Christ the King College 9014 Gingoog City
Pediatric Case Study “Pediatric Community Acquired Pneumonia”
Table of Contents I.
Introduction
II.
Nursing Health History
Biographic Data
Family health history
Personal history
Past medical history
Life style
Social history
Physical assessment
Assessment Data
Assessment Vital Signs
III.
Laboratory Results
IV.
Anatomy and Physiology
V.
Pathophysiology
VI.
Nursing care plan
VII.
Drug study
VIII.
Discharge plan
IX.
Evaluation
X.
Bibliography
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Pediatric community-acquired Pneumonia is a disease which individuals who have not recently been hospitalized develop on infection of the lungs. PCAP is a common illness that affects infants and children. PCAP occurs because the atmosphere or the areas of the lungs which absorb oxygen from the atmosphere become filled with fluid and cannot w
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PCAP occurs throughout the world and is a leading cause of illness and death. The cause of PCAP includes bacteria, viruses, fungi and parasites. PCAP can be diagnosed by symptoms and physical examination alone, through x-rays, examination of sputum and other tests are often used. Individuals with PCAP are primarily treated with antibiotic medication in the hospital some forms of PCAP can be prevented by v
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PCAP usually acquired via inhalation or aspiration of pulmonary pathogenic organism into a lung segment or lobe. Less commonly, PCAP results from secondary bacteria from a distant source, such as Escherichia coli urinary tract infection and or bactericidal. PCAP is due to aspiration of oro-pharyngeal content is the only form of PCAP involving multiple pathogens. The proportion of children with pneumonia who are diagnosed with specific etiology is low. Unlike adults, children usually do not produce adequate sputum specimens for Gram stain and culture. Blood cultures have a yield of less than 10% in patients with bacterial pneumonia. “Lung puncture” studies that are conducted in developing countries are obviously not met with enthusiasm in general pediatric practices. Prospective studies that have employed sensitive antibody test and
polymerase chain reaction techniques have suggested that in up to 20% of pediatric community acquired pneumonias, the infection is “mixed” (i.e., both S. Pneumonia and M. and C pneumonia); in these cases, the primary pathogen is not clear. Authors of these studies have also suggested that mixed infection with bacteria and respiratory v i r u s e s
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l i k e l y
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b e c o m e
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Many studies have looked at causes of pediatric pneumonia as it relates to certain readily available laboratory measurements. Many clinicians consider S. pneumonia to be likely cause of the lower respiratory infection if the picture is characterized by acute onset of high fever, pneumonia on chest radiograph, leukocytosis, and a rapid response to B-lactam antibiotics. Numerous studies have found that chest radiographs do not readily distinguish between bacterial, a typical bacterial, and viral pneumonia. A variety of laboratory test have been used in attempt to distinguish bacterial from viral pneumonia, including C-reactive protein and absolute neutrophil counts. One problem in using “screening” test is that specific cut off levels h a v e
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A recent study done in Europe found that although white blood cell count and C-reactive proteins were statistically higher in patients with pneumococcal infections, other clinical and laboratory and radiographic studies were of little value. Given the clinical, epidemiologic, and laboratory difficulties in pinpointing the cause of pediatric pneumonia, an additional approach is to divide patients by age. The primary bacterial pathogen in neonatal pneumonia is group B streptococci, although Escherichia coli and Listeria
mono
cytogeneses
have
also
been
reported
The mechanism is similar to that in neonatal sepsis, where colonization from the mother results in neonatal colonization and breakthrough infection. Chlamydia trachomatis is the most common sexually transmitted infection in the United States. The organism may reside in the genital tract of pregnant women and be transmitted in about 60% of cases to infants at the time of delivery. About one half of infants who acquire the organism develop conjunctivitis, and 20% eventually develop lower respiratory disease R E A S O N
F O R
C H O O S I N G
T H E
C A S E :
It is due to the motive to learn and apply our knowledge and skills incaring the patient with pediatric community acquired pneumonia (PCAP). Thi s
is a
rare
F a m i l y
case
since
the
patient
C e n t e r e d
is only
3
years
old
O b j e c t i v e s :
Our family centered objectives would remain to be our most significant motive in conducting
this
case
study.
They
are
as
follows:
• The pa re nt s of t he pa t ien t will b e ab le t o und e rsta n d the cau se s a nd t h e r a p e u t i c
m a n a g e m e n t
r e g i m e n
• The parents will be able to consider and demonstrate the proper way of breastfeeding a n d
g u i d e l i n e s
f o r
t h e
c o n d i t i o n .
• The parents will be able to verbalize the importance of increase fluid intake.
