Clinical Case Study: Pneumonia

I. INTRODUCTION/ OVERVIEW OF THE CASE
Pneumonia is an acute infection of the lung parenchyma. It can be caused by a virus, bacteria, mycoplasma, or fungus. It may also result from aspiration of foreign material into the lower respiratory tract (aspiration pneumonia). Pneumonia occurs more often in winter and early spring. It is common in children but is seen most frequently in infants and young toddlers. Viruses are the most common cause of pneumonia in younger children and the least common cause in older children.

A. Environmental Status
Contaminated; crowded family living status; paternal side are smokers

B. Family History of Health and Illness
The 11-month-old Client X is diagnosed with pneumonia. Mother and grandparents has no history of any illnesses but other family
members had episodes of fever recently. Paternal side are all smoking

1. PNEUMONIA NCM 112B RLE - GROUP 3 December 16, 2021 A Clinical Case Study Presented to the Faculty of the Department of Nursing Ifugao State University College of Health Sciences

2. I. INTRODUCTION/ OVERVIEW OF THE CASE Pneumonia is an acute infection of the lung parenchyma. It can be caused by a virus, bacteria, mycoplasma, or fungus. It may also result from aspiration of foreign material into the lower respiratory tract (aspiration pneumonia). Pneumonia occurs more often in winter and early spring. It is common in children but is seen most frequently in infants and young toddlers. Viruses are the most common cause of pneumonia in younger children and the least common cause in older children. A. Environmental Status Contaminated; crowded family living status; paternal side are smokers B. Family History of Health and Illness The 11-month-old Client X is diagnosed with pneumonia. Mother and grandparents has no history of any illnesses but other family members had episodes of fever recently. Paternal side are all smoking

3. Name: Shaun Murphy Age: 11-month-old Gender: Male Room/Bed number: RM101/BN3 Attending Physician/Surgeon: Dr. Neil Melendez Chief complaints: Persistent fever, cough, with difficulty breathing and poor intake Diagnosis: Pneumonia Patient Information: II. Pathophysiology: Inflammatory response • Attraction of neutrophils • Release of inflammatory mediators • Accumulation of fibrinous exudates, RBCs, & bacteria Alveoli fill with fluid and debris (consolidation) Increased production of mucus (airway obstruction) Decreased gas exchange Resolution of infection • Macrophages in alveoli ingest and remove debris • Normal lung tissue restored • Gas exchange returns to normal

4. 4 Risk Factors: Prematurity Malnutrition Passive smoke exposure Low socioeconomic status Underlying cardiopulmonary, immune, or nervous system disease 2. Causes: 4 mos. – 5yrs. Respiratory viruses, Streptococcus pneumoniae, Chlamydia pneumoniae, Mycoplasma pneumoniae 3. Clinical Manifestations: Antecedent viral URI Fever (38.5˚C to 40.5˚C or 101˚F to 105˚F) Cough Increased respiratory rate History of lethargy, poor feeding, vomiting, or diarrhea in infants Chills, headache, dyspnea, chest pain, abdominal pain, and nausea or vomiting in older children Severe pneumonia: flushed cheeks; lips and nail beds demonstrating central cyanosis

5. I. HEALTH HISTORY A. History of Past illness Bronchial asthma; diagnosed with moderate risk of pneumonia, Bronchial Asthma moderate exacerbation B. History of Present illness 4 days prior – undocumented fever; no associated cough, cold, & difficulty of breathing. Given with paracetamol 2 days prior - intermittent fever, now with cough, no associated colds, and still has difficulty breathing Few hours prior - persistent fever, cough, with the difficulty breathing and poor intake August 23, 2021 – admitted due to difficulty of breathing and cyanosis C. Vital Signs RR: 52 breaths/min; SpO2 is normal (95%–100%) on room air; PR: 152 cycles/ min.; T ˚ of 38.4 °C and weight of 5.5 kg D. Prior Management & Medications Paracetamol; no known allergy

