Pneumonia & Marasmic Kwashiorkor

TABLE OF CONTENTS
I.
II. III. IV. V. VI. VII.

INTRODUCTION
OBJECTIVES BIOGRAPHICAL DATA PHYSICAL EXAMINATION LABORATORY WORK-UP ANATOMY AND PHYSIOLOGY PATHOPHYSIOLOGY

VIII. NURSING CAE PLAN

IX.

PHARMACOLOGY

Pneumonia is an inflammation of the lungs caused by an infection. It is also called Pneumonitis or Bronchopneumonia. Pneumonia can be a serious threat to our health. Although pneumonia is a special concern for older adults and those with chronic illnesses, it can also strike young, healthy people as well. It is a common illness that affects thousands of people each year in the Philippines, thus, it remains an important cause of morbidity and mortality in the country. There are many kinds of pneumonia that range in seriousness from mild to life-threatening. In infectious pneumonia, bacteria, viruses, fungi or other organisms attack your lungs, leading to inflammation that makes it hard to breathe. Pneumonia can affect one or both lungs. In the young and healthy, early treatment with antibiotics can cure bacterial pneumonia. The drugs used to fight pneumonia are determined by the germ causing the pneumonia and the judgment of the doctor. Its best to do everything we can to prevent pneumonia, but if one do get sick, recognizing and treating the disease early offers the best chance for a full recovery. A case with a diagnosis of Pneumonia may catch ones attention, though the disease is just like an ordinary cough and fever, it can lead to death especially when no intervention or care is done. Since the case is a toddler, an appropriate care has to be done to make the patients recovery faster. Treating patients with pneumonia is necessary to prevent its spread to others and make them as another victim of this illness.

Kwashiorkor vs Marasmus Both marasmus and kwashiorkor are disease that arise due to an inadequate diet and starvation. There are subtle differences between the two conditions. Let us take a look at what they are: Symptoms A kid who is suffering from marasmus can be identified at a glance. He will have dry and lose skin hanging over the glutei. The child loses adipose or fat tissue from normal areas of the body like the buttocks and the thighs. The child is usually irritable and has an exceptionally strong appetite. The child also has alternated layers of non pigmented or pigmented hair.

A patient with kwashiorkor suffers from damaged absorption. He may also display abnormal burns, nephrosis or a chronic liver disease. The child may also suffer from loss of muscular mass, edema or other immunodeficiency symptoms. The child also suffers from vomiting, infections and diarrhea.
Causes Marasmus is caused by a severe nutritional deficiency in general. It is usually found in very young infants and very young children. It can be prevented by breastfeeding. It is actually caused by the total or partial lack of nutritional elements in the food over a period of time. Kwashiorkor is actually the result of a lack of protein in the diet. It is different from marasmus, which is a total lack of nutrition in the diet. The term kwashiorkor is derived from an African term which means first- second child. This is because it usually affects children who are weaned away because of the birth of a second child.

Ii.objectives :

-GENERAL OBJECTIVES To gain knowledge, skills and ability in the nursing care and management.

-SPECIFIC OBJECTIVES 1. To do an extensive study on a patient with pneumonia and marasmic kwashiorkor. 2. To be able to identify and differentiate the significant findings of the laboratory results. 3. To discuss the anatomy and physiology of the organ involved, as well as the pathophysiology of the disease process. 4. To explain the nurses role in assessing and working with patients diagnosed with pneumonia and marasmic kwashiorkor. 5. To evaluate the effectiveness and the need for improvement with regards of the health care rendered.

iii.biographical data

Name: Patient X

Age: 4 years old

Sex: Male Marital status: Single Address: Babatngon, Leyte Religion: Catholic Name of Mother: Mrs. E Name of Father: Mr. Z Date of Admission: August 15, 2011 Physician: Dr. B Diagnosis: Pneumonia very severe; marasmic kwashiorkor Occupation: Housewife Occupation: Farmer

A.PRESENT HEALTH HISTORY:

2 weeks prior to admission, patient was noted to have cough, non-productive with low grade fever. No medication was taken, no consultation done. 1 week prior to admission, productive cough was noted, with yellowish phlegm and patient was still feverish. Patient was brought to the barangay health care center and was given paracetamol for fever. No meds was given for cough. 1 day prior to admission, bipedal edema with flaking was noted and associated with anorexia. Patient was given home remedy of herbal oil without relief. 2 hours prior to admission, above signs and symptoms persisted, causing the patients parents to seek medical advise, hence, was admitted at Leyte Provincial Hospital under the care of Dr, B.

b. PAST HEALTH HISTORY:

Patient was delivered through normal spontaneous vaginal delivery at home assisted by a hilot with good cry and activity. Patient had no immunization. Patient had been hospitalized at Leyte Provincial Hospital last year due to electrocussion. He underwent amputation of the right thumb.

