Pediatric Community-Acquired

Pneumonia, Dengue Fever without

Warning signs
Presenters:
Abugan, Jessie Maye
Banto, Sittie Jamiah
De Sesto, Rhys Carlo
H. Salic, Yanisah
Limba, Mahana Hajaar
Manabilang, Shereen
Tate, Suzette Rae

Objectives:
GENERAL OBJECTIVES:
After an hour and half of case
presentation, the presenters, the students and
the clinical instructors will be acquainted with
the health condition and the health status of
the patient.


Specific Objectives

Presenters will be able to:
Comprehensively discuss the case of the patient including the vital
information, nursing history, family history, medical history, and
nursing independent actions done to the patients;
Integrate the physical assessment and review of systems, nursing
care plan, diagnostic findings, and medical interventions in the
concept map of the disease process specifically of the patients
case;
Modify and make necessary changes to the case study to uphold
the standards excellence;
Utilize constructive criticism from the critic group and the clinical
instructors to further enhance case presentation skills; and
Create a health education plan that will help the patient in the
maintenance and promotion of health outside of the hospital
environment.

Students will be able to:
Categorize the health problems of the patient into its
nature or condition, modifiability of the problem,
preventive potential, and salience.
Sequence and prioritize the health problems presented in
the case in accordance with the criteria of prioritization of
health problems;
Formulate queries that are relevant to the case presented;
Recommended adjustments in the case study for the
betterment of the presentation; and
Professionally assess end evaluate the progress of the
presenters in their case presentation skills.

Clinical Instructors will be able to:
Cite the progress and skills of the students presenting
the case;
Recommended for further assessment and
development of skills;
Clarify any information and advice for reevaluation for
a case study that upholds the standards of excellence;
Identify the strengths and weaknesses of the
presentation and the case presenters; and
Utilize the presented data for evaluation of the class.


DEFINITION OF TERMS

Broncho pulmonary.segment of lung supplied by a segmental bronchus and its accompanying pulmonary artery
branch. Each segment is shaped like an irregular cone with the apex at the origin of the segmental bronchus and
the base projected peripherally onto the surface of the lung.

Chest indrawing. the lower ribs on both sides of the chest are pulled in when the child breathes in. This is very
abnormal as the lower chest normally moves out when a child breathes in. When resting, children should never
have chest indrawing, a definite inward movement of the lower chest wall while breathing in (inspiration).

Community-acquired pneumonia (CAP). is one of several diseases in which individuals who have not recently
been hospitalized develop an infection of the lungs (pneumonia). CAP is a common illness and can affect people of
all ages. CAP often causes problems like difficulty in breathing, fever, chest pains, and a cough. CAP occurs because
the areas of the lung which absorb oxygen (alveoli) from the atmosphere become filled with fluid and cannot work
effectively.

Pneumonia. is an inflammation of the lungs caused by infection. Bacteria, viruses, fungi or parasites can cause
pneumonia. Pneumonia is a particular concern if you're older than 65 or have a chronic illness or weak immune
system. It can also occur in young, healthy people.Pneumonia can range in seriousness from mild to life-
threatening. Pneumonia often is a complication of another condition, such as the flu.

CAP occurs throughout the world and is a leading cause of illness and death. Causes of CAP
include bacteria, viruses, fungi, and parasites. CAP can be diagnosed by symptoms and physical examination alone,
though x-rays, examination of the sputum, and other tests are often used. Individuals with CAP sometimes
require treatment in a hospital.

Pneumothorax or collapsed lung. is the collection of air in the space around the
lungs. This buildup of air puts pressure on the lung, so it cannot expand as much as
it normally does when you take a breath.
Oxygen saturation. measures the amount of oxygen carrying hemoglobin in the
blood.
Retraction is a medical term for when the area between the ribs and in the neck
sinks in when a person with asthma attempts to inhale. Retractions are a sign
someone is working hard to breathe. Normally, when you take a breath, the
diaphragm and the muscles around your ribs create a vacuum that pulls air into
your lungs. (It's kind of like sucking liquid through a straw.) But if a person is having
trouble breathing, extra muscles kick into action
Rhonchi. an abnormal sound heard on auscultation of an airway obstructed by
thick secretions, muscular spasm, neoplasm, or external pressure. The continuous
rumbling sound is more pronounced during expiration and characteristically clears
on coughing, whereas gurgles do not. a rattling in the throat; also, a dry, coarse
rale in the bronchial tubes, due to a partial obstruction. Suggests the presence of
chronic inflammation accompanied by presence of small amounts of tenacious
exudate.