6. PHYSICAL ASSESSMENT 6 No skin disease but cyanotic Hot and flushed skin No murmur, have substernal retractions, rales on the lung fields, and weak sucking reflex Coughing & has difficulty of breathing Tachycardia Abdomen is soft and non-distended Glasgow coma scale scores mild

7. DIAGNOSTICS & LABORATORIES Chest Radiograph/ Chest X-ray Normal chest X-ray shows normal size and shape of the chest wall and the main structures in the chest Bilateral pneumonia Infected the both lungs Blood test White blood cell count Hemoglobin Level Platelet count Hematocrit value 4.5 to 11.0 × 109/L 95 to 130 g/L. 150,000 to 450,000 32% to 42% 17.5 x 109/L 109 g/L 87,000 0.349% Increased WBC N ormal Hgb N ormal Platelet D ecreased Hct RT-PCR Uterine uniformly separate with the two separate cervices Negative Negative, not a suspect for Covid-19 Pulse Oximetry 95%-100% on room air 95-100% on room air Normal, the client has enough oxygen in his body Diagnostics/ Laboratory Findings Normal Values Patient's Result Interpretation

8. PLANNING Nursing Diagnosis Number of Priority Supporting Data Justification Ineffective airway clearance related to inflammation and presence of secretions secondary to pneumonia as evidenced by persistent cough, difficulty of breathing and rales heard at the lung field 1 Persistent cough, difficulty of breathing, presence of substernal, rales heard on the lung fields It is the top priority because considering the patient’s age, this situation could be life threatening if the airway is not patent. Removal of secretions are needed to relieve airway obstruction and reduce further infection and airway inflammation Altered body temperature related to infection as evidenced by elevated body temperature, hot, flushed skin and elevated heart rate 2 Elevated body temperature of 38.4°C, hot and flushed skin, increased heart rate of 152 cycles per minute Altered body temperature is the 2nd nursing diagnosis because it could be a sign of inflammation and infection in the lungs. Furthermore, not giving immediate attention would pose a greater risk such as dehydration Risk for deficient fluid volume as evidenced by fever and weak sucking reflex 3 Fever, weak sucking reflex According to Ebeledike, et al. (2021), if eating and drinking is poor, the child may be at risk for fluid deficit. This increases the risk for dehydration if the child has fever.

9. NURSING CARE PLAN Assessment Data Nursing Diagnosis Outcomes   Subjective Data: “My baby has a persistent fever, cough, hard to breathe and less milk intake. She was given paracetamol 4 days ago to relieve his fever but no cough. Two days after, his cough developed already” as verbalized by the mother   Objective Data: Vital Signs: T˚: 38.4°C , HR: 152 cycle/min, RR: 52 bpm , Wt.: 5.5kg  Oxyhemoglobin saturation is normal (95%- 100%) on room air Glasgow coma scale scores are normal S/ Sx : Persistent cough , Rales heard in the lung fields , presence of substernal retraction , abnormal chest x-ray , weak sucking reflex Diagnostics: chest radiograph , blood extraction , rapid testing Result: negative RT-PCR, WBC 17.5 x 109/L , Hgb level of 109 g/L , HCT 0.349%, Platelet count 87,000 chest radiograph (CXR) reveals bilateral pneumonia   ↑WBC ↓Hematocrit Altered body temperature related to infection as evidenced by elevated body temperature, hot, flushed skin and elevated heart rate Short Term Goal: After 8-12 hours of nursing intervention, the infant's body temperature of 38.4°C will be at normal range of 36.5- 37.5°C Long Term Goals: After seven (7) days of nursing intervention, the patient’s body temperature of 38.4°C will be within normal limits as evidenced by measurements of normal value of 36.7°C and skin is well-balanced. The patient’s infection will be managed, monitored and controlled. Ineffective airway clearance related to inflammation and presence of secretions secondary to pneumonia as evidenced by persistent cough, difficulty of breathing and rales heard at the lung f ield Short term Goal: After 24 hours the infant's airway will be clear as evidenced by clear breath sounds and i s free of dyspnea and absence of rales on the lung field   Long term Goal: After 3 days o f intervention the infant will demonstrate the following: Maintain clear, open airways as evidence by normal breath sounds, normal rate and depth of respirations, and ability to effectively cough up secretions after treatments. The infant’s mother will classify methods to enhance secretion removal, recognize the significance of changes in sputum to include color, character, amount, and odor and identify and avoid specific factors that inhibit effective airway clearance.

