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 withpneumonia is necessary to
prevent its spread to others and make them as another victim of this illness.
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 sideof 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.
NURSING PROFILE

a. Patient’s Profile

Name: R.C.S.B.

Age: 1 yr,1 mo.

Weight:10 kgs

Religion: Roman Catholic

Mother: C.B.

Address: Valenzuela City

b. Chief Complaint: Fever

Date of Admission: 1st admission

Hospital Number: 060000086199

c. History of Present Illness

2 days PTA – (+) cough

(+) nasal congestion, watery to greenish

(+) nasal discharge

Tx: Disudrin OD

Loviscol OD

Few hrs PTA - (+) fever, Tmax= 39.3 C

(+) difficulty of breathing

(+) vomiting, 1 episode

Tx: Paracetamol

Sought consultation at ER: Rx=BPN, Salbutamol neb.

IE: T = 38.3C, CR= 122’s, RR= 30’s

 (+) TPC

SCE, (-) retractions, clear BS, (-) cyanosis, (-) edema

d. Past Illness

(-) asthma

(-) allergies

e. Family History

PMHx: (+) asthma (mother)

f. Activities of Daily Living

• Sleeping mostly at night and during afternoon

• Usually wakes up early in the morning (5AM) to be milkfed.

• Eats a lot (hotdogs, chicken, crackers, any food given to her)

• Active, responsive

• BM (1-2 times a day)

• Urinates in her diaper (more than 4 times a day)

• Likes to play with those around her

g. Review of Systems

Neuromuscular: weakness of muscles

Integumentary: (-) cyanosis

Respiratory: tavhypnea; (+) DOB; (+) coarse crackles, (+) wheezes,

Digestive: food aversion, vomits ingested milk

Salbutamol Ventolin
Syrup
β2
adrenoceptor Paracetamol Omol Syrup Anti-pyretic
agonist Analgesic
acts on the β2 reducing the
adrenoceptors of activity of the
bronchial cyclooxygenase(
muscle, with COX)
little or no action enzyme; this
on the β-1 enzyme
adrenoceptors of participates in
the heart. the production of
1 tbsp prostaglandins
3x a day which in turn are
Bronchospasm & involved in the
excessive pain and fever
secretions of processes.
tenacious mucus 125/vol
(e.g. bronchial 5ml every
asthma, chronic 6 hrs
asthma, chronic Relief of pain &
bronchitis) for rapid lowering
Hypokalemia, of fever in
tachycardia, tremor, bronchitis
muscle cramps Allergic reactions, GI
> Administer medicine at disturbances
the time specified or as > Administer medicine at
close to that time as the time specified or as
possible—if there is a close to that time as
delay, document it. possible—if there is a
> Evaluate client's delay, document it.
condition and medication
compatibility
CUES NURSING Bacterial nsg. Int stimulate coughing and
S> “Nahihirapan yata microorganism help remove secretions
Monitor > Chest physical
syang huminga saka enter the airways respiratory patterns,
lagi na lang sumusuka ↓ therapy helps mobilize
including rate, depth, bronchial secretions
ng plema,” as Inflammation of and effort.
the lung/s > Bronchodilators
verbalized by the Pt’s > Assist with
↓ decrease airway
grandmother. clearing secretions resistance secondary to
O> (+) sputum Air sacs filled from pharynx by
with pus & other bronchoconstriction
production offering tissues and
liquids gentle suction of the
Rapid, shallow ↓
breathing oral pharynx if
Presence of Eval
(+) crackles, necessary
obstructions in the > Provide postural After 8 ours of
airways drainage, percussion, Nursing Intervention,
↓ and vibration as
Nsg Dx the Pt’s breathing had
Inability to ordered no more adventitious
Ineffective breathe properly > Administer sounds
Airway medications such as (crackles/gargles)
bronchodilators or
Clearance present when
related to Plan inhaled steroids as
ordered. auscultated
inability to After 8 hours of
maintain clear Nursing
airway as Intervention, the Rat
characterized Pt’s breathing
by (+) sputum, will have no With secretions in the
(+) crackles, more airway, the respiratory
rapid & shallow rate will increase
adventitious
> It is preferable for the
breathing sounds present client to cough up
(crackles/gargles) secretions. Gentle
when auscultated suctioning of the
Sci Ex posterior pharynx may