COLEGIO DE SAN GABRIEL ARCANGEL

BACHELOR OF SCIENCE IN MIDWIFERY

A CLINICAL CASE IN PARTIAL FULFILLMENT OF

THE REQUIREMENTS IN CLINICAL PRACTICE

(NEONATAL PNEUMONIA)

SUBMITTED BY:
ANDAYA, ISABEL T. DOLOR, KELLY GRACE C.
BADRINA, RIO M. IB-IB, REBECCA L.
BARAUNTONG, NAVILA A. LAZARTE, ALESSANDRA L.
CABACUNGAN, DONNA B. MARTE, JANICA ELOISE S.
CALVADORES, ANDREA M. MILAR, JASMINE B.
CASTILLO, KIMBERLY MAE L. PANTALEON, ROSANA
CRUZ, AIRIES A. QUIMSON, STEPHANIE MAY B.
CRUZADA, CLAIRE DENISE C. SALON, BERNADETH ANN ROSE
DICE, GEMIE ANN L. SOTOMAYOR, SHAMARIE

SUBMITED TO:

ANTHONY VINCENT STA. ANA, RN, MAN

 Neonatal Pneumonia | CDSGA – Midwifery Department

TABLE OF CONTENTS

I. Preliminaries
A. Introduction …………………………………………………………………………………………………………………………...........................3
B. Case Objectives………………………………………………………………………………………………………………………………..………4
II. Health History
A. Biographic Data……………………………………………………………………………………………………………………………..…………7
B. Chief Complaint or Reason for Clinic Visit………………………………………………………………………………………………..………….8
C. History of Present Gestation/Disease……………………………………………………………………………………………………..…………...8
D. History of Past Gestation/Disease………………………………………………………………………………………………………..……………9
III. Anatomy and Physiology………………………………………………………………………………………………………………………………..……………10
IV. Pathophysiology………………………………………………………………………………………………………………………….….......................................10
V. Drug Study……………………………………………………………………………………………………………………………………………...……...….….11
VI. Management…………………………………………………………………………………………………………………………………………...……...………13
A. Health Care Plans……………………………………………………………………………………………………………………...……….…......15
VII. Conclusion…………………………………………………………………………………………………………………………………………...……………......17
VIII. Bibliography……………………………………………………………………………………………………………………………………..................................18
IX. Appendices ………………………………………………………………………………………………………………………………………...……………...….19

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I. Preliminaries
A. Introduction

A 23-year-old mother who has an obstetrical score of G2P2 residing in Area-D San Jose Del Monte Bulacan rushed her 11-day-old son to Holistic Care General Hospital
because of noisy breathing sounds. As stated by the mother, she noticed the unusual sound when breathing until on the eleventh day, she then sought medical assistance as she
observed that the signs and symptoms were getting worse. The neonate was delivered via normal spontaneous delivery in a lying-in clinic and no other complications were noted.

Neonatal pneumonia is a serious respiratory infection that affects newborns during the first 28 days of life. The transmission of this condition can occur from the mother or
environmental exposure and is caused by various bacterial, viral, and fungal organisms. Factors such as geographical location, hygiene practices, and socioeconomic status can
affect the spread of neonatal pneumonia. There’s still a risk for certain infants like those born with congenital anomalies, premature or low birth weight infants, and infants born to
mothers with intrauterine infections. Being aware of these factors will help us to prevent the child from getting sick.

Infants can develop rapid and severe signs of neonatal pneumonia, like respiratory distress, grunting, cyanosis, and sepsis. Some of the common signs are difficulty in
breathing, fast or shallow breathing, chest or abdomen retractions, and blue dusky skin. These early symptoms can also notify us to make some measurements and bring them to a
pediatrician if the neonate is in danger.

Early recognition and prompt treatment are paramount in reducing morbidity and mortality associated with neonatal pneumonia. Diagnostic evaluations may involve clinical
assessment, blood tests, and imaging studies like X-rays. The choice of antibiotic therapy depends on the suspected pathogens and local resistance patterns. Prevention strategies
play a crucial role in reducing the incidence of neonatal pneumonia. These include improving prenatal care, promoting maternal vaccination, ensuring a clean and sterile delivery
environment, practicing appropriate hand hygiene, and promoting exclusive breastfeeding.

