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›


Ocampo, Marlon Sales, Jonhson
Opena, Rosemarie Samson, Aiza

Oribiada, Clariver Santos, Mark Francis

Paloma, Ronie Talaue, Tyrone Jig
Pascual, Angelie Tanseco, Ma. Shiela
Pascual, Genalyn Tolentino, Ryan Joe
Resurreccion, Carls Burg

›



Mr. Felix Aquino,RN
 Table of contents
I. INTRODUCTION
G Background study
G Significance of the study
G Scope and limitation
G Goal and objectives
G Overview of the disease
G Anatomy and physiology of affected
system
II. BIOGRAPHIC DATA
III. NURSING HEALTH HISTORy
a.Past health history
b.Present health history
c.Chief complaint
d.Family history
IV. ACTIVITIES OF DAILY LIVING
V. PHYSICAL ASSESSMENT
VI. LABORATORY-DIAGNOSTIC RESULTS
VII. NURSING PRIORITIZATION
VIII.NURSING CARE PLAN
IX. PATHOPHYSIOLOGY
X. DRUG STUDY
XI. DISCHARGE PLAN
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The group chose Pneumonia as our case to be study out of curiosity.
This is our first time to encounter this kind of case and because of that, our group
was interested in it. We are willing to do this case to challenge our mind in
analyzing the problem and to enhance our hidden knowledge, and also to gain
new experiences which would bring new learnings for the member of the group.

 



This case study will help the group in understanding the disease process
of the patient. This would also help the group in identifying the primary needs of
the patient with Pneumonia. By identifying such needs and health problems arise
the the group can now formulate an individualized care plan for the patient that
would address these needs and problems effectively. Effective management of
the problems identified will help the petient to recover faster and maintain a
holistic sense of wellness even while in the hospital.
This case study would also equip the group with knowledge, skills and
attitude on how to mnage future patients with the same or similar disease.


  

This case study was conducted at Dr. Jose N. Rodriguez Memorial
Hospital in Caloocan City to a 8 month old pneumonia patient in cooperation of
the patient¶s mother.

 

After this case study, we will be able to know what pneumonia is, causes of
pneumonia, how it is acquired and prevented, its prevention and treatments of
the occurence of pneumonia.

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G Define what is pneumonia
G Trace the pathophysiology of pneumonia
G Enumerate the different signs and symptoms of pneumonia
 G Formulate and apply nursing care plans utilizing the nursing process
G To learn new clinical skills as well as sharpen our current clinical skills
required in the management of the patient with pneumonia.
G To develop our sense of unselfish love and empathy in rendering
nursing care to our patient so that we may be able to serve future
clients with higher level of holistic understanding as well as
individualized care.

""# 

Pneumonia is an inflammatory illness of the lung. Frequently, it is

described as lung parenchyma/alveolar inflammation and abnormal alveolar
filling with fluid (consolidation and exudation).

The alveoli are microscopic air-filled sacs in the lungs responsible for
absorbing oxygen. 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.

Typical symptoms associated with pneumonia include cough, chest pain,

fever, and difficulty in breathing. Diagnostic tools include x-rays and examination
of the sputum. Treatment depends on the cause of pneumonia; bacterial
pneumonia is treated with antibiotics.

Pneumonia is a common illness which occurs in all age groups, and is a

leading cause of death among the elderly and people who are chronically and
terminally ill. Additionally, it is the leading cause of death in children under five
years old worldwide. Vaccines to prevent certain types of pneumonia are
available. The prognosis depends on the type of pneumonia, the appropriate
treatment, any complications, and the person's underlying health.

  
* Elevated fever
* Productive or non-productive harsh cough
* Shallow respiration
* Restlessness
* Cyanosis
* Diminished/adventitous breath sounds
* Nasal flaring
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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. 

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  "
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. 

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

› %
The pharynx, or throat carries foods and liquids into the digestive tract and also carries
air into the respiratory tract. 

 %
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. 


 
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. 

 
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.

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



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. 

©"
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. 

