This document provides a case study on a 5-year old male patient diagnosed with pneumonia. It includes an introduction to pneumonia, the patient's data, health history, physical assessment findings, definitions of key terms, developmental tasks, anatomy and physiology of the respiratory system, and pathophysiology of pneumonia. The objectives are to understand the patient's condition, underlying causes, appropriate medical and nursing interventions, and formulate a nursing care plan.
The vast majority of children diagnosed with pneumonia in the outpatient setting are treated with oral antibiotics. High-dose amoxicillin is used as a first-line agent for children with uncomplicated community-acquired pneumonia, which provides coverage for S pneumoniae.
The vast majority of children diagnosed with pneumonia in the outpatient setting are treated with oral antibiotics. High-dose amoxicillin is used as a first-line agent for children with uncomplicated community-acquired pneumonia, which provides coverage for S pneumoniae.
Ten percent of all pregnancies are complicated by hypertension (HTN).Eclampsia and preeclampsia account for about half of these cases worldwide.
In 1619, Varandaeus coined the term eclampsia in a treatise on gynecology.
DEFINITION: Eclampsia is defined as the clinical presentation of an unexplained seizure, convulsion, or altered mental status in the setting of the signs and symptoms of preeclampsia. It is considered a complication of severe preeclampsia.
A woman with preeclampsia develops:
--- high blood pressure (>140 mmHg systolic or >90 mmHg diastolic)
--- protein in the urine
--- swelling (edema) of the legs, hands, face or entire body.
The aetiology, epidemiology, and investigative management of herpes zoster (shingles). The patient details have been changed and anonymised to protect the identity of the individual.
Herpes zoster by dr bashir ahmed dar associate professor medicine sopore kas...Prof Dr Bashir Ahmed Dar
Herpes zoster (or simply zoster), commonly known as shingles and also known as zona, is a viral disease characterized by a painful skin rash with blisters in a limited area on one side of the body, often in a stripe. The initial infection with varicella zoster virus (VZV) causes the acute (short-lived) illness chickenpox which generally occurs in children and young adults.
CHAPTER 15 r Evaiuation and Management (EM) Services,fA,.docxbartholomeocoombs
CHAPTER 15 r Evaiuation and Management (E/M) Services
,/fA, four types of medical decision making, in order of complexity from most to
List the fi
least risk
,d--A-
A-
,lr,
-lr-
Inpatient time spent at the bedside or nursing station during or after
the visit is what kind of time?
21. Thepatient's will reflect the
. nrm-ber of systems examined by a brief statement of the findings.
/ZZ. I discussion with a patient andlor family concerning one or more of
the following areas: diagnostic results, impressions and/or
recommended diagnostic studies; prognosis; risks and benefits of
treatment; instruciions for treatment; importance of compliance with
treatment; risk factor reduction; and patient and family education is
23. The history is the
physician.
information the Patient tells the
Ol4r11bcrd .rasvl-crs are located in Appendix B, while the full answer key ls only available in the TEACE
Iffir Ecsorrrces on Erolve.
-4
,r{
/n.
,{
13. Complexity of medical decision making is based on three
ve types of presenting problems from the most risk and least recovery to
and most recovery:
19. Counseling and coordination of care are what kind of factors in most
cases?
U/O. ,r*"that is used as a guide for outpatient services is what kind of time?
Cop].right @ 2015 by Saunders, an impdnt of Elsevier Inc' A1I rights reserved'
CHAI{ER 15 r Evaluation and Management (E/l[l Sersices
6n. ,n"re is no distinction made between the new and established patients
in this service department of a hospital:
25. Those services rendered by a physician whose opinion or advice is
requested by another physician or agency in the evaluation and/or
treatment of a patient is a(n) whereas the
physician who has primary responsibility for the patient in the hospital
is called
r'26. Whencritically ill patients in medical emergencies require the constant
attendance of the physician (e.g., cardiac arrest, shock, bleeding, and
respiratory failure) to stabilize them, what kind of care is needed?
27. When care is provided
same patient by more
conditions, the care is
for similar services
than one physician
(e.g., hospital visits) to the
on the same day for different
,6. *nuris the name for the assumption of the total or speciflc care of a
patient from one physician to another that does not constitute a
consultation?
