St.

Paul University Philippines Tuguegarao City, Philippines 3500 School of Health Sciences

Community Acquired Pneumonia A Case Presentation

In partial fulfilment of the requirements in PHC 102 Related Learning Experience

Prepared by: Angel Baloran Oliver Empedrad Mark Zingapan Josette Atanacio Abigail Gannaban Glady Labuguen Jonna Morales Faye Nang Sheena Saribay Shella Mae Usquisa

Table of Contents I. Introduction a. Definition b. Statistics c. Significance d. Scope and Limitations II. Objectives III. Patients Profile IV. Nursing Health History V. Physical Assessment VI. PERSONS Functional Health Pattern VII. Anatomy and Physiology VIII. Laboratory Examination IX. Drug Study X. Nursing Care Plan XI. Discharge Charge Plan

Introduction

Pneumonia is an inflammation or infection of the lungs most commonly caused by a bacteria or virus. Pneumonia can also be caused by inhaling vomit or other foreign substances. It also refers to the consolidation or solidification of the air sacs with the inflammatory exudates. Community-acquired pneumonia (CAP) refers to pneumonia acquired outside of hospitals or extended-care facilities. It is one of the most common infectious diseases diagnosed by clinicians. 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. CAP is usually acquired via inhalation or aspiration of pulmonary pathogenic organisms into a lung segment or lobe. Less commonly, CAP results from secondary bacteraemia from a distant source, such as Escherichia coli urinary tract infection and/or bacteraemia. CAP due to aspiration of Oropharyngeal contents is the only form of CAP involving multiple pathogens. Signs and symptoms of CAP includesdifficulty in breathing, fever, chest pain and cough.CAP can be diagnosed by symptoms and physical examination alone, through xrays, examination of the sputum and other tests are often used. Individuals with PCAP are primarily treated with antibiotic medication in the hospital some forms of PCAP can be prevented by vaccination.

Statistics World Wide

Pneumonia is a common illness affecting approximately 450 million people a year and occurring in all parts of the world. It is a major cause of death among all age groups resulting in 4 million deaths (7% of the world's yearly total). Rates are greatest in children less than five, and adults older than 75 years of age. It occurs about five times more frequently in the developing world versus the developed world. Viral pneumonia accounts for about 200 million cases. The World Health Organization estimates that one in three newborn infant deaths is due to pneumonia.

National

The Philippines ranks among the top 10 countries with the most recorded pneumonia cases. About 9,000 Filipino children die from the disease every year. In 2007, there were 605,471 reported pneumonia cases. Regional

Institutional (Saint Paul Hospital Tuguegarao)

Significance of the Study: The study will help the audience have an in-depth understanding on Community Acquired Pneumonia. For Nursing Students and Professionals, this will help them in identifying the primary needs of patients having this disease process, hence, it will serve as a guide in developing individualized nursing care plan for patients with CAP, and help them address these needs and problems effectively. Scope and Limitations: The Case Study was conducted at Saint Paul Hospital in Tuguegarao City to a 12year old Community Acquired Pneumonia client with the consent and participation of the patients mother.

General Objective: After the case presentation, the audience will have an understanding on Community Acquired Pneumonia, its causes, signs and symptoms, mode of transmission, and prevention.

Specific Objectives: 1. 2. 3. 4. 5. 6. To develop a comprehensive assessment of the client. To develop a nursing care plan appropriate for the clients diagnosed problem. To be able to teach the mother of the client for proper health maintenance. To lessen the risk of infection and development of complications of the client. To be able to provide an environment conducive for health. To enhance the care that will be given for other clients with the same diagnosis.

