ST.

MARYS COLLEGE Nursing Program Tagum City

A CASE STUDY ON

PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA

Presented to: Virginia B. Bellena, RN Lhevinne P. Genetializa, RN

In Partial Fulfillment of the Requirements In Related Learning Experience (RLE)

By:

Patrick Jayson A. Dela Torre Domine Mar Manuel L. Suico BSN 3A3 May, 2010

I. INTRODUCTION You would think that in the light of modern treatment and wide availability of antibiotics, Community Acquired Pneumonia would no longer kill us, right? Wrong! For in fact CAP is a very common problem globally and is associated with significant morbidity and mortality. Community acquired pneumonia (CAP) remains a serious illness with a significant impact not only on individual patients but also on society as a whole. It is a disease in which individuals who have not recently been hospitalized develop an infection of the lungs (pneumonia). CAP is a common illness and can affect people of all ages. This often cause problems like difficulty of breathing, fever, chest pains, and cough. Such complication occurs throughout the world and is a leading cause of illness and death. Causes of CAP include bacteria, viruses, fungi, and parasites. CAP can be diagnosed by symptoms and physical examination alone, through X-rays, examination of the sputum, and other tests are often used. Individuals with CAP sometimes require treatment in a hospital. The most common types of microorganisms are different among different groups of people. Newborns, children, and adults are at risk for different spectrum of disease causing microorganisms. Even when aggressive measures are taken, a definite cause for CAP is only identified in half the cases. It was recorded in the year 2003 that there are more than 5.5 Million people develop CAP and as many as 1.1 Million of these require hospitalization

each year. And in the year 2004 the mortality rate for persons with CAP ranges from less than 1% among outpatient and 30% among those requiring hospitalization. CAP was also considered the single most important cause of death in children under 5 years, responsible annually for approximately 20% of the 10 million under-5 deaths globally. In fact, this complication was considered one of the major causes of death from infectious disease in some places worldwide just like in United States, Philippines and Canada. (Medical-Surgical Nursing 7th edition by Brunner & Suddarth , Pathophysiology by Huffsttler & www.emedicine.com). The chronology we have came from the Department of Healths Health statistics which have been updated sometime last January 2007, documented that one of the leading causes of mortality in the Philippines is Pneumonia either community acquired or hospital acquired, it was actually ranked as top 5 leading cause of death among the Filipinos. For the adults, this occurs mainly as a complication of other chronic diseases like lung cancer, COPD, tuberculosis, and other debilitating illnesses that leave them bedridden most of the time and for the children, this remains to be a major killer. In the year 2004 it was recorded that in every 100,000 total population in the Philippines over 15,822 males died this year and 16,276 for the females. (www.healthstatistics.com). In Davao Oriental all of the leading causes of morbidity from 1992 to 1997 were due to communicable diseases and showed a reduction in rates for every 1000,000 population, except for pneumonia which ranges from 836.30 to 1,200.23 persons in both male and female. (www.healthstatics.com).

OBJECTIVES:

General: The objective of this study is to provide information regarding our patients condition from our data collected through patient-nurse interaction and with our thorough research about the case; it will alleviate his condition and aid for others to improve their well-being.

Specific: 1. To provide an outline about the case being studied. 2. To show the lifes history of the patient regarding his history of present illness, past medical history as well as his personal, family and socioeconomic history. 3. To present the patient need assessment in different nursing theorist. 4. To discuss the physical assessment of the patient in different systems. 5. To show its daily summary activities in the hospital through nurses assessment with nursing intervention and medical management. 6. To show the laboratory results of the patient with corresponding interpretation of the abnormal findings. 7. To review the anatomy and physiology of the organ involve in the disease process.

8. To identify the symptoms of the disease and relate it to the actual symptoms of the patient. 9. To show the etiology of the disease and relate it to the actual condition of the patient. 10. To discuss and trace the pathophysiology of the disease process. 11. To formulate nursing care plan in aiding progression to patients wellness. 12. To present the discharged plan of the patient in relation to his condition. 13. To review drugs regarding to his condition with nursing intervention. 14. To present the prognosis of the patient after rendering medical services and to present recommendations regarding to his disease. 15. To evaluate the study.

II. ASSESSMENT:

A. Biographical data Name: Agua Bendita Age: 12 years old Gender: Female Civil Status: Single Birthdate: September 08, 1997 Birthplace: Mati City, Davao Oriental Address: Purok Malinawon Dos, Tagum City Religion: Roman Catholic Nationality: Filipino Date and Time of Admission: May 26, 2010 / 1:13pm Final Diagnosis: Pediatric Community Acquired Pneumonia Type C Attending Physician: Dr. Elizabeth Derla, MD

B. Chief Complaint Prior to admission, a positive onset of nasal catarrh for 3 days and a positive onset of productive cough for seven days; a sticky yellow phlegm in moderate amount, dyspnea, and fever for 2 days on and off.

C. History of Present Illness Due to previous continuous activities from home like playing and mingling with her cousins , she was unable to meet the appropriate needs which was later on, 3 days prior to admission patient had onset of nasal catarrh. No cough and dyspnea observed. For the following day, positive onset of productive cough, a sticky yellow phlegm in large amount and positive for dyspnea occur. No consultation done. At night, she experienced fever with a temperature of 38.4C which was persistent and she took Paracetamol. And by the next day, it was relief for about an hour after taking Paracetamol in the afternoon then the fever again occurred on the next day. And on May 26,2010, around 1:00pm prompt hospitalization was done at Bishop Joseph Memorial Hospital.

D. Past Medical and Nursing History He was born full term at their house on September 08, 1997. With complete immunization. At 4 weeks old, she was diagnosed with sepsis neonatorum and due to severe infection in the blood it causes Agua Bendita to have cerebral palsy and undergone several treatment of antibiotics. At 2 years of age, she undergone some epileptic episodes and on that year she had her maintenance of Phenobarbital, an antiepileptic drug. In November,2005 her parents noticed that she had a cough for almost a week with a colored sputum. She had her check-up with her

mother and was diagnosed with PCAP. After which, her parents always sends her to hospital for nebulization for every long duration of cough. Eventually, her coughs decreased its frequency. Until by the age of 8 , she experienced productive cough with purulent sputum and difficulty of breathing, they tried to manage it with the use of expectorant drug but it doesnt relieved for 5 days so she was sent to the hospital and was admitted for 4 days and diagnosed with pediatric community acquired pneumonia at Bishop Joseph Memorial Hospital . For almost 4 years, she didnt experienced pneumonia. By the age of 12, she experienced sudden onset of nasal catarrh for 3 days and as verbalized Natakdan siguro na siya sa mga kadula niya sa balay as verbalized by mother . Kapoy pud na siya sige lang higda kay dili mana gud na siya makatindog tungod sa iyang kondisyon run and for 2 days with productive cough; a sticky yellowish phlegm in large amount and dyspnea occurs. Pain felt upon inspiration as per verbalized by Agua Bendita to her mother. They didnt seek for medical assistance for 7 days of cough until a sudden onset of on and off fever occur. Prompt admission done at Bishop Joseph Memorial Hospital and she was diagnosed with PCAP.