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B. CASE OBJECTIVES 

General Objectives

The main goal of this case is to understand the patient's condition by thoroughly reviewing the medical assessment, including physical examinations, laboratory tests, and
medical history provided by the hospital to which he has been admitted. Finding the patient's condition and alleviating the underlying cause is a further goal for us learners
and the support system of the patient. To know the treatment of the illness, relieve the patient's symptoms, as well as to improve their quality of life, healthcare services, or
targeted treatments.

Client's Specific Objectives: The client and those closest to them will be prepared shortly thereafter finishing this case study.

KNOWLEDGE:
● Clients learn about their specific medical condition, including its name, causes, symptoms, and how it affects the body of an infant.
● To gain an understanding of the expected course of their condition, including the potential outcomes, risks, and complications involved.
● To learn about different treatment approaches available for their condition, such as medications, lifestyle modifications, or alternative therapies.
● To receive advice on adopting certain lifestyle changes or avoiding certain environmental influences that could worsen their condition.
● To learn about the importance of regular check-ups, monitoring conditions, and adhering to the recommended treatment plan.
● To gain information about support groups, patient communities, online resources, or organizations that can provide additional information, assistance, or emotional
support.

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SKILLS:
● Patients will improve their decision-making skills by considering various factors, assessing risks and benefits, and making informed choices regarding treatment, care
plans, or lifestyle modifications by engaging in case studies.
● Healthcare providers, patients, and their families will improve their ability to communicate their health concerns, ask relevant questions, and actively participate in
healthcare discussions.

ATTITUDE:
● Patients will develop a deeper sense of empathy and compassion towards the people involved, recognizing the impact of their experiences, and fostering a desire to
help or support others.
● Patients will analyze information, consider different viewpoints, and evaluate potential solutions. encouraging patients to question assumptions, seek evidence, and
engage in reasoned decision-making.

Student-specific Objectives: The student will be capable of the following after completing this case study.

KNOWLEDGE:
● Students learn how to conduct thorough research on a specific topic or issue related to the case study. They acquire knowledge about locating and analyzing relevant
sources, such as scholarly articles, books, reports, and online databases.
● Depending on the subject area of the case study, students acquire in-depth knowledge about a particular field, industry, or discipline. They explore concepts, theories,
and practices relevant to the case and gain a deeper understanding of the subject matter.
● Making a case study involves presenting findings, analyzing data, and formulating conclusions. Students enhance their written and oral communication skills, as they
need to clearly articulate their thoughts, express ideas effectively, and coherently organize information.

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● In some instances, students work on case studies as a team. They develop skills in collaboration, cooperation, and coordination, learning how to communicate and work
effectively with peers to achieve common goals.

SKILLS:
● Students will develop their clinical reasoning skills by identifying patterns, understanding differential diagnoses, and knowing treatment plans based on the available
information.
● Students will have the opportunity to present their findings to their peers or faculty members. This experience helps them enhance their presentation skills, including
public speaking, slide design, and effective delivery of information.

ATTITUDE:
● Case studies will involve unexpected challenges or the need to adapt research methods. Being flexible allows students to adjust their approach, explore alternative
avenues, and find innovative solutions.
● Students will reflect on their process and outcomes. They can assess their strengths, weaknesses, and areas for improvement, enabling continuous learning and
growth.

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II. Health History

A. Biographic Data
Patient Initials: B.T
Age: 11 days old
Birthday: April 27, 2023
Address: City of San Jose Del Monte Bulacan
Sex: Male
Race: Filipino
Marital status: Single
Religion: Roman Catholic
Comorbidity: N/A
First Medical Diagnosis: Neonatal Pneumonia
Final Medical Diagnosis: PCAP-C

Mother Initials: B.A

Age: 23 years old
Birthday: July 3, 1999
Address: City of San Jose Del Monte Bulacan
Sex: Female
Race: Filipino
Marital status: Single
Religion: Roman Catholic

