anaphy pneumonia cp

Introduction• Pneumonia is an infection in one or both of your lungs. It

can be caused by bacteria, virus or aspiration of foreign object. Pneumonia is usually common in childhood occurring more frequently in infancy and early childhood. Clinically, pneumonia may occur either as a primary disease or as a complication of another illness.

• Approximately one-third of the pneumonia cases in the United States each year are caused by respiratory viruses. These viruses are the most common cause of pneumonia in children and young adults. In the Philippines, pneumonia is considered as the number 1 cause of child mortality in the year 2010.

Ten (10) Leading Causes of Child MortalityBy Age-Group (1-14) & Sex

No. & Rate/100,000 populationPhilippines, 2010

Cause

1-4 Years

Male Female Both Sexes Rate*

1. Pneumonia 1,640 1,455 3,095 232.6

2. Diarrheas and gastoenteritis of presumed infectious origin

482 334 816 9.3

3. Congenital anomalies 409 388 797 9.1

4. Septicemia 251 231 482 5.5

5. Other diseases of the nervous system 246 212 458 5.2

6. Accidental drowning and submersion 296 159 455 5.2

7. Dengue Fever and Dengue- hemorrhagic fever

195 223 418 4.7

8. Chronic lower respiratory diseases 213 202 415 4.7

9. Meningitis 179 154 333 3.8

10. Leukemia 148 91 239 2.7

Pneumonia

Patient’s Demographic Profile

Patient’s Name: E.L.Case No: 35466Birthdate: 4/22/02 Age: 12Birthplace: Marikina City Sex: MPresent Place of Residence: Marikina City

Nationality: Filipino Religion:

Roman CatholicLanguage/Dialect Spoken: TagalogMarital Status History: SingleEducational Attainment: Elementary Undergraduate

Sleep habits/ pattern: Regular Sleeping Time: 9pmHandedness: Right Waking Time: 8amEye Glasses: N/AContact Lenses: N/A Hearing Aide: N/A

Dentures: N/ADietary Habits/ Eating Pattern: RegularParticular Food Preference: ChickenExercise: Kind Play Frequency/Week: Everyday Duration: N/AAlcohol/Caffeine: N/ATobacco/Drug Abuse: N/ALiving Environment: Bungalow TypeSource of Income: ParentPast Medications: N/A

HEALTH HISTORY

• Chief Complaint: Cough and difficulty of

breathing of 6 days duration

History of Present Illness

The patient was apparently well until…

• 6 day PTA, the patient developed sudden onset of productive cough which was not associated with any other s/sx such as fever, colds, vomiting, or diarrhea. No interventions were done nor any consults made. Symptoms persist until

• 5 days PTA, and then cough was now accompanied by colds along with clear watery nasal discharge. Still no consults or interventions done.

• 4 days PTA, previously mentioned symptoms were now accompanied by DOB, assessed through fast breathing as described by the mother, nasal flaring, as well as “parang may halak” when the patient is breathing. No irritants or triggers were identified. S/Sx continues to persist.

• Due to persistence of these symptoms, the patient was brought for consult at the UERM ER, hence admission.

Review of Systems: (+) cough, colds, DOB, alar flaring; (-) fever, vomiting, diarrhea, cyanosis

Past Medical History• 2011 (8 years old) – Measles, Chicken Pox• November 2012 (9 years old) – Diagnosed with Acute Lymphocytic

Leukemia and started induction phase of chemotherapy• February 2013 – S/P Appendectomy• September 2013 – End of intensive phase chemotherapy• November 2013 – Start of maintenance phase of chemotherapy• May 2014 – Diagnosed with CNS Leukemia, started on triple intrathecal

chemotherapy then reintensification; Koch’s infection, started on HRZE; Bacterial Meningitis, treated with Piperacillin-Tazobactam, Ceftriaxone, Amikacin, Meropenem and Vancomycin

• August 2014 – Patient was declared to be in remission; CNS Leukemia, Febrile Neutropenia; t/c Mood Disorder secondary to a medical condition

Family HistoryLegends:

HypertensionDiabetes (DM)Asthma θPatient

Pediatric History

Birth History

• Patient was born full term at 38 weeks, to then 35 y/o G4P3 (3013) mother via Normal Spontaneous Delivery, attended by a midwife, at a lying in clinic. No fetomaternal complications noted. Mother had regular prenatal checkups and took ferrous sulfate and folic acid supplements. At birth, the patient had good cry with good activity, no cord coiling, no meconium stain aspiration. Birth weight was 7 lbs, while birth rate was unrecalled.

