Far Eastern University Institute of Nursing Summer 2009

CASE PRESENTATION CALALANG GENERAL HOSPITAL

Presented by: Chua, Michelle France Costales, Ronida Cristobal, Jo-anne Cubos, Maria Excelsa Del Rosario, Marvin Dizon, Keppler Hannes De Guzman, Erika Bianca Domingo, Avegail Domingo, Dionebe Jane Duru, Mary Grace Estrella, Christian R. Gonzaga, Jean Petit BSN 026-Group 102 Submitted to: Mrs. Ramona Jean Miraflores

TABLE OF CONTENTS
Introduction Background of the study Rationale for choosing the case Significance of the study Scope and limitation of the study Clinical Summary General data c/c History of present illness Past medical history Family history Physical assessment Body Part standard actual finding interpretation analysis with reference Patterns of functioning actual interpretation analysis Daily Activity Patterns before hospitalization during hospitalization Interpretation and analysis Patient's Concept of Health, Illness and Hospitalization. Labs / Diagnostic exams a. Date ordered b. exam c. Normal value d. Actual result e. Interpretation and analysis Impression/ Diagnosis Course in the ward (day to day progress report)

Clinical Discussion of the disease Anatomy and Physiology Schematic Diagram of the disease Drug Study

a. Date b. Generic and brand name c. Dosage, frequency and route (actual as ordered) d. classification e. Specific indication f. action g. side effects h. adverse reaction i. Nursing Considerations Ecologic Model Nursing Care Plan Long term objective Problem list/ prioritization NCP a. cues b. Nursing diagnosis c. goals and ojectives d. introduction e. rationale f. evaluation Discharge Planning medicines exercise treatments health teachings outpatient follow up diet Spiritual advice

Far Eastern University Institute of Nursing Case Presentation Calalang General Hospital I. INTRODUCTION Pneumonia is an inflammation of the lungs caused by an infection. It is also called Pneumonitis or Bronchopneumonia. The air sacs in the lungs fill with pus and other liquid. Oxygen has trouble reaching your blood. If there is too little oxygen in your blood, your body cells can't work properly. Because of this and spreading infection through the body pneumonia can cause death. Pneumonia affects your lungs in two ways. Lobar pneumonia affects a section (lobe) of a lung. Bronchial pneumonia (or bronchopneumonia) affects patches throughout both lungs. For most people, pneumonia can be treated at home. It often clears up in 2 to 3 weeks. But older adults, babies, and people with other diseases can become very ill. They may need to be in the hospital. You can get pneumonia in your daily life, such as at school or work. This is called community-based pneumonia. You can also get it when you are in a hospital or nursing home. This is called hospital-based pneumonia. It may be more severe because you already are ill. Respiratory viruses are the most common causes of pneumonia in young children, peaking between the ages of 2 and 3. By school age, the bacterium Mycoplasma pneumoniae becomes more common. Pneumonia usually starts when you breathe the germs into your lungs. You may be more likely to get the disease after having a cold or the flu. These illnesses make it hard for your lungs to fight infection, so it is easier to get pneumonia. Having a longterm, or chronic, disease like asthma, heart disease, cancer, or diabetes also makes you more likely to get pneumonia. Pneumonia can be a serious threat to our health. Although pneumonia is a special concern for older adults and those with chronic illnesses, it can also strike young, healthy people as well. It is a common illness that affects thousands of people each year in the Philippines, thus, it remains an important cause of morbidity and mortality in the country. There are many kinds of pneumonia that range in seriousness from mild to lifethreatening. In infectious pneumonia, bacteria, viruses, fungi or other organisms attack your lungs, leading to inflammation that makes it hard to breathe. Pneumonia can affect one or both lungs. In the young and healthy, early treatment with antibiotics can cure bacterial pneumonia. The drugs used to fight pneumonia are determined by the germ causing the pneumonia and the judgment of the doctor. Its best to do everything we can to prevent pneumonia, but if one do get sick, recognizing and treating the disease early offers the best chance for a full recovery. A case with a diagnosis of Pneumonia may catch ones attention, though the disease is just like an ordinary cough and fever, it can lead to death especially when no intervention or care is done. Since the case is a toddler, an appropriate care has to be done to make the patients recovery faster. Treating patients with pneumonia is necessary to prevent its spread to others and make them as another victim of this illness.