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First medical diagnosis:G2P1 PU 37 weeks AOG Cephalic presentation

Final medical diagnosis: G2P2 delivered via NSD to an alive baby boy

B. Chief Complaint or Reason for Clinic Visit

Noisy breathing

C. History of Present Gestation

On April 17, 2023 at exactly 5:41 a.m., a healthy baby boy was delivered via normal spontaneous delivery. Apgar score was 8/9 which indicates normal condition of the
newborn baby. Unang yakap was done to initiate aspiration and warm him. After a few minutes, the midwife did the timely cord clamping. No abnormal signs and symptoms were
observed and recorded. After unang yakap, newborn care was practiced. The midwife in charge put the baby under a droplight and instilled erythromycin on both eyes, injected
Vitamin k 0.1 ml and Hepatitis B vaccine 0.5 ml on his left and right vastus lateraris. During the admission of the baby and the mother, the midwife made sure that the baby was
breastfed by mother. They stayed in a lying-in clinic for about 24 hours. During their stay, the mother noticed unusual breathing sounds of the child however, she chose to
disregard it as she thought that it was typical infant behavior. After 24 hours of stay, newborn screening was done and they were discharged accompanied by the father of the child.

III. Anatomy and Physiology

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RESPIRATORY SYSTEM
The respiratory system exchanges O2 and CO2 between the air and the blood, regulates blood pH, helps produce sounds, moves air over the sensory receptors that detect smell,
and protects against some pathogens.

LUNGS
The lungs are the principal organs of respiration. The right lung has three lobes: the superior lobe, middle lobe, and the inferior lobe. The left lung has two lobes, called superior
lobe and inferior lobe. Each lobe receives air from its own branch of the bronchial tree, but they all have the same function: bringing oxygen into the bloodstream and removing
carbon dioxide. Lungs is where the process of gas exchange (respiration) takes place. In respiration, oxygen from incoming air enters the blood, and carbon dioxide, a waste gas
from the metabolism, leaves the blood.

BRONCHI
Bronchi are the large tubes that connect to your windpipe and direct the air you breathe to your left and right lungs. The main bronchi extends from the trachea to each lung.

TRACHEA
The trachea divides into left and right main bronchi, or primary bronchi, each of which connects to a lung. Trachea is lined with mucous membrane. This membrane consists of
pseudostratified columnar epithelium, containing numerous cilia and goblet cells. The cilia sweep the mucus embedded with foreign particles into the pharynx, where it is
swallowed.

ALVEOLI
Are small air-filled chambers where the air and the blood come into close contact with each other, this is where the lungs and the blood exchange oxygen and carbon dioxide
during the process of breathing in and breathing out.

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IV. Pathophysiology

Modifiable Risk Factor Non-Modifiable Risk Factor

Postnatal care: Environmental factor:

Exposed in family Neonatal Age:
Overfeeding 0-28 days old
members who smokes
Not burping every after
Polluted area
feeding

Signs and Symptoms

Noisy Breathing Sounds

NEONATAL PNEUMONIA

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V. Drug Study

Patient’s Initial: B.T Age: 11 Days Gender: M Date Handled: April /28 /2023
Medical Diagnosis: Pneumonia, RIGHT LOWER LUNG
Chief Complaint: Noisy breathing sounds

Medications Date Ordered/ Route of Mechanism of Indication Contraindication Client’s Response Responsibilities
Given/ Taken Administration/ Action
Dosage
Frequency
Generic: Ordered Route Ampicillin is used Antibiotic is used to Should not be used The client did not Close monitoring
Ampicillin 4/28/23 Administration: to treat various treat bacterial in neonates with a feel any adverse and appropriate
TIV bacterial infections infection of the known effects of drugs dosing of ampicillin
Brand: Dosage: 140 mg including lungs hypersensitivity or is always
Ampi Frequency: pneumonia allergy to the drugs recommended.
B.I.D for 1 week .