29. An inventory of body systems obtained
signs and/or symptoms that the patient
."{o. ,tthe physician who is standing by does so for 25 minutes, can he ot
she round the time up to 30 minutes for reporting purposes?
through questioning to identifY
may be experiencing is a(n)
of
Odd-numbered answers are located in Appendlx B, while the full answer key is only avaitrablc ir ft TEI'€E
Instructor Resources on Evolve.
Copyright @ 2015 by Saunders, an imprint of Elsevier Inc. A11 rights reserved.
CIL{PTER 15 r fyil*5on irnd Management (E/}vf) Services
PRACTICAT
Office or Other Outpatlent Services and Hospltal lnpatient Service
With the use of t.
Running Head Homework 2 Homework 2 Homework 2.docxwlynn1
Running Head: Homework 2
Homework 2
Homework 2
Care plan for MI
NUR3125
Fall 2017
This patient is presenting to the emergency with symptoms that indicate a Myocardial Infarction. The patient, who is a 48-year-old man, is stating a 3-day history of sub sternal chest pain that is radiating to his back. The symptoms started up while he was mowing his lawn. He stated the pain has eased up over time. He also reported mild trouble with breathing and some nausea but no vomiting. He exercises daily, but does report that he eats a lot of fast food. His last total cholesterol was 232 mg/dL. He also has a 15-year history of tobacco use and family history of myocardial infarction (MI), specifically his father had an MI at age 54 and his grandfather at age 58. His current blood pressure is elevated at 158/98 and heartrate of 102 bpm, his respiratory rate is currently high at 26 breaths/min and noted mild use of accessory muscles upon examination. Lungs are noted to have slight inspiratory crackles at both lung bases. Jugular venous distention is noted at less than 2cm bilaterally. His lab work reveals an elevated Troponin at 2.9 ng/ml, elevated Creatinine phosphokinase at 141 units/L, and an elevated CK-MB/CK isoenzyme at 2%. Elevated troponin indicates damage to the heart muscle, and the elevated Creatinine phosphokinase and CK-MB/CK isoenzyme along with all these other symptoms and labs indicate a heart attack. ECG is done and shows ST elevation and T wave inversion, also noted with premature ventricular contractions. The lab values and ST elevation point to a Myocardial Infarction and Transmural ischemia that will require immediate attention.
I have chosen three NANDA nursing diagnoses for this patient, with the first one being the priority. The three I choose are:
· Decreased Cardiac Output related to altered heart rate and ischemia as evidenced by ECG showing an ST elevation, elevated Troponin, and patient stating he has had chest pain for three days.
· Acute Pain related to tissue damage in the myocardium from inadequate blood supply as evidenced by elevated troponin labs and patient reporting chest pain that radiates to back for three days.
· Ineffective Health Maintenance related to deficient knowledge about self-care and treatment as evidenced by patient stating he eats fast food often and has had elevated blood pressure and cholesterol at past appointments, and patient admitting to smoking ½ pack of cigarettes daily despite family history of MI.
Care Plan Diagnosis #1 Myocardial Infarction
NANDA Diagnosis 1: Decreased Cardiac Output related to altered heart rate and ischemia as evidenced by ECG showing an ST elevation, elevated Troponin, and patient stating he has had chest pain for three days.
NOC (Nursing Outcome Classification) Label: Tissue Perfusion
Expected Client Outcomes:
1. Patient will demonstrate adequate cardiac output evidenced by blood pressure, heart rate, and heart rhythm within normal pa.
Final Project Case Study, Applied EpidemiologyEPI Case Study 4.docxvoversbyobersby
Final Project Case Study, Applied Epidemiology
EPI Case Study 4: Using Epidemiology in a TB Contact Investigation
Estimated Time to Complete Exercise: 1 hour 30 minutes
Suggested citation: New Jersey Medical School Global Tuberculosis Institute. /Incorporating Tuberculosis into Public Health Core Curriculum./ 2009: Epidemiology case Study 4: Using Molecular Epidemiology in a TB Contact Investigation STUDENT Version 1.0.
This exercise is drawn from an article published in Chest, “Mycobacterium tuberculosis Miniepidemic in a Church Gospel Choir” by Mangura and colleagues. 1 Specific aspects of the investigation have been altered, with permission from the authors, to assist in meeting the desired teaching objectives.
Students should be aware that this study describes one particular approach to a TB outbreak investigation. Despite nationally published guidelines and recommendations from the Centers for Disease Control and Prevention for conducting contact investigations, the actual practice implemented during these investigations can vary from program to program.
