Christ the king college

Calbayog city, samar

Case Study
(Pneumonia)
NURSING HEALTH
HISTORY
I. BIOGRAPHIC DATA

PATIENT’S PROFILE
NAME Doros, Nilhayjan Dote
AGE 1 year and 1 month
SEX Male
PERMANENT ADDRESS P9, Trinidad, Calbayog City, Samar
P9, Trinidad, Calbayog City, Samar,
PRESENT ADDRESS Philippines
BIRTHDATE Nov 19, 2021
PLACE OF BIRTH Calbayog City, Samar
ETHNICITY Filipino
RELIGION PIC (Aglipayan Movement)
EDUCATIONAL ATTAINMENT
PRIMARY LANGUAGE SPOKEN
HOSPITAL/ROOM St. Camillus Hospital, Room 202
DATE AND TIME ADMITTED December 07, 2022 at 3:30 pm
DATE OF DISCHARGE
ADMITTING PHYSICIAN Dr. Maria Elizabeth Abrugar Uy
ATTENDING PHYSICIAN Dr. Maria Elizabeth Abrugar Uy
IMPRESSION/FINAL DIAGNOSIS Pediatric Community Acquired Pneumonia

II. CHIEF COMPLAINT OR REASON FOR VISIT

“Nurse an akon anak gin iinubo pabalik-balik ngan damo plema nakukurian pag
ginhawa”, as verbalized by the mother.

III. HISTORY OF PRESENT ILLNESS

Mother reported that Nilhayjan was well until 1 day prior to admission when he
started to develop a low-grade fever. She thought that it was just due to the patient’s
physical activities. There was no chills and rigor. Mother medicated him with
paracetamol (Calpol) syrup but to no avail. Shortly after taking the medicine, patient
had one episode of vomiting amounting to approximately 1 tablespoon. Vomitus was
orange-tinged in color (same color as Calpol) containing mucus and previously
ingested food.

The patient’s fever was accompanied with productive cough. Sputum was light
yellow with some mucus. No medication taken for this problem.

Night prior to admission, mother noticed that Nilhayjan was snoring loudly. At 12
midnight, he suddenly started to cough continuously and developed shortness of
breath with rapid breathing. Hence, his admission the next day.

IV. PAST HISTORY

 Patient was also admitted months ago because of Pneumonia
Nilhayjan only lack 1 immunization for childhood illnesses to be completed next
month. No history of contracting other childhood illnesses. Noted allergies to sea
foods, chicken and egg. No reported accident and surgical procedure.

V. FAMILY HISTORY OF ILLNESS

Nilhayjan is 2nd of 2 siblings. His father have asthma and currently on medication.
His grandmother in paternal side also has asthma. Elder sister is 6 years old,
well and there is no history of consanguinity (See Figure 1).

VI. ADDITIONAL DATA FOR PEDIATRIC PATIENT

 A. Birth history

Patient was delivered via spontaneous vaginal delivery (SVD) at Calbayog District
Hospital on November 19, 2021 with birth weight of 2,500 g.

B. Feeding history

Nilhayjay was exclusively breastfed by his mother. Currently, introducing some

rice with soup

C. Growth and Developmental History

According to Erik Erickson’s Psychoanalytic theory of Psychosocial development,

the patient belongs in the Infant stage with chief psychosocial task of acquiring a
sense of Trust.

Patient’s anthropometric measurements are as follows: height = 67.6 cm; weight

= 8.5 kg, Both upper and lower central incisor (tooth) erupted.

Fine and Gross motor skills include picking up tiny objects using thumb and
forefinger (pincer grasp), Point and probe with forefinger, hold something out for you
to take (they won’t always let go), walk with both hands hold, rock.

VII. PHYSICAL/HEALTH ASSESSMENT

Entries in red are considered deviations from normal.

BODY PART INSPECTION PALPATION PERCUSSION AUSCULTATION
held upright and in no masses;
Head central position; not tender;
rounded smooth
(normocephalic)
black in color; fine and
Hair thick; smooth
evenly distributed; no
infestation
absence of dandruff;
Scalp no lesions and not tender
infections
well-trimmed pinkish
nails; concave smooth texture;
Nails curvature; capillary refill of
no presence of <2 seconds
clubbing
brown complexion;
intact and without
dryness; good skin turgor;
Skin presence of nevi;

Eyes
evenly distributed;
*Eyebrows symmetrically aligned; no masses
equal movements

thick; evenly
*Eyelashes distributed;
slightly curled upward

no lesions; skin intact;

