Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES

Tamag, Vigan City

COLLEGE OF NURSING

A CASE STUDY
On

PNEUMONIA
In Partial fulfillment
of the Requirements in
NCM 103

(Related Learning Experience)

Suero General Hospital

Presented to:
Krishna Bautista, RN
Clinical Instructor

Presented by:
Gaile Ann P. Momblanco
BSN III-Mulberry

January 2011
Republic of the Philippines
 UNIVERSITY OF NORTHERN PHILIPPINES
Tamag, Vigan City

COLLEGE OF NURSING

GRADING SHEET

CATEGORIES PERCENTAGE ACTUAL GRADE

Introduction
Personal Data
Nursing History/Past, Present,
Family
Pearson Assessment
Diagnostics Actual and Ideal
Anatomy and Physiology
Algorithm and Explanation of
Pathophysiology
Medical and Surgical
Management
Nursing Care Plan
Promotive and Preventive
Management
Drug Study
Discharge Planning
Summary and Copy of Updates
Bibliography
Appendix A and B (Consent and
Documentation)
Organization and Punctuality

TOTAL

C.I. REMARKS

KRISHNA BAUTISTA,RN
Clinical Instructor
 TABLE OF CONTENTS
CATEGORIES PAGE NUMBER
Introduction

General Objectives

Specific Objectives
Personal Data
Nursing History of:

Past Illness

Present Illness
PEARSON Assessment
Diagnostics:

IDEAL

ACTUAL
Anatomy and Physiology
Algorithm and Explanation of
Pathophysiology
Medical and Surgical Management:

IDEAL

ACTUAL
Nursing
Care Plan
Promotive and Preventive
Managements
Drug Study
Discharge
Planning
Summary and Copy
of Updates
Bibliography
Appendix A
(CONSENT)
Appendix B
(DOCUMENTATION)

INTRODUCTION
 A baby will make love stronger, days shorter, nights longer, bankroll smaller,

home happier, clothes shabbier, the past forgotten, and the future worth living for.

When you inhale you take in air with lots of oxygen, which you need to stay alive.

Healthy lungs let air pass through and speed by the alveoli, then into red blood cells.

Oxygen is delivered all over the body. But when you have pneumonia, liquid blocks the

alveoli in your lungs using liquid.

This is a case of a 4 months old baby boy residing at Margaay, Cabugaoa, Ilocos

Sur who was diagnosed with pneumonia last November 15, 2010. The baby was

admitted at Suero General Hospital on November 12, 2010 at 8:25 in the morning with

a chief complaints of cough and colds for two weeks. The vital signs were initially

taken and recorded and the admitting diagnosis was pneumonia.

Pneumonia is an acute infectious disease caused by pneumococcus, associated by

general toxemia and a consolidation of one or more lobes of either one or both lungs.

It is an inflammation of the lungs caused by infectious agent in which air sacs are filled

with pus or exudates so that air is excluded and the lungs become solid. Bacteria

commonly enter the lower airway but do not cause pneumonia in the presence of

intact host defense mechanism (Smeltzer & Bare, 2005). Often pneumonia begins

after an upper respiratory tract infection (an infection of the nose and throat). The

incubation period ranges from one to three days with sudden onset of shaking chills,

rapidly rising fever and stabbing chest pains aggravated by coughing and respiration.

The disease is transmitted through droplet infection or through indirect contact.

Upon further history taking, I found out that the mother of the baby is positive

in extensive PTB and she is now on her 3 rd month of anti-Koch’s treatment.

General Objective:

With the acquired information given by the mother of the patient, I aim to

present the case of Baby Boy comprehensively and formulate a case analysis that

would provide essential knowledge and skills in delivering quality health care to

patients diagnosed with pneumonia.

Specific Objectives:

This case study on pneumonia seeks to attain the following specific objectives:
  Describe the common characteristics of pneumonia.
 Know the history of past and present illness of the client.
 To assess the condition of the patient through the use of PEARSON Assessment

(Psychosocial, elimination, activity and rest, safe environment, oxygenation and

nutrition).
 Relate the significance of laboratory results to client’s condition or the disease

process.
 Present the anatomy and physiology of the system involved, in relation to the

condition of the patient.

 Identify the indication, mechanism of actions, contraindications, dosages and

frequency, adverse effects, and nursing responsibilities/interventions of the

drug administered to the client.

 To present nursing care plans formulated specifically based on client’s

condition.
 Recognize the medical and surgical interventions related to the patient and

make promotive and preventive management to help the client’s condition.

 Formulate a comprehensive discharge plan realistic to the needs and

compliance of the client.

 Present updates related to client’s case and condition.

Patient’s Profile

Personal Data:

Name: Jayson Factor Dela Cruz

Age: 4 months old
Sex: Male
Address: Margaay, Cabugao, Ilocos Sur
Civil Status: Child
Rank in the Family: Fourth Child
Religion: Iglesia ng Diyos
Birthday: June 28, 2010
Nationality: Filipino
Name of Significant others: Zenaida Factor Dela Cruz (Mother)
Date and Time of Admission: November 12, 2010/8:25am
Admitting Hospital: Suero General Hospital
Ward: Sto. Niño

Clinical Record:

Chief Complaints: Cough and Colds for two (2) weeks

Previous Illness and History: (+) history of infection and diarrhea when he was 2 mos. Old
due to poor hygiene.
Physical Findings: Skin is fair in color; nails are convex, cleaned and capillary refill returns to
original color after 2 seconds when pressed; normocephalic, symmetrical
facial features. Hair is black and evenly distributed and no infestations;
scalp is free from lesions lumps or masses; pupils are equally rounded, both
reactive to light and accommodation; nose is located at midline of the face
with watery nasal discharges; ears are symmetrical and at the level of outer
canthus of the eye; lips are pinkish in color, smooth, moist and free of
lesions; tongue lies at the midline and free of lesions also; neck is
symmetrical with the head in central position; lymph nodes are not
palpable; thorax rises and falls in unison with respiratory cycle; no chest
pain noted; fast breather but no shortness of breath noted; rales noted at
both lung fields; abdomen is round and no tenderness noted upon palpation;
normal bowel sounds; extremities grossly normal with full and equal pulses.
Weight: 8 kilograms
Initial Vital Signs: Respiratory Rate: 42bpm
Heart Rate: 150cpm
Temperature: 36.2 ˚C
Attending Physician: Dr. S. Saliganan
Working Diagnosis: t/c Pneumonia
Final Diagnosis: Pneumonia
Condition on Discharge: Improved

Nursing History of Past and Present Illness

A. Nursing History of Past Illness

Upon interview, the mother was asked about past history of illness of her

son. She told us that her son experienced an infection and diarrhea when he was

still two months old and was admitted at the same hospital for four days. Some

immunizations were already started to boost the immune system of the baby for

him to experience no further complications. The following immunization were

given to and received by baby boy with its corresponding dates:

 BCG – June 28, 2010

 Hep B – June 28, 2010/August 12, 2010/September 21, 2010

  DPT – September 21, 2010

 Poliomyelitiis – September 21, 2010/December 6, 2010

According to the patient’s mother, the baby is not used to have a monthly

check – up. But the baby is given a multivitamins everyday. No history of allergies

of any kind. I also noted that the mother of the child is positive in extensive PTB

but she’s now on her 3rd month of anti-Koch’s treatment.

