NOTRE DAME UNIVERSITY

College of Health Sciences

Cotabato City

Case Study on
Pediatric Community Acquired
Pneumonia and
Urinary Tract Infection

Submitted by:
Chara Marie N. De dios
Kashmira P. Canda

Submitted to:
Ma. Hazel D. Cayena, RN, MAN

CLIENTS HISTORY

PATIENT'S PROFILE
NieroRainiel Gomez, is a 2 years old male, residing at Purok 1, Rosary Heights 9,Cotabato City.
Her mother is Lorina Gomez, 36 y/o, works as a cashier teller and her father is Roni Gomez, 37
y/o, works as a security guard. Niero was born on November 2, 2012 and was born at Notre
Dame Hospita, Cotabato City. Their whole family is Filipino in nationality and Roman Catholic
in religion. He was admitted on February 16,2015 at the Pedia Respiratory Ward at
CotabatoRegiona and Medical Center with the chief complaint of cough and fever threedays
prior to admission. Hewas diagnosed with Pediatric Community Acquired Pneumonia and
Urinary Tract Infection.

The attending physician orders the following:

- IVF of D5 0.3 NaCl 500ml x 38 cc/o
- DAF with SAP
-VS Q4
-Chest Physiotherapy
-TSB
-Suction PRN
- CBC, BT
-UA
- CXR APL
-S/E
-Ceftriaxone 1.2 grms + D5W20 cc through soluset within 30 min
-Salbutamol 1neb q6
-Paracetamol 250 mg/5ml q4

HISTORY OF PRESENT HEALTH CONCERN

The patient is experiencing difficulty of breathing as been observed in his RR of 54bpm and is
experiencing cough and fever. The patient's mother verbalized that his son is very irritable and
crying three days prior to admission. The mother said that there is a pain but she dont know
where it is because her child only says that he is in pain but he would not point where it is. The
mother says that when the patient's head is elevated it would help relieve the breathing.

PAST HEALTH HISTORY

Problems at birth: None

Childhood Illnesses: None
Immunization: 1st dose of BCG
1 dose of Vit. K
3 doses of Hepa B vaccine
Surgeries: None
Accidents: None
Allergies: None

FAMILY HEALTH HISTORY

The patients mother is Lorina, 36 y/o and his father is Roni, 37 y/o. Both of his parents has
no illness and disease. In his mother side, his grandparents, uncles, and auntie died because of
Pulmonary Tuberculosis.

LIFESTYLE AND HEALTH PRACTICES

Their family usually wakes up on 6:00am. the mother usually cook hotdog and eggs in the
morning, and coffee for his husband and after that, the mother will perform bathingto her son and
after that the mother will go to work. His husband will be the one to look for his son. The patient
is fan of eating junk foods and plays with his friends to the point that his sweat will dry up in his
body.The environment that they are living is exposed in with smoke especially to the father and
his friends who visits at their home. The family manages to eat three times a day with different
foods like dried fish, vegetables, fish, and sometimes chicken and any other food that have
vegetablesbut theres no meat. The patient takes 7 ounce offormulated milk every night and they
usually sleeps at 10:30pm.

PHYSICAL ASSESSMENT
Neurological Assessment
Orientation

Not applicable

Appropriate behavior/communication

Crying

Level of Consciousness

Conscious

Emotional State

Anxious

Skin
General Color

Light brown

Texture

Smooth

Turgor

Goes back after 2 sec

Temperature

Warm

Moisture

Dry

Head
Facial Movements

Symmetrical

Fontanels

Closed

Hair

Fine

Scalp

Clean

Eyes
Lids

Symmetrical

Conjunctiva

Pale

Sclera

White

Reaction to light

R- Brisk
L- Brisk

Reaction to accommodation

Nose

Uniform constriction

Septum

Midline

Mucosa

Pinkish

Sinuses

Non-tender

Ears
External Pinnae

Symmetrical

Ear canal opening

No lesions but earwax has been seen

Hearing acuity

Normal

Mouth
Lips

Crack and dry lips

Tongue

Midline,slightlyrough,pinkish

Teeth

No missing noted

Gums

Pinkish

Uvula

Midline

Tonsils

Not Inflamed

Neck
Trachea

Midline

Thyroids

Non-palpable

Abdomen
General

Color is same as the other body parts

Configuration

Symmetrical

Bowel Sounds

Normoactive

Back and Extremities

Range of Motion

Normal

Muscle tone and strength

Fair

Spine

Midline

Cardiovascular Status
Point of Maximal Impulse (PMI)

5th ICS, midclavicular line

Heart Sounds

Regular

Peripheral Pulses

Regular

Capillary Refill

2 seconds

Respiratory Status
Breathing Pattern

Irregular

Shape of Chest
Lung Expansion

Symmetrical

Percussion

Resonant

Breath Sounds

Crackles during expiration and inhalation

Cough

Non-productive

GENERAL ASSESSMENT
The patient is crying and irritable upon observation he was also anxious. Fast breathing
is observed when doing inspection with an RR of 54 bpm. There is crackles sound heared upon
auscultation when the patient is inhaling and exhaling. The patienthas a pale conjunctiva and has
a crack and dry lips. The skin tone is evenly colored without unusual or prominent discoloration
in all parts of the body. Nailbeds are pinkish in color with a 160-degree angle between the base
and the skin.
ANATOMY AND PHYSIOLOGY
(Pneumonia)
Respiratory System
The respiratory system includes tubes that remove particles from incoming air and
transport air to and from lungs and the air sacs where gases are exchange.Respiratory is the
entire process of gas exchange between the atmosphere andbody cells.