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Name: Patient SJ
Address: Bagong Silang Caloocan City
Birthdate: December 5, 2008
Age: 8 months old
Civil status: child
Mother¶s name: Mrs. SE
Occupation: Housewife
Educational attainment: Second year High School
Father¶s name: Mr. SZ
Occupation: Cook
Educational attainment: First year college
Religion: Roman Catholic

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Upon interview the patient¶s mother was asked about past history of
illness of her son, she told us that her son had fever, cough and colds and
dyspepsia. The patient immunization was not yet completed, measles vaccine
was not yet given because patient SJ was only 8 months old. The mother
bring her son to vaccinized in the rural health center in Bagong Silang
Caloocan City. No history of allergies of any kind. Never been hospitalized.
 According to the patient¶s mother she gave medication of paracetamol
and carbocistein (loviscol) when her son is ill. She also gave leaves of ³tuba´
a herbal meds for dyspepsia. She give Vitamin C everyday.

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Prior to admission, the patient¶s mother told us that patient SJ was
experiencing Cough and Cold since September 8, 2009 and since September
10, 2009, she observed that the pateint chest expansion has more effort and
she think that the patient experiencing Difficulty of Breathing. The patients
mother also told that she thinks patient SJ get this illness because she
always bath her son early in the morning. September 11, 2009 at 5:00 in the
afternoon, patient SJ was admitted in the Pedia Ward with a chief complaint
of Cough and Cold and Difficulty in Breathing.

  

Cough and Cold and Difficulty of Breathing

  '   

There is no history of illness in the immediate family. The brother of

patient SJ grandfather in the side of his mother had a Pneumonia and his tito,
tita and grandfather in the side of his father had the histiry of Hypertension.

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Before During Interpretation and
hospitalization hospitalization analysis
Nutrition Patient SJ eat his He only drink I: There are big
meals 3 times a formulated milk 3-4 differences in his
day in almost ¼ of times a day in small nutrition before
his mother meals. bottle. and during
Commonly he hospitalization, he
drinks milk, eat loss his appetite in
rice, and he likes almost 75%.
potatoes and A: patients who
bananas. are hospitalozed
may have an
inadequate dietary
intake because of
 the illness or
disorder that
necesitated the
hospital stay or
because the
hospital¶s food is
unfamiliar or
unappealing.
Ref: Bruneer and
Suddhart¶s
Medical-Surgical
Nursing, 11th
edition, volume 1,
page 83

Elimination Normally Consume only 2 I: the consumption

consume 4 diapers of diapers before
diapers daily and during
hospitalization
was decreased.
A: decrease
elimination is due
to decrease food
intake.
Ref: Kozier and
Erb¶s
Fundamentals of
Nursing, 8th
edition, volume 2,
page 1288
Exercise Actively and long His play is limited I: before he is
period of playing and doesn¶t move active but when
too much. he hospitalized his
movement is
limited.
A: decreases
activity is because
of the Intravenous
fluid attach to him.
Limitting his
movement to
prevent the
intravenous line to
get tangle to him.
 Ref:
Fundamentals of
Nursing, Kozier,
chapter 34:
activity and
exercise
Rest and Sleep The patient was Patien takes a nap I: before
able to consume 8 20-30 mins 3 times hospitalization he
hours sleeping a day and at the had normal sleep
time and had a night he sleeps 3-4 pattern but during
schedule naps hours hospitalization he
twice a day. had abnormal
sleep pattern.
A: respiratory
condition can
disturb an
individual¶s sleep.
Shortness of
breath often
makes sleep
difficult. Hospitals
environment also
affects the sleep.
Environmental
and lack of
ventilation can
affect sleep.
Ref: Kozier and
Erb¶s
Fundamentals of
Nursing, 8th
edition, volume 2,
page 1170
Hygiene He was take a Never take a bath I: before
bath regularly, but his mother clean hospitalization, the
early in the him with wet towel patient take a bath
morning daily. regularly, early in
the morning but
when he was
hospitalized the
mother only done
sponge bathing.
A: due to
environment
setting (hospital
setting). The
 setting in the
hospital had no
available facilities
for bathing.
Ref: Kozier and
Erb¶s
Fundamentals of
Nursing, 8th
edition, volume 1,
page 742
Substance use The patient takes The patient I: the patient did
Vitamin C daily, receiving not takeVitamin C
also takes Cefuroxime 300mg during
paracetamol and TIV every 4 hours, hospitalization.
carbocistein hydrocortisone A: the patient¶s
(loviscol) when 85mg now then mother response
sick. 40mg TIV every 6 whem her children
hours, paracetamol had a fever she
90mg TIV every 4 give paracetamol
hours if and when they
neccessary/needed, have cough she
and salbutamol give carbocistein.
nebulization every 4 The doctor
hours. change the
medication to
relieve the
patient¶s illness.
Ref:
Fundamentals of
Nursing, Kozier,
chapter 43:
medication