Patients Profile Name: GZ Gender: Female Address: Carig Sur, Tuguegarao City, Cagayan Age: 12 yrs. Old Religion: Methodist Chief Complaint: Productive Cough, Colds and High Grade Fever Date of Confinement: November 30, 2011 Diagnosis: Community Acquired Pneumonia Attending Physician: Dr.Malillin Religion: Roman Catholic Birthday: September 19, 1999 Place of Birth: Quezon City

Nursing Health History

HISTORY OF PRESENT ILLNESS The present condition started 2 days prior to admission when the patient had a productive cough and colds. The patient complains that she feels dizzy before and after a meal that worsens during exertion. The patients mother gave her Paracetamol to treat the symptoms she experienced. The day prior to admission, the above condition persisted associated with neither fever, still no consultation done nor medication taken. Few hours prior to admission, due to persistence of the above condition, she was then brought in the institution and was then admitted on November 30, 2011 at 01:00PM. PAST MEDICAL HISTORY The mother stated that the client was hospitalized once, with the same diagnosis. The patient had no allergies to drugs or foods. The mother also claimed that the patient already completed all her vaccines. FAMILY HEALTH HISTORY The mother of the client claimed that both sides of the patient have no history of Pneumonia. And no other hereditary illnesses present such as diabetes, cancer and hypertension. SOCIAL HISTORY The mother also claimed that, their family are active and concern citizen of the community, they also mingle with their neighbours and always active participants in activities, education in their community. The patient's mother described their family as a traditional Filipino family, wherein they eat together, live together and giving respect with one another.

PHYSICAL ASSESSMENT Date of Assessment: Date examined: December 6, 2011 Time Examined: 8:00 AM I. GENERAL SURVEY

A paediatric female client, conscious, coherent and oriented to time, person, and place, and with a normal body built. A. Vital signs RR: 18 bpm TEMP: 35.4 C CR: 83 bpm BP: 100/70 II. HEAD AND NECK A. Head The head is round with no nodules or masses and depressions. B. Eyes The eyes are symmetrically aligned and eyebrows are evenly distributed with no discharge or discoloration on the eyelids. Conjunctiva on both eyes is pinkish in color, and the sclera is normal in color. The pupils are black round and equal in size and are reactive to light and accommodation. C. Ears The ears are symmetrically aligned and the color is same as the facial skin, it is firm and not tender. No serum and discharges noted.

D. Nose The nose is symmetrically aligned with the face, no discharges, with flaring nares. It is the same color with the face. It is not tender and no lesions present. The mucosa is pink. The sinuses are not tender when palpated.

E. Mouth The lips are pinkish in color and moist. No ulcerations or lesions noted. The tongue moves freely and not tender. The client possesses pink gums with no teeth yet. III. INTEGUMENT: 1. Skin The skin of the client is moist, pale and has a good skin turgor. Has a fair skin complexion. 2. Hair and Scalp The hair are equally distributed with a thin hair strands; well kept; no lice or dandruff seen/noted. 3. Nails Clients nails are normally transparent and convex. The surrounding cuticles are intact and without inflammations noted. Has a normal capillary refill with 1 to 2 seconds. IV. THORAX and LUNGS The chest contour is symmetrical, the spine is vertically aligned. The chest wall is intact, no tenderness or no masses noted. Upon auscultation wheezes was being noted. V. HEART There is no presence of abnormal pulsations when the heart was auscultated. No murmurs and friction rubs heard upon auscultation. VI. ABDOMEN The abdomen is intact, round and with normal bowel sound heard upon auscultation. Has a darken umbilicus. No deformities seen. VII. EXTREMITIES: On the upper extremities, there was no deformitiesnoted. She has an ongoing venoclysis of D5NM L at the right hand. While on the lower extremities, no deformities were noted.

PERSONS FUNCTIONAL PATTERN

P-SYCHOSOCIAL/PHYSIOLOGICAL Before Hospitalization: The patient already knows how to read alphabets and count numbers; she also knows how to write her name. She speaks itawes and tagalog. She loves to play with her school friends and whenever she is at home, she watches cartoon movies and read some educational books.

During Hospitalization: The patient has no interest in playing. Sometimes she is irritable and most of the time she only interacts with her aunt. Reading books is her past time.

E-LIMINATION

Before Hospitalization: The patient does not have any problem on her elimination pattern. She usually urinates 3-4 times a day without any difficulty. She added that the color of her urine is light yellow. She didnt feel any pain in urination. The patient defecates once a day usually early in the morning before going to school with yellow to brown color but not in regular pattern. Her aunt verbalized that the patient never used laxative. She verbalized that sometimes however, it is hard in consistency with dark color, which generally depends on what he eats.

