TABLE OF CONTENTS I. Introduction Patient's Profile History of Present Illness . . . . . . . . . . . . . . . . . . . . .p.3-4 a. Present History b. Dev't History c.

Medical History d. Social History II. Anatomy and Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. p.5-7 III.Pathophysiology. . . . . . . . . . . . . . .. . . .. . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . .p.8-9 IV. Diagnostic Evaluation/ Lab Exams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p.9 V. Medical Treatment and Evaluation Treatment . . . . . . . . . . . . . . . . . . ., . . . . . . . . .p.10-11 VI. Drug Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p.12-13 VII. Nursing Care Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p.13-15 a. Ongoing Assessment b. Diet c. Sex d. Possible Complication VIII. NCP and Discharge Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .p.16-20 a. Meds . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p.18 b. Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .p.18 c. Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p.19 d. Health Education . . . . .. . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p.19 e. Observe Signs and Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..p.20 f. Diet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p.19 IX. Implications to: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .p.20 a. Nursing Service b. Nursing Education c. Nursing Research X. References . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . .. . . .p.20

I. Introduction

Patients profile: Name: Eman A. Manzanilla Age :11 months old Birthday: October 2,2010 Address: Busay, Daraga Religion: Roman Catholic Weight: 6 kg Sex: male Nationality: Filipino Mother: E.M Date of Admission: October 10,2011 Time of Admission: 12:32 P.M Chief Complaint: On and off fever 4 days PTC with cough and cold for 3 days Admission Diagnosis: Pneumonia Moderate Risk

A. History of Present Illness Patient X, a 11 month old, Filipino, a resident of Busay Daraga, Legazpi City was admitted to Bicol Regional Teaching and Training Hospital (BRTTH) with a chief complaint of on and off fever 4 days PTC with productive cough and cold for 3 days.

4 days PTA (+) cough (+) nasal congestion, watery to greenish (+) nasal discharge Few hrs PTA - (+) fever, T= 39.3 C (+) difficulty of breathing (+) vomiting, 1 episode Sought consultation at ER: Rx=BPN, Salbutamol neb. SCE, (-) retractions, clear BS, (-) cyanosis, (-) edema a. Developmental History

According to Erik Erikson there are several stages of development, they are: Infancy: Birth to 18 Months, Early Childhood: 18 Months to 3 Years, Play Age: 3 to 5 Years, School Age: 6 to 12 Years, Adolescence: 12 to 18 Years, Young adulthood: 18 to 35, Middle Adulthood: 35 to 55 or 65, Late Adulthood: 55 or 65 to Death Patient X is in Infancy and has the developmental task of Hope: Trust VS Mistrust. The patient tends to cry when being touched by the student nurse and stops when being breastfed and held by the mother. b. Medical History Patient X had no previous record of hospitalizations c. Social History Patient is seen to have an adequate support system .His mother was very nurturing and is willing to care for the patient. 4

II. Anatomy and Physiology RESPIRATORY SYSTEM

The respiratory system is made up of the organs in your body that help you to breathe. Respiration = Breathing. The goal of breathing is to deliver oxygen to the body and to take away carbon dioxide. Lungs The lungs are the main organs of the respiratory system. In the lungs oxygen is taken into the body and carbon dioxide is breathed out. The red blood cells are responsible for picking up the oxygen in the lungs and carrying the oxygen to all the body cells that need it. The red blood cells drop off the oxygen to the body cells, then pick up the carbon dioxide which is a waste gas product produced by our cells.

The red blood cells transport the carbon dioxide back to the lungs and we breathe it out when we exhale. 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.