Feeding History• The patient was breastfed from birth to 6 months and

was changed to Nestogen 1:1 dilution up to 2 years of age, consuming 4-5 8oz. bottles per day. Semi-solid food was introduced at 6 months old. At 9 months, patient was able to eat solid food. No allergies to food. At present, the patient has decreased appetite, and was being fed with lugaw with ulam so that the patient can swallow food easier.

Immunization • Completed primary immunization (1 BCG, 3 Hep B, 3

DPT, 3 OPV, 3 Hib, 1 measles vaccine, 1 MMR).

Developmental History• Milestones unrecalled. Patient stopped schooling in

2012 when he was in grade 4. At present, patient is able to read with good comprehension and write legibly.

Social History• Mother is a housewife, while father is an OFW. Their

house is rented with 5 family members residing. No nearby factories. The surrounding environment was clean and was not congested. Meralco provides their electricity and NAWASA for water.

Gordon’s Functional Health Pattern

Gordon’s Pattern Before Hospitalization

During Hospitalization

Nursing Diagnosis

1. Health Perception-Health Management Pattern

S: “May mga iniinom siyang gamot for maintenance kasi may ALL siya at wala din siyang allergies”, as verbalized by the mother.

S: “Lumalaban para hindi mamatay”, as verbalized by the patient.

O: Patient is seen having DOB with crackles and currently taking medications such as Fluimuciln 200mg.

Readiness for enhanced therapeutic regimen management

2. Nutritional-Metabolic Pattern S: “Usually kumakain kami ng 9:00 sa umaga, 11:00 sa tanghali, at 7:00 sa gabi. Mahilig nga yang kumain ng chicken. Ako na din nagpapakain sa kanya kasi di niya kaya dahil nanghihina siya”, as verbalized by the mother.

S: “Mahina siya kumain ngayon. Hindi niya nauubos ung pagkain”, as verbalized by the mother.O: Consumed inadequate amount of nutrients in meeting needs. Water intake: 210cc/8hr Food intake: 559 calories

Altered nutrition less than body requirements

3. Elimination Pattern S: “Mga apat hanggang limang beses siya umiihi sa isang araw tapos isang beses naman ung pagdumi”, as verbalized by the mother.

S: “Naka-diaper yan pag umiihi. 1 a day naman siya dumumi araw-araw naman yun”, as verbalized by the mother.O: Output of 510cc and 1 diaper soaked.

Readiness for enhanced urinary and bowel elimination

4. Activity and Exercise S: “Nag-stop na siya pumasok simula 2012 dahil sa sakit niya tsaka hindi na siya makalakad. Usually naliligo siya ng 9am tapos after lunch nanonood lang siya ng tv. Once a day lang siya mag-toothbrush”, as verbalized by the mother.

S: “Lagi lang siyang nakahiga minsan inuupo naming. Di na niya kaya gumalaw mag-isa”, as verbalized by the mother.O: Patients is immobile with generalized weakness as evidenced by muscle grade of 2/5 on both upper and lower extremities.

Impaired physical mobility

5. Sleep and Rest S: “Natutulog yan ng mga 10 ng gabi tapos nagigising siya ng mga 9 ng umaga. Tanghali na siya magising. Pag tanghali naman natutulog siya ng mga 1 oras. Kaming dalawa lang magkatabi sa kwarto”, as verbalized by the mother.

