CAGAYAN COLLEGES TUGUEGARAO

COLLEGE OF HEALTH

A case Study on
Severe Pneumonia

Submitted by: Dennis F. Gallardo

Submitted to: Robert Balungaya, RN

GENERAL OBJECTIVE
After this case study, I will be able to know what Pneumonia is, causes of
Pneumonia, how it is acquired and prevented, its treatments and prevention
of the occurrence of Pneumonia
SPECIFIC OBJECTIVES
After the completion of this study, I will be able to:
o Define what is Pneumonia
o Trace the pathophysiology of Pneumonia
o Enumerate the different sign and symptoms of Pneumonia
o Identify and understand different types of medical treatment
necessary for the treatment of Pneumonia
o Formulate and apply nursing care plans utilizing the nursing process

INTRODUCTION
 Pneumonia is characterized by inflammation of the alveoli and terminal
airspaces in response to invasion by an infectious agent introduced into the
lungs through hematogenous spread or inhalation. The inflammatory cascade
triggers the leakage of plasma and the loss of surfactant, resulting in air loss
and consolidation. This is in contrast to pneumonitis, which is caused by
noninfectious agents such as radiation or chemicals.
An inhaled infectious organism must bypass the host's normal
nonimmune and immune defense mechanisms in order to cause pneumonia.
The nonimmune mechanisms include aerodynamic filtering of inhaled
particles based on size, shape, and electrostatic charges; the cough reflex;
mucociliary clearance; and several secreted substances (eg, lysozymes,
complement, defensins). Macrophages, neutrophils, lymphocytes, and
eosinophils carry out the immune-mediated host defense.
Conditions that allow pneumonia-causing infectious organisms to circumvent
the upper airway defense mechanisms include the following:
• Intubation, tracheostomy, impaired cough reflex, and aspiration: These
conditions provide infectious organisms with easier access to the
alveoli and terminal airspaces.
• Ciliary dyskinesia, bronchial obstruction, viral infection, cigarette
smoke, and certain chemical agents: These conditions create
disruption in the mucociliary blanket.
• Anatomic abnormalities (eg, sequestrations), gastric fluid aspiration or
other causes of noninfectious inflammation, altered pulmonary blood
flow, and pulmonary edema: These conditions increase the
predisposition for pneumonia.
• Immunodeficiency and immunosuppression: These conditions increase
predisposition for pneumonia.
Mortality/Morbidity
The United Nations Children's Fund (UNICEF) estimates that 3 million
children die worldwide from pneumonia each year. Although most fatalities
occur in developing countries, pneumonia remains a significant cause of
morbidity in industrialized nations.
I have chosen this case Pneumonia because it 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 this case is a
child, 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’S PROFILE
Name: J.V.
Address: 181, Ninada Street, Lltex road, Quezon City
Age: 4yrs. and 4 months
Birthday: December 28, 2004
Sex: Male
Nationality: Filipino
Religion: Roman Catholic
Date & Time of Admission: January 18, 2009 (07:00 am)
Mode of Arrival: cuddled by mother
Chief Complaint: abdominal pain, cough and colds
Source of Information: patient, & chart, SO
Admitting Diagnosis: severe Pneumonia
Final Diagnosis: severe Pneumonia
Attending Physician: Dr. Karen Lorenzo MD

NURSING HISTORY

PAST MEDICAL HISTORY

 According to the patient SO, he had completed his childhood
immunization. He had no allergy to foods or medications. He experienced
common diseases such as fever, cough and colds she usually took OTC drugs
(Paracetamol syrup, Neosep syrup) to manage his fever cough and colds.
On June 2006 the patient was admitted at Government Hospital due to ilues.

HISTORY OF PRESENT ILLNESS

According to the SO, 3 days prior to admission the patient experienced

sudden onset of squeezing pain at Para gastric area aggravated by activity.
No meds taken or consultation made.

2 days PTA the patient still have the same abdominal pain, this time
was more severe, and associated with DOB and fever of 38°C. His mother
gave him paracetamol. No consultation was made.