III.Pathophysiology
Entry of microorganism to nasal passages

Invasion of the respiratory system

Activation of the immune response (mucus production)

cough

Ineffective immune response results to overwhelming infection

Hazy portion of chest pain

Invading lunch parenchyma

Release of endotoxins & exotoxins

Continuous mucus production

Massive inflammation

Altered gas exchange

Consolidation

Dyspnea

Pneumonia is a serious infection or inflammation of your lungs. 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 cant 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. Bacteria are the most common cause of pneumonia. Of these, Streptococcus pneumoniae is the most common. Other pathogens include anaerobic bacteria, Staphylococcus aureus, Haemophilus influenzae, Chlamydia pneumoniae, C. psittaci, C. trachomatis, Moraxella (Branhamella) catarrhalis, Legionella pneumophila, Klebsiella pneumoniae, and other gram-negative bacilli. Major pulmonary pathogens in infants and children are viruses: respiratory syncytial virus, parainfluenza virus, and influenza A and B viruses. Among other agents are higher bacteria including Nocardia and Actinomyces sp; mycobacteria, including Mycobacterium tuberculosis and atypical strains; fungi, including Histoplasma capsulatum, Coccidioides immitis, Blastomyces dermatitidis, Cryptococcus neoformans, Aspergillus fumigatus, and Pneumocystis carinii; and rickettsiae, primarily Coxiella burnetii (Q fever). 7 The usual mechanisms of spread are inhaling droplets small enough to reach the alveoli and aspirating secretions from the upper airways.

Other means include hematogenous or lymphatic dissemination and direct spread from contiguous infections. Predisposing factors include upper respiratory viral infections, alcoholism, institutionalization, cigarette smoking, heart failure, chronic obstructive airway disease, age extremes, debility, immunocompromise (as in diabetes mellitus and chronic renal failure), compromised consciousness, dysphagia, and exposure to transmissible agents. Typical symptoms include cough, fever, and sputum production, usually developing over days and sometimes accompanied by pleurisy. Physical examination may detect tachypnea and signs of consolidation, such as crackles with bronchial breath sounds. This syndrome is commonly caused by bacteria, such as S. pneumoniae and H. influenzae.
HYPONATREMIA

Hypoosmolality (serum osmolality < 260 mOsm/kg) always indicates excess total body water relative to body solutes or excess water relative to solute in the extracellular fluid (ECF), as water moves freely between the intracellular compartment and the extracellular compartment. This imbalance can be due to solute depletion, solute dilution, or a combination of both. In the normal condition, renal handling of water is sufficient to excrete as much as 15-20 L of free water per day. Further, in the normal condition, the body's response to a decreased osmolality is decreased thirst. Thus, hyponatremia can occur only when some condition impairs normal free water excretion.[1] Generally, hyponatremia is of clinical significance only when it reflects a drop in the serum osmolality (ie, hypotonic hyponatremia), which is measured directly via osmometry or is calculated as 2(Na) mEq/L + serum glucose (mg/dL)/18 + BUN (mg/dL)/2.8.

8 IV. Diagnostic Evaluation/ Lab Exams and Interpretation Diagnostic Exams

TEST TO CONFIRM HYPONATREMIA Serum Sodium

Chemistry Sodium Potassium Chloride Total CO2 BUN Creatinine Glucose INTERPRETATION: Low amount of sodium beyond the normal range indicates that the patient has Hyponatremia, low sodium osmolality too. The rest of the figure are within the normal range. HEMATOLOGY Results Hgb Erythrocyte Vol. Leukocyte count Platelet count Segmenter Lymphocyte 11.3 gms% 34% 11800cumm 200,000cumm 74% 26 Normal Value 14-16 gms% 42-50% 5000-10000cumm 150,000-400,00cumm 36-66% 22-40 . 120 3.9 87 24 10 0.8 90 Normal Values 136-146 mmol/L 3.5-5.3 mmol/L 98-108 mmol/L 23-27 mmol/L 7-22 mg/dl 0.7-1.5 mg/dl 70-110 mg/dl Urine Sodium 60 mmol/L Potassium 30 mmol/L Osmolality 500 mosm/kg

9 INTERPRETATION:

Low amount of Hgb in the blood lowers the synthesis of erythropoietin which is needed to stimulate the reed bone marrow to produce red blood cell. The erythrocyte volume is lower than the normal value. It may be due to less oxygen that binds with the iron portion to make oxyhemoglobin. The leukocyte count is higher than the normal since the patients body need to combat pathogens by phagocytosis and immune response. Other components of the blood are within the normal range.