E. Personal, Family and Socio-economic History The only daughter of Mr. and Mrs. Bendita. A 12 year old girl who had cerebral palsy, always at their house together with her mother. And she spent her life staying at house and sometimes went to where her

mother wants to go but its very occasional. Agua Benditas playmates were here cousins who were at the same time her neighbors. The father of Agua was the bread winner in the family, he was a shoemaker and earned 7,000 pesos a month and her mother is a plain housewife taking care of Agua the whole time. Their income according for them is not enough to sustain the daily needs of the family. Aguas relationship with her parents was good because they were supportive to her needs. History of Pneumonia was not confirmed and it was only their first time to encounter such disease.

F. Patient Need Assessment Base on Maslows Hierarchy of Need Base on Henderson Base on Abdellah - Shes not able to promote optimal activity such as exercise, rest and sleep this was because of her activity at home. She is always lying on bed or sometimes in the ground while playing with her cousin since she cannot tolerate to stand or sit. It is not new to her to be exhausted after the day is done. Also she was not able to facilitate maintenance of supply oxygen, since early childhood she was suffering for neonatal sepsis the leads to cerebral palsy which is also one of the hindrances in persuading her activities.

Base on Gordon Base on Growth and Development According Freuds Psychosexual Theory, Agua was challenge with her latency stage since in this stage energy is directed to intellectual and physical activities and at the same time relationship to peers. Since Agua was staying only in the house with limited interaction to people.

Base on Havighursts Age Periods and Developmental Tasks Agua must learn physical skills, required for games, build healthy attitudes towards oneself- learn to socialize with peers- learn appropriate feminine role- gain basic reading, writing & mathematical skills- develop concepts necessary for everyday living- formulate a conscience based on a value system- achieve personal independence- develop attitudes toward social groups & institutions

PHYSICAL ASSESSMENT A. General Survey She was conscious, responsive and coherent. With normocephalic head and no lesions observed. Skin is smooth and very warm to touch, with thick and fine hair, scar noted at right and left arm and negative for cyanosis and nail beds are pink. Clubbing of finger not noted. Hair is black and evenly distributed with flakes on scalp. Eyes are black, asymmetrical, coordinately move in unison with pupils unequally reactive to light

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accommodation. Ears are symmetrical with color same as facial skin, no discharges noted and able to hear words in short distance only upon calling her name. Nasal catarrh noted and able to identify odors such as her food. Dry lips noted and unable to speak but can responds to questions. Tongue able to move but limited and dental caries noted. Neck able to hyperextend but very rigid and uncoordinated with hard movement with discomfort. She can able to swallow with difficulty. Frequent

salivation noted. With minimal effort in inspiration and pain felt at tolerable level with pain scale of 1, symmetrical chest expansion noted and crackles sound heard upon lung auscultation. Positive for productive cough, a sticky yellowish phlegm in moderate amount with respiration rate ranging from 28-34cpm. No chest pain felt with BP ranging from 100/60100/70mmHg. Hard uncoordinated movement noted with unequal strength on each body side.

B. Vital Signs DATE / SHIFT 4/26/10 4/26/10 3-11 TEMP C 36.3 38.4 38.8 39.3 100/70 BP mmHg 100/70 CR bpm 88 86 84 87 RR cpm 28 33 32 33 IVF- 450cc H20- 60cc 510cc 8:50pm IVF/KSS

TIME 1:13pm 04:00pm 6:00pm 8:00pm

INTAKE

OUTPUT

U-1x S-0

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10:00pm 4/27/10 11-7 12:00mn 2:00am 4:00am 7-3 8:00am 12:00nn 12:00nn

38.9 36 36 36.6 36 36.3 36.9 100/60 100/60 100/70

88 89 102 100 120 116 76

34 32 34 32 26 26 20 U- 2x S-1x

C. Nutritional Status Agua Bendita is 45 or 1.6 meters in height, weighing 25kls. And she has a normal BMI of 21.69, with regard of his height and weight. Shes on Diet as Tolerated wit Aspiration Precaution with IVF of #1 D5NM 1 L at 100cc/hr. She was eating with the help of her mother in lying position.

D. Neurologic Status Conscious, responsive and coherent. With spontaneous eye opening.

E. Integumentary System Smooth skin with thick and fine hairs evenly distributed, some scars noted at right and left arm. Cyanosis not noted.

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F. HEENT Head is normocephalic with no lesions. His eyes are black, asymmetrical, both eyes uncoordinately move in unison with pupils equally reactive to light accommodation. Ears are symmetrical with same color as facial skin and no dischargers and able to hear words in short distance only. No lesion on nose noted, nasal catarrh was not evident, nasal flaring not noted and able to identify odors such as food served. Able to hyperextend her neck with rigidity and uncoordinated rigid movement with discomfort noted. She can able to swallow with difficulty and also salivation noted in moderate amount.

G. Pulmonary System Minimal effort in inspiration and pain felt; 1. Crackles sound still heard upon lung auscultation with symmetrical chest expansion. Dullness to percussion still noted. Productive cough noted; a sticky yellowish phlegm in moderate amount with respiration rate from 2830cpm.

H. Cardiovascular System A lubb-dubb sound heard upon auscultation with a blood pressure ranging from 100/60 100/70 mmHg; no chest pain noted.

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I. Gastrointestinal System Defecated once on April 27, 2010 with a semi-solid stool, brown in color and in moderate amount with flat contour and borborygmic heard upon auscultation.

J. Musculoskeletal System Rigid coordinated movement noted with unequal strength on each body side

K. Genito-urinary System Urinated 2 times on April 27, 2010, amber yellow in color at moderate amount. With no pain sensation felt upon urination.