Mother observed that her child had lost appetite after his amputation. The child has no regular visit to a physician nor to any health care worker.

c. FAMILY HEALTH HISTORY: Patients parents claimed that they have heredo-familial disease like Diabetes Mellitus from the maternal side.

d. PSYCHOSOCIAL HEALTH HISTORY:

Patient is a 4- year- old child living with his parents, together with his 3 siblings in their own house made of light materials, without comfort room, and without electricity. Their source of water is from a nearby river, which they use in drinking and for washing clothes. His father is a farmer, who earns 100 pesos a day, while his mother is a plain housewife. Patients usual diet is coffee and root crops such as sweet potato and cassava. Patient usually sleeps from 7pm until 5 am, as claimed by the mother.

Diagnostic Exam: Hematology Date Taken: August 15, 2011 Exam

Hemoglobin Hematocrit

Result

Normal Values
Male: 140-175g/L Female:120-160g/L Male:0.42-0.50 Female:0.36-0.46

Significance

0.32
WBC Neutrophils Lymphocytes Monocytes

Decreased in anemia or presence of bleeding Increased in acute infections Decreased in anemia Normal

11.60x10/L 0.52 0.48

4.511.3x10/L 0.20-0.35 0.02-0.06

. ANATOMY AND PHYSIOLOGY :

The lungs constitute the largest organ in the respiratory system. They play an important role in respiration, or the process of providing the body with oxygen and releasing carbon dioxide. The lungs expand and contract up to 20 times per minute taking in and disposing of those gases. Air that is breathed in is filled with oxygen and goes to the trachea, which branches off into one of two bronchi. Each bronchus enters a lung. There are two lungs, one on each side of the breastbone and protected by the ribs. Each lung is made up of lobes, or sections. There are three lobes in the right lung and two lobes in the left one. The lungs are cone shaped and made of elastic, spongy tissue. Within the lungs, the bronchi branch out into minute pathways that go through the lung tissue. The pathways are called bronchioles, and they end at microscopic air sacs called alveoli. The alveoli are surrounded by capillaries and provide oxygen for the blood in these vessels. The oxygenated blood is then pumped by the heart throughout the body. The alveoli also take in carbon dioxide, which is then exhaled from the body. Inhaling is due to contractions of the diaphragm and of muscles between the ribs. Exhaling results from relaxation of those muscles. Each lung is surrounded by a two-layered membrane, or the pleura, that under normal circumstances has a very, very small amount of fluid between the layers. The fluid allows the membranes to easily slide over each other during breathing.

vii.PATHOPHYSIOLOGY :
Pneumonia is a serious infection or inflammation of your lungs. The air sacs in the lungs fill with pus and other liquid. Oxygen has trouble reaching your blood. If there is too little oxygen in your blood, your body cells cant work properly. Because of this and spreading infection through the body pneumonia can cause death. Pneumonia affects your lungs in two ways. Lobar pneumonia affects a section (lobe) of a lung. Bronchial pneumonia (or bronchopneumonia) affects patches throughout both lungs.

Bacteria are the most common cause of pneumonia. Of these, Streptococcus pneumoniae is the most common. Other pathogens C. include C. anaerobic bacteria, trachomatis, Legionella Moraxella Staphylococcus aureus, Haemophilus influenzae, Chlamydia pneumoniae, (Branhamella) psittaci, catarrhalis, pneumophila,

Klebsiella pneumoniae, and other gram-negative bacilli. Major pulmonary pathogens in infants and children are viruses: respiratory syncytial virus, parainfluenza virus, and influenza A and B viruses. Among other agents are higherbacteria including Nocardia and Actinomyces sp; mycobacteria, including Mycobacterium tuberculosis and atypical strains; fungi, including Histoplasma capsulatum, Coccidioides immitis, neoformans, Blastomyces Aspergillus dermatitidis, Cryptococcus

fumigatus, and Pneumocystis carinii; and rickettsiae, primarily Coxiella burnetii (Q fever).