10. NURSING CARE PLAN …continued Implementation Rationale Evaluation Independent: Assess the patient’s vital signs at least every 4 hours for the first 24 hrs. Provide a tepid sponge bath. accurate diagnosis and monitor effectiveness of nursing interventions To allow evaporative cooling. The goal was met after 12 hours of nursing intervention wherein the patient’s body temperature lowers from 38.4°C to 36.6°C. 3. Monitor and adjust room temp. 3. To regulate the client’s T˚ The goal was met after seven (7) consecutive days of nursing intervention. The patient’s body temperature is within normal value of 36.7 °C, and the skin is not too dry and not too oily. The patient’s WBC are in normal value of 4.6 x 10 9 /L and Hematocrit of 33%. The patient will maintain a normal heart rate. 4. Provide blanket 4. To warm the baby 5. Increase fluid intake 5. To maintain fluid status Dependent: 6. Administer antipyretics & antibiotics as prescribed by the physician. 6. To promote therapeutic therapy Educative: 7. Educate the mother on how to measure T˚, what T˚ needs antipyretic medications, signs and symptoms, and performing a tepid sponge bath 7. For the mother to independently determine the danger signs and tepid bath her child 8. Advice the mother to complete her child’s antibiotics. 8. To ensure that the bacteria causing illness is killed

11. DRUG STUDY Drug & Classification Route, Dose & Frequency Mechanism of Action Side Effects Nursing Responsibilities     Generic Name: Ceftriaxone Classification: Cephalosporins Third Generation antibiotic 80 mg/kg/day IV q.d. Bactericidal  Fever Nausea Tenderness at IV site Instruct caregiver to report when loose stool or diarrhea occurs with child Observe swelling and tenderness in the Generic name: PNSS (inhalation) Classification: Minerals and electrolytes PNSS for inhalation by nebulizer via facemask, q4h To liquify and remove thick secretion in the airway Dizziness Drowsiness Sneezing, stuffy watery eyes Position patient appropriately allowing optimal ventilation Monitor respiratory rate, oxygen saturation, and lungs sounds before and after administration. If more than one inhalation is ordered, wait at least 2 minutes between inhalations. Provide quiet environment Generic Name: Salbutamol Classification: Beta 2 - adrenergic receptor agonist Bronchodilator 1ml, PO, t.i.d It relieves nasal congestion and reversible bronchospasm Headache, dry mouth, Restless, Muscle cramps Observe patients for occurrence of adverse reactions

12. HEALTH PROMOTION/DISCHARGE PLAN Smoking cessation of family members living with the baby Teach parents to practice good hand washing, and use disposable suction catheters to prevent introduction of further infectious agents Avoid oily nose drops and oil-based vitamins or home remedies to avoid lipid aspiration into the lungs. Avoid oral feedings if the infant’s respiratory rate is 60 or greater to minimize the risk of aspiration of the feeding. Discourage parents from “force-feeding” in the event of poor oral intake or severe illness to minimize the risk of aspiration of the feeding. Position infants and ill children on their right side after feeding to minimize the risk of aspirating emesis or regurgitated feeding Promote coughing and expectoration of secretions if infant experiences increased mucus production. Encourage deep-breathing and coughing exercises at least every 2 hours. Administer chest physical therapy as indicated. Suction client if he or she cannot expectorate

13. 13 Evaluation The expected outcomes are that the client with pneumonia will: 1. Have effective respiratory rate, rhythm, and depth of respirations 2. Lungs clear to auscultation Ethico/legal & moral considerations In the case study given here are some of ethical considerations are applied: inform consent wring the patient’s parents has the rights to know the Medical condition of their child and allow him to undergo some test to understand more on the child medical condition, patients right and confidentiality protecting patient privacy are maintained and the access to care.