B. Rationale for Choosing the Case This study focuses on the client's diagnosis with pneumonia. This will help the nurse to be knowledgeable about the background of this illness. This will reveal etiology, causes, signs and symptoms, treatments and the proper nursing intervention and management that should be given to the patient experiencing this respiratory illness. It can be a guide for the nurses in rendering quality care to their clients having this condition, and so that we could also apply them on our future exposures as a student and eventually as a nurse. C. Significance of the Study The study will produce ways to further improve nursing practice in patient with pneumonia as it points out factors that contribute to poor nursing care. The study will extend the previous knowledge in dealing the cases of pneumonia. This will also provide further adequate information for future studies. D. Scope and Limitation of the Study Our study will discuss about bacterial pneumonia. We will going to define the different concepts and terms that is related to our study. We will also discuss the anatomy and physiology of the respiratory system. We will also discuss the different factors (modifiable and non-modifiable) that can contribute to this disease. The signs and symptoms of bacterial pneumonia, the medical treatment and the prevention of this disease will be discussed also. II. CLINICAL SUMMARY A. General Data NAME: C.A. M. SEX: Female BIRTHDATE: April 6, 1999 AGE: 10 y/o ADDRESS: 4A Rubyville Subd. F Lazaro ST. Canumay. Valenzuela City RELIGIOUS AFFILIATION: Roman Catholic CHIEF COMPLAINT: fever DIAGNOSIS: t/c ATP r/o Pneumonia ROOM AND BED NO.: 304 ATTENDING PHYSICIAN: Dr. Calalang and Dr. Licuanan B. Chief Complaint The client was brought to Calalang General Hospital by her parents because the client manifested a high temperature of 38c and accompanied by epigastric pain.

C. Nursing History History of present illness: The client first experienced sudden onset of fever last Thursday May 7, 2009. The family decided to confine C.M. at Calalang General Hospital in Valenzuela. Four days prior to confinement the client had fever with a temperature of 37.7 degrees centigrade. Three days before confinement the client was taken to a private clinic because she experienced low grade fever the medication that were given cefaclor,paracetamol. She still experienced fever 2day before admission into the hospital. One day prior to confinement still with fever and headache and client reported that she also experienced pain in chest that radiates towards her abdomen. No other symptoms were noted such as cough,colds, dysuria, vomiting and diarrhea. The chief complaint of the client when she was admitted is fever and the diagnosis is t/c Acute tonsillopharyngitis and r/o pneumonia. The medication given to her are Dicyclocerine 10 mg/ 5ml q8h, Ampicillin 500 mg/ 10 ml intravenous q6h, Paracetamol 500 mg/ 5ml q RTC & q4h 5ml and Ranitidine 250mg/10 ml q8h. Past health history: According to her mother C.M. has a childhood illnesses such as pneumonia at the age of 6months years old, Amoebiasis at age of 1yr. old and reoccurred when she was 2yrs. old. She also had a primary complex at the age of 7 yrs. old. The mother said that her daughter was vaccinated at the Chinese General Hospital and continued the remaining shots at Valenzuela. C.M. has a complete vaccinations and boosters. Her mother stated that her daughter has no allergies for foods but for the medications, she said that when C.M. was 7 yrs. old the nurse told them that the result of the skin test was positive and that drug cannot be used for her daughter. The mother cannot recall the name and the purpose of that drug. C.M. doesnt have any accidents. Our client had been hospitalized four times; the first time that she was hospitalized is at the Santa Rosario hospital in Valenzuela. She was confined there for 2 to 3 days because of pneumonia. The second time she had been hospitalized is at the Monte Falco in Maycauayan and she was confined there for 2 to 3 days because of amebiasis. The third time is again in Monte Falco Hospital, she was confined there for about 2 days because of her primary complex. The fourth time is her recent hospitalization in Calalang general hospital; the diagnosis is acute tonsillopharyngitis and r/o pneumonia. The medications that were prescribed and used by our client are the ff: Cefalaxin 250 mg 3x a day, Cefaclor 250 mg, Cloxacicilin and Ibufropen. While the medications that are being taken currently by our client are the ff: Dicyclocerine 10 mg/ 5ml q8h, Ampicillin 500 mg/ 10 ml intravenous q6h, Paracetamol 500 mg/ 5ml q RTC & q4h 5ml and Ranitidine 250mg/10 ml q8h. The client has never left the country before. Family History of present Illness D. Physical Assessment
HEAD TO TOE PHYSICAL ASSESSMENT