B. Nursing History of Present Illness

Prior to admission, the patient’s mother told me that baby boy was

experiencing cough and colds with watery nasal discharges accompanied with on

and off undocumented fever since October 29, 2010 and she observed that the

baby’s chest expansion has more effort and she think that the patient

experiencing difficulty of breathing. Prior to admission, she first brought baby boy

to Sinait District Hospital for check – up and he was given Cefixime drops to be

taken for seven days. November 12, 2010 at 8:25 in the morning, baby boy was

admitted in St. Niño ward at Suero General Hospital with chief complaints of cough

and colds for two weeks. After series of examination the working diagnosis given

by the physician of the child was to consider pneumonia.

PEA/RSON
Approach in Need Assessment

Admission to Home Visit

November 14, 2010 December 7, 2010
(During Hospitalization) (After the Hospitalization)
Patient Baby boy is 4
month old child, presently
residing at Margaay, Cabugao,
Ilocos Sur. He is the 4th child in Baby boy’s condition was
the family. He was admitted at improved after the
Suero General Hospital last hospitalization. He was awake
PSYCHOSOCIAL
November 12, 2010 exactly when I went to their house to
8:25 am with a chief complaint visit him and to check his
of cough and colds. He is condition. While I am speaking
active, conscious and playful. to his mother, he was staring
His psychosocial development at me and it seemed that he
according to Erik Erikson is was listening to what I was
 trust vs. mistrust which means saying.
to develop a sense of purpose
and the ability to initiate and
direct one’s own activities.

 Urinary output: Baby boy  Urinary output: Baby boy

changed his diaper 2 – 3 changed his underwear 8 –
times during the shift 10 times a day, orange in
normally with yellow color color and aromatic odor
of urine and aromatic odor. with 15 to 20 ml every void.
 Defecated once with little  He defecates once a day
amounts during the shift only with an amount of 50 –

ELIMINATION with greenish yellow in 70 ml of stool with yellow

color and soft consistency. orange in color and soft
 (+) diaphoresis
consistency.
Baby boy sleeps with intervals “Mga 10 pm siya natutulog
of 4 to 6 hours. He had enough ading tapos maaga siya
rest and crying at times only. nagigising. Paggising niya sa
He is jolly and playful also. He madaling araw naglalaro na
usually slept on supine yan. Pagsapit ng tanghali
position and sometimes on matutulog ulit siya mga isa o
ACTIVITY AND REST
prone position. During his dalawang oras.” As verbalized
hospitalization, there are times by the mother.
that he was irritated and
He is so jolly and gay during
cannot sleep well according to
the visit and also thumb
her mother.
sucking and clapping. He is
very active and playful.

He has a good skin

turgor. Soft skin and fair
complexion. No signs of skin
rashes on both upper and They live in a concrete
lower extremities. He was able house, with enough light and
to move his body in different good source of air.
positions with medium pillows
 Body temperature of
around him for safety
36.8 C
purposes. He was in a light
 SAFE and comfortable cold room. He  (-) Edema

ENVIRONMENT has no allergies on milk, food

 No signs of skin rashes
and medicine. He had a
or allergies on both
temperature of 36.2 C.
upper and lower

Laboratory analysis: extremities.

 WBC: 9.2x10^g/l
 Lymp%: 50.7%
 Gra.%: 44.7%
 HCT: 0.387L/L
 Hgb: 139. 5 g/l
 RBC: 4.73 m/U

“Nahihirapan siya huminga “Ayos naman na ang paghinga

minsan, kasi madami yata niya ngayon ading pero may
siyang plemas na di plemas pa rin kasi siya.” As
mailabas.”As verbalized by the verbalized by the mother.
mother.
 no cyanosis noted
 no cyanosis noted
 adventitious breath
 adventitious breath
sounds still noted
sounds noted
 Vital signs taken upon
Upon admission (November
Home Visit:
OXYGENATION 12, 2010)
 RR: 38 bpm
 RR: 40 bpm
 PR: 130 cpm
 PR: 120 cpm
 T: 36.5 ˚C
 T: 37.5 ˚C
 Breathes through the nose.
(November 14, 2010)
 (-)DOB
3:00 pm
 Effortless inspiration
 RR: 42 bpm
 Pinkish conjunctiva
 PR: 150 cpm
 T: 36.2 ˚C  capillary refill within 2-3
7:00 pm seconds
 RR: 40 bpm
 Afebrile
 PR: 141 cpm
 Still with watery nasal
 T: 37.8 ˚C
discharges.
 (-)usage of oxygen
 Still with white colored
 Effortless inspiration sputum.
 Breathes through the nose.
 capillary refill within 2-3
seconds
 With watery nasal
 discharges.
 With white colored sputum.
 The impression of the chest
x – ray of Baby boy was
Pneumonitis.
“Okay naman ang paggatas
niya ading. Hindi naman siya
“Magana pa rin naman siya sa
nawalan ng gana na uminom
pag-inom ng gatas niya
ng gatas.” As claimed by the
ading.” As claimed by the
mother.
mother.
Baby boy is bottle fed.
Still, he is bottle fed
He consumed 4 to 6 oz within
because his mother stopped
the shift. No signs of
breastfeeding him. He takes
dehydration were noted. He
his milk 5 times a day: after
had D5 IMB ½ liter, regulated
bath, 4 oz; lunch – 5 oz; 3 pm –
NUTRITION to 41 – 42 uggts/min
4 oz; 9 pm – 6 oz; and 5 am – 5
connected @ his right
oz.
metacarpal vein. His weight
during admission was 8 kg. Diet: Milk feeding (Milk:
Bonakid)
Diet: Milk feeding (Milk:
Bonakid)
 DIAGNOSTIC PROCEDURES

