Pneumonia Case Presentation - Final Draft

I. INTRODUCTION

Pneumonia is an inflammation of the lung parenchyma caused by various microorganisms which includes bacteria, mycobacteria, chlamydiae, mycoplasma, fungi, parasites and viruses. Pneumonia has been categorized into one of four categories: bacterial or typical, atypical, anaerobic/ cavitary, and opportunistic. The more widely used classification scheme categorizes the major pneumonias as community-acquired pneumonia, hospital-acquired pneumonia (nosocomial), immunocompromised host, and aspiration pneumonia. (Brunner and Suddarth, 2008)

Pneumonia is a major cause of death among all age groups. In children, many of these deaths occur in the newborn period. The WHO estimates that one in three newborn infant deaths is due to pneumonia. Over two million children under five die each year worldwide. WHO also estimates that upto 1 million of these (vaccine preventable) deaths are caused by the bacteria Streptococcus pneumoniae, and over 90% of these deaths take place in developing countries. Mortality from pneumonia generally decreases with age until late adulthood. Elderly individuals, however, are at particular risk for pneumonia and associated mortality. The annual incidence of pneumonia is approximately 6 cases for every 1000 people for the 18-39 age groups. For those over 75 years of age, this rises to 75 cases for every 1000 people. Roughly 20-40% of individuals who contract pneumonia require hospital admission of which between 5-10% is admitted to a critical care unit. (www.who.int)

Bronchopneumonia is marked by patchy exudative consolidation of lung parenchyma, caused most commonly by staphylococci, streptococci, pneumococci, Heamophilus influenzae, Pseudomonas aureginosa and coliform bacteria. Grossly the lungs show dispersed elevated, focal areas of palpable consolidation and suppuration. Histologic features consist of an acute (neurophilic) suppurative exudates filling airspaces and airways, usually about bronchi and bronchioles resolution of the exudates usually stores normal structure, but organization may occur and result in fibrous scarring in some cases, or aggressive disease may produce abscess lung in fibrous scarring in some cases.

Bronchopneumonia remains a common cause of death and is often found at autopsy. It typically develops in terminally ill patients, usually in dependent and posterior parts of the lungs. It is the second leading cause of morbidity and the fourth leading cause of mortality in the Philippine setting. (www.doh.gov.ph)

Why did we choose this case?

The group had their community health nursing exposure in Santo Rosario, Barangay Plainview and is familiar with this community. The group chose this pediatric patient because of the unusual case of an infant with a cleft palate who had pneumonia. We thought this is an interesting case that would enhance our knowledge and understand the health status and different factors that contributed to client’s condition.

II. OBJECTIVES

A. General Objective:

After obtaining this case study, our group will have the knowledge to understand the disease process and client’s condition, develop skills to make a plan of care suitable to the client’s needs, and proper attitude through effective nurse- patient interaction.

B. Specific Objectives:

To perform physical assessment required for our patient and assess the manifestations of the disease.

To understand the health status and different factors that would affect the client’s condition.

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http://www.doh.gov.ph/

To know the predisposing and precipitating factors that contributed to our client’s illness.

To determine the nursing management /interventions for a specific health problem identified.

To plan for an effective management of the problems identified that will help the patient recover from the disease.

To evaluate the outcome of nursing interventions and confirm if the nursing care is effective.

III. INITIAL DATA BASE

A. Family Structure, Characteristics and Dynamics

The family that we choose is a type of nuclear family which has five (5) members: Mr. J.E, the father; Ms. D.M, the wife; B.E, the eldest son who is eight (8) years old; followed by F.E., the four (4) year old daughter and the youngest daughter, Baby J.E. who is two (2) months old and our patient with a cleft palate. The family is currently residing at Santo Rosario, Barangay Plainview, Mandaluyong City.

The father is the head of the family and the one responsible for making decisions in the house. The mother is in charge of taking care of the house and children and usually makes the decision when it comes to health matters.

Ms. D.M mentioned that she discusses with her husband whatever family problems they may have and tries to resolve them as soon as they can.