• The parents will be able to identify potential complications and how to initiate appropriate p r e v e n t i v e
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c o r r e c t i v e
Nursing Health History:
Biographic Data
Name: Batang X Address: Barangay 20, Purok 7, Gingoog City Gender: Male Status: single/Child Birthday: April 25, 2009
Age: 3 years and 9 months
Birth place: Cagayan de Oro City Religion: Roman Catholic Nationality: Filipino Room: Pediatric Semi private Attending physician: Dr. Almero Chief Complaint: 4 days fever Date/Time admitted: January 20, 2013
a c t i o n s .
Diagnosis: Pediatric Community acquired pneumonia Family History: His paternal side has a genetic history of hypertension, his grandfather previously Diagnosed for CAP, One of his aunt in his mother side has DM after pregnancy, no other known illnesses. Personal History: 5 days prior to admission the child played under the rain and catches colds afterward, 4 days until Admission the child experienced high fever associated with cough, which prompted his mother to admit her son to the hospital. Past medical history:
The mother stated that the patient was hospitalized b e f o r e s t a t e d Diagnosed Bronco pneumonia when the child was still4 months old also when he was 1 yr. and 5 months he was diagnosed with same illness. The patient had no allergies to drugs. The mother also claimed that the patient already received complete vaccination Lifestyle: They live near the rice field at barangay 20, hot, and humid condition always causes the cough to her child as the mother stated. The child often plays at the market with the other kids every time his mother brings him to work.
Social History: The mother describes her son sociable, and always mingles with other kids much often plays at the mud bridges on the rice fields. The community knows their family well, they respect them, and they have a peaceful community, and consider their family at peace with everyone. Developmental Task:
Psychosexual Theory
According to Freud’s Psychoanalytic theory the patient is under Anal stage, where he has a need to control, and his area of pleasure is in the anus or activities related in that area.
Psychosocial Theory
According to Erickson’s psychosocial theory the patient is under, Autonomy vs. Shame and doubt, where the child need a degree of freedom inorder to meet his need for control.
Cognitive Theory
According to Piaget’s cognitive theory the patient is under, Preoperational, the child is ego centric and relates everything that is presently happening is because of him.
Moral development Theory
According to Kohlberg’s Moral development the child is under pre conventional stage where in a child will do good inorder to receive reward, and avoid to do wrong action to avoid punishment. Physical assessment Mouth The lips are pinkish in color and moist. No ulcerations or lesions noted. The tongue moves freely and not tender. The client possesses pinkgums INTEGUMENT: 1 . S k i n The skin of the client is moist, pale and has a good skin turgor.Has a fair skin complexion. 2.Hair and Scalp The hair are equally distributed with a thin hair strands; wellkept; no lice or dandruff seen/noted. 3.Nails Client’s nails are normally transparent and convex. Thesurrounding cuticles are intact and without inflammations noted. Has anormal capillary refill with 1 to 2 seconds. THORAX and LUNGS The chest contour is symmetrical, the spine is vertically aligned. T h e c h e s t w a l l i s i n t a c t , n o t e n d e r n e s s o r n o m a s s e s n o t e d . U p o n auscultation rales was being noted. HEART
There is no presence of abnormal pulsations when the heart was auscultated. No murmurs and friction rubs heard upon auscultation.
BREAST T h e b r e a s t s a r e e v e n w i t h t h e c h e s t w a l l , s k i n i s s m o o t h a n d intact. Areola is round and bilaterally the same. The nipples are round and equal in size, no discharge noted. The breast are not tender, no masses or nodules noted.
ABDOMEN The abdomen is intact, round and with normal bowel sound heard upon auscultation. No deformities seen.
EXTREMITIES: On the upper extremities no deformities noted. Has a D5IMB½ L at the left hand. While on the lower extremities, no deformities were noted.
GENITAL AND RECTAL: Upon inspection there were no deformities, no rashes, no abnormal secretions were present.
Admission data: Client came from home to the hospital ambulatory, accompanied by his mother, with fever and productive cough noted. Assessment vital signs: Temperature: 38.6 Pulse: 120 bpm Respiratory Rate: 26cpm Height: 3’2” Weight: 12 klg Allergies: No known allergy III. Laboratory Assessment
Components
Normal Values
Result
Clinical Significance
WBC
4,500–11,000/mm3
9.6
normal
Hemoglobin
12-16 g/dL
14.1
Normal
Hematocrit
36-46 %
42.4
Normal
Platelet
150,000-
234, 000
350,000/mm3
Differential Count: Normal Values
Result
Segmenters
45% - 70%
53
Lymphocytes
18%-45%
39
Monocytes
4-8%
8
IV.
Anatomy & Physiology of the Respiratory System
The respiratory system is situated in the thorax, and is responsible for gaseous exchange between the circulatory system and the outside world. Air is taken in via the upper airways (the nasal cavity, pharynx and larynx) through the lower airways (trachea, primary bronchi and bronchial tree) and into the small bronchioles and alveoli within the lung tissue. Move the pointer over the coloured regions of the diagram; the names will appear at the bottom of the screen)
The lungs are divided into lobes; The left lung is composed of the upper lobe, the lower lobe and the lingula (a small remnant next to the apex of the heart), the right lung is composed of the upper, the middle and the lower lobes.
