Lorma Colleges COLLEGE OF NURSING NCM102

A Case Study of: Ms. A.B Name of the Patient As Partial Requirement for NCM102 Submitted by: BSN II-2 Group 3 (Sevilla) Nursing Students

March 3, 2011

I. INTRODUCTION

Integrated Management of Childhood Illness IMCI (Integrated Management of Childhood Illness) was first developed in 1992 by UNICEF and the World Health Organization (WHO) with the aim of prevention, or early detection and treatment of the leading childhood diseases. The IMCI is a general approach recognizing that in most cases, more than one underlying cause contributes to the illness of the child. IMCI combines proven experience into an effective approach for managing the sick child. While the management of childhood illness focuses on treatment, it also provides the opportunity to lay emphasis on prevention of illness through education on the importance of immunization, micronutrient supplementation, and improved nutrition especially oral rehydration therapy (ORT), breastfeeding and infant feeding. IMCI seeks to reduce childhood mortality and morbidity by improving family and community practices at the home setting. Key factors in the childs immediate environment nutrition, hygiene, immunizations - are as important as medical treatment in improving health. IMCI is a guideline through which all community health interventions can be delivered to the child. Objectives of IMCI To reduce significantly global morbidity and mortality associated with the major causes of illnesses in children. To contribute to healthy growth and development of children The case management process is used to assess and classify two age groups: Age 1 week up to 2 months Age 2 months up to 5 years This process shows us how to use the chart to identify signs of serious disease such as pneumonia, diarrhea, malaria, measles, dengue hemorrhagic fever, meningitis, malnutrition, and anemia.

The case management process The chart describes the following steps; 1. Assess the child or young infant 2. Classify the illness 3. Identify the treatment 4. Treat the child 5. Counsel the mother 6. Give follow up care Classification table The classification tables on the assess and classify have 3 rows. Each color of the row helps to identify whether the child has a serious disease recurring urgent attention. Each row is colored either Pink means the child has a severe classification and needs urgent attention and referral or admission for inpatient care. Yellow- means the child needs a specific medical treatment such as an appropriate antibiotic, an oral anti-malarial or other treatment; also teaches the mother how to give oral drugs or to treat local infections at home. The health worker teaches the mother how to care for her child at home and when she should return. Green not given specific medical treatment such as antibiotics or other treatments. The health worker teaches the mother how to care for her child at home. Always start at the top of the classification table. If the child has signs from more than 1 row always select the more serious classification.

PNEUMONIA Pneumonia is an inflammatory process in lung parenchyma usually associated with a marked increase in interstitial and alveolar fluid. It is an infection that involves the small air sacs and the tissues around them. 3

The onset of pneumonia is marked by any or all of the following manifestations: fever, chills, sweats, fatigue, cough, sputum production and dyspnea. More than 150 million episodes of pneumonia are estimated to occur every year among children under five in developing countries, accounting for more than 95 per cent of all new cases worldwide. Between 11 and 20 million children with pneumonia will require hospitalization. South Asia and Sub-Saharan Africa have the highest incidence of pneumonia cases among children under five. These two regions combined bear the burden of more than half the total number of pneumonia episodes worldwide. It has been estimated that 10 per cent of all under-five deaths, are caused by severe infection. And a significant proportion of these infections is caused by pneumonia/sepsis (sepsis is a serious blood-borne bacterial infection that is also treated with antibiotics). If these deaths were included in the overall estimate, pneumonia would account for up to 3 million, or as many as one third (29 per cent), of under-five deaths each year. In the Philippines, acute respiratory tract infections and pneumonia are among the leading cause of morbidity and mortality. According to the Field Health Information System, acute lower respiratory tract infection and pneumonia is the leading cause of morbidity in the Philippines as of 2007. It is also the fourth leading cause of morbidity in the country as of 2005(updated as of January 9, 2009). According to the Field Health Information System, an estimated death of 24 per 1,000 live births would consist of deaths due to pneumonia, making it as one of the most common causes of under-five mortality in the country. The city health office of San Fernando, La Union has documented 23 cases of pneumonia in the year 2009. As of 2008, community-acquired pneumonia is the second leading cause of death and the second leading cause of discharges.

II. PATIENT AND FAMILY CENTERED OBJECTIVES At the end of this study the following will be resolved: 1. Improve the condition of the patient through proper nursing intervention based on the IMCI guidelines 2. The family will be able to identify measures that could minimize the risk of recurrence of the disease. 3. The family could identify possible risk factors that may have contributed to the development of the patients pneumonia and be able to avoid them. 4. Develop the familys support system and distinguish their respective roles in improving patients health status. 5. Involve the family in practicing proper health care of the patient.

III.