Respiratory is biological system for all organisms that involve gas exchange. Body
tissues received the oxygen by respiratory system and the rate of oxygen is increased during
exercise.
Organs of the Respiratory System.
The organs of the respiratory system can be divided into two groups. The upper
respiratory tract includes the nose, nasal cavity, and pharynx and the lower respiratory tract
includes the larynx, trachea, bronchial tree and lungs.
NOSE
Bone and cartilage support nose internally. Its two nostrils are openings through which
air can enter and leave the nasal cavity. Many internal hairs guard the nostril for preventing entry
large particles carried in the air.
NASAL CAVITY
The nasal cavity is a hollow space behind the nose. The nasal septum, composed of bone
and cartilage, divides the nasal cavity into right and left portions. Nasal conchae are bones that
curl out from the lateral walls of the nasal cavity on each side, dividing the cavity into
passageways. Nasal conchae also support the mucous membrane that line the nasal cavity and
help increase its surface.The mucous membrane filters, warms, and moistens incoming air.
Ciliary action carries particles trapped in mucus to the pharynx, where they are swallowed.
PHARYNX.
The pharynx or throat is behind the oral cavity, the nasal cavity and the larynx. It is a
passageway for food travelling from the oral cavity to the esophagus and for air passing between
the nasal cavity and the larynx. It also helps produce the sounds of speech.Pharynx are consists 3
parts. Those are nasopharynx, oropharynx and laryngopharynx.

LARYNX.
The larynx is an enlargement in the airway at the top of the trachea and below the
pharynx. It is composed of muscles and cartilages and is lined with mucous membrane.The
larynx contains the vocal cords, which vibrate from side to side and produce sounds when air
passes between them. Inside the larynx, two pairs of horizontal vocal folds. The upper folds are
called false vocal cords and the lower folds are called true vocal cords. The glottis and epiglottis
help prevent foods and liquids from entering the trachea.
TRACHEA.
The trachea is a flexible cylindrical tube about 2.5 cm in diameter and 12.5cm in length.
It extends downward anterior to the esophagus and into the thoracic cavity, where it splits into
right and left bronchi.A ciliated mucous membrane with many goblet cells lines the tracheas
inner wall. This membrane filters incoming air and moves entrapped particles upward into the
pharynx, where the mucus can be swallowed. The cartilaginous rings prevent the trachea from

collapsing and blockingthe air-way. The soft tissues that complete the rings in the back allow the
nearby esophagus to expand as food moves through it to stomach.
BRONCHIAL TREE.
The bronchial tree consists of branched airways leading from the trachea to the
microscopic air sacs in the lungs. Its branches begin with the right and leftprimary bronchi,
which arise from trachea at the level of fifth thoracic vertebra. Each primary bronchus divides
into secondary bronchi, which in turn branch into tertiary bronchi and then into finer and finer
tubes.Among the smaller tubes are bronchioles that continue to divide, giving rise to terminal
bronchioles, respiratory bronchioles and finally to very thin tubes called alveolar ducts. These
ducts lead to thin-walled outpouchings called alveolarsacs. Alveolar sacs lead to smaller
microscopic air sacs called alveoli.The branches of the bronchial tree air passages whose mucous
membranes filter incoming air and distribute the air to alveoli throughout the lungs. The alveoli
provide a large surface area of thin simple squamous epithelial cells through which gases can
easily be exchanged.
LUNGS
The lungs are soft, spongy, and cone-shaped in the thoracic cavity. The mediastinum
separates the right and left lungs medially and diaphragm and thoracic cage enclose
them.Visceral pleura firmly attach to each lung surface and folds back to become the parietal
pleura.A major branch of the bronchial tree supplies each lobe. A lobe also has connections to
blood and lymphatic vessels and lies within connective tissues. Thus, a lung includes air
passages, alveoli, blood vessels, connective tissues, lymphatic vessels and nerves.

PATHOPHYSIOLOGY

PRECIPITATING FACTORS
>sweat dries in his body
>organisms from environment & other
people
Z

>father that are chain smoker living in the

same house

PREDISPOSING FACTORS
>AGE
>GENDER
>EXPOSURE
>Lost of
appetite
>Sputum
production

>Fever
Occurrence of
Bronchopneumonia
Bacteria
invades
Inhalation
localized of
alveolar
cell
inorganism
the
Mucus
production
pathological
inflammation

>Fast breathing

>Cough Pulmonary edema

>Crackles in
PNEUMONIA

the lungs
Airway
SIGNS &
obstruction
SYMPTOMS