Few hours PTA, the patient could not any more tolerate the pain; he
was brought to EAMC hence he admitted.

FAMILY HEALTH HISTORY

According to the patient SO, both his maternal and paternal have a
history of Cancer, PTB, and Bronchial Asthma. PTB is evident on the patient’s
grand father and uncle while cancer and bronchial asthma is evident on the
patient aunt.
Personal/ Social History
The patient is the 4th among 6 siblings. He was lived with 7 other
households’ member. His father work as a garbage collector and his mother
is a house wife they consumed or used tap not boiled water.

PATHOPHYSIOLOGY

Predisposing factor Etiology Precipitating factor

Age S. pneumoniae UPTI
Immune defenses environment
 Immune defenses

Infecting organism enter in the airway

Activation of defense mechanism

Failure to penetrate the pathogen is secreted or dies

Pathogen

Pathogen reached the lungs

Pathogen multiplies in the alveoli

Inflammation irritation of airway

Exudates come from Goblet cell

Bacteria erode the lung
mucus
Dead space occluded the production
happened Air way

Cough crackles
CO2 pagocytosis

Hyperventilation
WBC fever chill altered LOC
RR

Impaired O2 and CO2

consolidadtion exchange

Hypoxia

Trigger the kidney

Released of erythropoietin

Long bones RBC

PHYSICAL ASSESSMENT

Date assessed: May 25, 2009

Time: 10:30pm
Initial vital signs:
T=37.9 PR=140bpm RR=25cpm
General Appearance: the patient is conscious and coherent with ongoing of
D5NM 500ml at 750cc level hook at his left arm, intact and infusing well.

Area Technique Normal Actual Findings Evaluation

Assessed Findings
skin Inspection/ Skin normally Skin is moist d/t
Moisture Palpation dry hyperthermi
a
Temperature Palpation Normally warm 37.9 o C d/t
hyperthermi
a
Hair Inspection/ Smooth Rough Due t o
Texture Palpation poor
hygiene
Nose and
Teeth Inspection Oval, symmetric Oval, symmetric
Nares and without but with Due to the
discharge discharge presence of
colds
Teeth Inspection Firmly set, shiny Firmly set, shiny Due to poor
with tooth decay hygiene
Thorax and Auscultation Clear breath Presence of Due to
Lungs sounds breath sound congestion

LABORATORY RESULTS

HEMATOLOGY RESULTS
May 18, 2009
Parameter Normal Value Results Analysis
WBC 5-10 x 10 g/L 18.1 Increased due to
infection
Hgb M 140-170g/dl 165 Increased due to
infection
Hct M 39%-54% .30 Decreased
RBC 4.6- 10 g/l 10.4 Increase due t o
hypoxia
Differential Count

Lymphocytes
20%-40% .50 Increased due to
infection

PEARSON’S FUNCTIONAL HEALTH PATTERN

Date and Time of Interview: May 25, 2009 (11:00 PM)

Functional Heath Before hospitalization During hospitalization
Pattern
Psychological The patient is 4yrs and The patient looks pale
4 months old due to his current
condition.
Elimination According to the SO, the According to the SO,
patient usually void 5 to the patient void 3-4
6 times a day. He times a day. Have a 240
doesn’t have any ml/ shift yellow amber
problem in voiding. color urine and dark
brown stool.
Rest and Sleep According to the SO, the The patient can’t sleep
patient usually spends well because of the
his time for playing and hospital routines.
sleeping. He sleeps for
about 6-8 hours at
night.
Safety and Security His SO provides all the The SO together with
safety and security that his health care providers
he need make him safe and
secured.
Oxygenation The patient has The patient had
difficulty in breathing difficulty of breathing
prior to hospitalization due to his condition
Nutrition The patient usually eats The patient in on DAT.
2 -3 times a day He doesn’t have any
problem m in
swallowing
Spirituality According to SO, The The SO prays for the
patient was baptized in sooner recovery of the
Roman Catholic. They patient
go to church every
Sunday together with
his friends, bothers and
sisters