*Eyelids no discharge; no edema,
20 blinks per minute
mass or lesions
anicteric;
capillaries evident
*Sclerae
black in color;
equally round and
reactive to light and
*Pupils accommodation;
3 mm pupil dilation

brown in color

no tearing; no edema
*Iris

*Lacrimal sac no tenderness

BODY PART INSPECTION PALPATION PERCUSSION AUSCULTATION

transparent;
*Cornea
shiny; smooth;
positive corneal
sensitivity reflex

shiny; pinkish
*Palpebral
Conjunctivae
transparent;
capillaries evident
*Bulbar
Conjunctivae
coordinated; move in
unison with parallel
*Extraocular
alignment
movement
able to see and identify
objects in near and far
*Visual distance
Acuity

Ears color same as facial

skin; skin is smooth
*Auricles and without nodule; firm; pinna
symmetrical; pinna recoils after it is
aligned with the outer folded; not
canthus of the eye; tender, no
presence of yellowish lesions present
cerumen discharge
*Gross normal voice tone
Hearing audible
Acuity test

Nose centrally located; same not tender; no

color with lesions;
facial skin; smooth and
no discharge; intact
intact and in midline;
firm

*Nasal
not tender
Septum
not tender
*Facial
Sinuses

*Trachea central placement in spaces are

midline of the neck equal
on both sides

*Thyroid gland not visible; no not palpable

enlargement

Chest

*Anterior skin intact; chest apex beats wheezes

Thorax moved symmetrically palpable at 5th during expiration
with respiration; intercostal on the upper
space within zone bilaterally
midclavicular
line; vocal
fremitus equal
bilaterally;

symmetrical; flat; no tenderness;

*Breasts
no discharge lesions;
masses;
nodules
no
symmetric; spine tenderness; wheezes
*Posterior no masses;
Thorax vertically aligned during expiration
skin intact; on the upper
full and
zone bilaterally
symmetric
thorax
expansion;
 aortic pulsations first and
no visible pulsations, present (strong); second heart
surgical scars, cardiac apex beats sounds
Cardiovascula bulging or palpable at the heard with normal
r superficial dilated 5th intercostal intensity and
System veins at precordial space lateral to frequency; no
area midclavicular additional heart
line; no thrill or murmur detected;
heave HR=112 bpm

not distended and

moved with
Abdomen respiration;
umbilicus is
centrally located and
inverted;
no surgical scars

BODY PART INSPECTION PALPATION PERCUSSION AUSCULTATION

brown skin;
D5LMB 500 mL at 200
Upper mL level running at
extremities 27 cc/hr at right
metacarpal vein via
IV cannula; complete
digits

able to urinate without

GU system difficulty; voids 5-6
times per day with
yellow to dark yellow
colored urine

no deformity, intact
Musculoskeleta muscles strength, no no reflexes of
l system tremors upon tenderness; upper and lower
(Muscles, movement; masses/lumps limbs present
Bones normal power of all with normal
& Joints) muscles intensity

oriented, and
Neurologic coordinated, responds
System appropriately, no
neurologic
dysfunctions
IX. LABORATORY FINDINGS
ntries in red are considered deviation from normal.

Full Blood Count and Automated Differentials

Date/Time: 12/23/2021 @ 11:35 AM

Components Result Normal Values Significance

White blood count 21.1x103/µL 5-14.5 Indicates infection

Red Blood Cell 5.27X106/µL 4.7-6.1 Within normal value
Hemoglobin 108.0g/dL 90.0-135.0 Within normal value
Hematocrit 33.6% 29.0-49.0 Within normal value
Platelet 514x103/µL 140-450 Indicates infection
Neutrophil % 40.0% 35-75% Within normal value
Lymphocyte % 38.3% 20.0-50.0 Within normal value
Monocyte % 10.9% 3-6 % Indicates infection
Eosinophil % 10.7% 0.0-3.0 Indicates infection
DRUG STUDY
 Name of Drug Classification Mechanism of Action Indication Contraindication Side Effects Nursing Evaluation
Responsibilities