Generic: Ordered Route Should not be used The client did not
Gentamicin 4/28/23 Administration: Gentamicin is used To prevent bacterial by persons with feel any adverse Ensure to provide
TIV to prevent and treat infection history of effects of drugs the correct amount
Brand: Dosage: 11mg serious bacterial hypersensitivity and of dosage of this
Maxigen Frequency: infection. It works has known history drug on the

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Gentacare O.D x7 Days by stopping the of allergy or serious specified time

growth of bacteria. toxic reaction to prescribed
gentamicin or any
other
aminoglycosides

Generic: Ordered: Route Should not be used The client did not
Ventolin 4/28/23 Administration: Salbutamol actives Acute and severe to those who have feel any adverse Assess breathing
Nebules Inhalation adenyl cyclase the bronchospasm pre-existing or like effects of drugs sounds and
enzyme that uncomplicated, factor of ischaemic respiratory rate first
Brand: Frequency: production of cyclic premature labor at heart disease, before giving
Salbutamol Q80 adenosine 22-37 weeks of Salbutamol. Ensure
Every 8 hours gestation, to give right dosage
prophylaxis of in a timely manner.
exercise induced
bronchospasm

VI. Management

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The patient is a baby boy who is 11 days old. The staff nurse took the patient’s vital signs like heart rate, respiratory rate, temperature, oxygen saturation level, and weight for
physical assessment. The doctor assessed the patient and advised the consenting mother’s patient that it is needed to perform some laboratory tests like complete blood count,
platelet count, chest X-ray, and covid rapid antigen test due to respiratory distress, crackle lung sound and persistent symptoms. At first, they nebulized the child to remove the
blockage of the airway then after the pediatrician noticed an improvement to the breathing sounds, they conducted the necessary laboratory tests and imaging. The doctor
confirmed that the chest x-ray result showed pneumonia in the right lower lung once the laboratory findings were released. The pediatrician revealed to the patient's mother the
findings of his laboratory tests and suggested that the patient needs to be admitted. The patient was given a seven-day stay in the preferred residence while being hooked up to IVF:
05 1MB at 12cc/hrs. or 12 drops per minute in the infusion set for the solution. Additionally, they started given medicines, gentamicin 11mg/IV once daily, salbutamol nebulizer
every eight hours, ampicillin 140mg/IV every 12 hours, day 2 to 4 continues antibiotics IVF to consume, day 5 shift to hep-lock and continue medicines until 7 days. Vital signs
were also monitored and recorded every four hours in each day.

Management of neonatal pneumonia typically involves a comprehensive approach that encompasses both medical and supportive care. It is stated in the book of Community-
acquired pneumonia among children: the latest evidence for an updated management that the management of childhood illnesses like Neonatal Pneumonia are providing
practical recommendations for diagnosis, treatment and supportive care. The first step for this is accurate diagnosis through clinical evaluation including a thorough medical
history, physical examination, and laboratory tests such as blood cultures and chest X-rays. Once Neonatal pneumonia is confirmed, prompt initiation of appropriate antibiotics is
crucial. The choice of antibiotic is typically guided by age of an infant or neonate and the suspected causative pathogens. In addition to antibiotic treatment, supportive care plays a
vital role in the management. Maintaining hydration and nutrition are essential to support the neonate’s immune system and facilitate recovery. Close monitoring of vital signs is
crucial to detect any signs of deterioration or complication of the patient. Infants with respiratory distress may benefit from non-invasive respiratory support such as nasal oxygen
therapy.

As a comparison for the practices of management that usually applies, all of those were observed in management of the patient in our case. Before the admission, the neonate was
subjected to several laboratory tests to thoroughly check if the initial diagnosis was right. Those tests as mentioned are Complete Blood Count, RT-PCR and X-ray. After accurate

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diagnosis, appropriate antibiotics were also instructed by the pediatrician. The antibiotic medicines that were given were stated above. Intensive monitoring of vital signs was also
done for seven days. Oxygen therapy was on stand-by but during the admission, it was not used. As part of the instruction of the doctor-in-charge, nebulization was done to remove
blockage of the airway. The nutrition and hydration of the baby were also monitored and recorded by checking the bowel movement, the intake and output of the neonate.