E. Patterns of Functioning A. Psychological Health 1. Emotional Pattern At her age, the Developmental task according to Erik Erikson is Industry vs. Inferiority. The child commonly expresses the feeling of being happy because according to her she loves to go out and play activities with her friends. Playing for her is one way of expressing herself because according to her she can do whatever she like when she is playing. "Napakakulit talaga ng aking anak, pag lalo mong pinagsasabihan lalo niyang ginagawa, makulit lang talaga siya. Kapag sinabi mung wag siyang umakyat, aakyat siya kaya nga kung minsan iniisip ko i-reverse psychology siya. Hayun, di pa rin effective. Hyperactive yang batang yan" as the mother stated, she also added that her daughter is very talkative and active from 2 to 5 in th afternoon. According to her mother, her daughter is very friendly in such a way that she always makes friends to new acquaintances. On the other hand, she is snobbish to those who bullies her. The child states that she has friends in school because she participates in play activities like badminton during P.E and plays with her classmates during her vacant time . According to her mother, she has acceptable grades as stated, ok naman mga grades niya. So far ang pinakamababa ay 80. di ko naman siya masisisi dahil working kaming dalawa ng husband ko kaya di naming maasikasong turuan siya. The child verbalized, minsan bumabagsak rin ako, minsan naman nakaka-perfect ako sa GMRC subject ko. Madali lang naman kasi yun eh. If the client received a failing grade, she does not show the result of her test but her mother usually looks for the test paper because she have knew that their class had examination through telephone contact with the childs teachers. The child verbalized, nag-aaral na lang akong mag-isa pag bumagsak ako sa exam kasi nagagalit si mommy kapag nakita niya yung test paper ko tapos bagsak, wala naman kasing magtuturo sa akin. She still wants to get high grades in school. The mother stated that teachers has a problem of keeping her child quiet as the child verbalized, pinakamaingay yung section naming, maingay ren ako konti, kaya nga sabi ng mga teachers kami yung worst section. The child considers ghosts as her greatest fear. Even though this is the case, the mother and the child fight over as the child is fond of reading horror books when they go to bookstores. The client actually believes in ghost as her grandmother imparts it to her that is existing in real-life. When admitted to the hospital the patient admits thats she feels sad because she is in the hospital because she cannot play and watch television in the cable. She also stated that she wants to go home as soon as possible to see her grandmother. The patient verbalized ayaw ko nang magkasakit nakakalungkot dito sa hospital wala ako kalaro. She mentioned that she misses her friends and her schoolmates and wants to play with them as soon as she gets out of the hospital. Analysis:

Because she understands conservation, a school-age child is not fooled by perceptions as often as before. Interpretation: 2. Cognitive pattern The developmental task according to his age is Concrete Operational Phase. The patient considered a person healthy if the person is free from diseases and if that person is physically fit. She verbalized ok naman ang mga grades ko sa school, and believes that she can do better. Her lowest grade is in math which is 79 and her highest is in Filipino and computer class which is 89. She wants to study nursing in college and wants to go abroad and take her parents with her. She mentioned that she does not skip school, unless she is sick or there is a family occasion. The patient believes in the concept of life that you must make the most out of it, as the patient had stated "masarap mabuhay kasi nagagawa mo lahat ng gusto mo, nakakausap at nayayakap ang mga mahal mo sa buhay kasi kapag patay kana wala kana magagawa." She thinks that she is able to think rationally, hence, has problem-solving skills. She claims that she sometimes perfects her GMRC tests that she says that is actually situational and is very easy to answer. Even though this is the case, she does not apply all of these knowledge on her daily living. Analysis: An important part of developing a sense of industry is learning how to solve problems. Interpretation: 3.) Language The client speaks Tagalog and a little bit of English. The child is able to express herself with the people around her. The client is fond of speaking to strangers and making friends with them. As the mother verbalized, "Mas madami ng kaibigan yan kesa sakin." Analysis: Interpretation: 4) Self Concept The client sees herself as a playful and a jolly person. She also stated that she is always happy especially when her parents are around her. She always reads ghost pocket books, but mentioned that she is afraid of ghost thats why she dont want to be alone at night especially in the dark. She verbalized masunurin naman akong bata minsan, medyo pasaway lang minsan. The patient does not have any physical defects, and does not asks for any privacy at home since she is the only child. She is pretty much concerned about her looks as she does not want to be seen with disorganized hair. She does make it a point that her hair is combed and clipped. Being the only child, she has her own room. Because of her fear of encountering ghosts in her dark