Before:
Contraindicated with CNS: Do skin testing into
Generic name: Pharmacologic Pharmacologic Action: Lowers respiratory allergy to Headache, the intradermal area
Ceftriaxone Antibiotic Bactericidal. Inhibits infections caused cephalosporin or dizziness,
Cephalosporin synthesis of bacterial wall by Streptococcus penicillin. Use lethargy Protect drug from
causing cell death. pneumonia, cautiously with renal light
Patient’s Dosage: Staphylococcus failure, lactation,
Do not mix
IVTT q 12h aureus, pregnancy.
ceftriaxone with other
Haemophilus GI: antimicrobial drug
influenza, E. coli,
Enterobacter Nausea, During:
Use a separate
aerogenes. vomiting, syringe when giving
diarrhea, this drug
Intra-abdominal anorexia,
infections cause pseudomembr After:
by E. coli, anous colitis. Alert for adverse
reaction
Klebsiella
pneumoniae Local: pain Monitor signs and
inflammation symptoms of
of IV site bleeding or
gastrointestinal
effects (e.g. bleeding,
Hematologic: abdominal pain)
bone marrow
depression, Document
dec. WBC,
platelets, Hct
 Name of Drug Classification Mechanism of Action Indication Contraindication Side Effects Nursing Evaluation
Responsibilities

Before:
Hypersensitivity to CNS: Assess pt for
.
Generic name: Pharmacologic Anti- Pharmacologic Action: Treatment of the erythromycin or any Headache, infection (vital signs;
Clarithromycin infectives, macrolide Bactericidal. Inhibits upper/lower other macrolide dizziness, sputum, urine, and
antibiotic, anti-ulcer synthesis of bacterial wall respiratory tract antibiotics, patients lethargy stool at the beginning
causing cell death. infections receiving cisapride, of the therapy
Patient’s Dosage: including astemizole or
During:
125mg/ml Inhibits protein synthesis pneumonia, otitits pimozide, suspended Administer around
2.6ml BID of the bacteria at the level media, acute or potential GI: the clock, without
of the 50S bacterial maxillary sinusitis, bactermias, acute regard to meals,
ribosome. skin/soft tissue porphyria, severe Nausea, Food slows but does
hepatic or biliary not decrease the
infections, H. vomiting, extent of absorption.
pylori. disease or any other
diarrhea,
drugs that prolong QT
anorexia,
Infections caused interval or cause After:
pseudomembr
cardiac arrhythmias. Advise pt to report
by non anous colitis.
the signs of super
tuberculosis
Use cautiously in infection, (black, furry
(atypical)
patients w/ Local: pain overgrowth of the
Mycobacterium inflammation tongue; vaginal
hepatic/renal
sp; impairment, older of IV site
itching or discharge’
Preventionof MAC loose or foul smeling
adults & lactation. stools)
infections in HIV
infections. Instruct the pt to notift
the health care
professional if
symptoms do not
improve within a few
days.
 Name of Drug Classification Mechanism of Action Indication Contraindication Side Effects Nursing Evaluation
Responsibilities

Before:
Hypertropic obstructive Body as a Check the physicians Patient show sign of
Generic name: Funtional: Belongs to Pharmacologic Action: Management of cardiomyopathy or whole: order relief by becoming less
Ipratropium the class of adrenergics ipratropium is a reversible tachyarrhythmia Headache, irritable and playful
Salbutamol in combination with nonselective competitive bronchospasm pain, again
anticholinergics. antimuscarinic agent, it influenza,
During:
Brand: Duavent causes bronchodilation by chest pain.
Follow the 14 right
blocking the action of medication
acethylcholine induced GI: Nausea
Patient’s Dosage: stimulation of guanyl Position pt on high
Neb q 8h cyclase, hence reducing Respiratory: back rest position
formation of cyclic Bronchitis
guanosine dyspnea, After:
monophosphate at coughing Do back tapping after
parasympathetic sitea. you nebulize the
patient.
Salbutamol activates
Do not give food
adenylyl cyclases, the immediatetly may
enzyme that stimulates cause vomiting
the production of cyclic
adenosine.
XI. ANATOMY AND PHYSIOLOGY

Overview

The respiratory system is a body system that is composed of the upper and
lower pulmonary structures, bronchial/systemic circulation, and gas exchange at the
level of the lungs and tissue cells which work together to function for one main function:
to deliver oxygen into your body while removing waste gases.

In addition to gas exchange, the respiratory system performs other roles that
make it essential to our breathing which includes:

• Warming the air to match your body temperature and moisturizing it to the
humidity level your body needs.
• Protecting your airways from harmful substances and irritants. This is done by
coughing, sneezing, filtering or swallowing them.
• Supporting your sense of sense of smell

Upper Structures

These structures contain the nose, paranasal sinuses, pharynx, larynx, and epiglottis.
These structures not only provide passage for air to be breathed in and out, but it also
filters, humidifies, warms the outside air, and equalizes your ear pressure.
Lower Structures

This is composed of the trachea, bronchi, bronchioles, and alveoli. The primary
purpose of these structures is to move oxygen to and carbon dioxide from the alveoli
where gas exchange takes place. The primary purpose of these structures is to move
oxygen to and carbon dioxide from the alveoli where gas exchange takes place.