A. Health Care Plan

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Patient’s Initials: B.T. Age: 11 days old Gender: Female

Medical Diagnosis: Neonatal Pneumonia Chief Complaint: Noisy Breathing sounds

ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION

Physical Examination: Specific INDEPENDENT -To monitor the condition of the - The patient's condition was
Subjective - After 7 days of health care - Checking vital signs and baby improved and in great
-The mother noticed noisy management, the patient will physical appearance of the disposition.
breathing sound of the patient get appropriate medication to baby - To check if there's a sign of
achieve a resolution and avoid improvement in each day
complication. - Use of standardized tools

Health History: and guidelines to monitor -Removal of secretions which

further child's condition makes the airway clear
Maternal Health History
- To maintain supportive care
-Cough and colds during the time
- Institute isolation precaution and prevention spreading of
of gestation
- Assisting with nebulization as infection
ordered by the doctor
Review of system:
-Family members who are
- Administration and
smoking cigarettes and vaping
monitoring of antibiotic therapy

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-Residing in tough area (busy

streets and air polluted
environment)

DEPENDENT: - To be educated on how to help -Mother became vigilant and

keen to the patient’s
the baby to be cured and knowing
condition, was able to
-Educate the mother on the right the prevention of triggering
distinguish between normal
way to breastfeed the baby and factors of having neonatal
and abnormal behavior/ action
what to do to ensure that mother pneumonia 
of the baby  
take care of the baby in a right
way. 

COLLABORATIVE:
-To remove blockage of the -Able to maintain open
-Nebulization to remove airway airways, have normal
blockage on the pathway of air. breathing, normal rate or
respiration.

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-Antibiotic Therapy given: -To fight over the causative

Ampicillin and Gentamycin as pathogens and helps to prevent
Pediatrician ordered further complications and spread
of infection 

-Checking daily vital signs - To see progress of the neonate’s

monitoring  health

VII. Conclusion
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A mother (G2P2) bought his 11-day old baby to the Holistic Hospital for Check-up as his son was having noisy breathing sounds. The first thing that was done to the baby was
getting his vital signs. Nebulization was done after the pediatrician heard crackles sound. RT-PCR test was done to determine if pneumonia was caused by Covid-19 virus. Upon
checking on the result of RT-PCR, it turned negative. X-RAY test was followed after. Results showed that the baby was positive for pneumonia on his right lung. Doctor instructed
to proceed for confinement of his baby for monitoring and preventing to worsen the disease. Vital signs were recorded every four hours in seven days. Antibiotics which are
gentamicin and ampicillin were given in a timely manner. IV Fluid was maintained. Signs and symptoms were observed and intervened. After a week of intervention, the condition
of a baby with neonatal pneumonia improved. No untoward signs and symptoms were seen. Doctor taught the mother how to take good care of the baby, highlighted the
importance of observation and being keen for the signs and symptoms that the baby might show. The student midwives were able to know the causing factor, risk and management
of neonatal pneumonia. All of which are a helping hand for the course and to be exposed in such a complicated situation. Significant information was analyzed and understood.
Overall, the KSA of the patient's parents and students were done. All of the objectives were met.

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VIII. Bibliography
A. Books
• Vanputte, et al. (2018) Seeley’s Essentials of Anatomy & Physiology, 10th Edition
• Kozier, et al. (2004) Fundamentals of Nursing: Concepts, Process and Practice, 7th Edition
• Pilliteri, A. (2003) Maternal & Child Health Nursing: Care of the Childbearing & Childbearing Family, 4th Edition
• Nascimento-Carvalho, Cristiana M. "Community-acquired pneumonia among children: the latest evidence for an updated management." (2020): 29-38.
B. Electronic Resources

• Tesini, B. (2022) Neonatal Pneumonia from https://www.msdmanuals.com/professional/pediatrics/infections-in-neonates/neonatal-pneumonia

• Cunha, J. (2021) Gentamicin from https://www.rxlist.com/gentamicin/generic-drug.htm
• Apego, R. (2014) Drug Study Salbutamol from. https://www.scribd.com/doc/202383786/Drug-Study-Salbutamol
• DrugBank Online (2005) Ampicillin from https://go.drugbank.com/drugs/DB00415

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X. Appendix

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