General Objectives:

After an hour of case presentation, the student nurse will be able to present the summary of the different aspect of the client’s case in order to promote further consciousness and awareness of the condition for the promotion of health and prevention of further complications as equally significant to the client’s wellness.

Specific Objectives:

After an hour of case presentation, the students will be able to:

accomplish assessment to gather pertinent data about the client as deemed relevant to the case name the major health problem of the client defined the technical terms found in the course of study to facilitate better understanding

present the anatomy and physiology discuss the pathophysiology of the client’s disease condition present laboratory studies conducted therein present other ideal laboratory studies and their implication to support the diagnosis of the disease determine the appropriate nursing diagnosis for the client’s case

create a plan of care appropriate for the client’s condition commit to effectively execute or implement nursing care plan for the client, including all nursing interventions suited evaluate the efficiency of the nursing care provided according to the nursing care plan

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 the older adults and those with chronic illnesses.

It can also strike young and 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 the lungs, leading to inflammation that makes it hard for an individual to breathe. Pneumonia can affect one or both lungs. In young and healthy individual, early treatment with antibiotics can cure bacterial pneumonia.

The drugs used to fight pneumonia are determined by the germ causing pneumonia and the doctors findings. It is best to do everything we can to prevent pneumonia, but if one 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 one’s attention, though the disease is just like an ordinary cough and fever, it can lead to death especially when there is no immediate intervention done. Since the case is an infant, an appropriate care has to be done to promote faster recovery for the patient.

Treating patients with pneumonia is necessary to prevent its spread to others and make them as another victim of this illness. Bronchopneumonia is an illness of the lungs which is caused by different organism like bacteria, viruses, and fungi and characterized by acute inflammation of the walls of the bronchioles.

It is also known as pneumonia. Streptococcus pneumoniae (pneumococcus) and Mycoplasma pneumoniae both are the common bacterium which causes bronchopneumonia in the adults and children. Acute inflammation of the walls of the smaller bronchial tubes, with varying amounts of pulmonary consolidation due to spread of the inflammation into peribronchiolar alveoli and the alveolar ducts; may become confluent or may be hemorrhagic.

In Philippines, the case of pneumonia is one of leading cause of mortality and morbidity among Filipinos, 75-85% of the population acquired the disease and the one affected the disease are those who are in low income status and the below poverty line individual. (www.DOH.org/pneumonia)

DEFINITION OF TERMS

Bradypnea - slower than normal rate (<10 breaths/minute), with normal dept and regular rhythm Dyspnea – distressful sensation of uncomfortable breathing that may be caused by certain heart conditions

Empyema – inflammatory fluid and debris in the pleural space. It results from an untreated pleural-space infection that progress from free-flowing pleural fluid to a complex collection in the pleural space.

Hypoxemia – decrease in arterial oxygen tension in the blood

Mycoplasma pneumonia – another type of Community Acquired Pneumonia (CAP), occurs most often in children and young adults and is spread by infected respiratory droplets through person-to-person contact

Pleural effusion – abnormal accumulation of fluid in the pleural space Pleural cavity – the area between the parietal and visceral pleurae a potential space

Substernal Retraction – indrawing beneath the breastbone, commonly manifested to infant and neonate with respiratory distress

Thoracentesis – insertion of a needle into the space to remove fluid that has accumulated and decrease pressure on the lung tissue; may also be used diagnostically to identify potential causes of a pleural effusion

Thoracostomy - done to drain fluid, blood, or air from the space around the lungs

BASELINE DATAName: Baby Boy

Address: P-5 Aguada Ozamiz City, Misamis Occidental

Age: 4 months old

Birth date: April 9, 2009

Birthplace: Aguada, Ozamiz City

Gender: Male

Religion: Roman Catholic

Nationality: Filipino

Father’s name : Felly Baguio Rone

Mother’s name: Neiva Dumanjug Dayondon

Date of Admission: September 6, 2009

Time of Admission: 6:25 AM

Chief Complaint : on and off cough associated with fever

Admitting Diagnosis: Bronchopneumonia Admitting Physician: Dr. Alimyon Montolo, MD

BACKGROUND HISTORY

DM HPN CANCER ASTHMA

Maternal - - - -

Paternal - - - -

The parents of the client both manifest (-) history of the following diseases: DM, Hypertension, Cancer, Asthma as interviewed.

HISTORY OF PRESENT ILLNESS

1 month prior to admission, Baby boy experienced on and off cough and associated with fever, with intercostal retraction, rapid and shallow breathing.

SOCIO-ECONOMIC BACKGROUND

The family of baby boy was very supportive; they have provided all his medication. Especially his medicine and payments for other diagnostic procedures to be done for his early and faster recovery.

GENERAL APPERANCE

• A 4-month old baby boy • Weigh 6.8 kilograms• Short brown hair• Cyanosis noted upon coughing • Rapid shallow breathing noted• Expressed his self through crying • Skin is warm to touch• Irritability noted due to his

condition

VITAL SIGNS

September 8, 2009

4 pm 8 pm

HR: 156 bpm HR: 160 bpm RR: 60 cpm RR: 64 cpm TEMP: 38.3 °C TEMP: 37.8 °C

September 9, 2009

4 PM 8 PM• HR: 150 bpm HR: 162 bpm• PR: 63 cpm PR: 54 cp• TEMP: 38 °C TEMP: 37.3 °C

• September 10, 2009

4 pm 8 pm HR: 149 bpm HR: 149 bpm RR: 38 cpm RR: 40 cpm TEMP: 37.5 °C TEMP: 37.4 °C

• September 11, 2009

4 pm HR: 140 bpm RR: 33 cpm TEMP: 36.9 °C

PHYSICAL ASSESSMENT

NeurologicalThe patient can able to expressed his self

through crying.