Community-Acquired Pneumonia
The term community-acquired pneumonia
(CAP) refers to a pneumonia in a previously
healthy person who acquired the infection
outside a hospital. CAP is one of the most
common serious infections in children. Although
death from CAP is rare in industrialized countries,
lower respiratory tract infection is one of the
leading causes of childhood mortality in
developing countries.


Key facts

Pneumonia is the leading cause of death in children worldwide. Pneumonia kills an
estimated 1.2 million children under the age of five years every year more than AIDS,
malaria and tuberculosis combined.
Pneumonia can be caused by viruses, bacteria or fungi.
Pneumonia can be prevented by immunization, adequate nutrition and by addressing
environmental factors.
Pneumonia caused by bacteria can be treated with antibiotics, but around 30% of
children with pneumonia receive the antibiotics they need.
Pneumonia is a form of acute respiratory infection that affects the lungs. The lungs are
made up of small sacs called alveoli, which fill with air when a healthy person breathes.
When an individual has pneumonia, the alveoli are filled with pus and fluid, which
makes breathing painful and limits oxygen intake.
Pneumonia is the single largest cause of death in children worldwide. Every year, it kills
an estimated 1.2 million children under the age of five years, accounting for 18% of all
deaths of children under five years old worldwide. Pneumonia affects children and
families everywhere, but is most prevalent in South Asia and sub-Saharan Africa.
Children can be protected from pneumonia, it can be prevented with simple
interventions, and treated with low-cost, low-tech medication and care.



Causes

Pneumonia is caused by a number of infectious agents, including
viruses, bacteria and fungi. The most common are:

Streptococcus pneumoniae the most common cause of bacterial
pneumonia in children;
Haemophilus influenzae type b (Hib) the second most common
cause of bacterial pneumonia;
respiratory syncytial virus is the most common viral cause of
pneumonia;
in infants infected with HIV, Pneumocystis jiroveci is one of the
most common causes of pneumonia, responsible for at least one
quarter of all pneumonia deaths in HIV-infected infants.



Etiology

Determining the cause of pneumonia in a
child is often difficult, but the patients age
can help narrow the list of likely
etiologies. Table 1
69
lists common and less
common causes of CAP by age group.


Clinical Evaluation

The strongest predictors of pneumonia in children are fever,
cyanosis, and more than one of the following signs of respiratory
distress: tachypnea, cough, nasal flaring, retractions, rales, and
decreased breath sounds.
Pneumonia should be suspected if tachypnea occurs in a patient
younger than two years with a temperature higher than 38C
(100.4F). Measurement of tachypnea requires a full one-minute
count while the child is quiet. The World Health Organizations age-
specific criteria for tachypnea are the most widely used: a
respiratory rate of more than 50 breaths per minute in infants two
to 12 months of age; more than 40 breaths per minute in children
one to five years of age; and more than 30 breaths per minute in
children older than five years.
Children without fever or symptoms of respiratory distress are
unlikely to have pneumonia.
Transmission
Pneumonia can be spread in a number of ways.
The viruses and bacteria that are commonly
found in a child's nose or throat, can infect the
lungs if they are inhaled. They may also spread
via air-borne droplets from a cough or sneeze. In
addition, pneumonia may spread through blood,
especially during and shortly after birth. More
research needs to be done on the different
pathogens causing pneumonia and the ways they
are transmitted, as this has critical importance for
treatment and prevention.


Symptoms

The symptoms of viral and bacterial pneumonia are similar. However, the
symptoms of viral pneumonia may be more numerous than the symptoms of
bacterial pneumonia.