G. Course in the Ward DATE / SHIFT 4/26/10 1:55pm NURSES ASSESSMENT . - Come this 12 y.o female patient in due to cough and fever under the service of Dr. Derla - CBC, CXR request for approval. - Still to inform AP - Vital signs checked and recorded. - Started with #1 -Pls. admit -DAT with Aspiration Precaution - CBC HCT PLT CT. NURSES INTERVENTION MEDICAL MANAGEMENT

D5LR 1L 100cc/hr Chest X-ray APL. - Medication prescribed. - Brought to ward without - #1 D5LR 1L @ 100cc/hr -D5NM 1L @SR -Piptaz 2.25g q 8hr IV

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unusualities.

ANST (-) slowly -Clarithromycin 5ml BID -Paracetamol 250 7ml q 4hr x 1 day then prn -VS q 2hrs -watch for seizures

4/26/10 3-11

S/O- Nagalintura jud na siya karon as

I- Vital signs monitored and

- Due meds given by NOD; paracetamol 5ml @ 4:00pm

verbalized by mother. recorded. T=38.4 C; dry lips, sweating forhead noted, skin very warm to touch, with dry mucous membrane 6:00pm -Temp: 38.8 C A- Altered thermoregulation: Hyperthermia r/t disease process. P- Within 3 hrs of nursing care will be able to: Maintain core temperature within normal range (36 C37.4) - Instructed mother t o increase oral fluid intake. - Aggressive TSB done - Instructed mother to provide loose clothes to promote air ventilation of body - Encouraged to comply drug regimen as prescribed

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 8:00pm

Skin not warm to touch Moist mucous membrane.

E- After 3hrs of nursing care; GOAL NOT MET as evidenced by; body temperature= 39.3C with skin very warm to touch

4/27/10 11-7

-Received on bed asleep responsive with IVF #1 D5LR 1L regulation @ 100cc/hr

-VS checked and recorded -Meds prepared. Due meds given

-Due IVTT meds @ 2am

4/27710 7-3

- Received on bed, awake and responsive with IVF #2 D5NM 1L @100cc/hr -Almost IVF dislodge

- IVF re-insertionattempted once successful -IVF re-inserted and infused well.

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4/27/10 3-11

S- Lagi, gi-ubo jud na siya, mga sobra

I- VS monitored and recorded - Due meds given, clarithromycin 5ml BID.

na isa ka semana as -Instructed verbalized by mother, mother to position RR= 34cpm; crackles on Moderate High noted upon auscultation, productive cough noted with yellowish sputum, salivation noted. A- Ineffective Airway Clearance r/t retained secretion secondary to PCAP P- Within 4 hrs of nursing care will be able to maintain airway patency as evidenced by: Diminish crackle sound Signs of respiratory distress will not be noted. Back Rest - Monitored feeding intolerance - Instructed mother to increase oral fluid intake. - Observed for signs and symptoms of respiratory distress. - Health teachings imparted about the importance of drug compliance and its proper administration.

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III. LABORATORY AND DIAGNOSTIC EXAMINATIONS

Hematology Date: April 26, 2010

LAB EXAM Hemoglobin Hematocrit WBC

NORMAL VALUES 140 170 g/L 0.40 0.5 g/L 5.0 10.0 x 10 9/L

RESULT 127 g/L 0.38 g/L 7.24 x 10 9/L

INTERPRETATION / IMPLICATION Normal Normal Normal indicates Bacterial infection,

Segmenters

0.55 0.64%

0.69 % inflammation and allergic response

Lymphocytes Monocytes Cosinophils Basophils Thrombocytes

0.25 0.35 % 0.03 0.06 % 0.01-0.05% 0.0-0.005% 150-440 x 10 9/L

0.24 % 0.05 % 0.01% 0.01 364.8 x 109/L

Normal Normal Normal Normal Normal

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X-RAY REPORT

46865

04-26-2010

CHESTPAL: Negative chest save for poor inspiratory effort

IV. ANATOMY AND PHYSIOLOGY

A. Written The air-conducting passages that bring air into the lungs are the nose, pharynx, larynx, trachea, bronchi, and bronchioles. The respiratory tract from the nose to the bronchioles is lined with ciliated mucous membranes. As air enters the nasal cavity, it is filtered, warmed and humidified. These three processes are primary functions of the respiratory mucosa, which consists of pseudostratified, ciliated, columnar epithelium and goblet cells. The epithelial surface is covered by a mucous blanket, which is secreted by both the goblet cells and the serous glands. Coarse dust particles are filtered by the hair in the nares, and fine particles are trapped in the mucous blanket. Ciliary action propels the mucous blanket posteriorly in the nasal cavity and superiorly in the lower respiratory tract toward the pharynx, from which it is swallowed or expectorated. Water for humidification is given up by the mucous blanket, and heat is supplied to the inspired air by a rich underlying vascular network. Inspired air is thus conditioned so that it reaches the pharynx nearly dust-free, at body temperature, and 100% humidified.

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Air passes from the pharynx into the larynx, or voice box. The larynx consists of a series of cartilaginous rings, united by muscles and contains the vocal cords. A triangular space between the vocal cords, the glottis, opens into the trachea and forms the division between the upper and lower respiratory tracts. Although the larynx has been thought of chiefly in relationship to phonation, its protective function is much more important. During swallowing, the rising action of the larynx, the closure of the glottis, and the door like action of the leaf-shaped epiglottis, at the entrance of the larynx, all serve to guide food and fluids into the esophagus. If foreign substances do get beyond the glottis, the cough function of the larynx assists in expelling these substances as well as secretions from the lower respiratory tract. The trachea is supported by horseshoe-shape cartilaginous rings and is about 5 inches long. The structure of the trachea and bronchi is analogous to a tree, and it is therefore called the tracheobronchial tree. The posterior surface of the trachea is flattened rather than round (because its cartilaginous ring are incomplete), and it lies immediately in front of the esophagus. The right and left mainstem bronchi are not symmetric. The right bronchus is shorter and wider and continuous from the trachea in a nearly vertical course. In contrast, the left bronchus is longer and narrower and continues from the trachea at a more acute angle. The right and left mainstem bronchi divide to become the lobar and then the segmental bronchi. This branching in ever-decreasing sizes