B. Socio-economic and Cultural Characteristics

The father works as a pedicab driver in their area while the mother does not work and stays in the house the take care of the children. The mother is also the one responsible in budgeting her husband’s income and allocates it for the basic needs of the family.

Both parents have reached 1st year high school. Their two children are currently studying; the eldest in grade 1 while the second is in preschool at the Barangay day care. They are both from living in Mandaluyong City but the mother was originally from Isabela. They are Roman Catholics

C. Home and Environment Our chosen family lives in a very small house, which is made up of mixed materials, located on a congested area. The house has inadequate space for 5 members of the family. They have one light, an electric and a television set. There is poor ventilation as they only have the one window, which is kept closed as it is being blocked by the bed and only have the door for air to circulate. The family sleeps on a double deck bed made from wood, which could almost reach the ceiling. The father sleeps on the upper portion while the mother and the baby sleep on the lower portion of the double deck bed and the children on the floor.

The presence of low ceiling and bed bugs is a health hazard for the members of the family. The stagnant water in front of their house is also good breeding site for vectors. Since they are living in a congested area, faulty community wirings are present and are considered a fire hazard.

They do not have a refrigerator for food storage and covers their leftover food, if any. For their water source, they use a communal faucet. They also use pour flush in the communal toilet in their area.

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The family is utilizing the free health care services being provided by the health center which is accessible in their area.

The garbage in their community is being collected twice a week (every Wednesday and Saturday) by the city’s garbage collectors. For public transportation, there are many public utility jeepneys, tricycles and pedicabs which are accessible in their area. There are also public phones available at the sari-sari store near their house. A small chapel is also near their house. Eateries and mini-market are also visible within the community.

D. Health Status of Each Family Member According to the respondent, there is no history of any disease or illness within their family except for the common cough and colds and due to climate change. The client is only two months old weighing 5.94lbs (2.7kg) and with a height of 60.5cm. Her Body Mass Index is 5.1 which is considered underweight for her age. She needs to gain weight before she undergoes palatoplasty or cleft palate repair. This surgical procedure is used to correct or reconstruct or cleft palate. She has been immunized with BCG and first shot of Hepa.B. She uses a special feeding bottle to lessen the possibility of aspiration. Their family does not use any herbal medicines.

E. Values, Habits, Practices on Health Promotion, Maintenance and Disease Prevention

According to the client’s mother, Baby J.E received the immunization intended for her age. Baby J.E. has not been able to get adequate sleep as she keeps on crying most of the time. Her mother also stated that she missed the regular scheduled check-up of baby J.E. As for Ms. D.M, she does not also have enough sleep as she needs to look after her Baby J.E. while her husband looks after their two kids. In terms of exercise or any physical activities, the little children usually play with other the children in their community in the streets. Their mother considers walking when going to market as her exercise. They do not use any bed nets to protect themselves from insects and mosquitoes. They use foot wears to protect their feet’s when walking outside. They watch television as a form of their relaxation.

III. SPECIFIC CASE STUDY

NAME: Baby J. E.ADDRESS: 245 Sto. Rosario, Plainview, Mandaluyong CityAGE: 2 months old DATE OF BIRTH: July 18, 2011

A. Pediatric Case Study

1. Health History

Two days prior to admission, Baby J.E. already had coughs but without colds. Few hours prior to admission, she already had difficulty of breathing

a. Birth History

The baby was delivered normally at 9 months.

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b. Developmental History

According to Piaget’s Cognitive Development, Baby J.E.’s sensorimotor development is under the primary circular reaction wherein hands-mouth and ear-eye coordination develop. When fully alert, the extremities and head are constantly moving. The baby was able to hold her head up when placed in prone position. Baby J.E. has already developed her social smile.

c. Feeding History

Baby J.E. was initially breast fed by the mother but due to the baby’s congenital condition of having a cleft palate, there is the aspiration of milk during breastfeeding. Hence, the mother started using breast pump to collect milk and used a medicine dropper to feed the baby. After consultation with a physician, the mother was advised to use a special feeding bottle to help prevent aspiration.

d. Immunization

The baby is already immunized with BCG and the first dose of Hepatitis B.

