon receiving. Patient
X was conscious, afebrile and skin warm to touch with the following vital signs; Temp-
39 Celsius, PR- 113 bpm, and RR- 32 cpm.
c. Family Health History: (Data Not Available)
d. OB History: (Data Not Available)

C. DEVELOPMENTAL DATA
- According to Erik Erickson’s Stages of Psychosocial Development, the patient is an
infant (0-18 mos.) who develops either trust or mistrust to his mother or family during
this stage of his life. This is an important part of the development of an infant because
this is where their perspective of the world as well as their overall personality will be
molded. At this stage the infant is dependent of their caregivers. For Havighurst’s
Developmental tasks, the patient is said to be in the stage of infancy and early childhood
(0-5 years old). Havighurst said that these are babies who are just learning to walk and
talk and figuring out the world around them. Hence, at this stage of development the
patient is curious about the things around him.
- In relation to the patient, as a nurse during the assessment and monitoring of the patient
we must establish rapport with the patients’ caregiver or the mother since they are whom
the patient trusted most. Furthermore, when administering IV medications. At this case,
careful treatment of the patient must be given. We must ensure to attend to the patient’s
needs immediately and to avoid doing things that might cause trauma for the patient.
D. 13 AREAS OF ASSESSMENT

1. SOCIAL STATUS
Patient X is a Filipino Citizen born on January 5, 2020 at Kukang Liwayway City, he is
now 1 year-old. He lives at 10 Lower Matahimik Street, High City together with his mother. His
religion is Roman Catholic. Patient X is admitted on February 18, 2021 at 8:05 P.M. with Fever.
Upon the receiving the patient, he is cuddled by her mother.
Analysis: It shows that he is loved and supported by his mother but the presence of his father was
not seen.

2. MENTAL STATUS
Patient X is conscious and active, irritable at times. He recognizes his mother very well.
Analysis: The patient may be mentally as of right now but further observation must be done to
check if he is fully mentally healthy.

3. EMOTIONAL STATUS
Patient X is responding well to his mother. He breastfeeds well and cries when he is
hungry.
According to Erickson’s Theory infants are building trust and mistrust at this stage. Trust
developed when needs are attended immediately and mistrust if the contrary.
Analysis: He shows his emotions like how he cries when he wanted and needed something.

4. SENSORY STATUS
Patient X feels pain during IV medication administration proven by how he cries and his
facial grimace.
Analysis: The patient can respond to the stimuli brought by his environment or surroundings.
Hence, his sensory status can be considered to be well.

5. MOTOR STATUS
 Patient X seems comfortable when his mother cuddles him. He moves his legs and arms
when he cries. And also, he moves his arms when he wanted to be carried by his mother.
Analysis: The patient has no problem moving around, but still his movements are affected because of his
disease.

6. BODY TEMPERATURE
The table shows the body temperature of the patient within the three-day stay during the
7-3 shift.

DATE TIME TEMPERATURE

2/18/21 8 am 37.8
10 am 37.5
12 pm 37.4
2 pm 37.3
2/19/21 8 am 38.9
10 am 37.1
12 pm 39
2 pm 37.6
Analysis: Patient X has series of fever. Hence, his temp. is not consistently normal.

7. RESPIRATORY STATUS
The table shows the respiratory rate of the patient within the three-day stay during the 7-3
shift.

DATE TIME RESPIRATORY

RATE
2/18/21 8 am 36
10 am 38
12 pm 36
2 pm 38
2/19/21 8 am 35
10 am 31
12 pm 35
2 pm 39

Analysis: The respiratory of the patient is within normal range.

8. CIRCULATORY STATUS
The table shows the pulse rate and blood pressure of the patient within the three-day stay
during the 7-3 shift.

DATE TIME PULSE RATE

2/18/21 8 am 109
10 am 112
12 pm 115
2 pm 111
2/19/21 8 am 119
10 am 109
12 pm 106
2 pm 117
Analysis: The data shows that Patient X’s pulse rate is within normal ranges. However,
continuous monitoring is needed to check that the patients pulse rate will not go beyond the
normal range.

9. NUTRITIONAL STATUS
The patient was allowed to have a DAT diet. He is also breastfeeding from his mother
and eats well.
 Analysis: The patient is eating and feeding anything his mother feeds him. He can eat as tolerated
and also breastfeed which can give him adequate nutrition. However, the patients mother must
give more nutritious food to his child to promote faster recovery.

10. ELIMINATION
Patient X defecated two times on February 19, 2021 and urinated 3 times
Analysis: The patient has no trouble in elimination pattern.

11. REPRODUCTIVE STATUS

Patient X is a 1-year old male. Upon assessment of respiratory system patient’s genitalia
was recorded as in good condition.
Analysis: Patient X has normal reproductive system.

12. STATE OF PHYSICAL REST & COMFORT

Patient cannot manage to sleep well and is irritable at times. The patients mother cuddles
him when needed.
Analysis: The patient has not enough time to sleep and rest but comfort is given by his mother.

13. STATE OF SKIN APPENDEGES

The patient has a fair complexion, and has cracks on his lips. His skin is red and flushed.
His hair is evenly distributed and his nails are cut and clean.
Analysis: The patient shows dehydration and hyperthermia as observed by his skin color and
texture.

