Palawan State University

College of Nursing and Health Sciences

Puerto Princesa City

Submitted to:
EARL JUDE ARIAS, R.N
Clinical Instructor
Pediatric Ward/ ONP

In Partial Fulfillment of the Requirement in the NCM102_R.L.E

March 22, 2010

Submitted by:
SHARYLAINE GRACE R. RODRIGUEZ
BSN2-Grp.3
 INTRODUCTION

Pneumonia is an inflammation of the lungs caused by an infection. It is also called

Pneumonitis or Bronchopneumonia. Pneumonia can be a serious threat to our
health. Although pneumonia is a special concern for older adults and those with
chronic illnesses, it can also strike young, healthy people as well. It is a common
illness that affects thousands of people each year in the Philippines, thus, it remains
an important cause of morbidity and mortality in the country.
There are many kinds of pneumonia that range in seriousness from mild to life-
threatening. In infectious pneumonia, bacteria, viruses, fungi or other organisms
attack your lungs, leading to inflammation that makes it hard to breathe.
Pneumonia can affect one or both lungs. In the young and healthy, early treatment
with antibiotics can cure bacterial pneumonia. The drugs used to fight pneumonia
are determined by the germ causing the pneumonia and the judgment of the
doctor. It’s best to do everything we can to prevent pneumonia, but if one do get
sick, recognizing and treating the disease early offers the best chance for a full
recovery.
A case with a diagnosis of Pneumonia may catch one’s attention, though the
disease is just like an ordinary cough and fever, it can lead to death especially when
no intervention or care is done. Since the case is a toddler, an appropriate care has
to be done to make the patient’s recovery faster. Treating patients with pneumonia
is necessary to prevent its spread to others and make them as another victim of this
illness.
 PATIENT HISTORY

Personal Data

Name: A.D.S
Age: 1 y/o
Sex: Female
Birthday: December 29, 2008
Birthplace: Puerto Princesa City
Nationality: Filipino
Religion: Roman Catholic
Address: Purok Masigla, Santa Cruz, Puerto Princesa City, Palawan

ADMISSION
Date: March 3, 2010
Time: 1:40 PM
Attended Physician: Susan Zambrano, M.D
Principal Diagnosis: Bronchopeumonia
Other Diagnosis: Urinary Tract Infection
Chief Complain: Cough and DOB

Present Health History

As verbalized by the mother, two (2) weeks prior the admission the patient started
to have a cough with mucus production and experiencing lose of appetite. The
patient also experienced intermittent fever and difficulty of breathing, According to
the mother they tend to give amioxol for relief but after about a week of self-
medication, it is still present. Hence, they sought for medical consultation.

Past Health History

As stated by the mother of the client, it was the first time that her baby was been
hospitalized. She said that her baby have no allergies and did not undergone any
surgeries. She’s giving her vitamins as support for strong resistance.

Family Health History

The patient’s family has heredofamilial diseases like asthma and hypertension. The
common causes of morbidity in the family are influenza, cough and colds. They use
herbal and OTC drugs sometimes for remedy.

Present health status of each member:

Grandfather-deceased-hypertension
Grandmother-deceased-hypertension
Father- present condition-asthma
Mother-apparently well

Psychosocial History

The type of home is semi-concrete with three (3) rooms. The main source if income
is from their variety store. They are active in worship in church and any activities in
their barangay.

Their source of drinking water is from nawasa. They also have a water pump about
6 meters away from their house and a water-sealed toilet that about 7 meters away
from their house.
 PHYSICAL ASSESSMENT

A. General Physical Assessment

Weight: 10 kg
RR: 44 cpm
PR: 156 bpm
Temp: 36.9 ®C

B. Skin, Hair, and Nail Assessment

SKIN: light brown, warm and dry to touch. Skin fold returns to place after 1
second when lifted over the clavicle. No lesions and discoloration noted. No
edema noted.

HAIR: black in color, widely distributed on the head. No scalp lesions or

flaking. Fine black hair evenly distributed over and bilaterally sparsely on the
legs bilaterally.

NAILS: Fingernails medium in length, and thickness, trimmed shortly, pinkish

in color, and has a good capillary refill within two (2) seconds.

C. Head and Neck Assessment

Head symmetrically rounded and neck nontender. Neck symmetrical without

masses, scars, pulsations. Lymp nodes nonpalpable. Trachea in midline.
Thyroid nonpalpable.