S: “Di siya makatulog ng diretso kasi lagging may pumapasok na J.I. dito”, as verbalized by the mother.O: Presence of dark circles under eyes, restlessness.

Sleep pattern disturbance

6. Cognitive-Sensory S: “Wala naman siyang problema sa tenga or sa paningin”, as verbalized by the mother.

S: “Hindi siya makapagsalita minsan”, as verbalized by the mother.O: Patient is unable to communicate with poor eye contact.

Impaired verbal communication

7. Self Perception-Self Concept Pattern

S: “ Friendly daw siya. Takot daw siya sa aso pero sabi niya dati gusto niya mag-alaga. Di na din naman siya lumalabas ng bahay dahil sa sakit niya”, as verbalized by mother.

S: “Gusto niya daw gumaling para makapagaro na ulit siya sa bahay”, as verbalized by the mother.O: Patient shows attitude or willingness to recover

Readiness for enhanced self-concept

8. Sexuality and Reproductive

Not available Not available Not available

9. Role and Relationship S: “Apat lang kami sa bahay, ako tsaka ung dalawa niyang kapatid. Ako lang din nagbabantay sa kanya tsaka yang pinsan niya”, as verbalized by the mother.

S: “Dinadalaw siya ng mga kapatid niya dito. Natutuwa naman siya kasi sinusuportahan siya.”, as verbalized by the mother.O: Patient feels happy whenever his siblings visit him.

Readiness for enhanced family relationship

10. Stress and Coping S: “Pagnanapagod siya nagrerelax lang siya sa tabi. Wala naman siyang tantrums. Accident-prone siya syempre mahina ung katawan niya kaya din a siya makatayo kailangan may kasama siya palagi”, as verbalized by the mother.

S: “Natututog lang naman siya pag naiistress. Yun lang ginagawa niya sa ngayon para daw marelax siya”, as verbalized by the mother.O: Patient always sleep when he experience stress and fatigue.

Enhanced readiness for coping

11. Value and Belief and S: “Catholic kami. Minsan lang din kami nagsisimba kasi wala ding oras”, as verbalized by the mother.

S: “Nagpapray lang kami para gumaing na siya”, as verbalized by the mother.O: Patient prays before sleeping

Readiness for enhanced self concept

LABORATORY DATA

Chest

• Follow up chest radiograph (Sitting) since January 2, 2014 shows no significant change in the pneumonic opacities in the right lower lung field.

• Wedge like opacity in the right mid lung seen in lateral view is observed denoting atelectasis.

• The rest of the lung fields are clear

• Heart and great vessels are within normal size and configuration

• Other chest structures are not remarkable.

CBC Test Result Reference

HEMOGLOBIN 102g/L 140-160

HEMATOCRIT 30% 40-54

RBC 2.7x10^12/L 4.5-5.0

MCHC 33% 32-37

MCH 37.5pg 27.5-33.2

MCV 112fL 80-94

RDW 20.8% 11-15

WBC 8.1x10^9/L 5-10

NUETROPHILS 75% 40-75

LYMPHOCYTES 23% 20-45

PLATELET 211x10^9/L 150-440

MPV 11.8fL 7.5-11.5

Complete Blood Count(1-12-15)

Test Result Reference

HEMOGLOBIN 98g/L 140-160

HEMATOCRIT 30% 40-54

RBC 2.7x10^12/L 4.5-5.0

MCHC 31% 32-37

MCH 35.5pg 27.5-33.2

MCV 111fL 80-94

RDW 17.8% 11-15

WBC 5.5x10^9/L 5-10

NEUTROPHILS 79% 40-75

LYMPHOCYTES 21% 20-45

PLATELET 315x10^9/L 150-440

MPV 8.7fL 7.5-11.5

Anatomy and Physiology

Nose

• A hollow organ composed of bone cartilage,muscles and connective tissue.

• Main organ for smell or olfaction.

• Main air passage to the respiratory system.