Mechanics of Breathing
To take a breath in, the external intercostal muscles contract, moving the ribcage up and out. The diaphragm moves down at the same time, creating negative pressure within the thorax. The lungs are held to the thoracic wall by thepleural membranes, and so expand outwards as well. This creates negative pressure within the lungs, and so air rushes in through the upper and lower airways.
Expiration is mainly due to the natural elasticity of the lungs, which tend to collapse if they are not held against the thoracic wall. This is the mechanism behind lung collapse if there is air in the pleural space (pneumothorax).
Physiology of Gas Exchange
Each branch of the bronchial tree eventually sub-divides to form very narrow terminal bronchioles, which terminate in the alveoli. There are many millions of alveloi in each lung, and these are the areas responsible for gaseous exchange, presenting a massive surface area for exchange to occur over.
Each alveolus is very closely associated with a network of capillaries containing deoxygenated blood from the pulmonary artery. The capillary and alveolar walls are very thin, allowing rapid exchange of gases by passive diffusion along concentration gradients. CO2 moves into the alveolus as the concentration is much lower in the alveolus than in the blood, and O2 moves out of the alveolus as the continuous flow of blood through the
capillaries prevents saturation of the blood with O2 and allows maximal transfer across the membrane.
Significant Parts and organs involved:
The nose consists of the visible external nose and the internal nasal cavity. The nasal septum divides the nasal cavity into right and left sides. Air enters two openings, the external nares (nostrils; singular, naris), and passes into the vestibule and through passages called meatuses. The bony walls of the meatuses, called concha, are formed by facial bones (the inferior nasal concha and the ethmoid bone). From the meatuses, air then funnels into two (left and right) internal nares. Hair, mucus, blood capillaries, and cilia that line the nasal cavity filter, moisten, warm, and eliminate debris from the passing air.
The pharynx (throat) consists of the following three regions, listed in order through which incoming air passes:
The nasopharynx receives the incoming air from the two internal nares. The two auditory tubes that equalize air pressure in the middle ear also enter here. The pharyngeal tonsil (adenoid) lies at the back of the nasopharynx.
The oropharyrnx receives air from the nasopharynx and food from the oral cavity. The palatine and lingual tonsils are located here.
The laryngopharynx passes food to the esophagus and air to the larynx.
The larynx receives air from the laryngopharynx. It consists of several pieces of cartilage that are joined by membranes and ligaments, shown in Figure 2:
The epiglottis, the first piece of cartilage of the larynx, is a flexible flap that covers the glottis, the upper region of the larynx, during swallowing to prevent the entrance of food.
The thyroid cartilage protects the front of the larynx. A forward projection of this cartilage appears as the Adam's apple (anatomically known as the laryngeal prominence).
The paired arytenoid cartilages in the rear are horizontally attached to the thyroid cartilage in the front by folds of mucous membranes. The upper vestibular folds (false vocal cords) contain muscle fibers that bring the folds together and allow the breath to be held during periods of muscular pressure on the thoracic cavity (straining while defecating or lifting a heavy object, for example). The lower vocal folds (true vocal cords) contain elastic ligaments that vibrate when skeletal muscles move them into the path of outgoing air. Various sounds, including speech, are produced in this manner.
The cricoid cartilage, the paired cuneiform cartilages, and the paired corniculate cartilages are the remaining cartilages supporting the larynx.
The trachea (windpipe) is a flexible tube, 10 to 12 cm (4 inches) long and 2.5 cm (1 inch) in diameter (Figure 2).
The mucosa is the inner layer of the trachea. It contains mucus-producing goblet cells and pseudostratified ciliated epithelium. The movement of the cilia sweeps debris away from the lungs toward the pharynx.
The submucosa is a layer of areolar connective tissue that surrounds the mucosa.
Hyaline cartilage forms 16 to 20 C-shaped rings that wrap around the submucosa. The rigid rings prevent the trachea from collapsing during inspiration.
The adventitia is the outermost layer of the trachea. It consists of areolar connective tissue.
The primary bronchi are two tubes that branch from the trachea to the left and right lungs.
Inside the lungs, each primary bronchus divides repeatedly into branches of smaller diameters, forming secondary (lobar) bronchi, tertiary (segmental) bronchi, and numerous orders of bronchioles (1 mm or less in diameter), including terminal bronchioles (0.5 mm in diameter) and microscopic respiratory bronchioles. The wall of the primary bronchi is constructed like the trachea, but as the branches of the tree get smaller, the cartilaginous rings and the mucosa are replaced by smooth muscle.