A. Ideal diagnostic Procedures

Name and Purpose Normal Significant Nursing

of the procedure Values Values Implications

Hematology – grouped together  Low Hgb concentration may indicate anemia,  Levels decreased with
into profiles or panels, requiring recent hemorrhage or fluid retention causing reduced RBC production,
one requisition and a single hemodilution. Above-normal hemoglobin blood loss and hemolysis.
venous specimen. levels may be the result of
Hemoglobin levels peak
dehydration, excess production of red blood
 138-166g/l cells in the bone marrow, severe lung around 8 a.m. and are lowest
 Hemoglobin (Hgb)
disease, or several other conditions. around 8 p.m. each day.
 Hematocrit (Hct)  0.380-550 l/l  Low Hct suggests anemia, hemodilution or
massive blood loss. The most common cause  Levels may appear decreased
 RBC  4.2-6.5m/U of increased hematocrit is dehydration, and when Hgb is abnormal. The
with adequate fluid intake, the hematocrit Hgb level is usually
 WBC  4.0-12.0x10^g/l returns to normal. However, it may reflect a approximately 1/3 of Hct.
condition called polycythemia vera that is, Living at high altitudes
 Lymphocytes  25-50% when a person has more than the normal causes increased hematocrit
number of red blood cells. This can be due to
 50-80% values this is your body’s
 Granulocytes a problem with the bone marrow or, more
commonly, as compensation for inadequate response to the decreased
lung function (the bone marrow oxygen available at these
manufactures more red blood cells in order heights.
to carry enough oxygen throughout your
body).  Levels are easily influenced
 An elevated RBC count may indicate by fluid volume status;
absolute relative polycythemia. A decreased hypervolemia leads to lower
RBC may indicate Anemia; it may be due to hematocrit w/o actual
blood loss or lack of production of new RBC's
decreased RBC’s &
from the bone marrow.
 Abnormal WBC differential patterns provide hypovolemia &
evidence for diseases and other conditions. hemoconcentration reflects
 Lymphoctyes increase in numbers higher hematocrit than
(lymphocytosis) in certain types of chronic
 infections and lymphoid leukemia. They actually exists.
decrease in numbers in acute viral infections.
In a disease state, lymphocytes will become  Primary function of
reactive. A few reactive lymphs on a blood lymphocytes is to fight
smear is normal but if many are reactive chronic bacterial infection and
then this is a significant finding that the body
acute viral infections.
is responding to an infection of some sort.
 A minimal increase in granulocytes with mild  Granulocytes help the body
elevation of total white blood cells could
fight bacterial infections.
indicate infection. Persons who have lower
numbers of granulocytes are more likely to
get frequent and severe infections.

Chest X – ray:  Trachea – visible  Deviation from midline – tension In chest x – rays, waves
midline in the pneumothorax, atelectasis, pleural effusion. penetrate the chest and cause
The most commonly performed anterior mediastinal  Accentuated shadows – pneumothorax, an image to form on specially
diagnostic x – ray examination. It cavity. emphysema, pulmonary abscess, tumor &
sensitized film. Normal
is done to detect pulmonary  Hila – (Lung Roots) – enlarged lymph nodes.
visible above the  Visible – atelectasis. pulmonary tissue is radiolucent,
disorders, such as pneumonia, whereas abnormalities such as
heart, where
atelectasis, pneumothorax and infiltrates, foreign bodies, fluids
pulmonary vessels,
others. It is non-invasive medical bronchi & lymph and tumors, appear as densities
test. It marks images of the heart, nodes join the lungs. on the film.
lungs, airways, blood vessels and  Bronchi – usually not
the bones of the spine and chest. visible.
 Lung fields –
usually not visible
throughout, except
for blood vessels.
Gram Staining Test:

A Gram stain may be performed as part of the bacterial culture when a bacterial infection is suspected. It is performed on the same sample
as the culture, and the test results are reported out promptly to help guide treatment. The most commonly performed microbiology tests used to
identify the cause of an infection. Often, detecting the presence of microorganisms and determining whether an infection is caused by an organism
that is Gram-positive or Gram-negative will be sufficient to allow a doctor to prescribe treatment with an appropriate antibiotic while waiting for
more specific tests, such as a culture, to be completed. A negative Gram stain is often reported as "no organism seen." This may mean that
there is no bacterial infection present or that there were not enough microorganisms present in the sample to be seen with the stain under a
microscope. Positive Gram stain results usually include a description of what was seen on the slide. This typically includes whether the bacteria
are Gram-positive (purple) or Gram-negative (pink) as well as their shape — round (cocci) or rods (bacilli).

Sputum Culture and Sensitivity Test:

A sputum culture and sensitivity test is used to determine whether the patient's sputum (pulmonary secretion)
contains pathogenic bacteria or other infectious agents. If no bacteria or fungi grow, the culture is negative. If organisms that can cause
infection (pathogenic organisms) grow, the culture is positive. The type of bacterium or fungus will be identified with a microscope or by
chemical tests. It it is Normal: Sputum that has passed through the mouth normally contains several types of harmless bacteria, including some
types of strep (streptococcus) and staph (staphylococcus). The culture should not show any harmful bacteria or fungi. If Abnormal: Harmful
bacteria or fungi are present. The most common harmful bacteria in a sputum culture are those that can
cause bronchitis or pneumonia (Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, Klebsiella pneumoniae,
and Chlamydophila pneumoniae) ortuberculosis (Mycobacterium tuberculosis). Mycoplasma, a group of organisms similar to bacteria, can also
cause a type of pneumonia.
Arterial Blood Gas:

Arterial Blood Gas (ABG) Analysis is used to measure the partial pressures of oxygen (PaO2), carbon dioxide (PaCO2), and the pH of an
arterial blood sample. Oxygen content (O2CT), oxygen saturation (SaO2), and bicarbonate (HCO3-) values are also measured. A blood sample for
ABG analysis may be drawn by percutaneous arterial puncture from an arterial line. The ABG analysis is mainly used to evaluate gas exchange in
the lungs. It is also used to assess integrity of the ventilatory control system and to determine the acid-bas level of the blood. The ABG analysis is
also used for monitoring respiratory therapy (again by evaluating the gas exchange in the lungs).