GROWTH AND DEVELOPMENT

Age Theorist Stage of Outcome
Development
4 years and 4 Erik Erickson; Initiative vs.
>Imaginary
month sense of guilt
playmates or
Psychosocial (mimics; morecompanions are
Theory purposeful &
common; holds
active in goal
conversations and
setting) shares strong
emotions with
this invisible
friend.
Boasts,
>exaggerates,
and "bends" the
truth with made-
up stories or
claims of
boldness; tests
the limits with
"bathroom" talk.
>Cooperates with
others;
participates in
group activities.
Piaget: Preoperational- >Likes stories
preconceptual about how things
Cognitive Theory (egocentric, grow and how
magical thinking; things operate.
no cause-effect >Delights in
reasoning; uses wordplay,
symbols) creating silly
Language.
>Understands the
concepts of
"tallest,"
"biggest,"
"same," and
"more"; selects
the picture that
has the "most
houses" or the
"biggest dogs."
>Rote counts to
20 or more.

Freud: Phallic According to the

SO, The patient
Psychosexual (ego develops begins to fear
Theory objective that his father is
conscious reality; suspicious of his
Opedipus longing for his
complex - love of mother, and that
opposite-sex the father will
parent) punish him for his
desires.
Kohlberg: Preconventional According to the
Morality SO, she punished
Moral Reasoning her child if they
(based on commit mistakes.
external control;
observe
standards of
others to avoid
punishment or
receive rewards)
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Objective: Acute pain r/t After 1 hour of >Elevated head >Lowers After 1 hour of
•Use of accessory localized nursing of the bed, diaphragm, nursing
muscle. inflammation and interventions, the change position promoting chest interventions, the
•Dyspnea persistent cough. patient will frequently. expansion and patient was able
•Fatigue. display patent Assist patient expectoration of to display patent
•V/S taken as airway with with deep secretions. airway with
follows: T: 37.9 breath sounds breathing breath sounds
PR: 140 bpm RR: clearing and exercises. >Coughing is a clearing and
25cpm absence of >Demonstrated natural self absence of
dyspnea. or help patient cleaning dyspnea.
learn to perform mechanism.
activity like Splinting reduces
splinting chest chest discomfort,
and effective and an upright
coughing while in position favors
upright position. deeper, more
forceful cough
>Forced fluids to effort.
at least 3000 ml >Fluids
per day and offer especially warm
warm, rather liquids aid in
than cold fluids. mobilization and
expectoration of
secretions.
>Provided
supplemental >Fluids are
fluids. required to
replace losses
and aid in
mobilization of
secretion.
Assessment Diagnosis Planning Intervention Rationale Evaluation
Objective Hyperthermia r/t After 30 minutes > monitored V/S > for baseline Goal met as
Temp 37.9ºC inflammatory of nursing data evidenced by
Skin warm to response of the interventions the > Performed tepid > to facilitate lowered
touch body as evidence patient will have sponge bath heat loss through temperature
by increase in lowered evaporation and from 37.9-37.5
core temperature temperature from conduction ºC
37.9-37.5 ºC > demonstrated > to provide
proper proper
performance of knowledge and
TSB to empower the
SO in taking care
of the –patient
To slow down the
patient
metabolism