An epidemiologist investigating a TB outbreak works within the framework of an investigative team that includes persons with expertise in epidemiology, microbiology, TB surveillance, and environmental health. It is through the collaborative efforts of this team, with each member playing a critical role thatoutbreak investigations can result in a positive outcome.
Suggested Reading can be found on the CDC EXCITE website- How to Investigate an Outbreak: http://www.cdc.gov/excite/classroom/outbreak/index.htm
Note: The Works Cited page is in AMA (American Medical Association) style.
PART I. Identifying a Problem
This morning (June 21) the local health department (large town health department) received a telephone call from the infection control practitioner (ICP) from a nearby hospital reporting that 2 patients were seen in the emergency department (ED) late yesterday with complaints of fatigue, fever, night sweats, and cough. As part of their work-up, the ED physician ordered chest x-rays for both patients. The health department was informed that, in both cases, the radiology report indicated abnormal findings consistent with TB. As a result, both patients were admitted to the hospital with a diagnosis of suspected pulmonary TB. Once admitted, sputum samples collected from both patients were read as positive on microscopic smear with final culture identification pending.
You know that tuberculosis (TB) is an infectious disease caused by bacteria called Mycobacterium tuberculosis. The bacteria usually affect the lungs (pulmonary TB) but also can affect any part of the body outside the lungs (extrapulmonary TB) with the most common sites being the lymph nodes, bone, kidney, and pleura. While TB disease was once the leading cause of death in the United States, it can now be treated successfully with appropriate antibiotics. However, if not diagnosed early or not treated appropriately, TB ...
Telemedicine: Maintaining The Control and Clinical Outcomes During COVID-19 P...semualkaira
COVID-19 is a global challenge for health systems. The pandemic impacted traditional practice of our hospital's IBD program, favoring the implementation of telemedicine
appointments (TM).
1.2. Objectives: To describe and evaluate TM appointment effectiveness in a public IBD center in Chile during the pandemic.
Telemedicine: Maintaining The Control and Clinical Outcomes During COVID-19 P...semualkaira
COVID-19 is a global challenge for health systems. The pandemic impacted traditional practice of our hospital's IBD program, favoring the implementation of telemedicine
appointments (TM).
1.2. Objectives: To describe and evaluate TM appointment effectiveness in a public IBD center in Chile during the pandemic.
Delivering Micro-Credentials in Technical and Vocational Education and TrainingAG2 Design
Explore how micro-credentials are transforming Technical and Vocational Education and Training (TVET) with this comprehensive slide deck. Discover what micro-credentials are, their importance in TVET, the advantages they offer, and the insights from industry experts. Additionally, learn about the top software applications available for creating and managing micro-credentials. This presentation also includes valuable resources and a discussion on the future of these specialised certifications.
For more detailed information on delivering micro-credentials in TVET, visit this https://tvettrainer.com/delivering-micro-credentials-in-tvet/
Executive Directors Chat Leveraging AI for Diversity, Equity, and InclusionTechSoup
Let’s explore the intersection of technology and equity in the final session of our DEI series. Discover how AI tools, like ChatGPT, can be used to support and enhance your nonprofit's DEI initiatives. Participants will gain insights into practical AI applications and get tips for leveraging technology to advance their DEI goals.
Unit 8 - Information and Communication Technology (Paper I).pdfThiyagu K
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How to Build a Module in Odoo 17 Using the Scaffold MethodCeline George
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it describes the bony anatomy including the femoral head , acetabulum, labrum . also discusses the capsule , ligaments . muscle that act on the hip joint and the range of motion are outlined. factors affecting hip joint stability and weight transmission through the joint are summarized.
Safalta Digital marketing institute in Noida, provide complete applications that encompass a huge range of virtual advertising and marketing additives, which includes search engine optimization, virtual communication advertising, pay-per-click on marketing, content material advertising, internet analytics, and greater. These university courses are designed for students who possess a comprehensive understanding of virtual marketing strategies and attributes.Safalta Digital Marketing Institute in Noida is a first choice for young individuals or students who are looking to start their careers in the field of digital advertising. The institute gives specialized courses designed and certification.
for beginners, providing thorough training in areas such as SEO, digital communication marketing, and PPC training in Noida. After finishing the program, students receive the certifications recognised by top different universitie, setting a strong foundation for a successful career in digital marketing.