This section is a guide to analysis of the ABG. Follow the steps as indicated in order to best interpret the results:
step 1 - examine pH step 2 - examine CO2 step 3 - examine HCO3 step 4 - check PO2 levels

if low, indicates acidosis if high, indicates respiratory if high, indicates metabolic if low, indicates an interference
if high, indicates alkalosis acidosis (with low pH) alkalosis (with high pH) with ventilation process (should
if normal, check to see if if low, indicates respiratory if low, indicates metabolic acidosis evaluate the patient)
borderline (may be compensation) alkalosis (with high pH) (with low pH) if normal, indicates patient is
if normal, check for compensatory if normal, check for compensatory getting enough oxygen
problem condition
Pulse Oximetry:

Pulse oximetry is a simple non-invasive method of monitoring the percentage of haemoglobin (Hb) which is saturated with oxygen. The
pulse oximeter consists of a probe attached to the patient's finger or ear lobe which is linked to a computerized unit. The unit displays the
percentage of Hb saturated with oxygen together with an audible signal for each pulse beat, a calculated heart rate and in some models, a
graphical display of the blood flow past the probe. Audible alarms which can be programmed by the user are provided. An oximeter detects
hypoxia before the patient becomes clinically cyanosed.

Thoracentesis (in case of Pleural Effusion):

Thoracentesis is a procedure to remove fluid from the space between the lungs and the chest wall called the pleural space. It is done with
a needle (and sometimes a plastic catheter) inserted through the chest wall. This pleural fluid may be sent to a lab to determine what may be
causing the fluid to build up in the pleural space.

B. Actual Diagnostic Procedure

Name and Purpose Normal Actual Nursing

of the procedure Values Values Responsibilities

Hematology – grouped together
into profiles or panels, requiring
one requisition and a single
venous specimen.
 Hemoglobin (Hgb)
 Hematocrit (Hct)
 RBC
 WBC
 Lymphocytes
 Granulocytes
Chest X – ray:
The most commonly performed
diagnostic x – ray examination. It
is done to detect pulmonary
disorders, such as pneumonia,
atelectasis, pneumothorax and
others. It is non-invasive medical
test. It marks images of the heart,
lungs, airways, blood vessels and
the bones of the spine and chest.
 Explain the procedure to the significant others of
the patient to gain cooperation and reduces
anxiety.
 Ask the mother if the baby had ever felt faint,
sweaty or nauseated when having blood drawn.
 138-166g/l  139. 5 g/l N  Ask the mother to position he baby in a supine
position and hold him still while getting the
 0.380-550 l/l  0.387L/L N blood sample.
 Assess the veins to determine the best puncture
 4.2-6.5m/U  4.73 m/U N site then tie the tourniquet 5cm proximal to the
area.
 4.0-12.0x10^g/l  9.2x10^g/l N  Clean venipuncture site with an antimicrobial
swab. Wiping in a circular motion spiraling
 25-50%  50.7% ↑ outward.
 Collect or withdraw 5-7ml of venous blood into
 50-80% the syringe.
 44.7% ↓
 Apply pressure to the puncture site for 2-3
minutes or until bleeding stops.
 Check venipuncture site to see if hematoma has
developed.
 Observe client for signs and symptoms of
anemia, including pallor, dyspnea, chest pain
and fatigue.
 Refer results to Physician.
 Trachea – visible  Streaky densities in both  Explain the procedure to the significant others of
midline in the parahilar/paracardiac the patient to gain cooperation and reduces
anterior mediastinal areas are seen. anxiety.
cavity.  The thymus gland is  Instruct the mother to remove all the objects like
 Hila – (Lung Roots) – jewelries (if there is) in the body of the patient
visible.
visible above the because it may interfere with x-ray images.
 Pulmovascularity is
heart, where  The nurse should prepare the patient before
within normal limits.
pulmonary vessels, going to X-ray Room.
bronchi & lymph  Heart is not enlarged.  Assist the x-ray technologist in obtaining the
nodes join the lungs.  Diaphragm is normal in film.
 Bronchi – usually not position and contour.  Once the patient arrives at the exam area, the
visible.  Both costophrenic sulci patient will undress to the waist, and wear a
 Lung fields – usually and visualized bones are gown or drape as provided by the facility.
not visible intact.  Refer results to Physician.
throughout, except Impression:
for blood vessels. Pneumonitis
 ANATOMY AND PHYSIOLOGY OF ORGAN INVOLVED

Respiratory system

The respiratory system is an intricate arrangement of spaces and passageways

that conduct air from outside the body into the lungs and finally into the blood as well
as expelling waste gasses. This system is responsible for the mechanical process
called breathing, with the average adult breathing about 12 to 20 times per minute.

When engaged in strenuous activities, the rate and depth of breathing increases
in order to handle the increased concentrations of carbon dioxide in the blood.
Breathing is typically an involuntary process, but can be consciously stimulated or
inhibited as in holding your breath.

Nostrils/Nasal Cavities
During inhalation, air enters the nostrils and passes into the
nasal cavities where foreign bodies are removed, the air is
heated and moisturized before it is brought further into the
body. It is this part of the body that houses our sense of smell.

Sinuses

The sinuses are small cavities that are lined with mucous
membrane within the bones of the skull.

Pharynx
The pharynx, or throat carries foods and liquids into the digestive
tract and also carries air into the respiratory tract.
Larynx
The larynx or voice box is located between the pharynx and trachea. It is the location
of the Adam's apple, which in reality is the thyroid gland and houses the vocal cords.

Trachea
The trachea or windpipe is a tube that extends from the lower edge of the
larynx to the upper part of the chest and conducts air between the larynx
and the lungs.

Lungs
The lungs are the organ in which the exchange of gasses takes
place. The lungs are made up of extremely thin and delicate
tissues. At the lungs, the bronchi subdivides, becoming
progressively smaller as they branch through the lung tissue,
until they reach the tiny air sacks of the lungs called the
alveoli. It is at the alveoli that gasses enter and leave the blood
stream.

Bronchi
The trachea divides into two parts called the bronchi, which enter the lungs.

Bronchioles
The bronchi subdivide creating a network of smaller branches,
with the smallest one being the bronchioles. There are more
than one million bronchioles in each lung.

Avleoli
The alveoli are tiny air sacks that are enveloped in a network of
capillaries. It is here that the air we breathe is diffused into the
blood, and waste gasses are returned for elimination.