During Hospitalization: The patient urinates 2-3 times a day. She has straw colored urine. The patient defecates once every two days.

R-EST AND ACTIVITY

Before Hospitalization: She has the normal 6-8 hours sleep. She also has her nap time for 30 minutes a day. Sleeping, reading books and watching the television are her form of rest. She could perform activities of her daily living. According to her, she often plays with her siblings and do household chores, this serves as a form of exercise for her.

During Hospitalization: The patient usually sleeps at 9pm and wakes up at 5am. She doesnt have the adequate time of sleep since she is disturbed with the nurses that enter the room every now and then, and because of the environmental changes of her surroundings. She also has inadequate time to rest since she doesnt have enough time to sleep. Her activity was limited lying on bed but the patient is given her bathroom privileges.

S-AFE ENVIRONMENT

Before Hospitalization: In an interview, mother said that their house is a concrete bungalow, located along the highway and near to other houses. During Hospitalization: Admitted in St. Paul Hospital Pedia Ward.

O-XYGENATION

Before Hospitalization: The patient has no signs of difficulty of breathing.

During Hospitalization: The patient complains difficulty of breathing due to....

N-UTRITION

Before Hospitalization:

The patient eats 3 times a day and with afternoon snacks after coming from school. According to the patient, she eats meat, fish and also vegetables. She doesnt have any allergies on foods and drugs. Her appetite is moderate and usually depends on the food being served. She didnt complain any difficulty in swallowing.

During Hospitalization:

The patient has loss his appetite and hasnt eaten a lot.

S-PIRITUAL

The patient is a Methodist. They attend mass every Sunday. They believe in superstitious beliefs.

ANATOMY AND PHYSIOLOGY

Anatomically, the respiratory system structures are divided into: Upper respiratory tract and Lower respiratory tract The upper respiratory tract is located in the head and neck and consists of the: Nose Pharynx Larynx NOSE: Regions of the nose include the external nose and the nasal cavity. Air moves from the nostrils to the back of the nasal cavity where it exits through the posterior nares. The function of the nasal cavity is to clean, warm and dampen the air that enters so that it can travel throughout the body. REGIONS OF THE PHARYNX: Air moves into the nasal cavity through the nostrils (nasopharynx). The oropharynx opens into the oral cavity which encloses the lips, teeth, cheek, hard and soft palates, tongue and tonsils. Extending from the tip of the epiglottis to the glottis and the esophagus is the laryngopharynx and positioned in the anterior neck is the larynx.

LARYNX The larynx is a passageway between the pharynx and the lower airway structures. It is a short tube made up of supportive cartilage, ligaments, muscle and mucosal lining. The supportive cartilage prevents food and drink from entering the larynx while swallowing. The lower respiratory tract is located in the chest and makes up the: Trachea Bronchial tree Lungs Air passes from the larynx to the lungs (trachea).The trachea divides into the right and left primary bronchi (bronchial tree) and the large pair of spongy organs (lungs) are used for respiration. The lungs constitute the largest organ in the respiratory system. They play an important role in respiration, or the process of providing the body with oxygen and releasing carbon dioxide. The lungs expand and contract up to 20 times per minute taking in and disposing of those gases. Air that is breathed in is filled with oxygen and goes to the trachea, which branches off into one of two bronchi. Each bronchus enters a lung. There are two lungs, one on each side of the breastbone and protected by the ribs. Each lung is made up of lobes, or sections. There are three lobes in the right lung and two lobes in the left one. The lungs are cone shaped and made of elastic, spongy tissue. Within the lungs, the bronchi branch out into minute pathways that go through the lung tissue. The pathways are called bronchioles, and they end at microscopic air sacs called alveoli. The alveoli are surrounded by capillaries and provide oxygen for the blood in these vessels. The oxygenated blood is then pumped by the heart throughout the body. The alveoli also take in carbon dioxide, which is then exhaled from the body. Inhaling is due to contractions of the diaphragm and of muscles between the ribs. Exhaling results from relaxation of those muscles. Each lung is surrounded by a two-layered membrane, or the pleura, that under normal circumstances has a very, very small amount of fluid between the layers. The fluid allows the membranes to easily slide over each other during breathing.