FAMILY HEALTH HISTORY A. GENERAL DATA

A.B., a 3 year old girl who lives at Purok 4, Sevilla, San Fernando City, was brought to the Sevilla Health Center because of cough for 3 days. She was born February 19, 2007 to a Filipino couple. Her father, Mr. E.B., is a tricycle driver and her mother, Mrs. D.B., died when she was born. She was brought to the Health Center last February 24, 2011 with a weight of 12.5 kg and height of 32 inches. B. REASON FOR SEEKING HELP Three days prior to the interview, the father noticed that his child started to develop a cough accompanied by an increased breathing pattern. He did not seek consultation until after our group diagnosed her with pneumonia, due to fast breathing of 44 breaths per minute. C. HISTORY OF PRESENT CONDITION / ILLNESS The patients father claims that his child experienced cough for three days prior to the interview. D. PAST HEALTH HISTORY The patients father claims that his child has never been admitted to the hospital. He also mentioned that whenever her child experiences mild fever and colds, he buys over the counter medications. According to him, his child does not have any known allergy to any kind of food or drug. ENVIRONMENTAL HISTORY Their house is near the road where most vehicles pass by. His father said that their

house is made of wood in which is enough for his family to live in. According to him, cockroaches, flies and mosquitos are present at their house. They also own some appliances like television, radio and electric fan. They have electric connection and their source of water is via pump. They live in a place where houses are near each other. They cook their food using charcoal inside the house. E. FAMILY HISTORY The patients father claimed that the mothers side of the family has a history of being hypertensive but does not have any allergy to any kind of food or drug. They do not have a family history of being asthmatic. On the patients father side, there is no known serious condition. Aside from that, the mother died from cervical cancer. They have no other history of having serious illnesses.

F. LIFESTYLE AND HEALTH PRACTICES Activity Level and Exercise In her activity level, she is usually playing with other kids around her neighbourhood. This means that she is receiving daily activity or exercise for children around her age. Sleep and Rest She often takes a long nap in the afternoon, around 1 to 5 hours. Then she falls asleep at night between 11-12pm and wakes up depending on the noise level. She usually has around 8-10 hours of sleep.

G. DEVELOPMENTAL DATA Traditionally, infancy is designated as the period of time from 1 month to 1 year 7

of age. In these important months, an infant undergoes such rapid development that parents sometimes believe looks different and demonstrates new abilities each day. During this time, an infant triples birth weight and increases length by 50%. A babys senses sharpen and, with the process of attachment to caregivers, she forms a first social relationship. Because of the growth and learning potential that occurs, this first year is a crucial one. Without proper nutrition, a baby will not grow and physically thrive, and without proper stimulation and nurturing care by consistent caregivers, an infant may not develop a healthy interest in life or a feeling of security essential for future development.

Summary of Infant Growth and Development Month

0-1

Motor Development
Largely reflex

Fine Motor Development

Keeps hands fisted; able to follow object to midline

Socialization and Language

Play

2 3

Holds head up when prone Holds chest prone head and up when

4 5

Grasp, stepping, tonic neck reflexes are fading Turns front to back; no longer has head lag when pulled upright; bears partial weight on feet when held upright

Enjoys watching face of primary caregiver, listening to soothing sounds. Has social smile Makes cooing Enjoys brightsounds; colored mobiles differentiates cry Follows objects past Laughs out loud Spends time midline looking at hands or uses them as toy during the month(hand regard) Needs space to turn Handles well rattles

Developmental Task Theory of Robert Havighurst

A developmental task is a task in which arises at or about a certain period in the life of an individual. Havighurst has identified six major age periods: infancy and early childhood (0-5 years), middle childhood (6-12 years), adolescence (13-18 years), early adulthood (19-29 years), middle adulthood (30-60 years), and later maturity (61+). Basing on Havighursts Theory, our patient belongs in the infancy and early childhood stage wherein she is learning to distinguish right from wrong and developing a conscience. Psychosexual Theory of Sigmund Freud The psychosexual stages of Sigmund Freud are five different developmental periods during which the individual seeks pleasure from different areas of the body associated Oral Anal Phallic Latency Genital with sexual Birth to 2 4 6 13 feelings. to to to to and These stages 1year 3years 5years 12years Up are as follows:

Basing on this theory, our patient belongs to the anal stage wherein an infants pleasure center is in the anus. Also the infant relationship with its mother; continues to be a nutritive one. Psychosocial Theory of Erik Erickson Erik Erickson envisioned life as a sequence of levels of achievement. Each stage signals a task that must be achieved. He believed that the greater that task achievement, the healthier the personality of the person. Failure to achieve a task influences the persons ability to achieve the next task. Stages of Eriksons Psychosocial Theory are as follows:

Infancy Early Childhood Late Childhood School Age Adolescence Young Adulthood Adulthood Maturity

Birth 18 months 18 months 3 years 3 5 years 5 12 years 12 18 years 18 25 years 25 65 years 65 years to death

Trust vs. Mistrust Autonomy vs. Shame Initiative vs. Guilt Industry vs. Inferiority Identity vs. Role Confusion Intimacy vs. Isolation Generativity vs. Stagnation Integrity vs. Despair

Basing on this theory, she belongs to Infancy based on Eriksons theory the child developmental task is the Initiative vs. Guilt. During the initiative versus guilt stage, children begin to assert their power and control over the world through directing play and other social interaction. As observed, the child had already started social interaction with other children by observing her play with kids around her house. Cognitive Theory of Jean Piaget Cognitive development refers to how a person perceives, thinks, and gains understanding of his or her world through the interaction and influence of genetic and learning factors. This is divided into five major phases: Sensorimotor Phase Pre-conceptual Phase Intuitive Thought Phase Concrete Operations Phase Formal Operational Phase Birth to 2 years 2 3 years 4 6 years 7 11 years 11 adulthood

Basing on this theory, she belongs to the pre-conceptual stage in which she learns to use language and to represent objects by images and words. Her thinking is still egocentric: has difficulty taking the viewpoint of others.