The usual mechanisms of spread are inhaling droplets small enough to reach the alveoli and aspirating secretions from the upper airways. Other means include hematogenous or lymphatic dissemination and direct spread from contiguous infections. Predisposing factors include upper respiratory viral infections, alcoholism, institutionalization, cigarette smoking, heart failure, chronic obstructive airway disease, age extremes, debility, immune compromise (as in diabetes mellitus agents. Typical symptoms include cough, fever, and sputum and chronic renal failure), compromised consciousness, dysphagia, and exposure to transmissible

production, usually developing over days and sometimes accompanied by pleurisy. Physical examination may detect tachypnea and signs of consolidation, such as crackles with bronchial breath sounds. This syndrome is commonly caused by bacteria, such as S. pneumoniae and H. influenzae.

ASSESSMENT NURSING DIAGNOSIS >SUBJECTIVE

SCI-RATIONALE Bacterial microorganism enter the airways Inflammation of the lungs Air sacs filled with pus & other liquids Presence of obstruction in the airways Inability to breath properly

OBJECTIVE OUTCOME

IMPLEMENTATION > Monitor respiratory patterns, including rate, depth, and effort. > Assist with clearing secretions from pharynx by offering tissues and gentle suction of the oral pharynx if necessary.

RATIONALE > With secretions in the airway, the respiratory rate will increase. > It is preferable for the client to cough up secretions. Gentle suctioning of the posterior pharynx may stimulate coughing and help remove secretions. > Chest physical therapy helps mobilize bronchial secretions. > Bronchodilators decrease airway resistance secondary to bronchoconstrictio n.

EVALUATION

Ineffective Airway CUES Clearance related Kinukurian to inability to hiya maintain clear paghinga, airway as ngan may characterized by plema it iya sputum,crackles, ubo as verbalized by rapid & shallow breathing. the
significant other. >OBJECTIVE CUES sputum production Rapid,shallow breathing crackles,gargl es

After 8 hours of Nursing Intervention, the Pts breathing will have no more adventitious sounds present (crackles/gargles) when auscultated.

> Provide postural drainage, percussion, and vibration as ordered

> Administer medications such as bronchodilators or inhaled steroids as ordered.

ASSESSMENT

NURSING DIAGNOSIS

SCI-RATIONALE

OBJECTIVE OUTCOME

IMPLEMENTATION

RATIONALE

EVALUATION

SUBJECTIVE CUE(s) May hiranat tak anak as verbalized by the significant others. OBJECTIVE CUE(s) Febrile Temp= 38.9C moist skin tachypnea, RR= 33 cpm Age: 4 yr. Old

Altered body temperature related to bacterial invasion in the lungs as manifested by body temperature higher than normal, tachypnea , crackles.

Bacterial microorganisms (e.g. pulmonary pathogens) enter the airway These bacteria/viruses infects the lung/s Inflammation of the lung/s Signs and symptoms of Pneumonia (e.g. temperature may be greater than 37.5C), tachypnea, coughs with greenish secretions

After 2 hours of Nursing Intervention, the Pts temperature will decrease from 38.9 C to normal range (36.6 - 37.5 C).

> Monitor Pts temperature q1 hr

> Encourage Pt to Rest.

> Encourage Pt to increase fluid intake

> Encourage the Pts guardian to do tepid sponge bath. > Administer antipyretic medications as prescribed

To determine if the Pts temperature is above the normal body temperature > Allows the patient to recuperate physical strength > To maintain hydration status and increased fluid intake helps lessen febrility > Sponge bath with warm water evaporates off his skin, thus, cooling off the Pt > Promotes return of body temperature to normal.
>

ASSESSMENT

NURSING DIAGNOSIS

SCI-RATIONALE

OBJECTIVE OUTCOME

IMPLEMENTATION > Assess for recent changes in physiological status that may interfere with nutrition.

RATIONALE
> The consequences of malnutrition can lead to a further decline in the patient's condition that then becomes self-perpetuating if not recognized and treated. > Often toddlers will eat more food if other people are present at mealtimes. > Protein-calorie malnutrition most often accompanies a disease process > Cases of vitamin D deficiency have been reported among darkskinned toddlers who were exclusively breast fed and were not given supplemental vitamin

EVALUATION

SUBJECTIVE CUE(s) Dire hiya nakaon, it iya kinaon guin susuka la niya ngan mas magasa hiya yana, han una makusog man hiya kumaon as verbalize by the significant others.

OBJECTIVE CUE(s) vomits ingested milk Food aversion Decreased weight weakness

Imbalanced Nutrition due to frequent vomiting and not eating the usual foods taken as manifested by decreased weight, food aversion, and weakness.

Bacteria or virus attacks the lung/s weakened immune systems Pneumonia Symptoms of Pneumonia: nausea or vomiting, may experience profound weakness w/c lasts for a long time

After 4 hours of Nursing Intervention, the Pt will start taking foods which he usually eat (rice, crackers, chicken breast,etc)

> Provide companionship at mealtime to encourage nutritional intake.