Pharynx

• Pathway of breathing.• Connect the posterior

portions of the nasal cavity and oral cavity and remaining portions of the respiratory system

• Common pathway then functions in conducting air during inspiration and expiration.

Parts of pharynx:

• Nasopharynx• Oropharynx- found at the roof of the tongue.• Laryngopharynx

Larynx

• Voice box• Connects the pharynx

with the trachea• Lies in the middle of the

neck, below the hyoid bone in front of the fourth, fifth, sixth cervical vertebrae.

• Function: phonation

Trachea

• Windpipe• Continuous with the

larynx at the level of the sixth cervical vertebra up to the 4th thoracic vertebra.

• Function: passageway for air to reach the lungs

Bronchial Tree

2 main branch:• Right primary bronchi-

vertical, shorter, wider than the left... Why infection is more likely to occur on the right side.

• Left primary bronchi

Bronchi

Main or primary bronchus, is a passageway of airway in the respiratory system that conducts into the lungs.– No gas changes takes place in the bronchi

Bronchioles

• Passageway by which air passes through the nose or mouth to the alveoli(air sacs) of the lungs

Lungs

• Largest Organ in the Respiratory System

• They play an important role in respiration or the process of providing the body oxygen and releasing carbon dioxide.

• Receive blood from the pulmonary artery

Alveoli

• Functional unit of the lungs.

• Site of gas exchange

– Alveolar ducts• Tiny ducts that connect

respiratory bronchioles to alveolar sacs.

• Contains collection of alveoli.

PATHOPYSIOLOGY

Predisposing Factors

AgeGender

Contributing FactorsChemotherapy

LifestyleEnvironment

Bacteria

Streptococcus Pneumoniae

Organisms enter the respiratory system

Activate Body’s Defense Mechanism

Bacteria penetrate the lower respiratory tract (lungs)

Inflammation of the alveoli

Produces exudates

and coughing

Hypersecretion of mucus

Impaired 02 and C02

Increase WBC

Bronchoconstriction

CracklesDifficulty of breathing

Edema of the mucous membrane

- - - - - - Fluimucil

- - - Salbutamol

Increased Respiration Ventilation Demands

Exhaustion

Fatigue

Slow, shallow breathing

Hypoxia

Decreased Surfactant

ATELECTASIS

PNEUMONIA

Retention CO2

- - - - - - Piperacillin-Tazobactam

DRUG ANALYSIS

Drug Data Classification/ Dosage/ Frequency

Mode of Action

Indication Contraindication

Side Effect/ Adverse Effect

Nursing Responsibility

Fluimucil Mucolytic Agent/ 200mg 1sachet BID

Exerts mucolytic agent through its free sulfhydryl group which opens up the disulfide bonds in the mucoproteins thus lowering mucous viscosity.

Treatment for respiratory disorders compounded by excessive of thick and viscious secretions such as: acute bronchitis, pulmonary emphysema, mucoviscidosis, bronchiectasis

Patient with congenital Hypersensitivity to fructose

Hypersensitivity reactions have been reported in patients receiving acetycysteine, inlcuding bronchospasm , angioedema, rashes and pruritus, may occur.

>Nausea and vomitting, fever, sweating, blurred vision, disturbance of liver function.

>Monitor respirations and breath sounds.

>Elevate head of the bed and change position every 2 hours and prn

Keep environment allergen free

Encourage deep breathing exercise.

>Increase fluid Intake

Drug Name Classification/ Dosage/ Frequency

Mode of Action




Piperacillin/ Tazobactam

Antibiotic, extended-spectrum penicillin

2g +30cc D5W Q6 x 30ms

This allows the actual beta-lactamase to attack the bacterial cell wall by binding to penicillin binding proteins

Treatment of moderate to severe infections caused by piperacillin-resistant

History of allergic reactions to penicillins, cephalosporins or beta-lactamase inhibitors; hypersensitivity to any component of the product.

Most common: Diarrhea

Less Common:Bladder pain, Swelling face, blurred vision, changes in urination, dizziness, fever or sweating, headache. Nausea or vomiting, lower back or side pain.