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
The simplified electron and muon model, Oscillating Spacetime: The Foundation...RitikBhardwaj56
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A Strategic Approach: GenAI in EducationPeter Windle
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This slide is special for master students (MIBS & MIFB) in UUM. Also useful for readers who are interested in the topic of contemporary Islamic banking.
Chapter 4 - Islamic Financial Institutions in Malaysia.pptx
100289400 case-study-on-pneumonia-real
1. TA B L E O F CO N T E N T S
I. Introduction ----------------------------------------------------------- 1
II. Objectives ----------------------------------------------------------- 3
III. Patient's Data ----------------------------------------------------------- 4
IV. Genogram ----------------------------------------------------------- 5
V. Health History
i. Present Health Status ------------------------------------------------- 6
ii. Past Health History ------------------------------------------------- 6
VI. Physical Assessment ------------------------------------------------- 7
VII. Definition of Terms ------------------------------------------------- 12
VIII. Developmental Task ------------------------------------------------- 13
IX. Anatomy and Physiology ------------------------------------------------- 14
X. Pathophysiology ------------------------------------------------- 16
XI. Diagnostic Exams ------------------------------------------------- 20
XII. Laboratory Exams ------------------------------------------------- 21
XIII. Drug Study ------------------------------------------------- 23
XIV. Nursing Care Plan ------------------------------------------------- 26
XV. Discharge Planning Method --------------------------------------- 33
XVI. Prognosis ----------------------------------------------------------- 35
XVII. Bibliography ----------------------------------------------------------- 36
2. University of the Immaculate Conception
In partial fulfillment of the requirements
in NCM 101 – RLE 101
A Case Study:
Pneumonia
Submitted to:
Nena Evangelista, R.N.
Submitted by:
Montenegro, Roland Jireh
Cabuntalan, Amerah
Castillo, Manilyn
Masunag, Ronie
Cerdina, Jester
Pellegas, Chon
August 2009
3. I. 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.
(www.msn.encarta.com/org)
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. (www.wikipedia,.com/org)
To know the disease, we have to anticipate its warnings. Symptoms would include fever,
chills, cough (non-productive or productive), tachycardia, a crackling sound would be noted and
some would show labored breathing. These symptoms are common to almost all upper and lower
respiratory infections so it is important that we know the diagnosis.
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 pre-school, 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.
1
4. The death rate (or mortality) also depends on the underlying cause of the pneumonia.
Pneumonia caused by Mycoplasma, for instance, is associated with little mortality. However, about
half of the people who develop methicillin-resistant Staphylococcus aureus (MRSA) pneumonia
while on a ventilator will die. In regions of the country without advanced health care systems,
pneumonia is even deadlier. Limited access to clinics and hospitals, limited access to x-rays, limited
antibiotic choices, and inability to treat underlying conditions can leads to higher rates of death from
pneumonia. For these reasons, the majority of deaths in children under five due to pneumococcal
disease occur in developing countries. (DOH.gov.ph)
In a worldwide aspect of the disease, according to the World Health Organization (WHO)
that one in three newborn infant deaths are due to pneumonia and over two million children under
five die each year. Mortality from pneumonia generally decreases with age until late adulthood.
(www.reuters.com)
Knowing this, it can be safe to say that pneumonia is not ‘just’ a disease but ‘it is’ a disease.
It will be a challenge to the group for the client of J.F.G, 5 years old, a Filipino male who was
admitted because of cough and fever and was diagnosed of having pneumonia.
This would be a great opportunity for the group to study this case since the concept for this
duty is about Oxygenation. This would also present an opportunity in applying the learned skills of
giving care to the client and the implications as nurses. We must know our roles efficiently in our
chosen field of profession.
2
II. OBJECTIVES
5. General Objective:
At the end of the rotation, the group will be able to come up with a case presentation aimed
to determine the subject’s health concern, underlying causes for the disease and the intervention
including medical and nursing interventions for any complications that may arise during the duration
and as partial fulfillment of the requirements in Related Learning Experience, B.S. in Nursing,
University of the Immaculate Conception, Philippines.
Specific Objectives:
1. To identify a qualified client to be the subject of this case study.
2. Gather the needed data regarding the subject and the family.
3. Assess the health status of the client, including the past and present illnesses that the
subject would have.