IV. PHYSICAL ASSESSMENT A.GENERAL APPEARANCE The patient was seen sitting on her fathers lap and conscious. With the following

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vital signs of: Temperature 36.4 C Pulse rate 100 beats per minute Respiratory rate 44 breaths per minute Skin The patient has brown skin. Skin is smooth and soft to touch when being palpated. There are no lesions and masses palpated. Skin also has good turgor. Hair Patients hair is light brown fine, proportionately distributed on the head with no greasy scales on scalp noted. Presence of infestations noted. No tenderness upon palpation of scalp noted. Head The shape of the patients head is symmetrical. The head is round in shape. No tenderness upon palpation noted. Face Able to smile and frown, face is symmetrical in contour, no masses palpated.

Eyes Patients eyes are symmetrical. Patient can see clearly and reacts on moving objects. Patients eyes are not sunken, sclera is clear and moist.

Ears Top of the ear is in lined with the imaginary line drawn from the outer cantus. Both ears are symmetrical to each other. No presence of any drainage and tenderness noted upon assessment. Nose and Sinuses Nose is symmetrical to both sides. No tenderness of sinuses upon palpation. Mouth and Throat Patients lips are intact and moist. Oral mucosa is moist and reddish in color. Absence of lesions noted. Neck Able to hold her neck erect and at midline. Able to move neck from side to side without difficulty. No swelling or masses noted Pulsation is felt in carotid artery. Lymph nodes are non- palpable. Anterior Chest Patient experiences tachypnea with respiratory rate of 44 breaths per minute. Chest rises upon inspiration and falls upon expiration. No tenderness lumps and nodules felt during palpation. Wheezing heard upon auscultation.

Posterior Chest Posterior chest is symmetrical. No nodules and tenderness felt upon palpation. Heart 13

No pulsations. No murmurs heard upon auscultation. Breast Not assessed. Abdomen Abdomen is round and slightly protuberant. No swelling and tenderness noted. Veins are not visible upon inspection. No abnormal sounds heard on abdomen upon auscultation. Female External Genitalia and Anus Not assessed. Upper Extremities Fingers, hands and wrist are straight. Elbows are at the same height and symmetrical in appearance. Able to move arms and hands without pain. Capillary refill of 2 seconds. Able to grasp objects firmly. Lower Extremities Legs and thighs are slightly curved No lesions or edema noted. Able to move legs and feet without any pain.

V. SICK FORM MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS

Date: February 24, 2011 Childs Name: A.B. Age: 3 y/o Sex: F Weight: 12.5 kg Address: Purok 4, Sevilla, City of San Fernando, La Union, 2500 ASK: What are the childs problems? Cough Initial visit: ASSESS: (Encircle all signs present) Temperature: 36.4 C Follow-up visit:

CLASSIFY CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREAST FEED ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN VOMITS EVERYTHING CONVULSIONS (during the present illness) DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? YES NO For how long? 3days Count the breaths in one minute 44 breaths per minute. Fast breathing? Look for chest indrawing. Look and listen for stridor. Look and listen for wheeze. DOES THE CHILD HAVE DIARRHEA? YES______ NO_______ For how long? ____________days the child: Is there blood in the stool? awaken? Look at the childs general condition. Is Abnormally sleepy or difficult to Restless or irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking Drinking eagerly, thirsty? Pinch the skin of the abdomen. Very slowly (longer than 2 YES___

General Danger Signs Present? YES____NO

poorly? Does it go back: seconds)?

Slowly? DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5C NO___ Decide malaria risk: Does the child live in malaria area? stiff neck Has the child visited or stayed overnight in malaria in the past 4 weeks? If malaria risk, obtain a blood smear (+) (Pf) (Pv) (not done)

LOOK and FEEL Look or feel for Look for runny nose

Look for signs of MEASLES For how long has the child have fever? ______days Generalized rash and If more than 7 days, has fever been present everyday? One of these : cough, runny nose or red eyes Has the child has measles within the past 3 months? If the child has measles now or Look for mouth ulcers. If yes, are they within the last 3 months deep and extensive? Look for pus draining from the eyes. Look for clouding of the cornea. ASSESS DENGUE HEMORRHAGIC FEVER LOOK AND FEEL ASK: Look for bleeding from the nose or gums. Has the child had any bleeding from the Look for the skin petechiae. nose or gums or in the vomitus or stools? Feel for cold and clammy extremities. Has the child had black vomitus or black Check capillary refill._2_seconds. stools? Perform tourniquet test if child is 6

15

Has the child has persistent abdominal signs pain? than 3 days. Has the child had persistent vomiting? DOES THE CHILD HAVE YES_____NO______ Is there an ear pain? the ear. Is there ear discharge? behind the ear. If yes, for how long? ______days THEN CHECK FOR MALNUTRITION

months or older AND has no other AND has fever for more AN EAR PROBLEM?