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2. Physical Assessment

Date and Time Performed: Sept. 29, 2011 1:30pmWeight: 5.94 lbs (2.7kg)Height: 60.5 cmBMI: 5.1 UNDERWEIGHT

VITAL SIGNS:Respiration Rate: 63 cpmPulse Rate: 158 bpmTemperature: 36.8°C

BODY PARTS TECHNIQUE USED

FINDINGS ANALYSIS

General Appearance

Inspection Body built: small for age

Body odor: no odor

Hygiene and grooming: clean and neat

Signs of distress:crying

Underweight

Normal

Normal

Difficulty of breathing

Skin Inspection and Palpation

Color: brown

Symmetry of color: uniform

Edema: no edema

Skin lesions: none

Moisture: moist

Temperature of skin: within the normal range

Skin turgor: good

Normal

Normal

Normal

Normal

Normal

Normal

NormalHair Inspection and

PalpationDistribution:evenly distributed

Thickness: Thin hair

Texture and Oiliness: Silky hair

No infection or infestation

Normal

Normal

Normal

Nails Inspection and Palpation

Texture: smooth

Nail bed color: pinkishSurrounding tissue:

Normal

Normal

Normal

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intact epidermis

Blanch Test: returned to usual color (less than 4 seconds)

Normal

Face Inspection Facial features: symmetrical

Facial movements:symmetrical

Normal

Normal

Eyes Inspection Eyebrows: evenly distributed

Eyelashes:equally distributed

Eyelids:intact, close symmetrically

Pupils are constricting and dilating

Normal

Normal

Normal

Normal

Ears Inspection Auricles: aligned with the outer canthus of the eyes

Ear canal: with few earwax

Hearing acuity: normal voice is not audible due to no reaction of the baby and no widening of the eyes when the mother speaks loudly

Normal

Normal

For consultation with the doctor

Nose Inspection Symmetric and straight

Uniform color

Normal

NormalMouth Inspection Tongue is pinkish

Palate: cleft palate

Normal

InbornLungs Auscultation Breath sounds:

CracklesCrackle sounds produced are created when air is forced through respiratory passages that are narrowed by fluid or mucus

Abdomen Inspection Skin integrity:Unblemished

Umbilical cord:dry

Normal

Normal

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The respiratory system consists of all the organs involved in breathing. These include the nose, pharynx, larynx, trachea, bronchi and lungs. The respiratory system does two very important things: it brings oxygen into our bodies, which we need for our cells to live and function properly; and it helps us get rid of carbon dioxide, which is a waste product of cellular function. The nose, pharynx, larynx, trachea and bronchi all work like a system of pipes through which the air is funneled down into our lungs. There, in very small air sacs called alveoli, oxygen is brought into the bloodstream and carbon dioxide is pushed from the blood out into the air. When something goes wrong with part of the respiratory system, such as an infection like pneumonia, chronic obstructive pulmonary diseases, it makes it harder for us to get the oxygen we need and to get rid of the waste product carbon dioxide.

Anatomy of the Respiratory System

Nose – The nose is the only external part of the respiratory system and is the part where the air passes through. During inhalation and exhalation, air enters the nose by passing through the external nares or nostrils. mportant information about nose is the presence of the sticky mucus that is produced by the mucosa’s gland. This important characteristic moistens the air and traps the incoming bacteria and other foreign debris passing through the nasal cavity.

Conchae – these are three mucosa-covered projections or lobes that greatly increase the surface area of the mucosa exposed to the air. Aside from that, conchae increase the air turbulence in the nasal cavity.

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Palate – a partition that separates the nasal cavity from the oral cavity. Anteriorly, the palate that is supported by a bone called the hard palate and the one which is unsupported is the soft palate.

Paranasal Sinuses – these are structures surrounding the casal cavity and are located in the frontal, sphenoid, ethmoid and maxillary bones.

Pharynx– The pharynx is a 13 cm long muscular tube that is commonly called the throat. This muscular passageway serves as a common food and air pathway. This structure is continuous with the nasal cavity anteriorly via the internal nares.

Tonsils – clusters of lymphatic tissues found in the pharynx.