E. PATHOPHYSIOLOGY (Written on a separate sheet)

F. DIAGNOSTICS/LABORATORY TESTS
a. COMPLETE BLOOD COUNT (CBC)
A complete blood count (CBC) is a blood test used to evaluate your overall health and detect a wide range
of disorders, including anemia, infection and leukemia. This test is done to determine your general health
status: to screen for, diagnose, or monitor any one of a variety of diseases and conditions that affect blood
cells such as anemia, infection, inflammation, bleeding, disorder or cancer.
Indication: The test results indicates that all the values are normal except for the Hemoglobin which is
decreased in value, the WBC which has an elevated value, the neutrophilic segmentation which is also
elevated and the leukocytes that is decreased in value. This tests result itself indicates that the patient is
having infection and inflammation in his body.

b. URINALYSIS (UA)
A urinalysis is a test of your urine. A urinalysis is used to detect and manage a wide range of disorders,
such as urinary tract infections, kidney disease and diabetes. It involves checking the appearance,
concentration and content of urine. This test is done to screen for, help diagnose and/or monitor several
diseases and conditions such as kidney disorders or urinary tract infections (UTIs).

Indication: In accordance to the result of the Patients Urinalysis, the WBC is higher than the normal
values which indicates that the WBC is working to eliminate the infectious pathogen in the body of the
patient.
c. Chest x-rays
Chest x-rays (CXR) are a scan used to evaluate the lungs, heart and chest wall and can detect medical
conditions such as pneumonia, heart failure, emphysema, lung cancer, and tuberculosis. It is typically
performed to investigate symptoms such as SOB, chronic and persistent cough, chest pain, chest injury or
fever; to monitor the progress of chronic medical conditions such as cancer or heart failure.
Indication: The final diagnosis of the patient is that he is having a PCAP manifested by persistent cough.
G. NURSING PRIORITIZATION OF PROBLEMS
a. Actual Problem

Nursing Diagnosis/ Problem Rank Justification / Rationale

Ineffective airway clearance
related to excessive mucous
Ineffective breathing pattern
related to PCAP-C
Impaired Gas Exchange related
to ventilation-perfusion
imbalance
1st This is the first prioritized problem because according to
the ABC’s of Nursing Airway needs to be given
intervention first. Moreover, if there is no airway, there
can be no breathing hence no oxygenation of blood and
circulation will soon cease.
2nd This is the first prioritized problem because according to
the ABC’s of Nursing Breathings comes next to be given
intervention after Airway.
3rd This is the third to be given intervention because if there is
an impaired gas exchange there can be no oxygenation of
blood and therefore circulation will soon cease.

Elevated Body Temperature 4th This is the fourth prioritized nursing diagnosis because the
related to PCAP-C patient need to have normal body temperature at the end of
the shift not only to evaluate if he is getting better but also
to prevent further complication.

b. Potential Problem

Nursing Diagnosis/ Problem Rank Justification / Rationale

Risk for deficient fluid volume 1st This is the first prioritized potential problem because I
related to vomiting and according to Maslow’s Hierarchy of needs physiologic
 diarrhea secondary to needs shall be satisfied first.
moderate dehydration

H. NURSING CARE PLAN (Written in a separated sheet)

I. DRUG STUDY (Written in a separated sheet)
J. EVALUATION/REFFERAL
 Upon evaluation, the patient’s latest vital signs were normal. However, further monitoring is
needed to show if he is well and is recovering from his disease. and also, his diet must be
given importance and health education shall be given to the patients’ mother to promote
faster recovery of the patient.
K. IMPLICATION
a. To Nursing Practice
 In this case study I’ve learned about the different test than can be done to determine if the
patient has a community-acquired pneumonia. Hence, if I will work in this field I know what
tests can be done. Moreover, if I will have my duty I now know how to manage a pediatric
patient having this kind of disease. Though it is undeniable that the information I have
gathered in this case study I will read further and enhance my knowledge to give the proper
intervention that my patient will need.
b. To Nursing Education
 Patient teaching is one the needed intervention that a burse must render to its patient. With
this case study, I have learned that If I have a pediatric patient, especially infants, I will need
to develop rapport not only to the patient but to the caregiver or to the mother as well. As
what have Erickson said in his theory, that an infant is dependent to its caregivers. Hence, this
case study helps me enhance my knowledge of patient teaching to the mother with pediatric
patients.
c. To Nursing Research
* I recommend for suture researches to include in their studies the cultural values that may
affect the mothers’ perspective of the disease and its treatment. Moreover, studies shows that
not all the laboratory tests can prove if one has PCAP hence, I also suggest for research that
can expand or upgrade the test of PCAP since it is known to be one of the common cause of
mortality in children.
L. REFERENCES

Complete Blood Count (CBC)- Understand the Test * your Result s. (2020, February 19). Retrieved from
https://labtestonline.org/tests/complete-blood-count-cbc
CXR: What Can a Chest X-Ray Diagnose? - HealthEngine. (2019, November 1). Retrieved from
https://healthengine.com.au.info/chest-x-ray
George,H.L.L.K.M. (2012,October 1). Community-Acquired-Pneumonia in children. Retrieved from
https://www.aafp.org/afp/2012/1001/p661.html
Wilson,Shannon,&Shields. (n.d.). Nurses Drug Guide 2009. Upper Saddle River, NJ, United States:
Prentice Hall
Glines, A. (n.d.). Pediatric Community Acquired Pneumonia (PCAP) Retrieved from
https://www.scribd.com/doc/162423816/Pediatric-Community-Acquired-Pneumonia-PCAP
Sethi, S (2020, December 1). Community- Acquired Pneumonia Retrieved from
https://www.msdmanuals.com/professional/pulmonary-disorders/pneumonia/community-acquired-
pneumonia
Trustvs.Mistrust: Learning to Trust the World around us. (n.d.). Rerieved from
https://www.verywellmind.com/trust-versus-mistrust=2795741