4. Review and familiarize the anatomy and physiology of the respiratory system regarding
the present complication of the patient.
5. Formulate a relevant Nursing Care Plan with the identified problems of the client.
6. Formulate Drug Studies for all the drugs given to the client and be able to explain why
such drug is given to the client; and
7. Provide the subject as well as the family with the support systems, health teaching
appropriate to the client’s needs and the family as well including the formulation of
discharge plans.
3
III. PATIENT’S DATA
6. Patient’s name : J. J. F. A.
Age : 5 years old
Sex : Male
Religion : Roman Catholic
Nationality : Filipino
Address : San Jose, Digos City
Birth date : October 10, 2003
Birth place : Digos City
Father’s name : J. G. A.
Mother’s name : A. A.
Date of Admission : August 2, 2009 / 2:45 p.m
Registry Number: : 3738
Chief complaint : fever and cough
Admitting Diagnosis : CAP
Attending Physician : Dr. Lutero
4
V. HEALTH HISTORY
7. Present Health Status
The client is a 2-year old female child. Upon admission at Gonzales Maranan Clinic and
Hospital, client was complaining of LBM, fever, anorexia and vomiting. Client is having persistent
diarrhea and has had fever with 38.3 celcius for temperature when admitted. The client is
ambulatory, coherent and v/s results showed an elevated RR of 37 rpm, pulse rate of 84. No
intestinal parasite as result for fecalysis on the first day would indicate. Soft diet was prescribed, has
a standing order of TSB for fever. Platelet is below normal but WBC count is within range and with a
medical diagnosis of Pneumonia.
Past Health Status
Cough and fever has been noted to have onset 4 days prior to admission. Client has history
of pneumonia and was admitted to the hospital when he was three years old. By then he was
prescribed with Montelukast as his medicine. He was also admitted again 4 months after that with
the same prescribed drug. Client has suffered asthmatic attack when he was 3 years old and was
admitted to the hospital and was given Ventolin for treatment but has no record of any onset after
that. Immunizations were completed when he was one year old. Patient has not yet visited a dentist.
Latest medicines prescribed are Cefuroxime, Albuterol, Montelukast, and Naproxen.
6
VI. PHYSICALASSESSMENT
Patient: J.J.F.A.
8. Unit / ward: NS 1
Age: 5 years old Sex: Male Civil status: Child / Single
I. Vital signs: (latest)
Temperature: 36.9 celcius (axilla)
Pulse rate: 115 bpm (radial) 103 bpm (apical)
Respiratory rate: 23 rpm
Blood pressure: 100/70 mmHg
First Day Second Day Third Day
Temp. 38.1 36.5 36.9
Respiratory rate 28 24 23
Pulse rate 115 98 115
Blood pressure 110/80 110/70 100/70
II. Integument
Client has fair complexion and is consistent throughout the body. Abrasions were noted at
the right outer hip related to bicycle accident 2 months ago. There were no lesions, rashes and
lacerations noted. Mucus membranes are intact, moist and has no lesions present. Nails are cleaned-
short with no lesions noted on fingers. Hair is colored black and is evenly distributed on the head
scalp. No noted parasite on the hair and patient has good grooming.
7
III. HEENT
Head
9. Head circumference is 52 cm with normocephalic head configuration. No lesions, burns,
lacerations and cuts noted. Masses and depressions not noted on head.
Eyes
Pupils are black and equally rounded and constricts with light accommodation. Peripheral
vision and visual acuity were not assessed.
Ears
Auricle is symmetrical, tenderness were not noted. External surfaces are smooth with
discharges noted in small amount. Size of ears are symmetrical and proportional to the head. Ear
canal is pinkish in color.
Nose
Mucosal condition of nose is fine with pinkish color. No noted lesion but nasal flaring is
present. No profuse discharges present. Nose is symmetrical with the nasal septum at the midline and
intact with no lesions nor masses noted.
Mouth
Lips were pale in color and dry. Few cracks were noted but no lesions, cut nor ulcerations
noted. Gums are intact, pink in color and moist.
Pharynx
Pharynx located at the midline. Tonsils are non-palpable. No structural abnormalities noted.
8
IV. Neck / Lymph nodes
Trachea is at the midline. Range of motion for neck is normal. No reported stiff neck present
and was symmetrical. No signs of lesions, lacerations or pigmentation noted. Thyroid was non-
10. palpable and no enlargements noted. Carotid pulse is palpated with strong bounding pressure. No
distended neck vein noted.