> aid in lowering

> instructed the down the
SO to keep the temperature
patient rested > aid in lowering
> administered down the
antipyretics as temperature
ordered
Assessment Diagnosis Planning Intervention Rationale Evaluation
Name of the Dosage Mechanism Indication Contraindication Adverse effect Nursing
Objectives: Ineffective airway At the end of 15 >auscultated breath > to ascertain Goal met. The
Drug of action responsibility
- ( + ) crackles clearance r/t minutes the patient sound and assessed status and note patient was able to
Generic name:
- tachypnea 18 mg IV
increase Ranitidine is Duodenal
will be able to & Patients known
air movement to > Immune
progress System >
demonstrate assess
ranitidine
- ineffective q 8 hours
pulmonary a specific, benign
demonstrate have
>elevated the head Disorders: (urticaria, patient
behavior to
brand name:
cough secretion rapidly
as gastric
behaviors to hypersensitivity to angioneurotic
of the bed / change > to take abdominal
maintain clear
Zantac acting
evidenced by ulcer
maintain clear ranitidine
position or to edema, fever,
advantage of pain.
airway. Not
Classification: histamine
( + ) crackles, airway any component of bronchospasm, and
gravity decreasing presence of
Antacids, tachypnea,H2- Zantac Injection. hypotension
pressure to and
the blood in
Antireflux antagonist.
ineffective cough chest pain
diaphragm and emesis, stool
Agents & It inhibits >enhancing
Nervous System or gastric pain
Antiulcerants basal and Disorders:Headache
ventilation > drug may be
stimulated (sometimes severe),
>encouraged deep- > to minimize long added to total
secretion of breathing and dizziness
effort parenteral
gastric acid, coughing exercise >Gastrointestinal nutrition
reducing >instructed to Disorders: Acute
both the increased fluid pancreatitis,
>to liquefy diarrhea
volume and intake secretion
the acid and >| kept the
pepsin environment > To avoid
content of allergens free irritation of airway
the caused by
secretion. > gave expectorant allergens.
( bronchodilator ) as >to mobilized
ordered secretion
Name of the Dosage Mechanism of Indication Contraindication Adverse Nursing
Drug action effect responsibility
Ciprofloxacin 250- Inhibits Infections of Severe and Common:Na >Assess pt for
BRAND 500mg bacterial DNA the resp. persistent diarrhea usea, previous
NAME:Ciproba BID gyrase thus tract, during and after diarrhea, sensitivity
y preventing middle treatment vomiting, reaction>Assess
replication in ear,paranas rashUncom pt for any s/s of
susceptible al sinuses, mon:Anorex infection before &
bacteria eyes, ia, during
kidneys, headache,di treatment>Assess
urinary trac zziness, for adverse
fever, GI reactions
and
abdominal
pain,

Name of the Dosage Mechanism Indication Contraindication Adverse Nursing

Drug of action effect responsibility
Salbutamol 3-12 Facilitates/ Reversible Hypersensitivity Fine tremor of > drug may be
BRAND yrs4mg tab potentiates airway skeletal decrese
NAME:Ventolin BID the inhibitory obstruction muscle, sensitivity of
vilmax activity of including feeling of spirometry
GABA at the bronchial tension, a used for
limbic system asthma, compensory diagnosis of
and reticular chronic small increase asthma>syrup
 formation to bronchiti in heart rate, may be taken
reduce headache, as young as
anxiety, muscle age 2>monitor
promote cramps for evidence of
calmness and allergic rxn
sleep