Eye/VisionOur patient, have pale conjunctiva due

to fever. Eyelashes present curving outward. No lesions noted on the eyelid. Pupil equal, round, reactive to light and accommodation.

Ears/HearingOur patient doesn’t have hearing

problem, no discharges, symmetrical, no swelling and tenderness. Can respond normal voice tone. Intact with no lesions.

NoseOur patient doesn’t have nasal

problem, any discharges, any swelling and tenderness noted upon inspection and uniform in color.

Mouth/Tongue/Teeth/ Speech The patient had a pallor lips, reddened gums, without teeth. Thin whitish coating noted in the tongue, it moves freely without lesions.

Throat/NeckNeck is symmetrical with head, can

turned head from right to left gradually, but with resistance, no palpable lymph nodes.

Respiratory SystemPatient use accessory muscle in order to

breathe normally, presence of wheezing sound is heard upon auscultation and in normal hearing, with respiratory rate of 60-42 cpm., and nebulization was given.

Circulatory/CardiovascularPatient has a heart rate of 156-140

beats per minute. No edema and swelling noted. Good capillary refill less than 2sec.

GastrointestinalFlat abdominal contour, no tenderness or

distention. Thorax had dullness of sound due to decrease confluent and pleural effusion.

GenitourinaryPatient had excessive urination, with

minimum of 800cc per diaper

MusculoskeletalThe patient had normal upper and lower

extremities, symmetrical and no tenderness

IntegumentaryThe patient's skin was warm to touch, he

experience on and off fever, with good skin turgor. Negative of rashes, sores, and lesions.

A respiratory system functions to allow gas exchange. The gases that are exchanged, the anatomy or structure of the exchange system and the precise physiological uses of the exchanged gases vary depending on the organism.

In humans and other mammals, for example, the anatomical features of the respiratory system include airways, lungs, and the respiratory muscles. Molecules of oxygen and carbon dioxide are passively exchanged, by diffusion, between the gaseous external environment and the blood. This exchange process occurs in the alveolar region of the lungs.

The respiratory system can be conveniently subdivided into an upper respiratory tract (or conducting zone) and lower respiratory tract (respiratory zone), trachea and lungs. The conducting zone starts with the nares (nostrils) of the nose, which open into the nasopharynx (nasal cavity).

The primary functions of the nasal passages are to: 1) filter, 2) warm, 3) moisten, and 4) provide resonance in speech. The nasopharnyx opens into the oropharynx (behind the oral cavity).

PATHOPHYSIOLOGY

Predisposing factors Age (very young) Exposure (living)

Precipitating factors Daily ActivitiesEnvironmentDiet

Pathological Entry (inhalation) of organism: Bacteria or Viruses

Occurrence of localized inflammation

Mucus production Manifested by wheezing

Bacteria invades alveolar cell in

the lungs

Diminished surfactant

production Formation of

Hyaline membrane

BronchopneumoniaAirway

Obstruction

Signs And Symptoms

Fever, cough, chest pain, Rapid,

swallow breathing

LABORATORY REPORTS Urinalysis

Color: pale yellow Transparency: clear

Sp. Gravity: 1.010

pH: 6.0

Microscopic findings

RBC: 0-1/hpf

• Pus cells 0-1/hpf

• Epithelial cells: rare

• Crystals: Amorphous Urates (PD 4) – rare/hpf

• Bacteria: rare

HEMATOLOGY

TEST NORMAL VALUES

RESULT

Hematocrit 35.0-50.0% 33.0

Hemoglobin 12.0-16.5 g/dl 11.0

White cell count 5,000-10,000mm³ 3,600

Platelet count 150,000-400,000/mm³

275,000

Segmenters 55-65% 42

Lymphocytes 25-35% 58

Blood Type “B” RH type(+)

BLOOD CHEMISTRY

TEST NORMAL VALUES

RESULT

Sodium 136-145 mEq/L 132.7 mEq/L

Potassium 3.5-5 mEq/L 3.23 mEq/L

Radiographic Report

Chest X-ray: AP/Lateral view

– There are inhomogeneous parasites in both lower lung fields.

– The cilia and pulmonary vascular markings are within normal limits.

– The trachea is midline

The heart is not enlarged.

The hemi diaphragms and costophrenic angles are intact.

The rest of the osseous and soft tissue structures are unremarkable.

Impression: Pneumonia, bilateral

follow up chest x-ray is suggested.

DISCHARGE TEACHING PLAN

The medication of the patient is very important to continue depending on the duration that the doctor ordered for the total recovery of the patient.

Patient with Bronchopneumonia needs to have deep breathing exercise for lung expansion and clearing for progressive normal breathing pattern and have adequate rest periods.

The client must relax in order to recover his present condition and instructed significant others for minimal exposure to an open environment such as dusty and smoky area, which airborne microorganisms are present that can be a high risk factor that may cause severity of her condition. It is also important to maintain proper hygiene to prevent further infection. Significant others of the patient instructed that the baby should be bathe everyday.

Regular consultation to the physician can be factor for recovery to assess and monitor his condition

The diet of the patient is also a factor for fast recovery. Encouraged to eat nutritious foods intended for respiratory problem patient, the family of the patient plays a big role for the fast recovery