pneumonia

Case Study in Pediatric Intensive Care Unit

Patient Profile

a. Patient Data1. Name: Baby Girl A2. Date Admitted: September 01, 20133. Time of Admission: 5:25 am4. Age: 1 month old5. Gender: Female6. Religion: Roman Catholic

Diet: NPO7. Admitting Diagnosis: Pneumonia

b. Nursing History1. Chief Complaint

– 5 days prior to confinement patient experienced coughing, gasping and mottling appearance.

2. Present History– This is the first time patient was confined.

3. Past History– Not applicable

4. Personal and Social History– Not applicable

5. Obstetric History (Mother of patient)– G7P7 (T7P0A0L7), Delivered via Normal Spontaneous Delivery at JJASGEN– During pregnancy the mother only has four check-ups and not frequent and consistent for the last trimester as it should be and there are no medications taken. Mother is not a smoker and non-alcoholic. In addition, she only had one dose of tetanus toxoid.

6. Developmental History

Theoretical FindingsI. Piaget’s Stages of Cognitive

Development

a. Neonatal Reflex (1 month) – Stimuli are assimilated into the beginning of mental images.– Behavior entirely reflexive.

b. Primary Circular Reaction

I. Piaget’s Stages of Cognitive Development

Patient responses and spontaneously move on every stimulus. Patient gazes in the surroundings and objects. Can grip onto things using the hand. Spontaneous blinking.

– Hand-mouth and ear-eye coordination develop– Spends much time looking at objects and separating self from them– Infant brings thumb to mouth for a purpose to suck it.

II. Freud’s Psychoanalytic Theory

Oral Stage: Child explores the world by using mouth, especially the tongue.

III. Erikson’s Theory of Psychosocial Development

Development task is form a Sense of Trust vs. Mistrust.

I. Freud’s Psychoanalytic Theory

Patient spontaneously opens and closes mouth.

II. Erikson’s Theory of Psychosocial Development

Patients’ needs are given yet not all are given such as feeding, bathing, & cuddling due to illness

7. Feeding History– Breast milk

8. Immunization History– Only BCG and one dose of Hepatitis B.

Gordon’s Functional Health Pattern1. Nutritional and Metabolic Pattern

– Prior to confinement patient feeds on breast milk. On confinement patient is on NPO yet intravenous fluids are given to maintain hydration. Weight is 3.5 kg.

2. Elimination Pattern– Patient is able to urinate, yellowish in color and defecate, greenish in color and soft. Consumes at least 3-4 diapers per day.

3. Activity-Exercise Pattern– Patient has spontaneous movement grips on to things and cries at times.

4. Sleep Rest Pattern– Patient can sleep but sometimes disturbed due to coughing out of secretions.

5. Coping-Stress Tolerance Pattern– Coping mechanism of patient is through crying.

6. Value-Belief Pattern– Patient was baptized as a Roman Catholic.

Physical Assessment

Date Normal Abnormal AnalysisSeptember 01, 2013Integumentary System Hair is well

distributedPink lipsAbdomen is protruded

Dry skin Poor skin turgor Sharp long nails with black depositMottled Skin

Dry skin & Poor skin turgor; Indicates that the patient has inadequate fluids in the body.

Sharp long nails are actually normal but the presence of the black deposits in the nails may result to another infection if the patient accidentally scratches itself.

Mottled skin is caused by arterial hypoxemia meaning the patient has mixed oxygenated and unoxygenated blood due to poor pulmonary diffusion of oxygen of the blood.

Cardiovascular System

Heart Rate: 120 bpm No significant findings

Respiratory System O2 Saturation 99%Spontaneous breathing

Crackles upon auscultation on both lung fieldsUse of accessory musclesWhitish & Scanty secretionsCoughing

Crackles is the sign that the lumen is narrowing caused by mucus secretions

Coughing is a way of eliminating the secretions

Use of accessory muscles is a sign that the patient is having

difficulty of breathing

September 02, 2013Integumentary System Hair is well


Dry Skin Poor Skin Turgor Sharp Long Nail with black depositMottled Skin

Dry skin & Poor skin turgor; Indicates that the patient has inadequate fluids in the body.