Assessment Diagnosis Planning Intervention Rationale Evaluation

Objectives: Altered Nutrition: Within 8 hours of >Instructed >Gastric dilation Within 8 hours of
>weight loss less than body hospital duty, pt. client to eat may occur if re hospital duty, pt.
> lack of interest requirements r/t will be able to: smaller meals feeding is too was :
in food improper dietary 1. Verbalize and supplemental rapid following a 1. Verbalized
pattern understanding of snacks, as period of understanding of
nutritional needs appropriate. starvation diet. nutritional needs
for his age. >Established a > Malnutrition is for her age.2.
2.Identify minimum weight mood-altering Identified
possible effects goal and daily condition, leading possible effects of
of improper nutritional to depression and improper eating
eating habits requirements. agitation and habits.
affecting
cognitive
function/decision
making.
>Discussed with >Helps pt.
client the diet understand the
and snacks with importance of
substitutions of proper nutrition
preferred foods and the
when available. consequences
when it is
altered.
>Provided health >for adequate
teachings about information and
proper nutrition to promote
compliance
Name of Dosage Mechanism of Indication Contraindication Adverse effect Nursing
the Drug action responsibility
Cefuroxime Cefuroxime Cefuroxime, a Indicated in Known allergy to CV: phlebitis, >Before giving
750 mg IV semisynyhetic, the the cephalosporin thrombophlebitis drug, ask
q 6h broad- treatment of group of antibiotic GI: diarrhea, patient if he is
spectrum” the nausea, allergic to
second following vomiting, penicillin or
generation” infections anorexia cephalosporin.
cephalosporin due to Hematologic: >Obtain
antibiotic, cefuroxime- hemolytic specimen for
exerts its sensitive anemia, culture and
bactericidal organisms eosinophilia sensitivity
activity by >Lower Skin: tests before
interfering with respiratory maculopapular giving first
the synthesis of tract and dose. Therapy
the bacterial cell infections erythomatous may begin
wall. It binds to including rashes, urticaria, while waiting
penicillin- pneumonia pain, indurations, the results
binding protein >Urinary sterile abscesses, >Monitor
3 responsible tract temperature patient for
for the infection elevation signs and
synthesis of >Skin and symptoms of
peptidoglycan, a skin super infection
hetoropolymeric structure
structure that infections
gives the cell >Septicemia
wall its >Meningitis
mechanical .Gonorrhea
stability.
Name of the Dosage Mechanism Indication Adverse effect Nursing responsibility
Drug of action
Acetaminophen 1.2 mL q Inhibits the Mild pain Hema: EFORE:
( Paracetamol ) 4 hr PRN synthesis of Fever hemolytic anemia, > Advise parents or caregivers to
Classification: prostaglandins neutropenia, check concentrations of liquid
antipyretics, that may leukopenia, preparations. Errors have resulted
nonopioid serve as pancytopenia.Hepa: in serious liver damage.~ Assess
analgesics mediators of jaundice fever; note presence of associated
pain and Metabolic: signs (diaphoresis, tachycardia, and
fever, hypoGGI: malaise).
primarily in HEPATIC FAILURE, DURING:
the CNS HEPATOTOXICITY >Adults should not take
(overdose). acetaminophen longer than 10 days
GU: and children not longer than 5 days
renal failure (high unless directed by health care
doses/chronic use). professional.~ Advise mother or
Derm: caregiver to take medication exactly
rash, urticaria. as directed and not to take more
than the recommended amount.
AFTER:
>Advise patient to consult health
care professional if discomfort or
fever is not relieved by routine
doses of this drug or if fever is
greater than 39.5°C (103°F) or
lasts longer than 3 days.
 LEARNING FEEDBACK DIARY

Name: Dennis Gallardo Date: May 24- 27, 2009

Area: EAMC CI: Mr. Robert Balungaya, RN
General objective:
At the end of the 4 days duty, I will be able enhance my knowledge skills and
attitude regarding the delivery of health in the clinical area.

Specific objectives:
At the end of our 4 days clinical duty, I will be able to:
- Carryout skills I learned from school
- improve my skills regarding patient care
- establish rapport with my patient as well as health team in the EAMC
Insight:
Experience comprises knowledge of or skill in or observation of some thing
or some event gained through involvement in or exposure to that thing or
event.
Experience also is in deed the best teacher. I admit I really did learn a lot of
skills and knowledge inside the school but learning through my experience in
the actual hospital setting is really different. Gaining knowledge and skills in
my actual duty is more different and effective. I have developed a more
organized way of dealing with people that I never had before. Greatly I have
many educational experiences throughout the duration of our duty. One of
this was monitoring the I & O of my 3 patients. I also have been opened to
the different needs of my patients that would sure benefit me in rendering a
more quality care.
For all this learning experience, I appreciated and love more my future
profession. I have been realized that the greatest help we could offer to our
patient is giving them attentions and best quality of health service. I also
thank my CI because of assistance and learning he shared. It’s great under
your supervision…. GOD BLESSES!!!!!!