V. Medical Treatment and Evaluation Treatment

The patient was prescribed with antibiotics to treat this disease. The symptoms of pneumococcal pneumonia usually go away within 12 to 36 hours after you start taking medicine. Some bacteria such as S. pneumoniae, however, are now capable of resisting and fighting off antibiotics. The drugs that were prescribed to the patient were Salbutamol and Ipratropium. An antibiotic that was also prescribed was Penicillin G.
Patient was supposed to use the nebulizer every 6 hours. At 12:40P.M he was being prepared for nebulization. The cardiac rate was supposed to be taken before and after administration of the nebulizer. CR Before:183 After: 193 After administration patient experienced reduced labored breathing and reduced crackles. During treatment of hyponatremia, the serum sodium should not be allowed to rise by more than 8 mmol/l over 24 hours (i.e. 0.33 mmol/l/h rate of rise). In practice, too rapid correction of hyponatremia and thence CPM is most likely to occur during the treatment of hypovolemic hyponatremia. In particular, once the hypovolemic state has been corrected, the signal for ADH release disappears. At that point, there will be an abrupt water diuresis (since there is no longer any ADH acting to retain the water). A rapid and profound rise in serum sodium can then occur. Should the rate of rise of serum sodium exceed 0.33 mmol/l/h over several hours, vasopressin may be administered to prevent ongoing rapid water diuresis. 10 Pharmaceutically, vasopressin receptor antagonists can be used in the treatment of hyponatremia, especially in patients with SIADH, congestive heart failure or liver cirrhosis. A vasopressin receptor

antagonist is an agent that interferes with the action at the vasopressin receptors. A new class of medication, the "vaptan" drugs has been specifically developed to inhibit the action of vasopressin on its receptors (V1A, V1B, and V2). These receptors have a variety of functions, with the V1A and V2 receptors are expressed peripherally and involved in the modulation of blood pressure and kidney function respectively, while the V1A and V1B receptors are expressed in the central nervous system. V1A is expressed in many regions of the brain, and has been linked to a variety of social behaviors in humans and animals.

Restore sodium balance (treat the underlying cause which is pneumonia, IV infusion of hypertonic saline solution)

y y

Stop sodium loss Restore fluid balance (fluid and electrolyte intake)

The patient is expected to have better skin turgor, a cardiac rate and serum sodium that is within the normal range, reduced mucus production verified by an effective airway clearance.

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VI. Drug Study

Drug Contraindicatio n Salbuta mol
Pregnancy . blockers. Hypersens itivity to adrenergic amines Hypersensitivit y to fluorocarbons 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Nervousness Restlessness Tremor Headache Insomnia Chest pain Palpitations Angina Arrhythmias Hypertension Nausea and vomiting 12. HyperglycemiaHypo kalemia

Adverse Reaction

Indication

Route

Classificatio n

Relief of bronchospasm in bronchial asthma, chronic bronchitis,emphysema &other reversible COPDs

PO and Inhalatio n

Bronchodila tor (therapeutic) ; adrenergics (pharmacolo gic)

Ipatropi um

Hypertrophic obstructive cardiomyopath y& tachyarrhythmi a.

1.

Fine trremor of skeletal muscle

Treatment of reversible bronchospasm as sociated w/ obstructive airway diseases in patients who require more than single bronchodilator.

Inhalati on

adrenergics and other inhalants used in the treatment of obstructive airway diseases.