Difference between the Pediatric Airway and Adult Airway

There are a number of developmental characteristics that distinguish the pediatric

airway from the adult airway:

• The pediatric airway is smaller in diameter and shorter in length than the adult’s.
• The young child’s tongue is relatively larger in the oropharynx than the adult’s.
• The larynx in infants and young children is located more anteriorly compared with
the adult’s.
• The epiglottis in infants and young children is relatively long, floppy, and narrow.
• In children younger than 10 years of age, the narrowest portion of the airway is
below the glottis at the level of the cricoid cartilage.

Lungs

• These are the primary organs of the respiratory system.

• Their main functions are to transfer oxygen from the air to the blood and to
release carbon dioxide from the blood to the air.
• It takes up most of the space inside the chest and is surrounded by the chest wall
which is made up of the ribs and the muscles between the ribs.
• It is separated by the mediastinum, which contains the heart and other organs.
Below the lungs is the diaphragm, a thin muscle that separates the chest cavity
from the abdomen.
• The lungs also play a role in the body’s defenses against harmful substances in
the air, such as smoke, pollution, bacteria or viruses.
• These substances can pass through the nose and become trapped in the lungs.
The lungs would then produce a thick, slippery fluid (mucus), which can trap and
partly destroy these substances from the air. The cilia move rapidly to push the
mucus up through the bronchi, where it is removed by coughing or swallowing.

Lung Lobes

• The left lung has 2 lobes. The heart sits in a groove (cardiac notch) in the lower
lobe.
• The right lung has 3 lobes and is slightly larger than the left lung.
Bronchus

• The windpipe (trachea) is the tube-shaped airway in the neck and chest. It
divides into 2 tubes or branches called the main bronchi. One bronchus goes to
each lung. The area where each bronchus enters the lung is called the hilum.
• Each of the main bronchi divides or branches into smaller bronchi (which have
small glands and cartilage in their walls). These smaller bronchi eventually divide
into even smaller tubes called bronchioles, which have no glands or cartilage. At
the end of the bronchioles are millions of tiny sacs called alveoli. Surrounding
the alveoli are very tiny blood vessels (capillaries).
• The bronchi are lined with cells that have very fine hair-like projections called
cilia.

Pleural Membrane

• The pleura is a thin membrane that covers the lungs and lines the chest wall. It
protects and cushions the lungs and produces a fluid that acts like a lubricant so
the lungs can move smoothly in the chest cavity. The pleura is made up of 2
layers: o inner (visceral) pleura – the layer next to the lung o outer (parietal)
pleura – the layer that lines the chest wall
• The area between the 2 layers is called the pleural space.

Pulmonary Surfactant

 The lungs produce a mixture of fats and proteins called lung or pulmonary
surfactant. The surfactant coats the surfaces of the alveoli, making it easier for
them to expand and deflate with each breath.

Lymph Nodes around the Lungs

 Different groups of lymph nodes, which

are part of the lymphatic system, drain
fluid normally produced in the lung: o
bronchial nodes – lymph nodes
around the main bronchi
o hilar nodes – lymph nodes in
the area where the windpipe
divides into the main bronchi
o mediastinal nodes – lymph
nodes along the windpipe in
between the 2 lungs subcarinal
o mediastinal nodes – lymph
nodes just below the windpipe
where it divides into the main
bronchi.
XII. PATHOPHYSIOLOGY
Pneumonia is an infection of the lower respiratory tract that can be caused by bacteria, fungi,
viruses, protozoa, or parasites. Community-acquired pneumonia (CAP) occurs in patients who
have gotten the infection in the community compared to nosocomial pneumonia which is
acquired in a healthcare setting such as a hospital or a nursing facility. Pneumonia has
considerable morbidity and mortality, especially in older adults (McCance & Heuther, 2010).