D. Eyes Assessment

 Eyes are equal in size

 Symmetrically aligned
 Without protrusion noted
 Eyebrows sparse with equal distribution
 Lids pink without pitosis, edema, or lesions
 Lacrimal apparatus noedematous
 Sclera white without increased vasculasrity or lesions noted
 Palpebral and bulbar conjunctiva slightly reddened without lesions
noted. Irises uniformly brown.

E. Ear Assessment

 Ear are equal in size

 Negative for discharges and nontender

F. Nose Assessment

 External structure without deformity, asymmetry, or inflammation

 Nares patent
 Color is the same as the face
 Negative for discharges
 Frontal and maxillary sinuses nontender

G. Mouth and Pharynx Assessment

 Lips are moist, pinkish in color and negative for lesions

 Tonsils are not swollen
 Gums pink and moist without inflammation, bleeding, or discoloration
 Tongue midline, pinkish, and has no lesions.
H. Peripheral Vascular Assessment

ARMS: Equal in size and symmetrical bilaterally

Skin light brown in color, warm and dry to touch without edema,
bruising, or lesions noted.

LEGS: Equal in size and bilaterally symmetrical

Skin intact, pale brown, warm and dry to touch without edema,
bruising or lesions noted.
 LABORATORY STUDY

Diagnostic Results Normal Interpretatio Rationale

Procedure Values ns
CBC
 Hemoglobin 116 g/L Male: 135- The result of CBC, a
180 g/L hemoglobin screening test
Female: 120- test is slightly that is most
160 g/L below normal commonly
which may ordered
indicate some laboratory
form of procedure is
anemia. Also indicated to
indicates the client due
insufficient to her/his
oxygen supply intermittent
in the blood. fever of two
(2) weeks
DIFFERENTIAL which might
COUNT have already
49% 50-70% compromised
 Neutrophils Indicative of a the O₂ and
viral infection. Co₂- carrying
capacity of
56% 25-40% the blood as
 Lymphocytes Increase may well as to
be cause of determine
viral infection, any signs of
mononucleosi infection
s, chronic which is
bacterial indicated in
infections or some of the
lymphocytic components
leukemia. of blood.
6.000 x 5-10 x 10⁹/L
WBC Count 10⁹/L
Within normal
150-140 x range.
Platelet Count 400 x 10⁹/L 10⁹/L
Within normal
range.

URINALYSIS

 Color Colorless Straw/Amber

Change in
color may The
indicates diagnostic
bleeding and procedure of
Clear infection. choice would
 Transparency
have been
Negative Negative urine culture
 Albumin
to ascertain
Negative Negative Within normal pyelonephritis
 Glucose . However,
Indicates since urine
normal renal culture is not
reabsorption available in
of glucose. Ospiatl ng
Palawan or in
2-7/hpf Negative hospital in
Palawan,
Microscopic Exam
Indicative of urinalysis is
phagocytosis. the
 Puss Cells 0-7/hpf >2 hpf alternative.
 Although
Within normal exact agent of
limits. infection will
 RBC not be
determined,
Few Negative the presence
Few Negative of an infection
Epithelial Cells Few Bacterial can still be
Few infection is ascertained.
 Bacteria indicated.
 Squamous
 Mucus
threads
 A. Urates

ANATOMY AND PHYSIOLOGY

The lungs constitute the largest organ in the respiratory system. They play an
important role in respiration, or the process of providing the body with oxygen and
releasing carbon dioxide. The lungs expand and contract up to 20 times per minute
taking in and disposing of those gases.
Air that is breathed in is filled with oxygen and goes to the trachea, which branches
off into one of two bronchi. Each bronchus enters a lung. There are two lungs, one
on each side of the breastbone and protected by the ribs. Each lung is made up of
lobes, or sections. There are three lobes in the right lung and two lobes in the left
one. The lungs are cone shaped and made of elastic, spongy tissue. Within the
lungs, the bronchi branch out into minute pathways that go through the lung tissue.
The pathways are called bronchioles, and they end at microscopic air sacs called
alveoli. The alveoli are surrounded by capillaries and provide oxygen for the blood
in these vessels. The oxygenated blood is then pumped by the heart throughout the
body. The alveoli also take in carbon dioxide, which is then exhaled from the body.
Inhaling is due to contractions of the diaphragm and of muscles between the ribs.
Exhaling results from relaxation of those muscles. Each lung is surrounded by a two-
layered membrane, or the pleura, that under normal circumstances has a very, very
small amount of fluid between the layers. The fluid allows the membranes to easily
slide over each other during breathing.