Crackles upon auscultation on both lung fieldsUse of accessory musclesWhitish & Scanty secretions

Crackles is the sign that the lumen is narrowing caused by mucus secretions

Coughing is a way of eliminating the secretions

Use of accessory muscles is a sign that the patient is having difficulty of breathing

September 03, 2013Integumentary System Hair is well Dry Skin Dry skin & Poor skin


Poor Skin Turgor Sharp Long Nail with black depositMottled Skin

turgor; Indicates that the patient has inadequate fluids in the body.




Crackles upon auscultation on both lung fieldsUse of accessory musclesYellowish & Thick secretions

Crackles is the sign that the lumen is narrowing caused by mucus secretionsCoughing is a way of eliminating the secretionsUse of accessory muscles is a sign that the patient is having difficulty of breathing



Course in the Ward

Date/Assessment Doctor’s order Nursing Responsibility

Analysis

September 01, 2013GaspingMottlingCoughing

TPR q shift NPO Intubated patient ET

size 4 at level 9 Insert OGT IVF:

D50.3NaCl500cc, 15cc/hr

Start Ampicillin 100 mg TIV q6H

V/S q1H Gentamycin

25mg/IV OD I&O q shift Refer

Salbutamol nebule ½ + 1.5ml PNSS q4H

For feasible extubation this PM

IVF: D5IMB500cc x 15 cc/hr

oFor feasible extubation tomorrow

oRepeat CXR tom AM prior to extubation

Carry out doctor’s order accordinglyDocument vital signsMonitor Intake and OutputAdminister medications as ordered

TPR & v V/S q1H are ordered for continuous monitoring because the patient is experiencing respiratory distress and the patient is intubated

Patient is given IV fluids to maintain hydration

Gentamycin is given to promote the inhibition of microbial growth

I&O is ordered to monitor if the patient is experiencing any deficits or excess in their fluids.

Salbutamol is given to make the airway patent for oxygenation

Chest X-ray is ordered to assess if the patient can breathe on its own by checking for the amount of consolidated mucus.

September 02, 2013(+) Wheeze

HAA 15mg IV q6HSalbutamol nebule ½ + 1.5ml PNSS q8H

Hgt Monitoring q12HIncrease Salbutamol 1 nebule q4H

For CBC with PC

Carry out doctor’s order accordinglySend request from the labAdminister medications as ordered

Hydrocortisone is ordered because the patient was assessed to have wheeze this will interact with mast cells to prevent the release of histamines and this is a form of glucocorticoid

For ABG, if feasibleFor Blood Culture & Sensitivity

Hgt monitoring was necessary if the patient has enough glucose in the blood, since glucose is necessary of ATP production and it is the primary food of the brain.

CBC was needed in order to know the blood count esp. the WBC to know if there is an infection present.

ABG was also ordered to know the level of blood gases.

Blood culture and sensitivity was ordered to be able to know what type of infection the doctors are dealing with in order to administer a more potent antibiotic for the patient.

September 03, 2013

(+) mottling

(+) mottling (+) bradycardia(+) forceful ambubagging(+) thick secretions per ET

Start Dopamine 0.5cc + D5W 99.5cc= 100cc x 5 cc/hr

Suction secretion PRN

Instill 1cc of PNSS prior to suctioning q4H, gentlyContinuous dopamineContinuous present managementRefer

Carry out doctor’s order accordinglyAdminister medications as ordered

Dopamine was ordered because the patient experienced bradycardic episode, this will further increase the heart rate of the patient however; this may also cause bradycardia an adverse effect. Suctioning in order to clear the airwayInstillation of 1cc PNSS was necessary because the secretions of the patient are thick and this will further dissolve the mucus.

II. Review of Anatomy and Physiology

The Respiratory center is the medulla of the brain. The Respiratory System has two divisions namely: The Upper Respiratory Tract and Lower Respiratory tract.

UPPER RESPIRATORY TRACT

Nose – it serves as a passageway for air to pass to and from the lungs. It filters impurities and humidifies and warms the air as it is inhaled.