Look for pus draining from Feel for tender swelling

very low? THEN CHECK FOR ANEMIA

Look for visible severe wasting MUAC less than 115 mm. Look for edema of both feet. Determine weight for age. Very low? Not Look for palmar pallor. Severe palmar pallor? Return for next Immunization on _______________ (Date)

Some palmar pallor? CHECK THE CHILDS IMMUNIZATION STATUS? Encircle immunizations needed today? BCG HEP B1 DPT 1 OPV 1 HEP B2 DPT 2 OPV 2 MEASLES DPT 3 OPV 3 HEP B3 CHECK THE VITAMIN A SUPPLEMENTATION STATUS for children 6 months or older. Is the child six months or age or older? YES______NO______ Has the child received Vitamin A in the past 6 months? YES______NO______

Vitamin A needed today YES____NO_____ Albendazole/Meben dazole needed today YES____NO_____ Feeding Problems

CHECK FOR DEWORMING STATUS for children 12 months or older. Is the child 12 months of age or older? YES______NO_______ Has the child received albendazole/mebendazole for the past 6 months? YES_____NO_____ ASSESS CHILDS FEEDING if child has ANEMIA OR VERY LOW WEIGHT or is less than 2 years old. Do you breastfeed your child? YES______NO______ If yes, how many times in 24 hours?_____times. Do you breastfeed during the night? YES____NO_____ Does the child take any other foods or fluids? YES _____NO______ If yes, what food or fluids? _______________________________________________________________________ How many times per day?______times? What do you use to feed the child? ______________________________________________________________ If very low weight for age, how large are the servings? _______________________________________ Does the child receive his/her own servings?________ Who feeds the child and how? ___________________________________________________________________ During the illness, has the childs feeding changed? YES_____NO______ If yes, how? _____________________________________________________________________________________ ___ ASSESS CARE FOR DEVELOPMENT: Ask questions about how the mother cares for her child. Compare the mothers answer to the Recommendations for Care for Development for the childs age. How do you play with your child? _______________________________________________________________ How do you communicate with your child? ____________________________________________________

Care for Development Problems

ASSESS OTHER PROBLEMS

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS

Date: March 3, 2011 Childs Name: A.B. Age: 3 y/o Sex: F Weight: 12.5 kg Address: Purok 4, Sevilla, City of San Fernando, La Union, 2500 ASK: What are the childs problems? Cough Initial visit: ASSESS: (Encircle all signs present) Temperature: 37 C Follow-up visit:

CLASSIFY CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREAST FEED ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN VOMITS EVERYTHING CONVULSIONS (during the present illness) DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? YES NO For how long? 2days Count the breaths in one minute 40 breaths per minute. Fast breathing? Look for chest indrawing. Look and listen for stridor. Look and listen for wheeze. DOES THE CHILD HAVE DIARRHEA? YES______ NO_______ For how long? ____________days the child: Is there blood in the stool? awaken? Look at the childs general condition. Is Abnormally sleepy or difficult to Restless or irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking Drinking eagerly, thirsty? Pinch the skin of the abdomen. Very slowly (longer than 2 YES___

General Danger Signs Present? YES____NO

poorly? Does it go back: seconds)?

Slowly? DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5C NO___ Decide malaria risk: Does the child live in malaria area? stiff neck Has the child visited or stayed overnight in malaria in the past 4 weeks? If malaria risk, obtain a blood smear (+) (Pf) (Pv) (not done) signs of MEASLES

LOOK and FEEL Look or feel for Look for runny nose

Look for

17

For how long has the child have fever? ______days Generalized rash and If more than 7 days, has fever been present everyday? One of these : cough, runny nose or red eyes Has the child has measles within the past 3 months? If the child has measles now or Look for mouth ulcers. If yes, are they within the last 3 months deep and extensive? Look for pus draining from the eyes. Look for clouding of the cornea. ASSESS DENGUE HEMORRHAGIC FEVER LOOK AND FEEL ASK: Look for bleeding from the nose or gums. Has the child had any bleeding from the Look for the skin petechiae. nose or gums or in the vomitus or stools? Feel for cold and clammy extremities. Has the child had black vomitus or black Check capillary refill._1_seconds. stools? Perform tourniquet test if child is 6 Has the child has persistent abdominal months or older AND has no other signs pain? AND has fever for more than 3 days. Has the child had persistent vomiting? DOES THE CHILD HAVE AN EAR PROBLEM? YES_____NO______ Is there an ear pain? Look for pus draining from the ear. Is there ear discharge? Feel for tender swelling behind the ear. If yes, for how long? ______days THEN CHECK FOR MALNUTRITION Look for visible severe wasting MUAC less than 115 mm. Look for edema of both feet. Determine weight for age. Very low? Not very low? THEN CHECK FOR ANEMIA Look for palmar pallor. Severe palmar pallor? Some palmar pallor? CHECK THE CHILDS IMMUNIZATION STATUS? Encircle immunizations needed today? BCG HEP B1 DPT 1 OPV 1 HEP B2 DPT 2 OPV 2 MEASLES DPT 3 OPV 3 HEP B3 CHECK THE VITAMIN A SUPPLEMENTATION STATUS for children 6 months or older. Is the child six months or age or older? YES______NO______ Has the child received Vitamin A in the past 6 months? YES______NO______ CHECK FOR DEWORMING STATUS for children 12 months or older. Is the child 12 months of age or older? YES______NO_______ Has the child received albendazole/mebendazole for the past 6 months? YES_____NO_____ ASSESS CHILDS FEEDING if child has ANEMIA OR VERY LOW WEIGHT or is less than 2 years old. Do you breastfeed your child? YES______NO______ If yes, how many times in 24 hours?_____times. Do you breastfeed during the night? YES____NO_____