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continues down to the terminal bronchioles, the smallest airways that do not contain alveoli. Terminal bronchioles are about 1 mm in diameter. Bronchioles are not supported by cartilaginous rings but are surrounded by smooth muscle, which allows alteration in size. All the airways down to the level of the terminal bronchioles are called conduction airways because their main function is to serve as air conduits to the gasexchanging areas of the lung. There are about 23 generations of branching from the trachea to the terminal alveolar sacs. The individual alveolus is separated from its neighbor by a thin wall, or septum. Small openings in the septum, called the pores of Kohn, allow communication of air flow between terminal alveolar sacs. The alveolus has only one layer of cells, which is less than the diameter of a red blood cell in thickness. There are about 300 million alveoli in each lung, with a surface area about the size of a tennis court. Because the alveolus is essentially a gas bubble surrounded by a capillary network, the liquid-gas interface creates a surface tension, which tends to resist expansion on inspiration and favors collapse on expiration. The alveoli, however, are lined with a lipoprotein substance called surfactant, which lessens the surface tension, lowers resistance to expansion on inspiration, and prevents collapse of the alveoli on expiration. A deficiency in surfactant is believed to be an important factor in the pathogenesis of a number of lung diseases.

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The lungs are elastic, cone-shaped organs that lie within the thoracic cavity, or chest. They are separated by a central mediastinum, which contain the heart and great vessels. Each lung has an apex and a base. The right lung is larger than the left and is divided into three lobes by the interlobar fissures. The left lung is divided into two lobes. A serous membrane called the parietal pleura lines the inside of thoracic cavity. It is continuous with the visceral pleura that cover the surface of the lungs. And between the two closely opposed pleura forms a space called pleural space. It contains serous fluid that facilitates pleural surface adhesion and allows pleural surface to slide over each other without friction during inhalation and expiration.

B. Diagram

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V. SYMPTOMATOLOGY

SYMPTOMATOLOGY Cough that brings up a greenish or yellowish mucus

ACTUAL SYMPTOMS

IMPLICATION

It implies a normal reflex which helps to clear the breathing passages from excess secretions brought by goblet cells in response to trap foreign particles.

Fever

It implies infection where bodys natural response to fight germs and chills occurs when the fever is rising.

Stabbing or sharp chest pain

Prolonged or violent coughing can strain the muscles or ligaments of the chest wall and soreness may feel when you cough.

Dyspnea

Difficulty in breathing due to airway obstruction brought by excessive accumulation fluids in the alveoli which decreases the gas exchange mechanism..

Tachypnea

An increase in rate or rapid breathing that indicates

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obstruction in the air flow into and

out of the lungs due to increase accumulation of fluids.

Dullness to percussion

It implies decrease air in the lungs due to consolidation or a fluid collection within the lung tissues.

Increased fremitus

This result from vibration through more solid medium, consolidation or accumulation of mucous secretion.

A coarse low pitched popping Crackles sounds that are short and discontinuous which implies excessive fluid within the airways that brought abnormal breath sounds.

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VI. ETIOLOGY OF THE DISEASE

ETIOLOGY

ACTUAL SYMPTOMS She was 8 years old.

IMPLICATION

1. Age (common in all ages)

It is a common and significant morbidity and mortality in all ages because of different factors that individuals commonly expose which makes them at risk for acquiring pneumonia.

2. Race ( common in all race)

She was a Filipino.

Contributing factors in acquiring pneumonia are widely and commonly experience in different people at different race and some factors.

3. Gender (common in male)

Rate are higher in male than female in relation to men are more expose to such factors contributing to the disease process

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such as vices, industrial work that expose to air pollutants and mostly they went home late at night..

4. Environmental factors (sudden change in weather or cold weather and exposure to air pollutants) Because of her staying only in the house and playing the whole day with her cousins and lying on bed at all times and sometimes in the ground since she cannot tolerate standing or even just sitting because of her condition and their house located near at the highway .

In cold weather, hypothermia occurs to an individual if the body cant produce enough energy in order to keep the body warm. With this it causes decrease body normal functioning which includes the respiratory system. Aside from the fact that cold weather causes people to congregate together indoors which makes transmission of the organisms easier. Air pollutants decreases or alters the ability of lung defense mechanism.

5. Lifestyle (smoking and alcohol intake)

Scientist shown that alcohol consumption impairs an important

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defense barrier to lung infection and that smoking intensifies this. They tend to lost the movement of cilia-tiny hairs lining the airways that beat rhythmically to waft microorganism out which pave them a way to enter into the lungs.

6. History of respiratory disease (asthma and pneumonia)

For the adults, pneumonia occurs mainly as a complication of other chronic diseases like lung cancer, COPD, tuberculosis, and other At the age of 8yo, she was diagnosed with PCAP and when she was 11 yo, she was hospitalized due to pneumonia. debilitating illnesses this is due to disrupted normal lung defense mechanism.

7. Familial history of respiratory disease (asthma)

Individuals who have a family history of respiratory diseases may at risk for developing asthma.

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8. Malnourished

She was malnourished because her weight is not appropriate with her age

.Malnourished individuals are deficient In lungs defense mechanism due to improper balance of basic foodstuffs like carbohydrate, protein and other essential ingredients which alters the normal function of body organs.

9. Exposure to:

Bacteria

It initiates the inflammatory response and inflammatory Based on hematology result, his segmenters were increase at 0.40% which implicates bacterial infection, inflammation and allergic response. exudates causes alveolar edema. Most infectious pneumonia is caused by bacteria and 60-80% of all bacterial pneumonia is caused by Streptococcus pneumoniae.

Virus

It is usually mild but can

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set a stage for a secondary bacterial growth and by damaging epithelial cells.

Parasite

Histoplasmosis capsulatum releases in to the air when containing spores is disturbed and inhaled such exposure result in acute disease which is benign. It mainly affects the immunosuppressed.

Fungi

Pneumocystis carinii is an organism of mixed fungal and protozoal character that causes and acute, often fatal, respiratory infection in infants or immunocompromised patients.

10. Immunosuppressed

The defense mounted by an individual against the disease-causing agent antigen is deficient and not enough to destroy the antigen.