room, she enjoys staying on the living room to sleep. Still, her mother has control over this as she still occasionally enters her room. In addition, there are things she wants to do without her grandmother and parents knowing it and this includes cursing other people. Analysis: Girls become more interested in the way they look and dress. Although 10-yearolds enjoy groups, they also enjoy privacy. They like having their own bedroom or at least their own dresser, where they cans store a collection and know it is free from parents. Interpretation: B. Socio-cultural Health 1.) Social Interaction Pattern Regarding with the patient's relationship with her family and other members in their house, the patient said that, she has a harmonious relationship with them. She easily acquired new friends because she initiates conversation and willingness to meet strangers to be her playmates. The patient does not have any speech disability for her not to express her feelings or communicate with others. The patient also said that she has a good relationship with their neighbor children and even play badminton with them on her free time. She also mentioned that she attends flute class at school and play badminton once in a while. She is provided with play materials like gameboy and cellular phone to play on. She likes to have a laptop but since it is expensive, her mother cannot afford to buy one. She also expresses crushes on the opposite sex, and vice versa, some of her friends has crush on her. She tries to hide this from her parents, yet her mother is pretty much sure that her daughter has one. She also stated that she has a circle of friends around her, her mother also verbalized that she provides the appropriate play materials, allow her to participate in school activities and encourage her to pursue her interest, but she does not join any school affiliation. Her mother verbalized that she is very sociable with other people. Analysis: Many 10-year-olds spend most of their time playing hand-held or television remote-control games. They become increasingly interested in boys. Interpretation: C. Religious Beliefs and Practices 1) Spiritual pattern The familys religious affiliation is Roman Catholic. They do not go to church religiously. The child prays only when she is hoping for something to happen or wishing for something. Analysis:

Fowler describes faith as being present in both religious and non-religious people. Faith gives life meaning, providing the individual with strength in times of difficulty. For the client who is ill, faith whether in a higher authority (e.g., God, Allah, Jehovah), in oneself, in the health care team, or in a combination of all provides strength and hope. Fundamentals of Nursing By Barbara Kozier pp.997 School-age children begin to mature in terms of moral development as they enter a stage of pre-conventional reasoning. School- age children begin to learn about the rituals and meaning behind their religious practices, so the distinction between right and wrong become more important to them. School-age children are rule-oriented; when they pray, they may expect their God to follow rules also (if you are good and pray for something, you should receive it). This makes children of this age confused if a prayer is not immediately answered. Because they are still limited in their ability to understand others views, they may interpret something as being right because it is good for them, not because it is right for humanity as a whole. Interpretation: 2) Moral development The level of development according to Kohlberg is Conventional Moral. The child does not consider herself as disciplined because according to her she does not follow the commands of her mother. As the mother have stated "Napakapasaway ng aking anak, pinagsasabihan ko sya parati pero kapag sumosobra na pinapalo ko na para madala sya. ". According to the client when her mother is angry she tells her mother "i love you" to ease the anger but when her father is the one angry at her she cannot do something to ease the anger.

Patients concept of health, illness and hospitalization. Her own concept about health is that if a person can perform activities such as play with friends, eat, dance the person is healthy. Where as if a person cant perform the activities eat, dance, play with friends the person is ill. She said the environment in the hospital is quite and she is feels bored most times. But she feels better healthier than before when she was ill. F. LABORATORY AND DIAGNOSTICS EXAMINATIONS RESULT Date Procedure Norms Result Interpretation and Analysis

5/10/09

CBC Hemoglobin Total WBC Total PHI Hematocrit Segmenter 120-160 g/L 5-10x10 g/L 150-350 x 10 g/L 0.38-0.50 0.40-0.60 135.0 9.0 272 0.41 0.69 Normal Normal Normal Normal Abnormal Analysis: Elevation of segmenters may indicates presence of infection; means that many band (immature)cells are present as the body fights infection Lymphocytes 0.20-0.40 0.31 Normal