2. 3. 4. 5. 6.

nervousness nausea, myalgia/muscl e cramps dry mouth increased occular pressure

7.

angle-closure glaucoma

8. Penicil lin G
history of a hypersensitivi ty (anaphylactic) reaction to any penicillin

eye pain. Septicemia, empyema, pneumonia, pericarditis, endocarditis, meningitis

1. fever 2. chills 3. myalgias 4. headache

IV

extended spectrum Penicillins .Treatment of systemic infections.

5. exacerbation of cutaneous lesions 6. tachycardia

7. hyperventilati
on 8.vasodilatio n with flushing and mild hypotension

VII. Nursing Care Management a. Ongoing Assessment Assess the patient. Ask the mother questions about changes in bowel pattern or color of the patients stool, consumption, medications like aspirin or anticoagulants, vomit in his blood and medical history. Ask about the presence of sputum in the cough and take note of its color and consistency. Perform a physical exam, take note of the skin turgor of the patient, for any muscle cramps, dry, pale skin and muscle weakness. Perform Chest Physiotherapy to reduce secretions and fluids in the lungs. Organize and analyze the information you obtained during your assessment, looking for problems that your patient may have due to Pneumonia and Hyponatremia. These problems should be signs, symptoms or effects of Hyponatremia that are affecting your patient negatively. Formulate one or more nursing diagnoses based on the problem that you identified. In this case, your nursing diagnoses may be: 1) Hyponatremia R/T Vomiting 2) Ineffective airway clearance R/T excessive mucus AEB ineffective cough. 13

Write down the goals and objectives you want your client to meet based on the nursing diagnoses. In this case, your goal would be along the lines of: 1) Restore sodium balance 2) Stop sodium loss 3)Restore fluid balance b. Diet List the nursing activities needed to meet these goals. For preventing complications of hyponatremia, monitor your patient's intake and output and serum sodium and sodium osmolality .Do this by measuring how much fluid he drinks and the amount of fluid he loses through urine and by taking the serum sodium of the patient. Monitor vital signs, especially the cardiac rate, for signs of tachycardia in hyponatremia or sodium deficit.. Observe him for nausea and vomiting, muscle weakness, fainting dry, pale skin , dry mucous membranes and seizures. To monitor nutritional status, your interventions could be weighing your client daily and administering intravenous fluids as ordered if he is restricted from eating or drinking.

Review your client's condition and goals to see they have been attained. Check if vital signs are stable and if his output has been within the normal range of 30 milliliters per hour, showing he has maintained his normal fluid volume and if his serum sodium is within the normal range. Check also his skin integrity and auscultate the lung fields for signs of mucus retention and crackles. Look at his weight history to see if he has maintained a stable weight. If your objectives were not met, reassess your client and plan new interventions.

c. Sex Not applicable to the patient. 14

d. Possible Complication Initiate patient teaching. Teach the mother of the patient the signs and symptoms hyponatremia . Instruct her to call the health care provider if she notices any untoward signs of hyponatremia. Teach her about the patients medications, their expected side effects and how to take them. Consult the doctor before taking any over-the-counter medication.

15

IX.Discharge Plan a. Meds

y

Keep a written list of the medicines you take, the dose, and when and why you take them. Bring the list of your medicines or the pill bottles when you see your caregivers. Learn why you take each medicine. Ask your caregiver for information about your medicine.

There are many medicines that may cause Hyponatreia. Do not take any medicines, over-the-counter drugs, vitamins, herbs, or food supplements without first talking to caregivers. Do not take any medicine that has aspirin, naproxen, or ibuprofen in it without first asking your caregivers.

Always take your medicine as directed by caregivers. Call your caregiver if you think your medicines are not helping, or if you feel you are having side effects. Do not quit taking your medicines until you discuss it with your caregiver. If you are taking antibiotics (an-ti-bi-AH-tiks), take them until they are all gone even if you feel better.

y y

If you are taking medicine that makes you drowsy, do not drive or use heavy equipment. If you have other medical conditions such as high blood pressure, you need to control them. Take medicines as directed. Some medical conditions may increase your risk of GI bleeding, especially if they are not well-controlled.