V. Pulmonary breath sounds
Crackling breath sounds were heard with stethoscope when auscultated. Productive cough is
observed.
VI. Breast and Axillary Areas
Breast were normal and symmetrical with no lesion or masses noted. It has a lighter color
compared to face. Axillas does not have hair and is dry. Axillary lymph nodes were not palpable.
VII. Cardiovascular
The PMI (point of maximal impulse) was at the 5th
intercostals space, left mid claviclar line
with cardiac rhythm as normal. Cardiac rate is 103 at apical pulse and 115 bpm for the radial. Heart
sounds are normal with S1 and S2 sounds heard. No murmurs noted.
9
VIII. Peripheral / Vascular
Pulse Grade Equal or not equal
Temporal 2+ equal
11. Carotid 3+ equal
Radial 2+ equal
Peripheral pulses are strong and are equal. Varicosities, rashes and edemas were not noted.
IX. Abdomen
Skin integrity is normal, color is fair, masses and pulsation were not noted. Bowel sounds
were not assessed. Tenderness were not noted.
X. Musculoskeletal / Extremities
Range of motions was normal. Shoulders and arms were free from deformities. Nail beds are
pink in color with capillary refill of 2 seconds.
XI. Genitalis
Urinates 5 times a day with amber yellow and sometimes clear white urine. Appearance of
genitals was not assessed.
10
XII. Neuro-assessment Refer legend at last page of case study.
Eyes are open spontaneously. 5 pts.
Verbal response is Alert and oriented 5 pts.
Motor response is withdraws from pain 4 pts.
12. Result 14 pts.
Patient’s neuro-assessment is lethargic.
11
VII. DEFINITION OF TERMS
There were several words whose definitions are vague that it needs to be defined in order for
the reader to understand the case study. The following are words used in this case study whose
definition has been provided for easier comprehension on the reader’s part.
Pneumonia
13. - inflammation of the one or both lungs usually caused by an infection from a
bacteria, virus or from a parasite
Tachycardia
- increase in heart rate. An elevated heart / cardiac rate from the normal.
Palpitations
- fast or irregular beating that can be felt by the patient
Bronchus
- a tube leading from the windpipe to the lungs which provide passage of air
Contractions
- reduction in size
Pleura
- a thin transparent membrane that lines the chest wall and doubles back to cover the
lungs thus closing the narrow pleural cavity.
Dyspnea
- difficulty in breathing usually caused by a heart or lung disease
12
VIII. DEVELOPMENTAL TASK
Stages Developmental Task Evaluation
Erik Erikson's
Psychosocial Crisis:
Goals:
• Learning to do things on their
Patient has partially
established what is
expected at her age.
14. Initiative vs. Guilt own
• Begins to evaluate their own
behaviours
• Do things for a purpose
Patient is able to
stand, eat, play and
take a bath on their
own with any
assistance from his
parents and guardians.
Patient is
establishing his own
behaviours by applying
or doing what he
wants, saying what he
thinks and play what he
likes.
Freud’s Stages of
Development
Phallic Stage
Child’s genitals are the center for
pleasure. Activities would include
fantasy, experimentation with other
peers.
Major conflict:
Oedipus complex
The child seeks
immediate pleasure and
gratification by means
of his mother’s
attention and comfort.
Has identified his
father as his significant
person.
13
IX. ANATOMY AND PHYSIOLOGY
15. 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.
The first line of defense includes the hair in the nostrils, which serves as a filter for larger
particles. The epiglottis is a trap door of sorts, designed to prevent food and other swallowed
substances from entering the larynx and then trachea. Sneezing and coughing, both provoked by the
presence of irritants within the respiratory system, help to clear such irritants from the respiratory
tract.
Mucous, produced throughout the respiratory system, also serves to trap dust and infectious
organisms. Tiny hair-like projections (cilia) from cells lining the respiratory tract beat constantly,
moving debris, trapped by mucus, upwards and out of the respiratory tract. This mechanism of
protection is referred to as the mucociliary escalator.
14
16. Cells lining the respiratory tract produce several types of immune substances which protect
against various organisms. Other cells (called macrophages) along the respiratory tract actually
ingest and kill invading organisms.
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.
15
17. X. PATHOPHYSIOLOGY
.