The symptoms of pneumonia include:
rapid or difficult breathing
cough
fever
chills
loss of appetite
wheezing (more common in viral infections).
When pneumonia becomes severe, children may experience lower chest wall
indrawing, where their chests move in or retract during inhalation (in a healthy
person, the chest expands during inhalation). Very severely ill infants may be
unable to feed or drink and may also experience unconsciousness, hypothermia
and convulsions.

Risk factors

While most healthy children can fight the infection with their natural defences,
children whose immune systems are compromised are at higher risk of developing
pneumonia. A child's immune system may be weakened by malnutrition or
undernourishment, especially in infants who are not exclusively breastfed.

Pre-existing illnesses, such as symptomatic HIV infections and measles, also
increase a child's risk of contracting pneumonia.

The following environmental factors also increase a child's susceptibility to
pneumonia:
indoor air pollution caused by cooking and heating with biomass fuels (such as
wood or dung)
living in crowded homes
exposure to smoking

Treatment


Pneumonia caused by bacteria can be treated
with antibiotics. These are usually prescribed at a
health centre or hospital, but the vast majority of
cases of childhood pneumonia can be
administered managed effectively within the
home with inexpensive oral antibiotics.
Hospitalization is recommended in infants aged
two months and younger, and also in very severe
cases.


Prevention

Preventing pneumonia in children is an essential component of a strategy to
reduce child mortality. Immunization against Hib, pneumococcus, measles and
whooping cough (pertussis) is the most effective way to prevent pneumonia.

Adequate nutrition is key to improving children's natural defences, starting with
exclusive breastfeeding for the first six months of life. In addition to being effective
in preventing pneumonia, it also helps to reduce the length of the illness if a child
does become ill.

Addressing environmental factors such as indoor air pollution (by providing
affordable clean indoor stoves, for example) and encouraging good hygiene in
crowded homes also reduces the number of children who fall ill with pneumonia.

In children infected with HIV, the antibiotic cotrimoxazole is given daily to decrease
the risk of contracting pneumonia.

Economic costs
Research has shown that prevention and proper treatment
of pneumonia could avert one million deaths in children
every year. With proper treatment alone, 600 000 deaths
could be avoided.

The cost of antibiotic treatment for all children with
pneumonia in 42 of the world's poorest countries is
estimated at around US$ 600 million per year. Treating
pneumonia in South Asia and sub-Saharan Africa which
account for 85% of deaths would cost a third of this total,
at around US$ 200 million. The price includes the
antibiotics themselves, as well as the cost of training health
workers, which strengthens the health systems as a whole.


WHO response

In 2009, WHO and UNICEF launched the Global action plan for the
prevention and control of pneumonia (GAPP). The aim is to
accelerate pneumonia control with a combination of interventions
to protect, prevent, and treat pneumonia in children with actions
to:
Protect children from pneumonia include promoting exclusive
breastfeeding and hand washing, and reducing indoor air pollution;
Prevent pneumonia with vaccinations;
Treat pneumonia are focused on making sure that every sick child
has access to the right kind of care -- either from a community-
based health worker, or in a health facility if the disease is severe --
and can get the antibiotics and oxygen they need to get well.




VITAL INFORMATION

Name: Patient Candy

Room Number: 242 bed 1

Age: 6 years old

Gender: Female

Date of Birth: April 11,2007

Birth Place: Manila City

Cultural Group: Iliganon

Primary Language: Bisaya

Religion: Roman Catholic
Usual Health Care Provider: Physician
Reason for Health Contact: cough
Date of Admission: March 1, 2014
Source of History: Grandmother (50%) and chart (50%)
Attending Physician: Dr. Canoy, M.D
Impression/Final Diagnosis: Pediatric Community Acquired Pneumonia C,
Dengue Fever
Without warning signs.