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Normal Findings Actual Findings Interpretation and

Analysis
Posture The patient who The patient is I: the patient¶s
have breathing crying and breathing is
difficulties prefer irritated when in abnormal
to sit and may lying position because he has
 report feeling breathing
short of breath difficulties when
when lying flat in lying position
for even a brief A: the patient is
time experiencing
orthopnea
Ref: Bruneer and
Suddhart¶s
Medical-Surgical
Nursing, 11th
edition, volume 1,
page 75
Skin Color Skin color varies He has whitish I: the patient¶s
fromperson to skin color skin color is in
person and normal
ranges from A: the patient¶s
Ivory to deep skin color is
brown to almost varies from her
pure black mother.
Ref: Health Care
1 manual of
Norzagaray
College, page
119
Hygiene Clean, nice Sponge bath by I: the patient has
grooming and no his mother, no a good hygeine
unpleasant odor unpleasant odor, habbit.
wears shirt A: the patient¶s
without pants mother is
responsible to the
hygeine of her
child
Ref: Kozier and
Erb¶s
Fundamentals of
Nursing, 8th
edition, volume 1,
page 742
Nutritional Status The weight The patient I: the patient¶s
should weight is below weight is 5 kg
appropriate to normal range which mean that it
height. Should Kg is not in the
not overweight or BMI= -------- normal range of
underweight m2 7.8-9.2kg
A: the patient is
5kg underweight
 BMI= ----------- Ref: Kozier and
0.6m x 0.6m Erb¶s
Fundamentals of
BMI= Nursing, 8th
10.18kg/m2 edition, volume 2,
page 1236
Ref: Bruneer and
Suddhart¶s
Medical-Surgical
Nursing, 11th
edition, volume 1,
page 79
Age- Age should The weight is not I: the weight did
appropriateness appropriate to his appropriate to not reach the
height and the age. normal range and
weight. not compatible to
his height.
A: the infant¶s
height is normal
to his age but his
weight is not
normal because it
indicate
malnutrition.
Ref: Kozier and
Erb¶s
Fundamentals of
Nursing, 8th
edition, volume 1,
page 369
Verbal Complies with The baby want I: the patient is
simple verbal to cuddle by his scared to us
commands. mother and cry (interviewers) and
Displays fear of when put in the don¶t want to let
being left alone. bed. go by her mother
A: the patient
social
development is
normal
Ref: Kozier and
Erb¶s
Fundamentals of
Nursing, 8th
edition, volume 1,
page 317
 Non-verbal Creeps and The patient is I: the patient uses
crawls. Uses rolling in the bed pincer grasp with
pincer grasp with and grasping thumb and
thumb and anything he saw. forefinger.
forefinger. A: the patient
motor development
is normal in his
age.
Ref: Kozier and
Erb¶s
Fundamentals of
Nursing, 8th edition,
volume 1, page 317

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Normal Findings Actual Findings Interpretation and

Analysis
Temperature 36.5-37.5oc 37.2 oc I: there is no
increased or
decreased in the
temperature of
the patient.
A: the patient
temperature is
not too high or
not too low, it is
in the normal
range.
Cardiac Rate 120-160 bpm 135 bpm I: there is no
increased or
decreased in the
cardiac rate
A: the patient
cardiac rate is in
between normal.
Respiratory Rate 30-60 cpm 73 cpm I: Increased
respiratory rate
A: tachypnea

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Normal Findings Actual Findings Interpretation and

Analysis
Weight 5.4-7.6 kg 5 kg I: weight is below
normal
A: underweight
Ref: Kozier and
Erb¶s
Fundamentals of
Nursing, 8th
edition, volume 2,
page 1236
Ref: Bruneer and
Suddhart¶s
Medical-Surgical
Nursing, 11th
edition, volume 1,
page 79
Height 63.75 cm 68 cm I: the patient
height is 68 cm.
A: it is in the
normal range
which is 67.8-
72.3cm
Ref: Internet