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VII. PATHOPHYSIOLOGY

A. Written PNEUMONIA is a disease characterized by airway obstruction that is worse with expiration. With the following predisposing factors CAP could be acquired such Age which is common to all, Race that affects all people, Gender which men are at higher incidence of rate, Environmental factor such as sudden change in weather or cold weather and exposure to air pollutants, lifestyle is also one of the factor like smoking and alcohol intake, History of respiratory disease which is asthma, malnourished and immunosuppressed individual can be one of the factor. And the precipitating factor of this is the exposure to pathogens such as bacteria. Because of the said predisposing and precipitating factors organisms enter the respiratory tract through inspiration that lead to increase the mucous secretion of the goblet cells; because of the over production of secretion the cilia disrupts the activity and lead the bacteria flows with the blood stream and reaches the lungs then spread to the respiratory tract including the alveoli. Once inside the alveoli, bacteria travel into the space between the cells and also between the adjacent alveoli through the connecting pores that will trigger the immune system and responds by sending white blood cells specifically the neutrophils. Neutrophils engulf and kill the offending organisms and releases cytokines resulting to general activation of immune system, inflammation and edema of alveoli follows, because of this fluids leaked from surrounding blood

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vessels fill the alveoli then the alveoli becomes less elastic resulting to impaired oxygen transportation, lung tissue fills with exudates and fluid, changing from an airless state to a consolidate state and Community Acquired Pneumonia take place.

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B. Diagram Predisposing Factors -Age (common in all ages) -Race (affects all race) -Gender (common in male) -Environmental factors (sudden change in weather or cold weather and exposure to air pollutants -Lifestyle (smoking and alcohol intake) -History of Respiratory disease (asthma and pneumonia) -Familial history of respiratory disease (asthma) -Malnourished -Immunosuppressed

Precipitating Factors -exposure to pathogens such as bacteria

Organisms enter the respiratory tract through inspiration

Increase mucous secretions of goblet cells. Disrupts the cilia activity

_ _ _ _ _ S/S: Productive cough

Bacteria flow with the bloodstream and reach the lungs.

a greenish or yellowish mucus

Spreads to the respiratory tract including alveoli

Once inside in alveoli, bacteria travel into the spaces between the cells and also between the adjacent alveoli through connecting pores. 32

Triggers the immune system and responds by sending white blood cells specifically the neutrophils.

_ _ _ _ S/S: Fever

Neutrophils engulf and kill the offending organisms and releases cytokines resulting to general activation of immune system.

Inflammation and edema of the alveoli

Fluids leaked from surrounding blood vessels fill the alveoli Becomes less elastic resulting to impaired oxygen transportation Lung tissue fills with exudates and fluid, changing from an airless state to a consolidate state.

_ _ _ _ S/S: Dyspnea Tachypnea

_ _ _ _ _ S/S: Increase fremitus

Community acquired pneumonia

Dullness to percussion Crackles

TREATED:

IF NOT TREATED

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MEDICAL MANGEMENT: - Antibiotics like Penicillin and if patient is sensitive to it erythromycin will be given. - Hydration rounds for fever and tachypnea that results in insensible fluid loss - Antipyretic for fever - Antitussive for cough - Warm and moist inhalations like combivent in relieving bronchial irritation. - Nasal decongestant for nasal catarrh. - Oxygen at 6L/min per nasal cannula. NURSING INTERVENTION: 1. Promote bed rest to prevent fatigue. 2. Initiate chest and back tapping to increase the force in expectorating secretions. 3. Monitor V/S as well as the Breath sound every 4 hours. 4. Encourage to increase oral fluid intake. 5. Encourage to take high-calorie and high protein diet.

Complications - Sepsis - Respiratory failure - Pleural effusion - Atelectasis

DEATH

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VIII. PLANNING A. NCP Name of Patient: Agua Bendita Diagnosis: PCAP

Attending Physician: Dr. Elizabeth Derla Age: 12 yo. ACTUAL NURSING CARE PLAN

DATE/ SHIFT 4/26/10 3-11

ASSESSMENT Subjective Cues: Nagakalintura jud na siya karonas verbalized by mother. Objective Cues: Temperature = 38.8 degrees Celsius Dry lips

NEED P H Y S I O L O G I C Need

NSG. DIAGNOSIS Altered thermoregulation: Hyperthermia related to disease process. 1.

OBJECTIVE OF CARE Within 3 hours of nursing care will be able to; 1. Maintain core temperature within normal range ( 36-37.4 degrees celsius. 2. Skin is not warm to touch. 3. Able to have a moist mucous membrane.

NSG. INTERVENTION Independent: 1. Monitored vital signs. To obtain baseline data and notes progress and changes of condition. 2. Assessed fluid loss and instructed mother to increase oral fluid intake. To increase metabolic rate and diaphoresis. 3. Aggressive Tepid Sponge bath done. Enhances heat loss by evaporation & a. i conduction n 4. Instructed mother to c provide loose clothing o and provided cool n

EVALUATION Goal not met as evidenced by: 1. Body temperature still high; Temp = 39.3C. 2. Skin is very warm to touch. Still the patient got a fever after several nursing intervention to alleviate high body temperature.

Cause a rise in
Body temperature, it also acts as an antigen 2. 3. triggering immune 4. system responses. The 5. hypothalamus reacts to raise the set point 6. and the body respond by producing heat.

4:30 pm Sweating on forehead noted Skin very warm to touch Dry mucous membrane noted

Body thermoregulation

7:30 pm

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Reference: Fundamentals of Nursing -Harry & Perry

circulatingd by using air afan. i Dissipates heat by t convection and increase i comfort o n Dependent: i n g 1. Maintain IV fluids as / ordered by physician. to prevent dehydration r e 2. Administered antipyretic as ordered. To provide pharmacologic treatment to reduce fever. 3.Administered antibiotics as ordered. Treats underlying cause. Collaborative: 1. Monitored hematogic test.. Indicates presence of infection.

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Name of Patient: Agua Bendita Diagnosis: PCAP ACTUAL NURSING CARE PLAN DATE/ SHIFT 4/28/1 3-11 ASSESSMENT Subjective cues: Lagi, giubo jud na siya, mga sobra na isa ka semana as verbalized by mother. NEED NSG. DIAGNOSIS OBJECTIVE OF CARE

Attending Physician: Dr. Elizabeth Derla Age: 12 y.o

NSG. INTERVENTION b. Independent: 1. Monitored respiratory patterns, including rate, depth, and effort. With secretions in the airway, the respiratory rate will increase.

EVALUATION Goal partially met as evidenced by: 1. Expectorated secretions readily. 2. Crackles sound still noted.