Description of Patient:
INITIAL VISIT: During the patient visit, patient was sitting on bed,
conscious, coherent, responsive but restless, not in respiratory distress,
well groomed, with patent IVF of D5 NM hooked 1L @ 80 gtts/min,
inserted at left metacarpal vein, there is no redness and swelling noted in
the IV site, febrile, vital signs are T- 38.9, HR- 16O, RR- 28, BP- 100/60.
DAY 1: awake, lying on bed in a semi fowlers position, conscious,
coherent, responsive but restless, not in respiratory distress, well
groomed, with patent IVF of D5LR hooked 1L @ 80gtts/min, inserted at
left metacarpal vein, there is no redness and swelling noted in the IV site,
generalized body rashes febrile, T-38.5, HR-1O7, RR-22, BP- 100/60.
DAY 2: Asleep, flat on bed, still in patent IVF of D5LR hooked 1L @ 80
gtts/min, inserted in the left metacarpal vein, there is no redness and
swelling noted, slight rashes on the body, afebrile, T-35.4, HR- 100, RR-
18, BP- 100/60.


NURSING HISTORY

Chief Complaints:
Cough persisted associated with recurrence fever

Present History of Illness:
Two weeks prior to admission, Patient candy experienced (+) cough, initially associated with
difficulty of breathing and intermittent elevated body temperature, it was brought to the Doctor for
consultation and prescribed with clarithromycin unrecalled dose and paracetamol 250mg/15 ml
every 4 hours for fever which afforded temperature relief. One week prior to admission, Patient
candys cough is subsided after taking the medications for one week treatment of clarithromycin.
One day prior to admission, cough is persisted associated with recurrence Fever, T38.5C with chills.

History of Past Illness:
Patient Candy has completed immunizations, she has no known allergies to food, drug, or
any substances or to environmental factors. She had not experienced illnesses such as measles and
mumps, but had minor illnesses like fever and cough. She has no surgical history but had been
hospitalized last 2010 due to cough in Pagadian hospital; medications given cant be remembered
by the grandmother. In 2013, she was again hospitalized due to cough but they referred to
Mindanao Sanitarium hospital.


GORDONS ASSESSMENT OF
FUNCTIONAL HEALTH PATTERNS

BEFORE HOSPITALIZATION
DURING HOSPITALIZATION
HEALTH PERCEPTION/
HEALTH MANAGEMENT
Patient Candy prefers to
Doctors when she has a minor
illnesses such as fever and
cough. She has been
hospitalized twice, 2010 and
2013 due to cough.
Patient was admitted to
AMCC due to cough persisted
associated with recurrence of
fever.
NUTRITIONAL/
METABOLIC PATTERN
Patient Candy has a good
eating habits; she has always
completed three meals per
day with rice and vegetables/
meat for each meal. She loves
to eat vegetables with any
kinds. She doesnt have any
food allergies at all. She take
vitamins, cherifer. For fluids,
she drinks water 2 to 3 ml of
water, sometimes juices and
cokes.
BEFORE HOSPITALIZATION DURING HOSPITALIZATION
ELIMINATION PATTERN Defecates twice a day. No
urinary elimination
problem, urine yellow on
color
Has problem in defecation
since she cannot consume
a large amount of water
and she dont like to eat.
Had not removed bowel
for 2 days.
EXERCISE AND ACTIVITY She plays in school
together with her
classmates and in home,
she plays games in her
iphone and sometimes she
watch television.
In the hospitals, she no
longer do his usual activity
than before, rather, she
would just sit or lie down.
When she needs to walk to
the bathroom, she needs
assistance. But sometimes
she play games on her
iphone.
BEFORE HOSPITALIZATION
DURING HOSPITALIZATION
SLEEP / REST PATTERN Arise on bed at 5:30AM
and sleeps at 9:00PM.
She feels rested and is
ready for daily activities
after sleep. With that, she
can sleep without any aids
and she doesnt experience
any kind of nightmares.
She doesnt have any form
of insomnia.
She now has no regular or
fixed sleep- wake cycle. At
times she becomes very
restless.

SPIRITUAL RESOURCES According to the S.O. , She
participates in going to
church every Sunday to
pray with the family.
In the hospital, she
participates when pastor
comes and offer prayers
and helps to meditate with
her.