PATHOPHYSIOLOGY

A. Algorithm
 Precipitating Factor:
Predisposing Factor: age Environment

Entry of
microorganism
to nasal passages

Invasion of the
respiratory system

Activation of Coug
Immune response h
(mucus
production)

Ineffective
immune response
results to
overwhelming
Infection

Invading/inflammation
and edema of lung
parenchyma

Accumulation of
cellular debris, Rale
fluids and exudates
in the lungs

Massive
Hazy portion of inflammation Dyspne
the chest pain (pneumonia) a

airway
narrows

Deep shallow
breathing

hypoxia ↑

B. Explanation

When the immune system is healthy, it can generally ward off the entrance of

entrance of organisms or control them from multiplying and causing disease.

Pneumonia may develop even in healthy individuals, however, when the infecting

organisms are very strong. Pneumonia is an inflammatory illness of the lung.

Frequently, it is described as lung parenchyma/alveolar (microscopic air-filled sacs of

the lung responsible for absorbing oxygen from the atmosphere) inflammation and

(abnormal) alveolar filling with fluid. Pneumonia can result from a variety of causes,

including infection with bacteria, viruses, fungi, or parasites, and chemical or physical

injury to the lungs. Its cause may also be officially described as idiopathic, that is

unknown, when infectious causes have been excluded. Those with weaker immune

systems like infants or children are often the ones who catch pneumonia faster,

usually after a flu infection. There will be an activation of immune response through

mucus production and if it is ineffective immune response, it will lead to overwelming

infections.

As the infecting organism enters the lungs, the lung tissues usually become

swollen and inflamed, particularly the air sacs or alveoli. This is often due to the

migration of white blood cells in the area to fight off the infection. The alveoli then

becomes filled with pus and fluid resulting in the manifestations of fever, cough,

breathing problems and chills. Pneumococci spread from alveolus to alveolus, thereby

producing inflammation and consolidation along lobar compartments. The function of

the lungs become affected, and oxygen exchange may be reduced and becomes

inadequate for the need of the body. The alveolar exudate tends to consolidate so it

increasingly difficult to expectorate. The accumulation of cellular debris, fluids and

exudates in the lungs also contributes to the narrowing of airways which can lead to

respiratory failure. This is why pneumonia needs to be treated promptly as severe

complications can happen.

MEDICAL and SURGICAL MANAGEMENT

A. Ideal Medical and Surgical Management

Medical:

 Outpatient (if affebrile without respiratory distress)

1. Consider initial parenteral antibiotic at diagnosis

a. Ceftriaxone 50 mg/kg/day up to 1 gram IM x1 dose

- It is a cephalosporin/cephamycin beta-lactam antibiotic

used in the treatment of bacterial infections caused by
susceptible, usually gram-positive, organisms.

b. Start oral antibiotics

2. First-line oral agents

a. Amoxicillin 90 mg/kg/day PO divided q8 hours x7-10d

- Amoxicillin is used to treat infections due to organisms

that are susceptible to the effects of amoxicillin.
Common infections that amoxicillin is used for include
infections of the middle ear, tonsils,
throat, larynx (laryngitis), bronchi (bronchitis), lungs
(pneumonia), urinary tract, and skin. It also is used to
treat gonorrhea.

2. Alternative oral agents

a. Amoxicillin-Clavulanic Acid (Augmentin) or

- Amoxicillin kills or stops the growth of bacteria

that cause infection. Clavulanic acid is added to
help the amoxicillin to work better. This medicine
treats many different kinds of infections.

b. Erythromycin or

- Used to treat many different types of infections

caused by bacteria.

c. Clarithromycin or

- Clarithromycin is used to treat many different

types of bacterial infections affecting the skin
and respiratory system.
 -

d. Azithromycin

- Used to treat certain infections caused by

bacteria, such as bronchitis; pneumonia; sexually
transmitted diseases (STD); and infections of the
ears, lungs, skin, and throat. It works by stopping
the growth of bacteria.

 Inpatient (if febrile or hypoxic)

1. Cefotaxime 150 mg/kg/day IV divided q6 hours or

- An antibiotic used to treat a wide variety of

bacterial infections. This medication is known as
a cephalosporin antibiotic. It works by stopping
the growth of bacteria. This antibiotic treats only
bacterial infections. It will not work for viral
infections

2. Cefuroxime 150 mg/kg/day IV divided q8 hours or

- Used to treat certain infections caused by

bacteria, such as bronchitis; gonorrhea; Lyme
disease; and infections of the ears, throat,
sinuses, urinary tract, and skin.

3. If confirmed Pneumococcal Pneumonia

a. Ampicillin alone 200 mg/kg/day divided q8 hours

- Used for treating bacterial infections.

 Critically ill

Option 1

a) Cefotaxime 150 mg/kg/day IV divided q6 hours and

b) Erythromycin 40 mg/kg/day IV divided q6 hours

Option 2
 a) Cefuroxime 150 mg/kg/day IV divided q8 hours and

b) Cloxacillin 150-200 mg/kg/day IV divided q6 hours

- used primarily to treat infections caused by

staphylococci, streptococci, or pneumococci.

Other Medicine:

Aminoglycosides – Aminoglycosides are a group of antibiotics that are

used to treat certain bacterial infections. This group of antibiotics includes at

least eight drugs: amikacin, gentamicin, kanamycin, neomycin, netilmicin,

paromomycin, streptomycin, and tobramycin. All of these drugs have the same

basic chemical structure.

Surgery:

Although most patients with pneumonia do not require invasive therapy,

patients with abscess, empyema, or certain other complications may require

such treatment.

 Thoracotomy

Thoracotomy is the standard surgery for pneumonia. It requires general

anesthesia and an incision to open the chest and view the lungs.This procedure

allowsthe surgeon to remove dead or damaged lung tissue. Insevere cases, the

entire lobe of the lung can be removed. This is called alobectomy.Remaining

healthy lung tissue re-expands after surgery to make up for any removed

tissue.

 Chest Tubes

Chest tubes are used to drain infected pleural fluid. Tubes are not

typically required for pneumonia or abscesses. The tubes are insertedafter the

patient is given alocal anesthetic. Theyremain in place for two to four days, and

are removed in one quick movement. It can be very distressing, although some
patients experience no discomfort. Complications of chest tubes include

infection, accidental injury of the lung, perforation of the diaphragm, and fluid

build-up within the lung if the pleural fluid is removed too rapidly. Removing

the chest tubesmay cause the lung to collapse, requiring the reintroduction of

a chest tube to inflate the lung.