5/10/09

Urinalysis Color
straw, amber and transparent to yellowish

1+ yellow 1.010 6.5

Normal Normal Normal

Specific gravity 1.010-1.025 pH(Reaction) 4.5-8.0 (average:6) slightly acidic Clear

Transparency

hazy

Abnormal
Analysis: White blood cells, bacteria, pus or contaminants may cause cloudy urine. (Fundamentals of Nursing 7th edition by Kozier pg. 1264) Interpretation:

Albumin Sugar Puss cell

absent absent absent

negative negative 0.2/hpf

Normal Normal abnormal

Sq. epithelium Bacteria IMPRESSION/ DIAGNOSIS

few occasional

COURSE IN THE WARD (DAY TO DAY PROGRESS REPORT) On the first day of our interaction with the client we asked her situation before she was admitted; her mother said she had fever and headache. Her facial expression, movements, and the way she answers questions are appropriate for her conditions. She smiled, she was jolly she said she feels better and stronger than before. The next day which was on the 13th, the mother told us that her daughter will be discharged. She looked happy and she felt relieved from the obstruction such as the IV infusion, not long before then, she vomited and had an increase in temperature so the doctor ordered another IV infusion to infuse and continuation of medication. The third day, she said she felt better than before. Then we checked her vital signs, and give her medications. III. CLINICAL DISCUSSION A. Anatomy and Physiology 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. Lungs

The right lung has three lobes, while the left lung has two lobes. The two lungs are separated by a space called mediastinum. There are approximately three hundred million alveoli in the lungs. The right lung is broader, but shorter due to the presence of the liver on the right side of the abdomen. Residual volume is the amount of air that remains in the lungs after forceful expiration. It prevents collapse of the lungs during expiration.(1200ml) Tidal volume is the amount of air that moves in and out of the lungs with each normal breaths (500ml) Inspiratory reserve volume is the amount of extra air that can be inhaled after a normal breath Expiratory reserve volume is the amount of extra air that can be exhaled after a normal breath Total lung capacity is the total of all four volumes (residual, tidal, Inspiratory and expiratory reserve volume) Functional residual capacity is the amount of air that remains in the lungs after normal exhalation Pneumocytes. The type I pneumocytes line the alveoli whereas type II pneumocytes produce surfactant.

Thorax and diaphragm The thorax provides protection for the lungs, heart and great vessels The thorax is made up of 12 pains of ribs, bounded anteriorly by the sternum and posteriorly by the thoracic vertebrae The diaphragm is the main respiratory muscle for inspiration. It is supplied by the phrenic nerve. The ff are the accessory muscles: for inspiration: sternocleidomastoid, scalene,parasternal, trapezius, and perctoralis muscles. They are used during increased work of breathing C. Schematic Diagram of the disease Pathophysiology of Pneumonia Entry of Microorganism to Nasal Passage invasion of the respiratory system activation of immune response (cough) ineffective immune response results to overwhelming

invading lung parenchyma release of endotoxins and exotoxins continuous mucus production massive inflammation (pneumonia) with hazy portion of the chest and dyspnea altered gas exchange consolidation

C. Drug Study (see landscape page) III. ECOLOGIC MODEL (see landscape page) IV. NURSING PROCESS A. Long-term Objective B. Problem List C. Nursing Care Plans (see landscape page) D. Discharge Planning
METHODS Medication Describe the importance of regularly taking of prescribed medications including the potential unpleasant effects of non compliance Instruct the client to continue with follow up medical care Advise the client not to miss the intake of medications given by her physician upon discharge. Environment and exercise

Maintain a quiet, pleasant, environment to promote relaxation.-Provide clean and comfortable environment. Have regular exercise. Encourage walking everyday. Be active on physical activities.

Treatment Continue home medications. For the follow-up check-up repeat. Encourage patient to take multivitamins for immunity Health Teachings Explain the underlying disorder and treatment plan. Lifestyle change (proper food preference) general health measures (adequate sleep, proper diet, and maintaining a clean surrounding). Instruct patient to limit his activity for 24 to 48 hrs after discharge. Provide written and oral instructions about activity, diet recommendations, medications, and follow-up visits. Out Patient Patient will be advised to go back in the hospital in a specific date to have a follow-up check up after discharge. Consult doctor for are any problems or complications encountered. Diet diet as tolerated as much as possible Spiritual Nursing actions to help clients meet their spiritual needs include: providing presence supporting religious practices assisting clients with prayer referring client for spiritual counseling