Return for next Immunization on _______________ (Date)

Vitamin A needed today YES____NO_____ Albendazole/Meben dazole needed today YES____NO_____ Feeding Problems

Does the child take any other foods or fluids? YES _____NO______ If yes, what food or fluids? _______________________________________________________________________ How many times per day?______times? What do you use to feed the child? ______________________________________________________________ If very low weight for age, how large are the servings? _______________________________________ Does the child receive his/her own servings?________ Who feeds the child and how? ___________________________________________________________________ During the illness, has the childs feeding changed? YES_____NO______ If yes, how? _____________________________________________________________________________________ ___ ASSESS CARE FOR DEVELOPMENT: Ask questions about how the mother cares for her child. Compare the mothers answer to the Recommendations for Care for Development for the childs age. How do you play with your child? _______________________________________________________________ How do you communicate with your child? ____________________________________________________ ASSESS OTHER PROBLEMS

Care for Development Problems

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS

Date: March 5, 2011 Childs Name: A.B. Age: 3 y/o Sex: F Weight: 12.5 kg Address: Purok 4, Sevilla, City of San Fernando, La Union, 2500 ASK: What are the childs problems? Cough Initial visit: ASSESS: (Encircle all signs present) Temperature: 36.6 C Follow-up visit:

CLASSIFY CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREAST FEED ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN VOMITS EVERYTHING CONVULSIONS (during the present illness) DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? YES NO For how long? 2days Count the breaths in one minute 38 breaths per minute. Fast breathing? Look for chest indrawing. Look and listen for stridor. Look and listen for wheeze. DOES THE CHILD HAVE DIARRHEA? YES______ NO_______

General Danger Signs Present? YES____NO

19

For how long? ____________days the child: Is there blood in the stool? awaken?

Look at the childs general condition. Is Abnormally sleepy or difficult to Restless or irritable? Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking Drinking eagerly, thirsty? Pinch the skin of the abdomen. Very slowly (longer than 2 YES___

poorly? Does it go back: seconds)?

Slowly? DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5C NO___ Decide malaria risk: Does the child live in malaria area? stiff neck Has the child visited or stayed overnight in malaria in the past 4 weeks? If malaria risk, obtain a blood smear (+) (Pf) (Pv) (not done)

LOOK and FEEL Look or feel for Look for runny nose

Look for signs of MEASLES For how long has the child have fever? ______days Generalized rash and If more than 7 days, has fever been present everyday? One of these : cough, runny nose or red eyes Has the child has measles within the past 3 months? If the child has measles now or Look for mouth ulcers. If yes, are they within the last 3 months deep and extensive? Look for pus draining from the eyes. Look for clouding of the cornea. ASSESS DENGUE HEMORRHAGIC FEVER LOOK AND FEEL ASK: Look for bleeding from the nose or gums. Has the child had any bleeding from the Look for the skin petechiae. nose or gums or in the vomitus or stools? Feel for cold and clammy extremities. Has the child had black vomitus or black Check capillary refill._1_seconds. stools? Perform tourniquet test if child is 6 Has the child has persistent abdominal months or older AND has no other signs pain? AND has fever for more than 3 days. Has the child had persistent vomiting? DOES THE CHILD HAVE AN EAR PROBLEM? YES_____NO______ Is there an ear pain? Look for pus draining from the ear. Is there ear discharge? Feel for tender swelling behind the ear. If yes, for how long? ______days THEN CHECK FOR MALNUTRITION Look for visible severe wasting MUAC less than 115 mm. Look for edema of both feet. Determine weight for age.

very low? THEN CHECK FOR ANEMIA

Very low?

Not

Some palmar pallor? CHECK THE CHILDS IMMUNIZATION STATUS? Encircle immunizations needed today? BCG HEP B1 DPT 1 OPV 1 HEP B2 DPT 2 OPV 2 MEASLES DPT 3 OPV 3 HEP B3 CHECK THE VITAMIN A SUPPLEMENTATION STATUS for children 6 months or older. Is the child six months or age or older? YES______NO______ Has the child received Vitamin A in the past 6 months? YES______NO______

Look for palmar pallor. Severe palmar pallor? Return for next Immunization on _______________ (Date)

Vitamin A needed today YES____NO_____ Albendazole/Meben dazole needed today YES____NO_____ Feeding Problems