4:45pm

Ineffective Airway After 4 hours Clearance related span of care, to increase sputum airway clearance production will improve as secondary to evidenced by: Community Acquired 7. 1. Expectorate Objective Cues: Pneumonia. secretions readily. 8. Crackles 9. 2. Demonstrate sound heard Bacterial reduction of upon lung microorganism congestion with auscultation enters the airways breath sounds Need Persistent which cause cough with inflammation of the clear. sputum Airway lungs. Air sacs are10. production being filled with pus 3. Demonstrate Clearance and other liquids and behaviors to Sticky sputum, improve or yellowish in sputum formation color in happens. These will maintain clear moderate obstruct the airways airway such as increasing oral amount making it hard to fluid intake and Moderate breathe properly. avoiding salivation respiratory noted irritants. H Y S I O L O G I C

3. Demonstrated 2. Auscultated lung behaviors to improve fields. Noting areas of and maintain clear decreased airflow and airway such as abnormal breath sounds. increasing oral fluid Crackles are heard on intake and avoiding inspiration and/ or use of powders and expiration in response to sprays. thick secretions, and airway obstruction. 4. Signs of respiratory distress not noted. 3. Kept environment allergen free as much as possible. 8:45pm To avoid stimulation of cough.

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Reference: www.emedicine.com

4.signs of respiratory distress will not be noted. in conditioning

4. Elevated head of bed or place patient on MHBR. Lowers diaphragm, promoting chest expansion, mobilization and expectoration of secretions. 5. Encouraged increase oral fluid intake and offer warm rather than cold fluids. Fluids (especially warm liquids) aid in mobilization and expectoration of secretions. 6. Initiated chest and back tapping. To increase the force in expectorating secretions. 7. Assisted with/ monitor effects of nebulization treatments. Facilitates liquefaction and removal of secretions Dependent:

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8. Maintained body hydration thru IV fluids. Fluids are required to replace losses and aid in mobilization of secretions. 9. Administered appropriate medications like bronchodilators as indicated. Aids in reduction of bronchospasm and mobilization of secretions.

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Name of Patient: Agua Bendita Diagnosis: PCAP POTENTIAL NURSING CARE PLAN DATE/ SHIFT ASSESSMENT Subjective: Inganajud na siya magkaon maghigda, makalingkod mana siya pero dili mag dugay, dili pud na siya ka tindog mother verbalized Objective: -salivation noted - eating while in supine position - always spilling food -difficulty in swallowing noted -RR = 30cpm NEED S A F E T Y And S E C U R I T Y Need Free from Aspiration NSG. DIAGNOSIS Risk for aspiration related to body positioning while feeding secondary to Cerebral palsy. One of the clinical manifestation of cerebral palsy is to have very rigid movement accompany with unsteady gait , problem in balance, uncoordinated body movement and difficulty in swallowing that is potential for food aspiration. Reference: www.scribd.com OBJECTIVE OF CARE After 5hours of nursing interventions, the mother will be able to

Attending Physician: Dr. Elizabeth Derla Age: 12 yo.

NSG. INTERVENTION c. Independent: 1. Assessed the vital signs and condition of the patient. to obtain baseline data

EVALUATION

4/29/10 7-3

After 5 hours span of care, Goal met as evidenced by: 1.Mother able to demonstrate techniques to prevent aspiration like serving the right amount of food per swallowing and feeding her child at the right position. 2. Maintained a patent airway as evidenced by a stable respiratory rate; RR=30cpm. 3 .Signs of aspiration not noted. 2:10pm

9:10am

> demonstrate techniques to prevent aspiration 2.Instructed the mother to elevate client to her child free highest or best possible from position such as sitting aspiration upright in chair. normal gravity helps the food go down to maintain a your digestive tract patent airway smoothly thus preventing aspiration 3.Instructed the mother to avoid washing solids down with liquids. it may just add up to aspiration if present

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4. Kept suction setup available and use as needed. This is necessary to maintain a patent airway. 5. Offered foods with consistency that patient can swallow. Use thickening agents as appropriate. Cut foods into small pieces. Semisolid foods like pudding and hot cereal are most easily swallowed. Liquids and thin foods like creamed soups are most difficult for patients with dysphagia. 6. Positioned patient at 90-degree angle, whether in bed or in a chair or wheelchair. Use cushions or pillows to maintain position. Proper positioning of patients with swallowing difficulties is of primary importance during

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feeding or eating. 7. Provided oral care after meals. This removes residuals and reduces pocketing of food that can be later aspirated. 8. Explained to mother the need for proper positioning. This decreases the risk of aspiration. 9. Suctioned oropharynx noted as ordered. to prevent aspiration from moderate salivation.

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B. DISCHARGE PLAN M Medication: Salbutamol BID Paracetamol 7 ml if fever occurs Clarithromycin 5ml BID E Exercise: Do deep breathing exercise. Change position frequently. Avoid strenuous activities as it exhausts and triggers cough. May do activities with tolerable intensity level which could not cause undesired effects to the body. T Treatment: Always have nebulization kit ready at home for emergency cases, if cough recurs, and if there is difficulty of breathing or shortness of breath. Do chest ad back tapping as it increases the force in expectorating secretions. H Health Teachings Get plenty of rest. Adequate rest is important to maintain progress towards full recovery and to avoid relapse. Drink lots of fluids, especially water. Liquids will keep patient from becoming dehydrated and help loosen mucus in the lungs. Instruct to take the entire course of any prescribed medications. Medications must be continued according to the doctors instructions, otherwise the pneumonia may recur. Relapses can be far more serious than the first attack. Do hand washing. The hands come in daily contact with germs that can cause pneumonia.

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These germs enter ones body when he touch his eyes or rub his nose. Avoid being exposed to an environment with too much pollution and allergens such as smoke and dust. Smoke damages ones lungs natural defenses against respiratory infections. Protect others from infection. Try to stay away from anyone with a compromised immune system. When that isnt possible, a person can help protect others by wearing a face mask and always coughing into a tissue. And get plenty of rest and adequate sleep in order to refresh the body and mind and to allow regain of energy. O OPD Keep all follow up appointments. Even though feeling better, his lungs may still be infected. It is important to have the doctor monitor his progress. Refer immediately if cough is excessive and persistent, if there is shortness and difficulty in breathing, if there is any chest pain, cyanosis, and other unusualities. D Diet Avoid intake of food that could cause allergy such as seafoods, chicken, egg, shrimp, crab; and foods that could trigger cough such as polvoron, softdrinks, etc. frequent drinking of warm rather than cold fluids is good as it aids in mobilization and expectoration of secretions. Instruct to cook food thoroughly. Do not hurry eating meals to avoid aspiration and indigestion. Encourage patient to have a high-calorie intake and high-protein diet.