PHYSICAL ASSESSMENT AND REVIEW
OF SYSTEMS
(PEROS)


Areas Assessed Subjective Findings Objective Findings Problem Identified
General
Health
Survey

DAY 1:
Nanghihina sya as
verbalized by the
grandmother.
DAY 2:
wala na siyang
lagnatas
verbalized by the
grandmother
INITIAL VISIT:
*weakness
*weight 24.8 kg
*height - 127 cm
BMI-15.4
No body odor
Coherent
Responsive
Sitting on bed
Vital signs:
T-38.9,HR-160, RR- 28,BP-
100/60
DAY1:
*weakness
*weight 24.8 kg
*height - 127 cm
BMI-15.4
No body odor
Coherent
Responsive
Lying on bed in a semi fowlers
position
Vital signs:
T-38.5,HR-107, RR- 22,BP-
100/60
Day2:
No body odor
Coherent
Responsive
Flat on bed
Vital signs:
T-35.4,HR-100,RR-18,BP-
100/60
*Altered body
temperature:
Hyperthermia
* Risk for
Imbalanced
nutrition: less than
the body
requirements
Areas Assessed

Subjective Findings

Objective Findings Problem Identified
Integumentary
System

DAY1:
May rashes sya as
verbalized by the
grandmother

DAY2:
Same with DAY1
INITIAL VISIT:
Normocephalic head
Skin color brown
*good skin turgor
*skin warm to touch and dry
*no swelling or pitting edema as
noted.
*hair: equally distributed, no
presence of lice, no lesions and
scaly dry
*nail bed is smooth, firm and pink.
DAY 1:
Skin color brown
*good skin turgor
*skin warm to touch and dry
*no swelling or pitting edema as
noted.
*hair: equally distributed, no
presence of lice, no lesions and
scaly dry
*nail bed is smooth, firm and pink.
Generalized body rashes
DAY2:
Skin color brown
*good skin turgor
*skin warm to touch and dry
*no swelling or pitting edema as
noted.
*hair: equally distributed, no
presence of lice, no lesions and
scaly dry
*nail bed is smooth, firm and pink.
Subsided generalized body rashes
No complaints of pain in the IV site.


*Impaired skin
integrity


Areas Assessed

Subjective Findings

Objective Findings

Problem Identified

HEENT
Head and face
Eyes
Ears
Nose
Oral cavity

DID NOT
VERBALIZED ANY
CUES
INITIAL VISIT:
*pinkish conjunctivae, anicteric
sclerae, both eyes are reactive to
light, (+) blink reflex
*external ear canal w/o redness,
no discharges
* sinus not tender, no discharge
*moist lips, moist mucosa, pinkish
tongue
(+) PERRLA
Symmetrical Eyes
No dental problems noted
DAY1:
*pinkish conjunctivae, anicteric
sclerae, both eyes are reactive to
light, (+) blink reflex
*external ear canal w/o redness,
no discharges
* sinus not tender, no discharge
*moist lips, moist mucosa, pinkish
tongue
(+) PERRLA
Symmetrical Eyes
No dental problems noted
DAY2:
*pinkish conjunctivae, anicteric
sclerae, both eyes are reactive to
light, (+) blink reflex
*external ear canal w/o redness,
no discharges
* sinus not tender, no discharge
*moist lips, moist mucosa, pinkish
tongue
(+) PERRLA
Symmetrical Eyes
No dental problems noted
No problem
identified
Areas Assessed

Subjective Findings

Objective Findings

Problem Identified

Neck

DAY1:
Wala namang
problema sa leeg
nya as verbalized
by the grandmother
DAY2:
SAME WITH DAY1
INITIAL VISIT:
*no rigidity, appeared
smooth
*no presence of lumps
and masses
*carotid pulse equal
*controlled
movementsSymmetrical
DAY1:
*no rigidity, appeared
smooth
*nol presence of lumps
and masses
*carotid pulse equal
*controlled movements
Symmetrical
DAY2:
*no rigidity, appeared
smooth
*nol presence of lumps
and masses
*carotid pulse equal
*controlled movements
Symmetrical