Learn how to properly use the nebulizer and how to place the prescribed medicine into them.

17

b. Exercise Exercising makes the heart stronger, lowers blood pressure,

and helps keep you healthy. It is best to start exercising slowly and do more as you get stronger. Talk to your caregiver before you start exercising. Together you can plan the best exercise program for you. The patient is an infant and can only tolerate small range of exercises. c. Treatment Hyponatremia is a common disease but if left ignored its effects can be fatal. Accepting that you have a health problem is hard. You and those close to you may feel angry, sad, or frightened. These feelings are normal. Talk to your caregivers, family, or friends about your feelings. Let them help you. d. Health Education -Instruct patient to live a healthy lifestyle. Living a more healthy lifestyle may decrease your risk of having Hyponatremia in the future. Ask your caregiver about things you can do to decrease your bleeding risk.
y

Alcohol: Not applicable to patient because he is only 11 months old, but instruct mother to refrain from giving the patient alcohol in the future.

Constipation: If you are constipated, you may have a hard time having a bowel movement (BM) Do not try to push the BM out if it is too hard. Walking is the best way to get your bowels moving.
y

18

Eat foods high in fiber to make it easier to have a BM. Good examples are high fiber cereals, beans, vegetables, and whole grain breads. Prune juice may help make the BM softer. Caregivers may give you fiber medicine or a stool softener to help make your BMs softer and more regular. You can also buy these medicines at a grocery or drug store.

e. Observe Signs and Complications Observe for signs of brain herniation, death and possible coma.
A brain herniation is when brain tissue, cerebrospinal fluid, and blood vessels are moved or pressed away from their usual position inside the skull.

f. Diet Eat a healthy variety of foods: fruits, vegetables, breads, meats and fish, and dairy products. Eating healthy foods may help you feel better and have more energy. It may also help you heal faster. Ask your caregiver if you need to be on a special diet. Drink six to eight (8 ounce) cups of liquid each day. Follow your caregiver's advice if you must limit the amount of liquid you drink. Decrease the amount of caffeine you eat and drink. Caffeine may be found in coffee, tea, soda, sports drinks, chocolate, and food bars. Increase the intake of sodium as recommended by the Physician.

X. Implications to: a. Nursing Service Through this case study nursing service will improve in a way that the nurses will be more updated and informed with the latest treatments and previous nursing and medical interventions.

19

b. Nursing Education Through this case study nursing education will be more appreciated and sought for because as new information regarding diseases are disseminated, more questions will be raised and will only be answered through proper education. c. Nursing Research Through this case study nursing research will be delved deeper to further explain and understand certain medical conditions and find their corresponding nursing interventions and management. All of this is for the improvement of the condition of the patient and for the alleviation of pain and suffering. X. References - http://nursingcrib.com/nursing-notes-reviewer/nursing-diagnosis-for-respiratory-diseases/ http://www.umm.edu/patiented/articles/what_general_guidelines_treating_pneumonia_000064_ 7.htm -http://www.mayoclinic.com/health/pneumonia/DS00135/DSECTION=treatments-and-drugs -http://www.rxlist.com/penicillin_g_potassium-drug.htm -http://www.mims.com/Philippines/drug/info/Acumox/?q=penicillin - Fundamentals of Nursing by Barbara Koziers,Glenora Erb,Audrey Berman, Shirlee Snyder -Nursing Care Plans edition 6: Marilyn E. Doenges,Mary Frances Moorhouse,Alice C. GeisslerMurr 20

BICOL UNIVERSITY RIZAL STREET,LEGAZPI CITY COLLEGE OF NURSING NCM103

CASE STUDY ON HYPONATREMIA (PNEUMONIA MOD.RISK)

A case study of: E.A.M Name of Patient

As Partial Requirement for NCM103

Submitted by: Recto, Jessica Belle Nicolle D. NCM103 student Group 10

August 22, 2011