CHECK FOR DEWORMING STATUS for children 12 months or older. Is the child 12 months of age or older? YES______NO_______ Has the child received albendazole/mebendazole for the past 6 months? YES_____NO_____ ASSESS CHILDS FEEDING if child has ANEMIA OR VERY LOW WEIGHT or is less than 2 years old. Do you breastfeed your child? YES______NO______ If yes, how many times in 24 hours?_____times. Do you breastfeed during the night? YES____NO_____ Does the child take any other foods or fluids? YES _____NO______ If yes, what food or fluids? _______________________________________________________________________ How many times per day?______times? What do you use to feed the child? ______________________________________________________________ If very low weight for age, how large are the servings? _______________________________________ Does the child receive his/her own servings?________ Who feeds the child and how? ___________________________________________________________________ During the illness, has the childs feeding changed? YES_____NO______ If yes, how? _____________________________________________________________________________________ ___ ASSESS CARE FOR DEVELOPMENT: Ask questions about how the mother cares for her child. Compare the mothers answer to the Recommendations for Care for Development for the childs age. How do you play with your child? _______________________________________________________________ How do you communicate with your child? ____________________________________________________ ASSESS OTHER PROBLEMS

Care for Development Problems

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ANATOMY AND PHYSIOLOGY OF THE SYSTEMS INVOLVED

The Respiratory system consists of the external nose, the nasal cavity, the pharynx, the larynx, the trachea, the bronchi and the lungs. Although air frequently passes through the oral cavity, it is considered to be part of the digestive system instead of the respiratory system. The upper respiratory tract refers to the external nose, nasal cavity, pharynx, and associated structures; and the lower respiratory tract includes the larynx, trachea, bronchi, and lungs. Nose The nose consists of the external nose and the nasal cavity. The external nose is the visible structure that forms a prominent feature of the face. Most of the external nose is composed of hyaline cartilage, although the bridge of the external nose consists of bone. The bone and cartilage are covered by connective tissue and skin. The nasal cavity extends from the nares to the choane. The nares or nostrils are the external openings of the nose and the choane are the openings into the pharynx. The nasal septum is a partition dividing the nasal cavity into left and right parts. A deviated nasal septum occurs when the septum bulges to one side or the other. The hard palate forms the floor of the nasal cavity, separating the nasal cavity from the oral cavity. Air can flow through the nasal cavity when the mouth is closed or when the oral cavity is full of food. Three prominent bony ridges called conchae are present on the lateral walls on each side of the nasal cavity. The conchae increase the surface of the nasal cavity. Paranasal sinuses are air-filled spaces within bone. The maxillary, frontal, ethmoidal and sphenoidal sinuses are named after the bones in which they are located. The paranasal sinuses open into the nasal cavity and are lined with a mucous membrane. They reduce the weight of the skull, produce mucus, and influence the quality of the voice by acting as resonating chambers. The nasolacrimal ducts, which carry tears from the eyes, also open into the nasal cavity. Sensory receptors for the sense of smell are found in the superior part of the nasal cavity. Air enters the nasal cavity through the nares. Just inside the nares the epithelial lining is composed of stratified squamous

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epithelium containing coarse hairs. The hairs trap some of the large particles of dust suspended in the air. The rest of the nasal cavity is lined with pseudostratified columnar epithelial cells containing cilia and many mucus-producing goblet cells. Mucus produced by the goblet cells also traps debris in the air. The cilia sweep the mucus posteriorly to the pharynx, where it is swallowed. As air flows through the nasal cavities, it is humidified by moisture from the mucous epithelium and is warmed by blood flowing through the superficial capillary networks underlying the mucous epithelium. Pharynx The pharynx is the common passageway of both respiratory and digestive systems. It receives air from the nasal cavity and air, food, and water from the mouth. Inferiorly, the pharynx leads to the rest of the respiratory system through the opening into the larynx and to the digestive system through the opening into the larynx and to the digestive system through the esophagus. The pharynx can be divided into three regions: the nasopharynx, the oropharynx, and the laryngopharynx. The nasopharynx is the superior part of the pharynx. It is located posterior to the choaneae and superior to the soft palate, which is an incomplete muscle and connective tissue partition separating the nasopharynx from the oropharynx. The uvula is the posterior extension of the soft palate. The soft palate forms the floor of the nasopharynx. The nasopharynx is lined with pseudostratified ciliated columnar epithelium that is continuous with the nasal cavity. The auditory tubes extend form the middle ears open into the nasopharynx. The posterior part of the nasopharynx contains the pharyngeal tonsil, which aids in defending the body against infection. The soft palate is elevated during swallowing; this movement results in the closure of the nasopharynx, which prevents food from passing from the oral cavity into the nasopharynx. The oropharynx extends from the uvula to the epiglottis, and the oral cavity opens into the oropharynx. Food and drink all passes in the oropharynx. The laryngopharynx passes posterior to the larynx and extends from the tip of the epiglottis to the esophagus. The larynx (plural larynges), colloquially known as the voice box, is an organ in the neck