 Drainage of parapneumonic effusions with or without intrapleural

instillation of a fibrinolytic agent (eg, tissue plasminogen activator [TPA]) may

be indicated.

B. Actual Medical and Surgical Management

Medical:

 The medications given to my patient were:

 Ampicillin 200mg IV q 6˚ - Bactericidal activity against

susceptible organisms. Alternative to amoxicillin when unable to

take medication orally. The baby was given this type of medication

to treat the disease and the fact that he cannot take the

medication orally alone.

 Paracetamol 100mg/ml drops q 4˚/PRN – Antipyretic: Reduces

fever by acting directly on the hypothalamic heat-regulating center

to cause vasodilation and sweating, which helps dissipate heat.

Baby boy also experienced fever during his hospitalization so he

was given an antipyretic drug to relief the fever.

 Salbutamol ½ neb+2cc PNSS q 4˚ - Used as a quick-relief agent

for acute bronchospasm and for prevention of exercise-induced

bronchospasm. It is also given to the baby to manage of reversible

airway obstruction caused by the underlying disease.

 Cetirizine 1mg/ml/2ml OD – Symptomatic relief of allergic rhinitis

like, sneezing, runny & itchy nose, watery eyes; allergic conjunctivitis.
 Baby boy received this medication to relief his runny nose to lessen his

watery nasal discharges.

 Clarithromycin 125mg/5ml/2.5ml BID – Treatment of upper

respiratory infections caused by streptococcus pyogenes or S.
pneumonia.

 During the hospitalization of Baby boy, he was given an IVF of D5 IMB

½ liter to prevent dehydration and to be consumed within 12 hours and
hooked at right metacarpal vein with a drop factor of 41 – 42 uggts/min.
 Vital signs (Temperature, Pulse, and Heart Rate) were taken every shift
and recorded accordingly for comparative baseline.
 Hydration therapy to liquify mucous secretions and improve secretion
clearance.
 Bed rest to lessen fatigue and conserve energy.

 Position appropriately to prevent aspiration into lungs.

 Monitor laboratory studies; complete blood count, sputum exams and

others.
 Diet: Diet for age (milk feeding).

Surgical:

There was no surgical procedure done to my patient.

 NURSING CARE PLAN
NURSING NURSING NURSING
DIAGNOSIS OBJECTIVES INTERVENTIONS
ASSESSMENT ANALYSIS RATIONALE EVALUATION

S: PROBLEM 1: Microorganism Date: November INDEPENDENT: a) helps to check for Date:

enters the airway 14, 2010 any obstruction or November 14,
“Nahihiraoan  P – Ineffective passages Time: 3 :00 PM a) Assess airway accumulation of 2010
siyang huminga breathing patency. fluids and maintain Time: 7 :00 PM
ading dahil pattern adequate airway
 E - Related to After 4 hours of b) Assessed patency
madami siyang
retained small blood nursing respiratory b) Provides a basis for Level of
plemas na hindi intervention, the
secretions in the vessels in the rate. evaluating attainment:
mailabas.” As patient will:
bronchi. lungs (capillaries) adequacy of
verbalized by the  Loosen c) Noted chest - Goal
 S – as become leaky, ventilation.
mother of the evidenced by: secretions in movement; use met.
baby. and protein-rich the lungs.
of accessory c) Use of accessory
fluid seeps into  Manifest relief
muscles during muscles of AEB:
O:  (+) productive the alveoli of (or
improvement respiration. respiration may
 (+) productive  cough in) feelings of occur in response After 4 hours of
shortness of d) Assess to ineffective nursing
cough  With watery results in a less breath. rate/depth of ventilation. intervention,
functional area for  Feel respirations
nasal the patient:
 With watery comfortable. and chest d) Tachypnea, shallow
oxygen-carbon
discharges.  The patient’s movement. respirations, and
nasal dioxide exchange Loosened
Monitor for asymmetric chest
significant secretions in
discharges.  Shortness of signs of movement are
others will the lungs.
breath at times. respiratory frequently present
 Shortness of patient becomes Relate
failure (e.g., because of
relatively oxygen causative  Manifested
breath at  The impression cyanosis and discomfort of
factors and relief of (or
of the chest x – deprived, while severe moving chest wall
times. ways of improved
retaining tachypnea). and/or fluid in
preventing or in) feelings
 no cyanosis ray of Baby boy potentially lung.
managing of shortness
was damaging carbon e) Auscultate lung e) Decreased airflow
ineffective of breath.
 noted Pneumonitis. dioxide breathing fields, noting occurs in areas  Felt
pattern of the areas of consolidated with comfortable
 adventitious
 The baby. decreased/ fluid. Bronchial  The
breath sounds Mucus production absent airflow breath sounds patient’s
impression of
is increased and (normal over significant
noted
the chest x – adventitious bronchus) can also others
through the leaky
 With white breath sounds; occur in related
ray of Baby densities
e.g., crackles, consolidated areas. causative
colored sputum.
boy was rales, wheezes. Crackles, rhonchi, factors and
 Restlessness/ and wheezes are ways of
Pneumonitis.
f) Place patient heard on preventing
irritable at
 adventitious into high inspiration and/or or
times. Source: fowler’s expiration in managing
breath sounds
position. response to fluid ineffective
Scribd.com
noted g) Advise mother accumulation, breathing
to do back thick secretions, pattern of
 With white
tapping. and airway the baby.
colored h) Maintain a spasm/obstruction.
relaxed, calm f) Maximize lung
sputum.
and non- expansion and
 Restlessness/ decrease
stimulating
irritable at environment. respiratory effort.
times.
i) Documented g) Helps to manually
 Initial V/S respiratory loosen or dislodge
taken as secretions: secretions.
character and
follows: h) Establish optimal
amount of
RR: 42 bpm rest/ sleep pattern.
sputum. i) Expectorations
PR: 150 cpm may be different
j) Assist client
T: 36.2 ˚C with frequent when secretions
deep-breathing are very thick.
exercises.
Demonstrate to j) Deep breathing
significant facilitates
 others/ help maximum
client learn to expansion of the
perform lungs/smaller
activity; e.g.,
airways. Coughing
splinting chest
and effective is a natural self-
coughing while cleaning
in upright mechanism,
position. assisting the cilia
to maintain patent
airways. Splinting
reduces chest
discomfort, and an
upright position
favors deeper,
more forceful
cough effort.