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Normal Findings Actual Findings Interpretation and

Analysis
Skin Absence of ny Presence of I: there is wound
lesions wound in the in the lower left
abdomen abdomen of the
patient.
A: destruction of
the dermis of the
skin.
Ref: Health Care
1 manual of
Norzagaray
College page 115
Chest expansion Effortless More efforts I: there are much
inspiration when inhaling efforts in
inspiration
 A: shortness of
breathing
Ref: Kozier and
Erb¶s
Fundamentals of
Nursing, 8th
edition, volume 2,
page 1364
Breath sounds Air rushing There is I: not normal
through the adventitous sound heard in
respiratory tract sounds the bases of the
during inspiration lower lung lobes.
and expiration A: air passing
generates through fluid or
mucus in any air
passage causes
fine crackles.
Ref: Ref: Kozier
and Erb¶s
Fundamentals of
Nursing, 8th
edition, volume 1,
page 613

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Date Laboratory Component Normal finding Actual Interpretation
procedure results and Analysis
11-09-09 Complete RBC 3.50-5.50 3.77 I: all the
Blood HCT 42.0-52.0 27.6 components
Count PLT 150-450 267 are normal
WBC 5.0-10.0 9.1 except the
HGB 13.0-18.0 8.9 hemoglobin
LYM% 20.0-40.0 38.1 and
hematocrit
are both
below normal.
A: the
hemoglobin
and
hematocrit
concentration
is lower than
the normal,
 reflects the
presence of
fewer than
the normal
erythrocytesw
ith in the
circulation
may cause
anemia.
Ref: Ref:
Kozier and
Erb¶s
Fundamental
s of Nursing,
8th edition,
volume 2,
page 799-800

11-09-09 Urine Color Amber Light I: the patient¶s

examinatio Transparency Transparent yellow urine is
n Specific Gravity 1.010-1.025 Cloudy cloudy, low
Sugar Not present 1.005 specific
Reaction (ph) 4.5-8 Negative gravity and
Sterility No Acidic present of
microorganism Bacteria bacteria.
present A: white blood
cells,
bacteria, pus
or
contaminants
such as
prostatic fluid
may cause
cloudy urine.
Diluted urine
has a lower
specific
gravity and
causes
almost clear
or pale yellow
color. Slight
urinary tract
infection.
Ref: Ref:
Kozier and
 Erb¶s
Fundamental
s of Nursing,
8th edition,
volume 2,
page 1293
12-09-09 Radiology Chest X-ray normal There are Shows hazy
pulmunary hazy infiltrates,
tissue is infiltrates in which might
radiolucent the inner to mean that
middle there are
lung zones exudates
bilaterally. (secretions in
Heart is both lungs,
normal in probably
size and upper lobes)
configurati Ref: Dra.
on. Dianne
Mendoza,
college
physician

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Nursing problem Cues Justification
* Ineffective breathing G Tachypnea We choose
pattern G Dyspnea ineffective airway
G Tachypnea clearance as our
* Ineffective airway 73 cpm nursing priority
clearance G Orthopnea because there is
G Adventitious adventitous sounds
* Impaired gas exchange sound(fine and diffculty of
crackles) breathing and
G >Cough and shortness of
cold braething that
implies decreased
production of
oxygen and carbon
dioxide.
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Instruct and explain the patient¶s mother that the medication is very
important to continue depending on the duration that the doctor ordered for the
total recovery of the patient.

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Instruct the mother to let her child play but it should be limited to a short
period of time only to prevent the occurence of shortness of breathing.

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Advice the mother to keep her baby relax in order to recover in his
present condition. Intruct the mother to minimize the patient from exposure to an
open environment such as dusty and smoky area, which airborne microorganism
are present that can be a high risk factor that may cause severity of his condition.

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Encourage and expalin to the patient¶s mother that it is important to

maintain proper hygeine to prevent further infection. Instruct the patient¶s mother
to bath her baby every day and explain that bathing early in the morning is not a
factor or cause of having pneumonia. Instruct to increase fluid intake of the
patient.

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Regular consultation to the physician can be factor for recovery and to

assess and monitor the patient¶s condition.

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Diet as tolerated, meaning, the patient can eat everything until he can.
Diet plays a big role in fast recovery so that, instruct the mother to give nutritious
foods intended for respiratory problem.