Larynx - The larynx is the one that routes the air and food into their proper channels. Also termed as the voice box, it plays an important role in speech. This structure is located inferior to the pharynx and is formed by:

1. Eight rigid hyaline cartilages2. Spoon-shaped flap of elastic cartilage, which is called the epiglottis.

Thyroid cartilage – this is the largest hyaline cartilage that protrudes anteriorly in males and is referred to as the Adam’s apple.

Epiglottis – this is a flap of tissue that serves as a guardian of the airways as it protects the superior portion of the larynx.

Vocal folds – a pair of folds which is also called the true vocal cords that vibrate when air is expelled.

Glottis – the slit-like passageway between the vocal folds.

Trachea– Also called the windpipe, the trachea is about 10 to 12 cm long or about 4 incheas and travels dwon from the larynx to the fifth thoracic vertebra.

Main Bronchi– The main bronchi, both the right and the left, are both formed by tracheal divisions. There is a slight difference between the right and left main bronchi. The right one is wider, shorter and straighter than the left. This is the most common site for an inhaled foreign object to become lodged. When air reaches the bronchi, it is already warmed, cleansed of most impurities and well humidified.

Lungs– The lungs are fairly large organs that occupy the most of the thoracic cavity. The most central part of the thoracic cavity, the mediastinum, is not occupied by the lungs as this area houses the heart.

Bronchioles – smallest air-conducting passageways.Bronchial tree or respiratory tree – a network formed due to the branching and rebranching of the respiratory passageways within the lungs.Alveoli – air sacs. This is the only area where exchange of gases takes place. Millions of clustered alveoli resembles bunches of grapes and these structures make up the bulk of the lungs.

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Physiology of Respiration

The respiratory primarily supplies oxygen to the body and disposes of carbon dioxide through exhalation. Four events chronologically occur, for respiration to take place.

1. Pulmonary ventilation – this process is commonly termed as breathing. With pulmonary ventilation, air must move out into and out of the lungs so that the alveoli of the lungs are continuously drained and filled with air.

2. External respiration – this is the exchange of gases or the loading of oxygen and the unloading of carbon dioxide between the pulmonary blood and alveoli.

3. Respiratory gas transport – this is the process where the oxygen and carbon dioxide is transported to the and from the lungs and tissue cells of the body through the bloodstream.

4. Internal respiration – in internal respiration the exchange of gases is taking place between the blood and tissue cells.

Mechanics of Breathing

Breathing, also called pulmonary ventilation is a mechanical process that completely depends on the volume changes occurring in the thoracic cavity. Thus, a when volume changes pressure also changes, and this would lead to the flow of gases equalizing with the pressure.

Inspiration – also called inhalation. This is the act of allowing air to enter the body. Air is flowing into the lungs with this process. Inspiratory muscles are involved with inspiration which includes:

1. The diaphragm2. External intercostals

These muscles contract when air is flowing in and thoracic cavity increases. When the diaphragm contracts it slides inferiorly and is depressed. As a result the thoracic cavity increases. The contraction of the external intercostal muscles lifts the rib cage and thrusts the sternum forward. This increases the anteroposterior and lateral dimensions of the thorax.

Expiration – also called expiration. It the process of breathing out air as it leaves the lungs. This process causes the gases to flow out to equalize the pressure inside and outside the lungs. Under normal circumstances, the process of expiration is effortless.

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V. PATTERNS OF FUNCTIONING (GORDON’S)

Patterns of Functioning Before Hospitalization After/During Hospitalization

Analysis

1. Health Perception The mother stated that her baby oftentimes gets colds but it did not bother her for she thought it was normal.

After the baby was diagnosed with pneumonia, her mother became aware of the seriousness of the disease and promised to take care of her baby at her best.

The baby’s condition increased the awareness of the mother on pneumonia and provide extra care for her sick child,

Diagnosis: Ineffective Health Maintenance

2. Nutritional/Metabolic Pattern

According to her mother they have difficulty in feeding their baby due to her cleft palate. “Gumamit kami ng medicine dropper para padedehin siya. Nakaka-1 ounce lang siya kada oras kasi hirap siya” as verbalized by the mother.