Alveolar ducts are the final branches of the bronchial tree. Each alveolar duct has enlarged, bubblelike swellings along its length. Each swelling is called an alveolus. Some adjacent alveoli are connected by alveolar pores.
The respiratory membrane consists of the alveolar and capillary walls. Gas exchange occurs across this membrane. Characteristics of this membrane follow:
Type I cells are thin, squamous epithelial cells that constitute the primary cell type of the alveolar wall. Oxygen diffusion occurs across these cells.
Type II cells are cuboidal epithelial cells that are interspersed among the type I cells. Type II cells secrete pulmonary surfactant (a phospholipid bound to a protein) that reduces the surface tension of the moisture that covers the alveolar walls. A reduction in surface tension permits oxygen to diffuse more easily into the moisture. A lower surface tension also prevents the moisture on opposite walls of an alveolus or alveolar duct from cohering and causing the minute airway to collapse.
Alveolar macrophage cells (dust cells) wander among the other cells of the alveolar wall, removing debris and microorganisms.
A thin epithelial basement membrane forms the outer layer of the alveolar wall.
A dense network of capillaries surrounds each alveolus. The capillary walls consist of endothelial cells surrounded by a thin basement membrane. The basement membranes of the alveolus and the capillary are often so close that they fuse.
V.
Pathophysiology of PCAP
Predisposing
Precipitating
Age, weather, genetics
Environment
Aspiration of microbes
Failure of Defenses
Invasion of lower respiratory tract
Activation of b-cells
Release of antibodies Antigen- Antibody Reaction
Antigen Antibody Complex Adhere to the Mucosal Lining of the lower respiratory tract
Initiation of Immune system
Vasodilation Mucosal Irritation
Increase blood flow
Increase mucus production
Vaso-congestion
Accumulation of mucus
Increase plasma Hydrostatic Pressure
Productive Cough
Ineffective airway clearance
Escape of plasma
Increase capillary permeability
Escape of RBC Serum and Fibrin
Transportation of phagocyting cells
Exudate formation
Engulfing of Antigen
Edema Narrowing of airways
Filling of bronchi and alveoli Use of accessory muscles Consolidation of lung Increase respiration
Asymmetrical chest expansion
Decrease lung inflation
Ineffective Breathing pattern
Cell becomes infected
Detection of the infected cell by the T-cells Effector T-cells destroys antigen
Regulatory T-cell Strengthen Act of effector cells
Effector and Regulatory Cells Synthesize and release cytokinase
Altered Temperature Regulating Mechanism in the Hypothalamus
Hyperthermia
VIII.
Discharge Planning
Medication
Advise patient to take home medication Encourage
patient
S.O
to
continue
medication Salbutamol syrup, 5 ml TID, as prescribed Exercise
Instruct and teach client to exercise as can be tolerated.
Health teaching
Eat
nutritious
food
(green
leafy
vegetables). Encourage ambulation and adequate fluid intake. Diet
Advise the client to eat nutritious food especially those have vitamin C (for fast healing against infection.) Advise the client drink plenty of water and limit caffeine.
Spiritual
Encourage the client to continue religious activity( e.g. Attending mass)
Outpatient ( checkup)
•Advice to make follow-up one week after or when the medication is stopped, report for any unusalities,
Treatment
•Instruct the client to do the following
measures. Observing hand hygine Avoiding playing under the rain or under the heat of the sun
Diet Analysis
Food Group Meat, Fowl, or Fish Vegetables Fruits Breads, Cereals, Rice, Pasta Milk Fats, Oils, Sweets Additional Fluid
Quantities 2-3 servings daily 3 servings daily 2 servings daily 4-7 servings daily 2-5 glasses (8-oz) daily 1 serving daily 3-4 glasses daily
IX. Evaluation
Time consuming, Energy draining, brain busting, this is how I describe a Case Study. For a novice point of view it is very hard to make such work, though we have complete sources of information, we still learning how to get the right information out of those sources. But such task worth such effort, the knowledge and experience I gained was worth it. I learned time management, that is very important in my course. By doing this Case study It gave me more understanding about the disease process by which was a very big question mark back when I was still on my fresh years. Time worth Spent, Energy drained reasonably, and Brain busted in exchange for a better one, this is what this case study left me,
XI.
Bibliography
1) Blackwell’s Nursing Dictionary Second Edition (2005), Blackwell’s Publishing Ltd. 2) Maternal & Child Health Nursing Sixth Edition (2010),Adele Pillitteri, Lippincott Williams & Wilkins 3) Fundamentals of Nursing Eight Edition, Kozier & Erb’s, Pearson, Prentice Hall 4) Nurses Pocket Guide, Diagnoses Prioritized Interventions, and rationales, Marilynn E.Doenges,Mary Frances Moorhoouse,Alice C. Murr, 12th edition. 5) Lippincott’s Nursing Drug Guide, Amy M. Karch, 2011