CAP is most commonly caused by aspiration or inhalation of microorganisms through the

nasopharynx or oropharynx. Microorganisms are usually trapped in the mucous-producing cells
and cilia that line the upper airway. Factors that can impair the lungs' first line of defense
include suppressed cough reflex, decreased ciliary action, decreased activity of phagocytic
cells, and the accumulation of secretions. If the microorganism gets past the upper airways line
of defense, the next line of defense is the airway epithelial cells which contain alveolar
macrophages. Alveolar macrophages release cytokines and cause widespread inflammation in
the lungs in an attempt to activate the immune response. The products of inflammation
(inflammatory mediators, immune complexes) can damage the lung tissue and cause the
terminal bronchioles to fill with infectious debris and exudates. Some microorganisms also
release toxins which can cause further damage to the alveolar walls. Accumulation of exudates
can leads to alveolar edema resulting in dyspnea and hypoxemia (McCance & Heuther, 2013,
Miskovich-Riddle & Keresztes, 2006).

Typical bacteria will usually cause lobar pneumonia which is characterized by consolidation in a
portion of the entirety of one lung (Miskovich-Riddle & Keresztes, 2006 ). In lobar pneumonia,
biproducts of inflammation such as cytokines damage the fragile alveoli and cause edema. This
edema becomes are good medium for further bacterial proliferation and colonization. The
inflammatory response results in solidification of the lung tissue as it fills with exudate of blood,
fibrin, bacteria, etc. causing a reddened appearance of the lungs. This is called red hepatization.
Red hepatization eventually progresses to gray hepatization; the lung tissue turns gray from fibrin
deposition and phagocytosis by neutrophils of the inflammatory biproducts and microorganisms.
Resolution follows when neutrophils are replaced by macrophages, eventually eliminating the
infection (McCance & Heuther, 2010).

Atypical pathogens generally cause bronchopneumonia or interstitial infiltrate characterized by

patchy inflammation and edema of both lung.
XIII. HEALTH MODEL

Agent–Host–Environment Model

ENVIRONMENT

Cold
,
season
Climate change
Air Pollution, Dust

HOST
AGENT
Streptococcus Family history
pneumoniae, influenza
A, Mycoplasma Age
pneumoniae and
Chlamydophila
pneumoniae
XIV. NURSING CARE PLAN

Nursing Diagnosis Nursing

Rationale Planning Interventions Rationale Evaluation
Assessment

Subjective Cue: Ineffective breathing • Assess respiratory Manifestation of After 8 hours of nursing
Ineffective breathing pattern occurs when After 8 hours of rate,depth and ease respiratory distress is intervention the pt’s
‘Plemahon ak anak pattern and airway inspiration and nursing dependent on breathing had no more
nakukurian pag clearance relating to expiration does not interventions, the indicative of the degree adventitious sounds
ginhawa”, as increased sputum provide adequate patient will of lung involvement (wheezing) present when
verbalized by mother’ production occurring ventilation. Infection achieve timely and underlying general auscultated.
with infection and production of resolution of
status
sputum current infection
Objective Cues:
subsequent without
interference with complications. High fever greatly
-tachypnea airflow. increases metabolic
• Monitor body
(RR=34 cpm) demands and oxygen
temperature
-O2 sat = 94% When bacterial consumption and alters
-prolonged expiratory microorganism enter cellular oxygenation
-phase -nasal flaring
the airways it leads to
-productive cough Promotes
inflammation of the
-elevated shoulders
-use of accessory
lungs thus air sacs • Elevate head of bed expectoration, clearing
muscles of filled with pus & other and change position
respiration -barrel liquid that became an frequently
chest -wheezes obstruction to the
and rhonchi on airways. • Administer Dilates the airway for
both lung fields medications such as effective breathing
upon auscultation bronchodilators as
ordered
• Keep Precipitation of type or
environmental respiratory reactions
pollution to a that can exacerbate
minimum e.g. dust, the condition
smoke

• Administer A variety of
medication as medications may be
prescribed by the used to decrease
physician mucus and to improve
respiration
XV. DISCHARGE PLANNING

Medication Advise family to administer patient’s prescribed home

medications religiously for optimum recovery

Exercise Recommend to:

get plenty of rest

Teachings Educate family on:

proper use of metered-dose inhaler, nebulizer, and incentive

spirometer
importance of adhering to therapeutic regimens

Hygiene Instruct to preserve a clean and stress free, free of pollutants

and second-hand smoke environment
Encouraged to maintain cleanliness of the house and
surroundings
Encouraged to provide a well-ventilated area

Out-Patient Direct mother to:

alert medical staff immediately for any untoward

manifestations (e.g., trouble talking or breathing, fever, cough)
bring back the patient a week after discharge for follow-up
check up

Diet Encourage to:

drink plenty of water

avoid cold drinks

Spirituality Counsel about:

prayer therapy
using own religious rituals, practices, and resources to cope
with the hospital experience on the quality of life