The patient’s mother started using a special feeding bottle for babies with cleft palate as instructed by the physician. They bought and used it which led to improvement of her feeding. “Nakaka-3oz siya oras-oras”, as verbalized by the mother.

The baby’s weight slightly increased due to the improvement of her feeding but still below normal and not enough to undergo cleft palate surgery.

Diagnosis: Ineffective Infant Feeding

3. Activity/Metabolic Pattern

Sucking, swallowing Babinski, palmar grasp and fencing reflex are present. She already learned social smile.

Reflexes remains the same.

Reflexes are normal although there is risk for aspiration in swallowing because of her cleft palate.

4. Sleep/Rest Pattern The baby was restless and has a disrupted sleeping pattern due to coughing and warm environment.

During hospitalization,the baby was able to sleep at long intervals at night and takes naps during the day.

After hospitalization:her hours of sleep decreased at night in short intervals and her naps became shorter because of continuous crying.

Infants normally sleeps around 12 hours but the patient has not been able to establish normal sleeping pattern.

Diagnosis: Altered sleep pattern.

5. Elimination Pattern According to the mother, the newborn defecates 2 times a day with yellowish and semi-formed stool and urinates around 3 times a day.

Bowel movement of the newborn was increased to 3 times a day due to increased feeding and urinates around 4 times a day.

Bowel movement and urination of the baby increased because of increased intake of milk.

6. Value/Belief Pattern The parents believe and have a strong faith in God and would like to have the baby baptized

They would like to baptize their baby before having her cleft palate surgery. They

Their family has a strong faith in God and they believe that He will guide and help them in surviving

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but have not done yet due to lack of financial resources.

believe that God will guide her through it. “At pati na rin ayokong maging tiyanak siya”, as verbalized by the mother.

every endeavor in life.

7. Cognitive Perceptual Pattern

The mother verbalized that her baby has no sensory defects.

During hospitalization, the mother stated that there were some simple tests done to check the baby’s hearing. She verbalized that “parang hindi nakakarinig yung anak ko”.

The mother was advised to consult a physician at VRPMC for accurate hearing test.

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VI. FIRST LEVEL ASSESSMENT

1. Health Threat

Poor home/environment

Inadequate living space

Poor lighting and ventilation

Accident Hazard

Fire hazard

Unhealthy lifestyle

Cigarette smoking

Threat for cross infection

2. Health Deficit

Ineffective airway clearance

3. Foreseeable Crisis

Hospitalization of a family member

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VII. SECOND LEVEL ASSESSMENT

Cues/Data Family Nursing Problems Second Level AssessmentHEALTH THREATPoor home/environment :

a. The 5 members of the family are living in small house.

Inadequate living space Inability to provide a home environment conducive to health maintenance and personal development due to inadequate family resources, specifically financial constraints/limited financial resources.

a. The house has blocked window

b. They only have one elec-tric fan

c. The family has only one fluorescent light

Poor lighting and ventilation Inability to provide a home environment conducive to health maintenance and personal development due to inadequate family resources, specifically financial constraints/limited financial resources.

Accident hazard:

a. The house is made of light materials

b. Family lives in a con-gested area

c. Present faulty wiring

Fire hazard Inability to recognize the presence of the condition or problem due to denial about is existence or severity as a result of fear of consequences of diagnosis of problem, specifically economic /cost implication.

Inability to recognize the presence of the condition or problem due to attitude /philosophy in life which hinders recognition / acceptance of a problem

Unhealthy lifestyle:a. The father is a smoker Cigarette smoking Inability to recognize the

presence of the condition or problem due to attitude /philosophy in life which hinders recognition / acceptance of a problem

Inability to provide adequate nursing care to the risk member of the family due to lack of knowledge about the health condition (complication)

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Threat for cross infection:a. The house has poor venti-

lationCross infection Inability to provide a home

environment conducive to health maintenance and personal development due to:a. Failure to see the benefits

of investment in home en-vironmental improve-ment.

b. Lack of knowledge of preventive measures.