of mammals involved in protection of the trachea and sound production. The larynx houses the vocal folds, and is situated just below where the tract of the pharynx splits into the trachea and the esophagus. Sound is generated in the larynx, and that is where pitch and volume are manipulated. The strength of expiration from the lungs also contributes to loudness. The trachea, or windpipe, is the bony tube that connects the nose and mouth to the lungs, and is an important part of the vertebrate respiratory system. When an individual breathes in, air flows into the lungs for respiration through the windpipe. Because of its primary function, any damage incurred to the trachea is potentially lifethreatening. The bony skeletal trachea is comprised of cartilage and ligaments, and is located at the front of the neck. The trachea begins at the lower part of the larynx and continues to the lungs, where it branches into the right and left bronchi. It measures 3.9 to 4.7 inches (10-12 cm) in length, and .62 to .7 inches (16-18 mm) in diameter. The trachea is composed of 16 to 20 c shaped rings of cartilage connected by ligaments, with a ciliated-lined mucus membrane. It is this structure that helps push objects out of the airway should something become lodged. Larynx The larynx is the portion of the breathing, or respiratory, tract containing the vocal cords which produce vocal sound. It is located between the pharynx and the trachea. The larynx, also called the voice box, is a 2-inch-long, tube-shaped organ in the neck. We use the larynx when we breathe, talk, or swallow. Its outer wall of cartilage forms the area of the front of the neck referred to as the "Adams apple". The vocal cords, two bands of muscle, form a "V" inside the larynx. Each time we inhale (breathe in), air goes into our nose or mouth, then through the larynx, down the trachea, and into our lungs. When we exhale (breathe out), the air goes the other way. When we breathe, the vocal cords are relaxed, and air moves through the space between them without making any sound. When we talk, the vocal cords tighten up and move closer together. Air from the 25

lungs is forced between them and makes them vibrate, producing the sound of our voice. The tongue, lips, and teeth form this sound into words. The esophagus, a tube that carries food from the mouth to the stomach, is just behind the trachea and the larynx. The openings of the esophagus and the larynx are very close together in the throat. When we swallow, a flap called the epiglottis moves down over the larynx to keep food out of the windpipe. Trachea The trachea is a tube-like portion of the breathing or "respiratory" tract that connects the "voice box" (larynx) with the bronchial parts of the lungs. Each time we inhale (breathe in), air goes into our nose or mouth, then through the larynx, down the trachea, and into our lungs. When we exhale (breathe out), the air goes out the other way. The esophagus, the tube that carries food from the mouth to the stomach, is just behind the trachea and the larynx. The openings of the esophagus and the larynx are very close together in the throat. When we swallow, a flap called the epiglottis moves down over the larynx to keep food out of the windpipe. The trachea is also called the windpipe, weasand (sometimes written wesand or wezand) or wesil. "Cut his weasand with thy knife." The Tempest, Shakespeare. Bronchi The trachea divides into left and right main (primary) bronchi. Each of which connects to a lung. The left main bronchus is more horizontal than the right main bronchus because of it is displaced by the heart. Foreign objects that enter the trachea usually lodge in the right main bronchus, because it is more vertical than the left main bronchus and therefore more in direct line with the trachea. The main bronchi extend from the trachea to the lungs. Like the trachea, the main bronchi are lined with pseudostratified ciliated columnar epithelium and are supported by C- shaped pieces of

cartilage. The large air tubes leading from the trachea to the lungs that convey air to and from the lungs. The bronchi have cartilage as part of their supporting wall structure. The trachea divides to form the right and left main bronchi which, in turn, divide to form the lobar, segmental, and finally the subsegmental bronchi. Bronchi are plural of bronchus from the Greek word bronchos, a conduit to the lungs. Lungs The lungs are the principal organs of respiration. Each lung is cone-shaped, with its base resting on the diaphragm and its apex extending superiorly to a point about 2.5 cm above the clavicle. The right lung has three lobes called the superior, middle and inferior lobes. The left lung has two lobes called the superior and inferior lobes. The lobes of the lungs are separated by deep, prominent fissures on the surface of the lung. Each lobe is divided into bronchopulmonary segments separated from one another by connective tissue septa, but these separations are not visible as surface fissures. There are 9 bronchopulmonary segments in the left lung and 10 in the right lung. The main bronchi branch many times to form the tracheobronchial tree. Each main bronchus divides into lobar bronchi as they enter their respectibe lungs. The lobar (secondary) bronchi, two in the left and three in the right lung, conduct air to each lobe. The lobar bronchi in turn give rise to segmental (tertiary) bronchi, which extends to the bronchopulmonary segments of the lungs. The bronchi continue to branch many times, finally giving rise to bronchioles. The bronchioles also subdivide numerous times to give rise to terminal bronchioles, which then subdivide into respiratory bronchioles. Each respiratory bronchiole subdivides to form alveolar ducts, which are like long, branching hallways with many open doorways. The doorways open into alveoli which are small air sacs become so numerous that the alveolar duct wall is little more than a succession of alveoli. The alveolar ducts end as two or three alveolar sacs, which are chambers connected to two or more alveoli. There are about 300 million alveoli in the lungs. As the air passageways of the lungs becomes smaller, the structure of their walls changes. The amount of cartilage decreases