16
Predisposing factors
Patient is 5 years old where pneumonia
is more common to these ages
Precipitating factors
Lifestyle factors: Exposed to second-hand
smoke (uncles and aunties).
Does not wash hands unless father is
present
Only eats meat and does not prefer eating
vegetables nor fruits.
Inflammation of the lungs
Weakened immune system
Aspiration of organism inhabiting the upper airways
Organisms invade the lungs and conducts bacterial growth
Mucus production is increased and plugs the alveoli
and is further filled with fluid and debris from WBC’s
produced to fight the infection
Fever
18. 16
If not treated.... If treated .......
17
Narrative
The alveoli (air sacs) of the lungs becomes blocked
with mucus secretions.
Crackling
breath sound
Less functional are for oxygen-
carbon dioxide exchange
The alveoli (air sacs) of the lungs
becomes blocked with mucus
secretion
Patient becomes oxygen deprived
and retention of Carbon dioxide
Patient becomes oxygen deprived
and retention of Carbon dioxide
Consolidation occurs
Atelectasis
Respiratory failure
Death
Administration of anti-infectives
and bronchodilators to inhibit
bacterial growth and promotes
dilation of the bronchi
Mucus secretions are loosened and
will be expectorated
Infection is stopped and
inflammation is resolved.
Alveoli will be clear from
secretions
Lung activity will
return to normal
19. A picture of a lung with
pneumonia with close-up for
alveolar sac filler with mucus
secretions
The lung is sterile. It is part of the lower respiratory tract. The upper respiratory tract has
bacteria for its normal flora. Factors such as being 5 years old increases that risk for pneumonia
(WHO) as well as exposure for second hand smoking, also not washing of hands and the imbalanced
nutrition increases the risk for the child to have pneumonia.
The bacteria in the upper respiratory tract gets aspirated in the lungs where it grows in
number and thus results in the inflammation of the lungs. This inflammation causes the body to
increase its temperature as it compensate in fighting for the infection. Mucus secretion is then
increased. Fluids and debris from WBC’s sent to fight the infection also invades the alveolar sac. The
alveoli then is plugged and blocked with secretions which causes the crackling breath sound. If it is
treated with anti-infectives to inhibit the bacterial growth and bronchodilators to dilate the bronchi
and for loosening the secretions, the infection is stopped and inflammation is resolved. This results in
secretion of the mucus and lungs will return to normal state.
18
20. If untreated on the other hand, the child becomes oxygen-deprived and retention of CO2 will
result. After that, consolidation will occur which is when the alveoli becomes solid due to the
quantities of the fluids, debris and mucus secretions in it. (www.science.jrank.org)
When the alveoli becomes solid, this will cause lung collapse (atelectasis) which would later
then result to respiratory failure and when it is not treated immediately can cause death.
A comparison between clear alveoli and alveoli with
mucus secretions caused by pneumonia
19
21. XI. DIAGNOSTIC TESTS
A chest x-ray is a routine radiographic method for evaluating the heart, lungs and other
organs found on and in the chest area. Since this case is about the lungs, A CXR would be
appropriate. It is an important test for pneumonia in unclear situations. CXR can reveal areas of
opacity which would represent consolidation.
Patient's radiology result showed heart normal in size, infiltrates on both upper and lower
lobes.
20
XII. LABORATORY EXAMS
22. Several laboratory examination was done to the patient which the results are shown below
with their significances on her disease and condition.
Laboratory
Examination
Result Normal
Values
Significance
Hematocrit test
Packed-cell
volume
Fecalysis
Urinalysis
8. pH
CBC
- Thrombocytes
42%
No intestinal
parasite
6.0
37 – 49 %
slightly
acidic
It is used to determine the packed-
cell volume which would indicate the
hemoglobin in the blood. Any
increase in Hct will show a decrease
in volume plasma. An elevated Hct
will signify increase In Hgb. If Hgb is
elevated, that means that the body is
creating more Hgb to accommodate
the low level of oxygen in the body.
Pneumonia can be caused by several
factors, parasitic is one of them. This
test is done to check if there are
presence of parasites which would
cause the pneumonia.
Check the hydration status of the
patient, if it is highly acidic –
dehydrated, if it is alkalinic – over
hydrated.