> Determine healthy body weight for age and height. > Assess client's ability to obtain and use essential nutrients.

PHYSICAL EXAMINATION
GENERAL SURVEY: awake but apathetic, afebrile, Coherent and responsive to Touch. SKIN: IPHAIR INAILS: ISKULL IPFACE: Normocephalic Uniform consistency, Absence of masses Convex curvature, pallor and cyanosis Dry hair, and presence of lice Edema, flaky paint appearance of skin due to presence of peeling. Dry skin, pallor. Skin stays pinched, tented or moves back slowly.

I-

Thinning of eyebrows, Dry skin, sunken eyes, checks and temples

EYES: IFlakiness of skin, plagues discharge, rim of sclera visible between lid and iris, excessively pale sclera, swelling or tenderness over lacrimal gland.

EARS: AURICLES IBluish color of earlobes ( cyanosis), symmetrical and auricle aligned with outer canthus of eye,

Pflaky, dry and scaly skin, pinna recoils after it is folded EXTERNAL EAR CANAL AND TYMPANIC MEMBRANE INOSE: Presence of discharge, scaling , sticky grayish tan color cerumen.

I-

Symmetric and straight, no tenderness, nasal septum intact and in midline, pale mucosa

MOUTH: LIPS AND BUCCAL MUCOSA IPallor, blisters; localized swelling; fissures, crusts of the lips. Buccal mucosa appears pale, excessive dryness. TEETH AND GUMS Brown discoloration of the enamel, presence of plague and tartar, red gums, spongy texture and swelling that partially covers the teeth. TONGUE/FLOOR OF THE MOUTH Central position, smooth red tongue due to Vitamin B deficiency, dry furry tongue and discoloration. SALIVARY GLANDS Pallor and dryness PALATES AND UVULA Discoloration (pallor) , positioned in midline of soft palate. OROPHARYNX AND TONSILS

I-

I-

II-

INECK: I-

edematous, Presence of plagues, swollen

head centered , muscles equal in size , muscle weakness, limited range of motion TRACHEA

II-

central placement in midline of neck THYROID GLAND gland is not fully movable with swallowing.

THORAX AND LUNGS: IPPOSTERIOR THORAX Chest asymmetric flaky, asymmetric and increased fremitus Associated with consolidated lung tissue As in pneumonia PAIareas of dullness or flatness over lung tissue Adventitious breathe sound ( crackles) ANTERIOR THORAX Abnormal breathing patterns and sounds (crackles).

PPABREAST: IPAXILLAE: IPABDOMEN: IAPP-

asymmetric areas of dullness or flatness over lung tissue Adventitious breathe sound (cackles)

asymmetry, localized discoloration flaky and dry skin

asymmetry flaky and dry skin

Globular abdomen, soft with abdominal bruit Hypoactive bowel sounds large dull areas tenderness and hypersensitivity

MUSCULOSKELETAL SYSTEM: MUSCLES: IAtrophy (decreased in size), asymmetry

P-

flaccidity (weakness) BONES:

IP-

Muscle wasting presence of tenderness or swelling

DRUG NAME AMPICILLIN

DOSAGE:250mg IVTT every 6 hours

GENERAL ACTION PENICILLIN

SPECIFIC ACTION acts as a bactericidal agent against micro organsims by inhibiting cell wall synthesis during active multiplication.

INDICATION Respiratory tract or skin and skin-structure infections. GI infections or UTIs. Bacterial meningitis or septicemia. Uncomplicated gonorrhea.To prevent endocardiris in patients having dental, GI, and GU procedure.

CONTRAINDICATION Contraindicated in patients hypersensitivity to drug or other penicillins. Use cautiously in patients with other drug allergies (especially to cephalosporins) because of possible crosssensitivity, and in those with mononucleosis because of high risk of maculopapular rash.

NURSING RESPONSIBILITIES Before giving drug, ask patient about allergic reactions to penicillin. A negative history of penicillin allergy is no guarantee against a future allergic reaction. Give drug I.M. or I.V. only if prescribed and he infection is severe or if patient cant take oral dose. Watch for signs and symptoms of hypersensitivity, such as erythematous maculopapular rash, urticarial, and anaphylaxis. >decrease dosage in patients with impaired renal function. To prevent bacterial endocarditis in patient at high risk, give drug with gentamicin. PATIENT TEACHING: Tell patient to take entire quantity of drug exactly as prescribed, even after he feels better. Instruct patient to take oral form on an empty stomach 1 hour before or 2 hours after meals.