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and the amount of smooth muscle increases, until at the terminal bronchioles, the walls have a prominent smooth muscle layer, but no cartilage. Relaxation and contraction of the smooth muscle within the bronchi and bronchioles can change the diameter of the air passageways. For example, during exercise the diameter can increase, thus increasing the volume of air moved. During an asthma attack, however, contraction of the smooth muscle in the terminal bronchioles can result in greatly reduced air flow. In severe cases, air movement can be so restricted that death results. As the air passageways of the lungs become smaller, the lining of their walls also changes. The trachea and bronchi have pseudostratified ciliated columnar epithelium, the bronchioles have ciliated simple cuboidal epithelium. The ciliated epithelium of the air passageways functions as mucuscilia escalator, which traps debris in the air and removes it from the respiratory system. The respiratory membrane of the lungs is where gas exchange between the air and blood takes place. It is mainly of the alveoli and surrounding capillaries but theres some contribution by the alveolar ducts and respiratory bronchioles it is very thin to facilitate the diffusion of gases. Pleural cavity In human anatomy, the pleural cavity is the body cavity that surrounds the lungs. The pleura are a serous membrane which folds back upon it to form a two-layered, membrane structure. The thin space between the two pleural layers is known as the pleural cavity; it normally contains a small amount of pleural fluid. The outer pleura (parietal pleura) is attached to the chest wall. The inner pleura (visceral pleura) covers the lungs and adjoining structures, viz. blood vessels, bronchi and nerves. The pleural cavity, with its associated pleurae, aids optimal functioning of the lungs during respiration. The pleural cavity also contains pleural fluid, which allows the pleurae to slide effortlessly against each other during ventilation. Surface tension of the pleural fluid also leads to close apposition of the lung surfaces with the chest wall. This physical relationship allows for optimal inflation of the alveoli during respiration. The pleural cavity transmits movements of the chest wall to the lungs, particularly during heavy breathing. This occurs because the closely opposed chest wall transmits pressures

to the visceral pleural surface and hence to the lung itself.

DIAGRAM OF PATHOPHYSIOLOGY

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PNEUMONIA PATHOGENS Modifiable Factors 1. Exposure to transmissible agents 2. Exposure to dust and second hand smoke

Non-Modifiable Factors 1. Age

Streptococcus pneumoniae invade the respiratory tract

Adherence to alveolar macrophages: exposure of cell wall components Alveolar walls thicken Inflammatory Response: Attraction of neutrophils; release of inflammatory mediators; accumulation of fibrinous exudates, red blood cells, and bacteria Onset of cough

Increased WBC Onset of fever

Consolidation of lung parenchyma Crackling sound on auscultation Leukocyte infiltration (neutrophils and macrophages) Difficulty of Breathing Deposition of fibrin on pleural surfaces; phagocytosis in alveoli

PATHOPHYSIOLOGY Macrophages in alveoli ingest and remove degenerated neutrophils, fibrin and bacteria

Mucus Production

The invading organism causes symptoms, in part, by provoking an overly exuberant immune response in the lungs. The small blood vessels in the lungs (capillaries) become leaky, and protein-rich fluid seeps into the alveoli. This results in a less functional area for oxygen-carbon dioxide exchange. The patient becomes relatively oxygen deprived, while retaining potentially damaging carbon dioxide. The patient breathes faster and faster, in an effort to bring in more oxygen and blow off more carbon dioxide. Mucus production is increased, and the leaky capillaries may tinge the mucus with blood. Mucus plugs actually further decrease the efficiency of gas exchange in the lung. The alveoli fill further with fluid and debris from the large number of white blood cells being produced to fight the infection. Consolidation, a feature of bacterial pneumonias, occurs when the alveoli, which are normally hollow air spaces within the lung, instead become solid, due to quantities of fluid and debris. Streptococcus pneumonia, a major cause of bacterial pneumonia, generally resides in the nasopharynx and is carried asymptomatically approximately 20%-50% of healthy individuals. It is the most common type of community-acquired pneumonia. Viral infections increase attachment of S. pneumonia to the receptors on respiratory epithelium. Once inhaled into the alveolus, pneumococci infect type II alveolar cells. They multiply in the alveolus and invade alveolar epithelium. Pneumococci spread from alveolus to alveolus through the pores of the Kohn, thereby producing inflammation and consolidation along lobar compartments. Inflamed and fluid-filled alveolar sacs cannot exchange and carbon dioxide effectively. Alveolar exudates tend to consolidate, so it is increasingly difficult to expectorate. Bacterial pneumonia may be associated with significant ventilation-perfusion mismatch as the infection grows.

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SYMPTOMATOLOGY

fever chills cough tachypnea breathing with grunting or wheezing sounds labored breathing that makes a child's rib muscles retract (when muscles under the rib cage or between ribs draw inward with each breath) chest pain decreased activity poor feeding (in infants)

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VI. EVALUATION The Groups goal in this study is to help stabilize and improve the patients health and well-being and to at least help the father of the patient deal with the situation in order to prevent risk of recurrence of infection, prevent further complications and because the father/family is the one who is primarily responsible in achieving the patients health goal. Many interventions were done according to the level of knowledge and understanding of us student nurses about the disease, health teachings and follow up visits checking the patients progress. The group was able to identify that the patients condition improved and that the goals were achieved. During the first day of handling the patient, her vital signs were taken and recorded. Proper nursing interventions based on the IMCI guidelines were given to help improve patients condition. On the last day that the group handled the patient, vital signs were normal, respiration returned to normal, he was afebrile, the crackling sound during auscultation diminished and his cough was almost gone. The father was able verbalize his understanding of proper interventions to prevent recurrence and complication of the disease like washing hands with soap and water and feeding his daughter with vegetables. The father was also able to verbalize the importance of rest and sleep. He learned that putting the patient to sleep at the right time is important. He also realized the importance of religiously giving the patients vitamins. He has also verbalized his understanding of not spitting everywhere. The father also verbalized the importance of going to the barangay health centre or to the district hospital when his children experiences health deviations.