Used to determine the platelet count
23. - WBC
- Platelet
281 g / L
12.4 k/uL
244 k/uL
5.0 – 10.0
250 - 400
and the coagulation time of the
patient’s blood. This test was done to
know if there is a need for platelet
transfusion.
When WBC is above normal, this
indicates that an infection is present in
the body because it will try to fight
the foreign organism by creating more
WBC’s.
Test is done to indicate if there is the
need for platelet transfusion.
22
XV. DISCHARGE PLANNING METHOD
24. I. Medication
Before the patient is discharged, the mother must be encouraged to follow the prescribed
medications of her child with the right dose at the right time. This could be also enhanced by
explaining to the mother the reason why the drug is given and the possible effects that may occur. It
would also minimize the chances of stopping the medication once the mother understands them. Also
teach the mother that even if the child's symptoms have been relieved, medications must still be
continued according the doctor's instruction, otherwise pneumonia may recur and it will be worse
than the previous attack.
II. Exercise
Encourage the mother to let the child have frequent exercises such as walking, arm raising,
to enhance the lung function but inform the mother to avoid places that are prone to pollution, dust
and infections such as smoking places to prevent straining the child's lungs. Advise the mother to
balance the child's daily physical activities and provide adequate rest periods. Encourage the mother
to reposition the child from side to side turning into a favorable and comfortable position to promote
good circulation in the body.
III. Teaching
Inform the mother that the child needs to have adequate rest because it is important to
maintain progress toward full recovery. Ask the parents to have the child washed his hands
frequently to avoid further infections brought by other microorganisms. Ask the parents not to
expose the child in places with too much pollutions. Define the importance of increasing the oral
fluid intake of the child in his recovery as well as adequate rest. These are needed by the child to
maintain his optimum level of health.
33
IV. Out-patient instructions
25. Remind the family to have follow-up check-ups with the doctor. Inform for any
appointments they may have and request the parents to bring the child to a health care facility as
soon as any problems will occur. Even though the patient may feel and look better, his lungs may
still be infected and it is important that the physician monitors the child.
V. Diet
Tell about the importance of eating a well-balanced diet. If asked if multivitamins can be
given, refer it to the physician. Remind about the increased fluid requirements and advise foods that
are rich in natural vitamins such as fruits.
34
XVI. PROGNOSIS
26. J. J. F. A. was admitted due to fever and cough. He had a fever with a temperature of 38.1
celcius which was later resolved and lowered to 36.9. The patient is ambulatory, coherent and has an
IV tube inserted on his right arm. Current medicines are Cefuroxime = 750 mg, IVTT, Albuterol = 1
neb + 2cc NSS, q4 and Montelukast = 4mg O.D., HS, PO. The vital signs: Temperature is 36.9, pulse
rate is 115 bpm, respiratory rate is 23 rpm and Blood pressure is 100/70. Productive cough is still
noted but with fewer secretions expectorated. The patient is lethargic according to the neuro-
assessment, no noted abnormalities in physical assessment regarding the patient’s present condition.
Nasal flaring is reduced, the patient is currently on moderate high back rest position. Thus patient is
showing a good prognosis.
35
XVII. BIBLIOGRAPHY
Books
Carpenito-Moyet, L.J., Handbook of Nursing Diagnoses; (12 ed.), Philadelphia, 2008.
27. Corbett, J.V., Laboratory Tests and Diagnostic Procedures with Nursing Diagnoses; (7th
ed.),
San Francisco, California, 2008.
Doenges, M.E., et.al., Nurse's Pocket Guide; (11 ed.), California, 2007.
Deglin, J.H. & Vallerand, A.H.; Davis' Drug Guide for Nurses; (20 ed.), F.A. Davis
Company, Philadelphia, 2009.
Elsevier, M., Mosby's Pocket Dictionary of Medicince, Nursing and Health Professions; (5th
ed.), Elsevier Incorporated, Singapore, 2006.
Johnson, J.Y., Textbook of Medical-surgical nursing; (11 ed.), 2008.
Compilations, articles and etc.
Rosalejos, I.L., Growth and Development handouts; NCM 101, Davao City, 2009
Internet sites
www.scribd.com
www.wikipedia.com/org
www.nursingcrib.com
www.wrongdiagnosis.com
www.encarta.msn.com
www.medscape.com/nurse/Amoeba
www.science.jrank.org/pages/529/ /Diagnosis
www.reuters.com/org
41
IV. GENOGRAM
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