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IX.
DATE
GENERIC NAME/ BRAND NAME

DRUG STUDY
CLASSIFICA -TION INDICATION MECHANISM OF ACTION DOSAG E& FREQUE NCY TIME GIVEN ADVERSE REACTIONS NSG. CONSIDERATIONS

NonParacetamol/ opioid Biogesic analgesic

To relieve mild to moderate pain due to things such as headache, muscle and joint pain, backache and period pains. It is also used to bring down a high temperature. For this reason, paracetamol can be given to children after vaccinations to prevent postimmunisation pyrexia (high temperature). Paracetamol is often included in cough, cold and flu

Inhibits the synthesis of prostaglandins that may serve as mediator for pain and fever.

2507ml q 4hrs x1 day then PRN

Assessment & Drug Effects Side effects are rare with paracetamol Monitor for S&S of: when it is taken hepatotoxicity, even at the with moderate recommended acetaminophen doses. Skin doses, especially in rashes, blood individuals with poor disorders and nutrition. acute inflammation of Patient & Family the pancreas Education have Do not take other occasionally medications (e.g., occurred in cold preparations) people taking the containing drug on a regular acetaminophen basis for a long without medical time. One advice; overdosing advantage of and chronic use can paracetamol cause liver damage over aspirin and and other toxic NSAIDs is that it effects. doesn't irritate Do not self-medicate the stomach or children for pain more causing it to than 5 d without

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remedies.

bleed, potential Side effects of aspirin and NSAIDs.

consulting a physician. Do not use for fever persisting longer than 3 d, fever over 39.5 C (103 F), or recurrent fever. Do not give children more than 5 doses in 24 h unless prescribed by physician.

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DRUG STUDY
DATE
GENERIC NAME/ BRAND NAME

CLASSIFICA -TION

INDICATION

MECHANISM OF ACTION

DOSAGE & FREQUE NCY

ADVERSE REACTIONS

NSG. CONSIDERATIONS

Piperacillin tazobacta m

antibiotic

Respirator y tract, skin, bone and joint infections Infections from penicillinas eproducing staphyloco cci

. Interferes with cell wall replication of susceptible organisms; osmotically unstable cell wall swells and bursts from osmotic pressure

2.25g q 8hrs ANST slowly

CNS: headache, insomnia, dizziness, fever, lethargy, hallucinations, anxiety, depression GI: nausea, vomiting, diarrhea, abdominal pain, constipation, pseudomembr anous colitis GU: oliguria, proteinuria, hematuria, glomeruloneph ritis HEMA: anemia, increased bleeding time, bone barrow depression INTEG: rash, pruritus

Assess patient for previous sensitivity reaction to penicillins Assess patient for signs and symptoms of infection Obtain C&S before beginning drug therapy Assess for allergic reactions Identify urine output Monitor blood studies Monitor electrolytes Assess bowel pattern daily Monitor for bleeding Assess for overgrowth of infection

Precautions: Pregnancy, lactation, seizures, hypersensitivity to cephalosporins, renal insufficiency in children

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META: hypokalemia, hypernatremia SYST: anaphylaxis, serum sickness

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DRUG STUDY
DATE
GENERIC NAME/ BRAND NAME

CLASSIFICA -TION

INDICATION

MECHANISM OF ACTION

DOSAGE & FREQUE NCY

ADVERSE REACTIONS

NSG. CONSIDERATIONS

Phenobarb ital

Barbiturat esedative, anticonvul sant.

Used as a sedative in anxiety or tension states.

It depresses the sensory cortex, reduces motor activity, changes cerebellar function, and produces drowsiness, sedation and hypnosis. Its anticonvulsant property is exhibited at high doses.

1 tab HS

Bradycardia, hypotension, syncope; drowsiness, lethargy, CNS excitation or depression, impaired judgment, confusion, nervousness, headache, insomnia, nightmares, hallucinations, anxiety, dizziness; rash, thrombocytopenia, megaloblastic anaemia; respiratory depression, apnoea (especially with rapid IV admin),

Observe patients receiving large doses closely for at least 30 mins to endure that sedation is not excessive. Keep patient under constant observation when drug is administered every hour or more often if indicated Monitor serum drug levels. Serum concentrations >50 mcg/ml may cause coma. Therapeutic serum concentrations of 15-40 mcg/ml produce anticonvulsant activity in most patients. Expect barbiturates to produce restlessness when given to patients in pain because these drugs do not have analgesic action Be prepared for paradoxical responses Monitor for drug interactions. Barbiturates increase the metabolism of many drugs, leading to 49

decreased pharmacological effects of those drugs. Avoid administering with betablockers, calcium channel blockers, warfarin, oral contraceptives

50

DRUG STUDY
DATE
GENERIC NAME/ BRAND NAME

CLASSIFICA -TION

INDICATION

MECHANISM OF ACTION

DOSAGE & FREQUE NCY

ADVERSE REACTIONS

NSG. CONSIDERATIONS

clarithromy -cin

Treatment of the following infections due to Agents for susceptible atypical organisms: upper mycobact respiratory tract erium infections, including streptococcal pharyngitis, acute bacterial exacerbations of chronic bronchitis and tonsillitis, lower respiratory tract infections, including bronchitis and pneumonia, acute otitis media, skin and skin structure infections, nongonococcal urethritis, cervicitis, gonorrhea, and

Antiinfectives

Inhibits protein synthesis at the level of the 50S bacterial ribosome. Bacteriostatic action against susceptible bacteria. Active against the following gram positive anaerobic bacteria: Staphylococcus aureus, ataphylococcus pneumoniae, streptococcus pyogenes (group A strep). Active against these gramnegative aerobic bacteria: Haemophilus

5ml BID

CNS: dizziness, seizures, drowsiness, fatigue, headache. CV: chest pain, hypotension, palpitations, QT prolongation (rare) GI: pseudomembrano us colitis, abdominal pain, diarrhea, nausea, cholestatic jaundice, elevated liver enzymes, dyspepsia, flatulence, melena, oral candidiasis. GU: nephritis, vaginitis. HEMAT: anemia, leucopenia, thrombocytopenia. DERM:

Assess patient for infection (vital signs, appearance of wound, sputum, urine, and stool; WBC) at beginning of and troughout therapy. Observe for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Notify the physician or other health care professional immediately if these occurs. Administer 1 hr before or 2 hr after meals. Instruct patient to take medications as directed and to finish the drug completely, even if they are feeling better. Tell patient to take missed doses as soon as possible unless almost time for the next dose; do not double doses. Advise patient that sharing of this medication may be dangerous.