HEALTH DEFICITa. Presence of cough, colds,

fever, aspiration (cleft palate)

Illness state (Bronchopneumonia)

Inability to provide adequate nursing care to the sick member of the family due to inadequate knowledge about the health condition (complication and management)

Inability to provide a home environment conducive to health maintenance and personal development due to inadequate family resources, specifically financial constraints/limited financial resources.

FORESEEABLE CRISIS:a. Hospitalized August

31,2011b. Discharge September

6,2011

Hospitalization of a family member

Inability to provide a home environment conducive to health maintenance and personal development due to inadequate family resources, specifically financial constraints/limited financial resources.

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VII. PRIORITIZATION

HEALTH THREATINADEQUATE LIVING SPACE

Criteria Computation Actual Score

Justification

1. Nature of the problem 2/3 x 1 0.67 The problem is a health threat.

2. Modifiability of the problem

1/2 x 2 1 Household items should be arranged properly to maximize living spare.

3. Preventive potential 3/3 x 1 1 Increasing the living space will provide adequate movements when performing household chores.

4. Salience of the problem 0/2 x 1 0 The family does not consider this as a problem.

Total 2.67

POOR LIGHTING AND VENTILATIONCriteria Computation Actual

ScoreJustification



1/2 x 2 1 The family may remove the hindrance blocking the window for air circulation.

3. Preventive potential 3/3 x 1 1 The family can open the door to facilitate air circulation


Total 2.67

FIRE HAZARDCriteria Computation Actual

ScoreJustification



1/2 x 2 1 The family does not have adequate financial resources. However, wires can be properly arranged to reduce the possibility of accidents.

3. Preventive potential 2/3 x 1 0.67 Fixing faulty wires can help prevent fire in the community.


Total 2.34

CIGARETTE SMOKINGCriteria Computation Actual

ScoreJustification



1/2 x 2 1 The resources and intervention needed are available in the community to

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solve the problem.3. Preventive potential 2/3 x 1 0.67 The problem can be reduced

through conducting health teachings to the community.


Total 2.34

CROSS INFECTIONCriteria Computation Actual

ScoreJustification



1/2 x 2 1 The family does not have enough knowledge about the transferability of the disease.

3. Preventive potential 2/3 x 1 0.67 The infection can be prevented through proper ventilation and sanitation if the family will comply with health teaching being imparted.


Total 2.34

HEALTH DEFICITINFFECTIVE AIRWAY CLEARANCE


Justification

1. Nature of the problem 3/3 x 1 1 The problem is a health deficit.


1/2 x 2 1 Health teachings can be imparted to add knowledge

3. Preventive potential 2/3 x 1 0.67 Monitor the feeding of the baby.

4. Salience of the problem 2/2 x 1 1 A condition or a problem not needing an immediate attention

Total 3.67

FORESEEABLE CRISISHOSPITALIZATION OF THE FAMILY


Justification

1. Nature of the problem 1/3 x 1 0.33 The problem is a foreseeable crisis


1/2 x 2 1 The family does not have enough financial resources

3. Preventive potential 2/3 x 1 0.67 The family may seek medical attention to a public hospital.

4. Salience of the problem 2/2 x 1 1 A condition or a problem not needing an immediate attention

Total 3

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IX. EVALUATION

A. Learning Experience

This study helped our group enhanced our knowledge on the disease process of pneumonia. We were also able to apply the skills learned in Community Health Nursing and Health Assessment. Based on the data gathered, the group was able to understand the health status of the patient, identify the predisposing and precipitating factors that contributed to our client’s illness and formulated the nursing care plan and interventions suitable to the client’s needs.

B. Problems Encountered

This is the group’s first case presentation and below are some of the problems encountered in doing this presentation:

There was limited time in gathering data since it was raining hard on the day we were at the community.

The house of the family is small with low ceiling and could only accommodate two and at most three students at a time.

The group is working on two case presentations simultaneously which are both first case presentations in two different subjects which have the same due date.

Final examination is fast approaching and we also need to prepare for all the subjects for the exams.

Some members of the group were late during the agreed time to meet.

While we understand that this is part of our learning experience, the group tried stay focus, asked the cooperation of each member and managed our time wisely in order to achieve our goal to come up with this case presentation.

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Documents

Pneumonia Case Presentation - Final Draft