Paranasal Sinuses – These are spaces that are lined with nasal mucosa and ciliated pseudostratified columnar epithelium. These are connected by series of ducts that drain into the nasal cavity. Sinuses are named by their location: Frontal, Ethmoidal, Sphenoidal and Maxillary. The function of the sinuses is to serve as a resonating chamber in speech and it is also a common site for infection.

Pharynx – or throat, is a tube-like structure that connects the nasal and oral cavity to the larynx. The nasopharynx is located posterior to the nose and above the soft palate. The oropharynx houses the faucial, or palatine, tonsils. The laryngopharynx extends from the hyoid bone to the cricoid cartilage. The pharynx functions as a passageway for the respiratory and digestive tract.

Larynx – it is the voice organ that connects the pharynx and trachea. Major function is for vocalization and protects the airway from foreign substances and facilitates coughing. Epiglottis is a valve flap of cartilage that covers the opening of the larynx during swallowing.

LOWER RESPIRATORY TRACT

Lungs – is the major organ of the respiratory system, which is a paired lung elastic structure that enclosed in the thoracic cage and this is where gas exchange transpires.

Pleura – it is a serous membrane that lines the lungs and wall of the thorax. The pleura have small amounts of fluid that lubricates the thorax and lungs to permit smooth motion of the lungs within the thoracic cavity with each breath.

Bronchi & Bronchioles – has several divisions of the bronchi. Lobar bronchi (3 in right lung; 2 in the left lung) and it is divided into segmental bronchi (10 on the right; 8 on the left lung), which is a structure identified when choosing the most effective postural drainage position for a given patient. Segmental bronchi are then divided into subsegmental bronchi that are surrounded by connective tissue that contains arteries, lymphatics and nerves. It is then branch into bronchioles which contains submucosal glands that produces mucus that covers the lining of the airways and it also lined with cilia that creates a whipping motion that propels mucus and foreign substances away from the lungs toward the larynx and branches out into the terminal bronchioles. Terminal bronchioles are considered to be the passageway between the conducting airways and the gas exchange airways.

Alveoli – this is where oxygen and carbon dioxide takes place. It has 3 types: Type I are epithelial cells that forms the alveolar walls, Type II are cells that secretes surfactant, a phospholipid that lines the inner surface and prevents alveolar collapse, Type III are large phagocytic cells that ingest foreign matter (e.g mucus, bacteria) that acts as a defense mechanism.

Functions of the Respiratory System

Oxygen Transport – oxygen is supplied to, and carbon dioxide is removed from, cells by way of the circulating blood. Respiration – process of gas exchange between the atmospheric air and he blood and between the blood and cells of the body. Ventilation – movement of air in and out of the airways that continually replenished the oxygen and removes the carbon dioxide from the airways and lungs. Pulmonary Diffusion – is the process by which oxygen and carbon dioxide are exchanged at the air-blood interface while Pulmonary Perfusion – is the actual blood flow through the blood circulation.

Respiratory Difference in Children

Ethmoidal and Maxillary sinuses are present at birth; frontal sinuses and sphenoid sinuses do not develop until the age of 6 and 8.

Respiratory mucus function in newborn produces little amounts of mucus, which makes them more susceptible to respiratory infections.

In infants, the walls of the airways have less cartilage thus there are not so strong and it collapses every exhalation.

Immature development has also an advantage lessened amount of smooth muscle in the airway means that an infant does not develop bronchospasm. Therefore, wheezing may not be a prominent finding in infants even when lumen of the airway is severely compromised.

III. Pathophysiology

Risk Factors Associated with PNEUMONIA

Age: 1 month oldNPO Status

Exposure to environmentPoor Hygienic PracticesAnatomical Presentation

Nasogastric TubingExposure to sick individuals

Impairment of Host’s Defense against Microorganism

Staphylococcus aureus; Streptococcus pneumoniae colonizes the lower respiratory tract

Inflammatory reaction in the alveoli

Producing exudates that interferes with the diffusion of oxygen and carbon dioxide