1. Facilitates
liquefaction and
COLLABORATIVE: removal of
secretions.
1. Assist with/ Postural drainage
monitor effects may not be
of nebulizer effective in
treatments and interstitial
other pneumonias or
respiratory those causing
physiotherapy; alveolar
e.g., incentive exudates/destructi
spirometer, on. Coordination of
IPPB, treatments/schedul
percussion, es and oral intake
postural reduces likelihood
drainage. of vomiting with
coughing and
 Perform expectorations.
treatments
between meals 2. Aids in reduction of
and limit fluids bronchospasm and
when mobilization of
appropriate. secretions.
Analgesics are
2. Administer given to improve
medications as cough effort by
indicated:e.g. reducing
mucolytics, discomfort. But
expectorants, should be used
bronchodilators, cautiously because
analgesics. they can decrease
cough effort/
depress
respirations.

 Bronchodilator

 Salbutamol
½ neb+2cc
PNSS q4˚

NURSING NURSING NURSING

DIAGNOSIS OBJECTIVES INTERVENTIONS
ASSESSMENT ANALYSIS RATIONALE EVALUATION

S: PROBLEM 2: Infectious agents Date: November INDEPENDENT: Date:

(Pyrogens) 14, 2010 November 14,
“Nilagnat siya P – Hyperthermia Time: 7 :00 PM Provide tepid  Enhances heat 2010
noong kadarating E – Related to sponge bath. loss by evaporation & Time: 8 :00 PM
naming ditto sa physiologic conduction.
response to After 1 hour of Monitor
hospital at
umabot ito ng 38 infectious stimulate comprehensive patient’s vital  Notes progress Level of
C tapos ngayon process. nursing signs (esp. and changes of attainment:
S – as evidenced Monocytes temperature). condition.
ulit nilagnat intervention, the
by: temperature of - Goal met.
nanaman siya.” release
Promote bed
 Increased
As verbalized by patient will
body Pyrogenic cytokines rest, encourage  Reduces body
the mother of the subside: from relaxation skills. heat production. AEB:
temperature
patient. (37.8 C) Stimulate 37.8 C to
 Restlessness/  To minimize After 1 hour of
O: Anterior 37.4 C. Wrap shivering. comprehensive
irritable at hypothalamus extremities with nursing
Increased body cotton blankets.
times. intervention,
temperature results in
the
(37.8 C)  Skin: warm COLLABORATIVE:
 (+) productive to touch. Elevated  Reduces fever by temperature of
 (-) thermoregulatory  Administer anti- acting directly on patient
 cough set point pyretic as the hypothalamic subsided: from
dehydration
ordered. heat-regulating 37.8 C to
 With watery leads to
 flushed skin Paracetamol center to cause
nasal Increased Heat 100mg IV PRN. vasodilation and 37.4 C.
conservation sweating, which
discharges.  Administer helps dissipate
(Vasoconstriction/b
 Restlessness/ ehaviour changes) antibiotic as heat.
Increased Heat ordered.  Ampicillin is used
irritable at production Ampicilin 200mg to treat diseases
(involuntary
times. IV q °6. caused by
muscular
contractions)  Monitor bacterial
Skin: warm to
touch. laboratory infections.
 (-) dehydration values as
result in obtained.  Laboratory tests
 flushed skin (Blood CS) may indicate
FEVER
which organism is
responsible for
Reference: fever.
NursingCrib.com
 NURSING NURSING NURSING
DIAGNOSIS OBJECTIVES INTERVENTIONS
ASSESSMENT ANALYSIS RATIONALE EVALUATION

S: PROBLEM 3: Persons at risk for Date: November INDEPENDENT: Date:

infection are 14, 2010 November 14,
“Nagkaimpeksyon P – Risk for Infection those whose Time: 3 :00 PM  Monitor vital  During this period 2010
na siya noong [Spread] signs closely, of time, potentially Time: 6 :00 PM
natural defense
dalawang buwan mechanisms are especially fatal complications
E – related to After 3 hours of
palang siya kaya inadequate to during may develop.
inadequate comprehensive Level of
natatakot pa rin protect them from initiation of
secondary defenses nursing attainment:
kami ngayon baka the inevitable therapy.
(presence of interventions and
mas malala pang injuries and - Goal met.
existing infection, health educating  Monitor the
impeksyon ang exposures that
immunosuppression the significant following for
dumapo occur throughout
) others of the signs of AEB:
sakanya.” As the course of patient, they will: infection:  Very high fever
verbalized by the living. Infections
S – as evidenced After 3 hours of
mother of the accompanied by
by: occur when an Identify  Elevated comprehensive
patient. sweating and
[not applicable: organism (e.g., interventions to temperature nursing
chills may indicate
presence of signs bacterium, virus, prevent, reduce interventions
O: septicemia.
and symptoms fungus, or other risk and spread and health
Increased body establishes an parasite) invades of secondary  Yellow or yellow- educating the
temperature actual diagnosis.] a susceptible infection. green sputum is significant
(37.8 C) host. If the host’s  Color of others of the
indicative of
 (+) productive (patient’s) patient, they:
respiratory respiratory
immune system secretions infection.
cough Identified
cannot combat
 With watery the invading  Effective means of interventions
organism reducing, clearing to prevent,
nasal  Demonstrate/ reduce risk and
adequately, an of infection.
discharges. encourage spread of
infection occurs. good hand  Promotes secondary
 Shortness of Infections prolong washing expectoration, infection.
healing, and can technique. clearing of
breath at
result in death if  Change infection.
times. position
untreated.
frequently and  Reduces likelihood
 no cyanosis
provide good
of exposure to
pulmonary
noted other infectious
Source: NANDA toilet.
 Limit visitors as pathogens.
 Restlessness/
indicated.
irritable at  Patients with poor
nutritional status
times.
may be anergic, or
Skin: warm to unable to muster a
touch.  Assess cellular immune
 (-) dehydration nutritional
response to
flushed skin status,
including pathogens and are
weight, history therefore more
 The impression
of the chest x – of weight loss, susceptible to
ray of Baby and serum infection.
boy was albumin.
Pneumonitis.
 adventitious Antimicrobial drugs
breath sounds include antibacterial,
noted antifungal,
COLLABORATIVE:
 With white antiparasitic, and
colored
Administer or antiviral agents.
sputum.
teach use of
antimicrobial  Ampicillin is
(antibiotic) drugs used to treat
as ordered. diseases
caused by
 Ampicilin bacterial
200mg IV q °6. infections.
  Treatment of
upper respiratory
infections caused
by streptococcus
 Clarithromycin pyogenes or S.
125mg/5ml/2.5 pneumonia.
ml BID
 PROMOTIVE AND PREVENTIVE MANAGEMENT

The following promotive and preventive managements will be imparted to

mother of the baby:

 Promote adequate ventilation:

 Note color, amount, and odor of secretions.