>Assess patient’s general condition

>Review laboratory data.

>Increase fluid intake

>Assist client when changing of position

>Encourage handwashing

Drug Name Classification/ Dosage/ Frequency

Mode of Action




Salbutamol Respiratory drug anti asthmatic

1 neb/ Q8

StimulatesB2 adrenergic receptors which are predominant receptors in bronchial smooth mucle of the lungs.

Relaxes the smooth muscles of airway from trachea to terminal bronchioles.

>Bronchospasm with reversible obstructive airway disease.

Prevention of>Bronchial Asthma, Chronic Onstructive pulmonary disease

>History of hypersensitivity reaction to salbutamol or any its component.

>Patient’s with pre-existing cardiac tachyarrhythmias

>Fine tremor of skeletal muscles esp in the hands and nervousness are the most common side effect.

>palpitations, chest discomfort, headache,muscle cramps,

>Assess the general condition of patient

>Monitor Vital Signs

>Assist patient when changing in position.>Increase fluid Intake

>DBE

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

O> asleep with difficulty in breathing and presence of crackles in both lungs, V/S as follows HR 73, Tempt. 36.0 C, RR 18, BP, 100/70

Ineffective airway clearance r/t retained secretions as manifested by difficulty of breathing and presence of crackles.

After 5 hours of nursing intervention, the patient will maintain airway patency as evidence by normal respiratory rate.

>Assess client’s general condition.

>Monitor Vital Signs

>Position client in semi-fowlers.

>Administer medications PRN

>Promote deep breathing exercise and coughing exercises

>Maintain oxygen at 0.5 LPM

>Promote safety by raising side rails

>To have a baseline data

>for respiration distress>To promote respiration

>To mobilize secretions.

Nursing goal was met as evident by RR of 18 breaths per minute.


O> has limited range of motion, limited ability to perform gross or fine motor skills and has difficulty in timing, always assisted by his mother when doing activities, with muscle grade of 2/5 both upper and lower extremities

Impaired physical mobility r/t decreased muscle strength as manifested by muscle grade of 2/5

After 6 hours of nursing intervention, the client will be able to maintain position of function and skin integrity.

Assess client’s general condition.

Monitor Vital Signs

Provide safety measures by raising the side rails.

Elevated the head

Observe movement when client is unaware of observation.

Note emotional and behavioral responses to problems of immobility.

Determine presence of complication related to immobility.Assist the significant other in repositioning the client.

> To have a baseline data.

After 6 hours of nursing intervention, the goal is partially met; The muscle grade of the client is still 2/5


S> “Hindi siya makatulog sa gabi dahil nahihirapan siyang huminga at dahil may mga lumabas pasok dito katulad pag papainumin ng gamot o kaya titignan siya” as verbalized by the patient’s mother.

O> Appears restless with dark circle under his eyes.

Disturbed Sleeping Pattern r/t interruptions as manifested by dark circles under his eyes.

After 8 hours of nursing intervention, the client will be able to show signs of improved sleep.

>Assess general condition.

>Identify presence of factors known to interfere with sleep, including current illness, hospitalization

>Note environmental factors.

To have a baseline data.

To identify the cause.

These factors can reduce client’s ability to rest and sleep at a time when more rest is needed.

After 8 hours of nursing intervention, the client was not able to show signs of improved sleep; the client still has dark circle under his eyes and restlessness.

>Assess client’s usual sleep pattern and compare with current sleep disturbance.

>Observe for physical signs of fatigue.

>Manage environment setting.

>Provide bedtime care such as straightening bed sheets, changing damp linens or gowns.

> Turn on soft music, calm TV program, quiet environment.

>Perform monitoring and care activities without waking client whenever possible.

>To ascertain intensity and duration of problems.

>To maintain daytime light and night time dark.

To promote physical comfort.

To enhance relaxation.

Allows longer periods of uninterrupted sleep esp. during night.

anaphy pneumonia cp

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