White blood cells (neutrophils) migrates in the alveoli

Doctor ordered:Blood Culture & Sensitivity

Signs & Symptoms:Elevated WBCElevated Neutrophil

Doctor ordered:CBC with PC

Signs & Symptoms:Production of secretionsAuscultatory Rales

Impaired Gas Exchange

Signs & Symptoms:Fever of 38.1H CFlushed SkinWarm to Touch

Production of Secretions and Mucosal Edema occurs

Partial / Total Occlusion of the alveoli

Decrease in alveolar tension

Venous blood entering the pulmonary circulation passes through the under ventilated area and travels to the left side of the heart poorly oxygenated. The mixing of oxygenated and

oxygenated or poorly oxygenated blood

Arterial Hypoxemia

Signs & Symptoms:MottlingAlteration of O2 SatRestlessnessIrritability

Ineffective Airway Clearance

Doctor ordered:Chest X-ray Signs & SymptomConsolidation

PNEUMONIA

III. Laboratory Examinations

Complete Blood Count with Platelet Count

Lab Exams Result Normal values Clinical Significance Clinical manifestation Nursing Responsibility

Hemoglobin 134 g/L 125-168 g/L Normal None Secure request to the LabEnsure safety of the patientObserve the findings Notify the Physician, if there are alterations to the values

Hematocrit 0.42 0.37-0.42 Normal None

White Blood Cell 20.8 x109/L

5-10 x109/L Increased WBC; indicative of an infection

Fever

Platelet Count 593x109/L

150-400x109/L

Increased in Platelet ; indicative of hypercoagulation

Fast coagulation

Differential CountNeutrophils 0.68 0.36-0.66

Increased Neutrophil; signifies acute infection

Fever

Lymphocytes 0.28 0.22-0.40 Normal NoneMonocytes 0.02 0.04-0.08 Normal NoneEosinophil 0.02 0.01-0.04 Normal None

Hgt MonitoringGlucose

92mg/dL 70-110mg/dL Normal None Ensure safety of the patientObserve the findings Notify the Physician, if there are alterations to the values

IV. Drug Study

Generic name

Brand name Classification Action Indication Dosage/route/frequency

Nsg. responsibility

Gentamycin Garamycin Aminoglycoside

Gentamicin is an aminoglycoside that binds to 30s and 50s ribosomal subunits of susceptible bacteria disrupting protein synthesis, thus rendering the bacterial cell membrane defective.

Gram-negative infections

Pediatric:2–2.5 mg/kg q 8 hr IM or IV.Infants and neonates: 2.5 mg/kg q 8 hr.Premature or full-term neonates: 2.5 mg/kg q 12 hr.

Note the history of Allergy to any aminoglycosides.

Note for adverse effect such as acute renal failure.

Albuterol Salbutamol Bronchodilator It relieves nasal congestion and reversible bronchospasm by relaxing the smooth muscles of the bronchioles. The relief from nasal congestion and bronchospasm is made possible by the following mechanism that takes place when Salbutamol is administered.

To control and prevent reversible airway obstruction caused by asthma or chronic obstructive pulmonary disorder (COPD)

Each actuation of aerosol dispenser delivers 90 mcg albuterol; 2 inhalations q 4–6 hr; some patients may require only 1 inhalation q 4 hr; more frequent administration or larger number of inhalations not recommended.

Check for History: Hypersensitivity to albuterol

Monitor vital signsMonitor for adverse reactions: tachycardia, palpitations and restlessness

Hydrocortisone

Hydrocortone phosphate

Glucocorticoid Hydrocortisone is a corticosteroid used for its anti-inflammatory and

Allergic states—severe or incapacitating allergic

Pediatric Patients: IV, IM or subcutaneous (hydrocortisone and

Establish baseline and continuing data on BP, weight, fluid and electrolyte

immunosuppressive effects. Its anti-inflammatory action is due to the suppression of migration of polymorphonuclear leukocytes and reversal of increased capillary permeability.

conditions hydrocortisone sodium phosphate) 20–240 mg/day usually in divided doses q 12 hr.

balance, and blood glucose.

Note: A high protein, calcium, and vitamin D diet is advisable to reduce risk of corticosteroid-induced osteoporosis.

Do not abruptly discontinue drug; doses are gradually reduced to prevent withdrawal symptoms.