 Tell to the mother the importance and proper way of giving

expectorants as prescribed.

 Encourage parents to maintain adequate hydration of the baby

because adequate hydration liquify viscous secretions and improve

secretion clearance.

 Teach how to use nebulization to promote mucus secretions.

 Perform mild chest physiotherapy to promote mobilization of secretions

for easier expectorations.

 Instruct mother to avoid over exposure to crowded places because some

people might have existing infection and the baby may acquire it.

 Advice mother not to ignore cough and colds. Rather encourage mother
to visit health centers for the child to be examine.

 Instruct mother to elevate head of the baby when feeding to prevent

aspiration.

 Teach the mother how to count the RR of the baby because RR is one of
the major indicators of complications.

 Encourage parents to maintain good personal hygiene of the baby and

even the whole member of the family, cover nose and mouth when

sneezing or coughing and wash hands after sneezing, coughing, cleaning

the nose or going to the toilet.

 Ensuring that children have adequate nutrition, including exclusive

breastfeeding during the first six months of life, can help protect them

from pneumonia.

 Tell to the parents the importance of having the baby vaccinated or

complete the immunity.

 Viral Influenza Vaccines (Flu Shot) – Vaccines against the flu

(or a "flu shot") use inactivated (not live) viruses. They are

designed to provoke the immune system to attack antigens

contained on the surface of the virus.

 Pneumococcal Vaccines – The pneumococcal vaccine protects

against S. pneumoniae bacteria, the most common cause of

respiratory infections.
 DRUG STUDY
Name Dosage Mechanism Indication Contraindication Adverse Nursing
and
of Drug Frequency of Action Effects Responsibilities

 Explain the action

of the drug to the
Respiratory tract Lethargy, watcher.
Infections caused hallucinations,  Before giving drug,
by S. Contraindicated seizures, dizziness, wait for the result
pneumoniae (for to patients nausea, vomiting, of the skin test.
Ampicillin 200mg IV An aminopenicillin gastritis, anemia, 
merly D. hypersensitive to Confirm the
q 6˚ that inhibits cell agitation,
pneumoniae). drugs or other activation and
wall synthesis confusion,
Staphylococcus prenicillins. admixture of vial
during stomatitis. contents.
microorganism aureus (penicillina
multiplication. se and  Check for leaks by
nonpenicillinasepr squeezing
oducing), H. container firmly. If
influenzae, and leaks are found,
Group A beta- discard unit as
sterility may be
hemolytic
impaired.
Streptococci.
 Give drug 1-2
hours before or 2-3
hours after meals.

100mg/m Decreases fever Relief of mild to Contraindicated In rare cases  Verify the
l drops by inhibiting the moderate pain with allergy to hypersensitivity doctor’s order.
Paracetamol q 4˚/PRN effects of and treatment of acetaminophen. reactions,  Assess patient’s
pyrogens on the fever predominantly fever.
Use cautiously skin allergy  Assess allergic
hypothalamic
with impaired (itching and rash), reaction.
action leading to
hepatic function. may appear. Long-  Assess
sweating and term treatment
vasodilation. hepatotoxicity.
with high doses  Monitor liver and
may cause a toxic
Relieves pain by renal function
hepatitis with
inhibiting the test.
following initial
prostaglandin  Monitor blood
symptoms:
nausea, vomiting, studies, especially
synthesis at the
sweating, and CBC and pro-time
CNS but does not if patient is on
have anti- discomfort.
Occasionally a long-term therapy.
inflammatory
gastrointestinal
action because of discomfort may be
its minimal effect seen.
on peripheral
prostaglandin
synthesis.

Stimulates beta 2 Relief of Hypersensitivity Headache;  Determine history of

receptors of Bronchospasm to Salbutamol, tremor; previous
Salbutamol ½ bronchioles by in bronchial tachycardia; medication.
also to atropine
neb+2cc increasing levels asthma chronic hypertension;  Monitor for evidence
and its
PNSS q of camp which Bronchitis anxiety. of allergic reaction.
relaxes smooth Emphysema derivatives. Rarely
4˚  Assess lung sounds,
muscles to and other nausea, pulse, and blood
Produce Reversible vomiting, and pressure before
Bronchodilatation. Obstructive skin rash can administration and
Pulmonary be observed during peak of
diseases. medication. Note
 amount, color, and
character of
sputum produced.
 Monitor pulmonary
function tests
before initiating
therapy and
periodically
throughout course
to determine
effectiveness of
medication.
 Observe for
paradoxical
bronchospasm
(wheezing). If
condition occurs,
withhold
medication and
notify physician or
other health care
professional
immediately.

Symptomatic Contraindicated Central nervous  Explain the action

Competes with relief of allergic in patients system: of the drug to the
Cetirizine 1mg/ml/ histamine for H1- rhinitis like, Somnolence, watcher.
hypersensitive to
receptor sites on sneezing, runny & fatigue, dizziness  Tell the mother
2ml OD drug or any of its
effector cells in itchy nose, watery that breast-feeding
the eyes; allergic components, in Gastrointestinal:
breastfeeding is not
gastrointestinal conjunctivitis. Xerostomia
tract, blood women. Used recommended.
vessels, and cautiously in
respiratory tract
 patients with  Instruct mother to
renal or liver use a specially
impairment. marked spoon or
container to
measure your
medicine.

125mg/5 Hypersensitivity Central nervous  Tell patient’s

ml/2.5ml Exerts its to clarithromycin, system: Headache significant others
Clarithromyci antibacterial erythromycin, or to take drug as
BID
n action by binding any macrolide Gastrointestinal: prescribed even
to 50S ribosomal antibiotic; use Diarrhea, nausea, after he feels
subunit resulting with pimozide, abnormal taste, better.
in inhibition of astemizole, heartburn,  Advice mother of
protein synthesis. cisapride, abdominal pain the patient to
terfenadine report persistent
Skin: rash, adverse effect
urticaria seen on the baby.
 Inform mother of
the baby that drug
may be taken with
or without food.