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chancroid. Prevention od disseminated Mycobacterium avium complex (MAC) infections in patient with advanced HIV infection. Extended-release suspension (ZMax) acute bacterial sinusitis and community acquired pneumonia in adults.

influenzae , Moraxellla catarrhalis, neiserria gonorrheae. Also active against: mycoplasma, legionalle, Chlamydia pneumoniae, ureaplasma urealytcum, borrelia burgdoferi, M. avium. Not active against methicillinresistant S. aureus.

photosensitivity, Stevens-Johnson syndrome, rashes. EENT: ototoxicity. F and E: hyperkalemia. MISC: angioedema.

Instruct patient not to take azithromycin with food or antacids. May cause drowsiness or dizziness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known. Advise patient to use sunscreen and protective clothing to prevent photosensitivity reactions. Advise patient to report symptoms of chest pain, palpitations, yellowing of skin or eyes, or signs of superinfection (black, furry overgrowth on the tongue; vaginal itching or discharge; loose or foul smelling stools). Instruct patient to notify health care professional if fever and diarrhea develop, especially if stool contains blood, pus, or mucus. Advise patient not to treat diarrhea without advice of health care professional. Instruct parents, caregivers or patients to notify health care professional if symptoms do not improve.

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X. SYNTHESIS OF CLIENTS CONDITION / STATUS FROM ADMISSION TO PRESENT

a. Conclusion We have concluded that prevention is our best defense especially to those individuals who are exposed to such factors that could readily acquired pneumonia. But the needs where not fully satisfy, this will hinders the body normal functioning to achieve well the regular role and act upon for those foreign bodies. And base from our patient that she was a 12 year old child who is suffering from cerebral palsy and just staying at home with her mother while always lying on the floor because she cant tolerate sitting and standing position and their home was near at the highway that increases the vulnerability of our patient.

b. Patients Prognosis Overall impression of our patients prognosis was partially good. From his onset of illness, she didnt seek medical assistance which by the following day she experienced productive cough, dyspnea and later on fever. Her family was supportive which they were able to comply with the said prescription. But though she was only admitted for 4 days but still productive cough noted, a sticky yellowish phlegm in moderate amount before she was discharged and she have neurological problem which was cerebral palsy that considers to be another factor that could contribute for acquiring pneumonia again.

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Generally patient stabilize for 3-7days while for those treated as outpatients usually feel well enough to return to work in 4 or 5 days; almost all recover in 2 weeks. Which makes the prognosis good after taking medications as ordered. When CAP does not treated, several complications may take place such as sepsis, respiratory failure, atelectasis, pleural effusion and unfortunately may even lead to death.

c. Recommendations We recommend auxiliary study and reconnaissance of this case of a patient with Pediatric Community Acquired Pneumonia, in relation to the Oxygenation be done. Her status quo has seriously affected her daily routine and activities mainly her health. With this, we suggest that the patient should comply with her treatment and medical regimen and abide to the orders that her doctor had given to her. Seek for medical consultation if necessary. We recommend that the forthcoming researchers would put forth more effort and exertion in discovering and unearthing means of helping a client with a similar situation not just for the sake of basic researching but also to alleviate and reduce the number of incidence of the spread of this disease and would obtain new trends to treat the said ailment. To share the result of their study to the world for the betterment of everyone.

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XI. EVALUATION OF THE OBJECTIVES OF THE STUDY In the study presented, we are able to present all the informations thoroughly assessed and studied with regards to our patients case. With such informations we are able to uplift our knowledge regarding Pediatric Community Acquired Pneumonia and its underlying interventions to alleviate the clients present condition and to develop his wellbeing. This is evidenced by the outline presented about the case being studied that includes its mortality and morbidity rates, the presentation of the lifes history of the patient regarding her history of present illness, past medical history as well as her personal, family and socio-economic history, by presenting the patient need assessment in different nursing theorist, by discussing the physical assessment of the patient in different systems, by showing its daily summary activities in the hospital through nurses assessment with nursing intervention and medical management and the laboratory results of the patient with corresponding interpretation of the abnormal findings by reviewing the anatomy and physiology

of the organ involve in the disease process, by identifying the symptoms of the disease and relate it to the actual symptoms of the patient, by showing the etiology of the disease and relate it to the actual condition of the patient, by discussing and tracing the pathophysiology of the disease process, by formulating nursing care plan in aiding progression to patients wellness, by presenting the discharged plan of the patient in relation to her condition, by reviewing drugs regarding to her condition with nursing intervention, by presenting the prognosis of the patient after

57

rendering medical services and to present recommendations regarding to her disease and by summarizing and evaluating the case being studied.

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XII. BIBLIOGRAPHY

BOOKS: Fundamentals of Nursing Concepts, Process and Practice 7 th Edition Authors: Barbaras Kozier, Glenora Erb, Aubrey Berman and Shirlee Sryder Published by: Oearson Education Inc., Copyright 2004 Medical-Surgical Nursing 7th edition Authors: Brunner & Suddarth 2007 Lippincotts Nursing Drug Guide by Amy M. Karch Copyright Lippincot Williams and Willkins Nurses Pocket Guide Diagnoses, Prioritized Intervention and Rationales, 10th Edtion Authors: Marilynn E. Doenges, Mary Frances Moorhouse and Alice C. Murr Published by: F.A. Davis Company, Philadephia, Pennsylvania Copyright 2006 Nursing Care Plans Guidelines for Individualizing Patient Care, 6th Edition Authors: Marilynn E. Doenges, Mary Frances Moorhouse and Alice C. Murr Publisher: F.A. Davis Company, Philadephia, Pennsylvania Copyright 2002 Pathophysiology Author: Huffsttler Medical-Surgical 11th Edition Author:

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Medical-Surgical 5th Edition Authors: Wilma J. Philips, Virginia Cassmeyer, Judith K. Sands, Mary Kay Lehman Publisher: C and E Publishing Inc.

INTERNET: http://www.rn.com/getpdf.php/607.pdf http://www.merck.com/mmhe/sec14/ch173/ch173a.html http://www.emedicine.com/ped/topic962.htm http://www.webmd.com/a-to-z-guides/hemophilia http://www.mayoclinic.com/health/ http://www.healthstatistics.com http://www.wikipedia.com

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