Ranitidine Zantac H2-Blocker Inhibits acid secretions

For patients with hyperacidity, gastric ulcerations and duodenal ulcers

Tablets—75, 150, 300 mg; effervescent tablets and granules—25, 150 mg; syrup—15 mg/mL; injection—1, 25 mg/mL

History: Allergy to ranitidine

Monitor V/S and Intake and output

Ampicillin Ampicin Antibiotic Bactericidal action against sensitive organisms; inhibits synthesis of bacterial cell wall, causing cell death.

Treatment of infections caused by susceptible strains of Shigella, Salmonella, Escherichia coli, Haemophilus influenzae, Proteus

Pediatric Patients25–50 mg/kg/day IM or IV in equally divided doses at 6–8 hr interval

Assess for history: Allergies to penicillins.Drug should be taken round-the-clock.Culture infected area before treatment; reculture area if response is not as expected.Check IV site

mirabilis, Neisseria gonorrhoeae, enterococci, gram-positive organisms (penicillin G–sensitive staphylococci, streptococci, pneumococci)

carefully for signs of thrombosis or drug reaction.

Dopamine Dopress Inotropic Sympathetic precursor to norepinephrine that increases the heart rate.

DOPAMINE (dopamine hydrochloride) is indicated for the correction of hemodynamic imbalances present in the shock syndrome due to myocardial infarctions, trauma, endotoxic septicemia, open heart surgery, renal failure, and chronic cardiac decompensation as in congestive failure.

IV- The recommended initial dose is 1-5 mcg/kg/min, up to 5-10 mcg/kg/min according to patient's response.

Dilution before administration to patient.

Monitor V/S and Intake and Output

Monitor adverse effect such as bradycardia.

V. Nursing Care Plan

Assessment Diagnosis Planning Intervention EvaluationObjective:Crackles upon auscultation on both lung fieldsUse of accessory musclesYellowish & thick secretionsMottling appearanceAlteration on oxygen saturationProductive Cough

Ineffective Airway Clearance related to thick mucus secretions in the alveoli sac

After 30 minutes of nursing intervention patient’s airway will be free from secretion.

Assess the need in performing suctioning.Assess oxygen saturation; if O2 Sat. is below 95% hyperventilate using the ambu bag. Prepare suctioning machine and catheterPrior to suctioning hyperventilate three times.Apply intermittent suctioning.Note the color, consistency and amount of the secretions.After suctioning ventilate.Administer Salbutamol nebule to dilate the bronchioles as ordered.Reassess if there are still secretions present

After 30 minutes of nursing intervention patient’s airway is free from secretions.

Assessment Diagnosis Planning Intervention EvaluationObjective:Crackles upon auscultation on both lung fieldsUse of accessory musclesYellowish & thick secretionsMottling appearanceDecreased oxygen saturation of 84%Productive Cough Bradycardic, Heart rate of 90 bpm

Impaired Gas Exchange related to thick mucus secretions in the alveoli sac

After 30 minutes of nursing intervention patient’s O2 will increase to 99%

Assess patient O2 Saturation.Administer Dopamine to increased cardiac rate as ordered.Apply continuous ambubagging and oxygenate patient to 10LpmReassess patient’s status

After 30 minutes of nursing intervention patient’s O2 is increased to 99%

Assessment Diagnosis Planning Intervention EvaluationObjective:Flushed skinRestlessnessAgitatedWarm to Touch with a temperature of 38.1HCIncreased in WBC

Altered thermoregulation related to presence of an infection.

After 1 hour of nursing intervention patient’s temperature will be reduce.

Apply Tepid Sponge BathAssess temperature every 15 minutesKeep patient safe on bedNote for allergy prior to giving antibioticsAdminister antibiotic therapy round the clock as ordered to maintain a desired level of effectiveness of the drug Assess for adverse reactions of the drug

After 1 hour of nursing intervention patient’s temperature is reduced from 38.1H C to 37.1H C.

pneumonia

Documents

time patient

mechanism of patient

patient gazes

patient accidentall

patient data1

elimination pattern

confinement patient

sleep rest pattern patient