14. 14 REFERENCES Centers for Disease Control and Preventions, (2019) Sudden Unexpected Infant Death and Sudden Infant Death Syndrome: Parent and Caregivers. https://www.cdc.gov/tobacco/data/ Better health channel (accessed 2021) https://www.betterhealth.vic.gov.au/health/ Healthline. (2019). Pneumonia in Children. American Academy of Pediatrics. Retrieved from: https://www.healthychildren.org/English/health-issues/conditions/chest-lungs/Pages/Pneumonia.aspx Nguyen, T. K., Tran, T. H., Roberts, C. L., Graham, S. M., & Marais, B. J. (2017). Child pneumonia - focus on the Western Pacific Region. Pediatric respiratory reviews, 21, 102–110. Retrieved from: https://doi.org/10.1016/j.prrv.2016.07.004 Stanford Children's Health. (2021). Pneumonia in Children. Stanford Children Health. WHO. (2014). Revised Who Classification and Treatment of Childhood Pneumonia at Health Facilities: Evidence Summaries. WHO. Retrieved from https://apps.who.int/iris/bitstream/handle/10665/137319/9789241507813_eng.pdf Pokhrel et. al. (2021). Antibiotic Use and Treatment Outcomes among Children with Community-Acquired Pneumonia Admitted to a Tertiary Care Public Hospital in Nepal. Trop Med Infect;6(2):55. Retrieved from: https://doi:10.3390/tropicalmed6020055.PMID:33923973;PMCID:PMC8167730 . Ebeledike C, Ahmad. (2020). Pediatric Pneumonia. StatPearls Publishing LLC. Andrade, L. Z., & Da Silva, V. M. (2014). Ineffective airway clearance: prevalence and spectrum of its clinical indicators. https://doi.org/10.1590/1982-0194201400054 https://www.scielo.br/j/ape/a/YWrdDNcGp75d6pJ8hPPjkjd/?lang=en Ebeledike, C., Ahmad, T., & Martin, S. D. (2021). Pediatric Pneumonia (Nursing). StatPearls Publishing LLC. https://www.ncbi.nlm.nih.gov/books/NBK568682/#_NBK568682_pubdet_ Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner and Suddarth’s textbook of medical-surgical nursing (12th ed.). Philadelphia: Lippincott Williams & Wilkins. Gulanick, M., Myers, J. (2014). Nursing Care Plans: Diagnoses, Interventions, and Outcomes. 8th ed. Mosby and Elsevier, Inc., USA. Swearingen, P. L. (2016). All-in-one nursing care planning resource: medical-surgical, pediatric, maternity, psychiatric nursing care plans. 4th edition. Elsevier Inc. Missouri. Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L., and Harding, M. (2010). (ninth edition). Medical-surgical nursing: assessment and management of clinical problems. Elsevier Inc. Timby , B. K., and Smith, N.E., (2010). Introductory medical-surgical nursing. 10 th ed. Wolters Kluwer. Lippincott Williams & Wilkins.

15. GROUP 3 Members Thank you! Domingo, Jovelyn 2. Hullana, Michelle 3. Numbalgan, Angel 4. Dulawan, Genevieve 5. Manacdol, Valerie 6. Taguiling, Keilly Ruth 7. Delos Reyes, Irene 8. Dulnuan, Hezlyne Joy 9. Daulayan, Sarah 10. Kitong, April Flor 11. Bayongobong, Fe 12. Chinolong, Chicy