*No problem
identified
Areas Assessed

Subjective Findings

Objective Findings

Problem Identified
Respiratory
System

INITIAL VISIT:
Lisod siya ug
ginhawa,as
verbalized by
grandmother.
DAY1:
OK ra iyang
pagginhawa,as
verbalized by the
grandmother
DAY2:
Di na siya ga lisod
ug ginhawa, ok na
siya, as verbalized
by the
grandmother.
INITIAL VISIT:
*equal chest
expansion
* RR- 28 bpm
* O2 sat- 90
No pain on chest as
claimed
DAY1:
Equal chest expansion
RR-22
O2 sat- 96
No pain on chest as
claimed
DAY2:
*equal chest
expansion
* RR- 18 bpm
* O2 sat- 97
No pain on chest as
claimed

DIFFICULTY OF
BREATHING
Areas Assessed

Subjective Findings

Objective Findings

Problem Identified

Cardiovascular
System

No subjective data
INITIAL VISIT:
* no murmur
*BP- 100/60 mmHg
*HR- 160 bpm
Tachycardia

DAY1:
* no murmur
*BP- 100/60 mmHg
*HR- 107 bpm
Tachycardia

DAY2:
* no murmur
*BP- 100/60 mmHg
*HR- 100bpm
Tachycardia

TACHYCARDIA
Areas Assessed

Subjective Findings

Objective Findings

Problem Identified

Breast and Axilla

Did not verbalize
any cues.
INITIAL VISIT:
*no discharge
*symmetrical in
shape
* fair color
DAY1:
*no discharge
*symmetrical in
shape
* fair color
DAY2:
*no discharge
*symmetrical in
shape
* fair color

No identified
problem
Areas Assessed

Subjective Findings

Objective Findings

Problem Identified

Gastrointestinal
System and the
Abdomen

No subjective data INITIAL VISIT:
*soft, globular,
normal active
bowel sound
*nondistended
Nontender
DAY1:
*soft, globular,
normal active
bowel sound
*nondistended
Nontender
DAY2:
*soft, globular,
normal active
bowel sound
*nondistended
Nontender


No identified
problem
Areas Assessed

Subjective Findings

Objective Findings

Problem Identified

Genitourinary
System/
Reproductive
System

No subjective data
INITIAL VISIT:
*Equal in size of RS.
*no discharges
*yellowish urine
No pain upon voiding
as claimed
Brown stool
DAY1:
*Equal in size of RS
*no discharges
*yellowish urine
No pain upon voiding
as claimed
DAY2:
*Equal in size of RS
*no discharges
*yellowish urine
No pain upon voiding
as claimed
No identified
problem
Areas Assessed

Subjective Findings

Objective Findings

Problem Identified

Musculoskeletal
System

Did not verbalize
any cues
INITIAL VISIT:
Sitting on bed

*arm circumference
are equal
Can touch her nose
and toes
DAY1:
*arm circumference
are equal
Can touch her nose
and toes
DAY2:
*arm circumference
are equal
Can touch her nose
and toes
No problem
identified
Areas Assessed

Subjective Findings

Objective Findings

Problem Identified

Neurologic System

No subjective data INITIAL VISIT:
*awake, respond to
pain but not crying
by grimacing face

No identified
problem
Lymphatic/
Hematologic
Did not verbalize
any cues

Hyperthermia
related to infection







NORMAL ANANTOMY AND
PHYSIOLOGY OF RESPIRATORY
SYSTEM


Organs 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. 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.



The Nose


The uppermost portion of the human respiratory system, the nose
is a hollow air passage that functions in breathing and in the sense
of smell. The nasal cavity moistens and warms incoming air, while
small hairs and mucus filter out harmful particles and
microorganisms. This illustration depicts the interior of the human
nose. The prominent structure between the eyes that serves as the
entrance to the respiratory tract and contains the olfactory organ. It
provides air for respiration, serves the sense of smell, conditions
the air by filtering, warming, and moistening it, and cleans itself of
foreign debris extracted from inhalations.


The Trachea, Bronchi Aviolar Ducts
and Avioli

The trachea (windpipe) divides into two main bronchi (also mainstem bronchi), the
left and the right, at the level of the sternal angle at the anatomical point known
as the carina. The right main bronchus is wider, shorter, and more vertical than the
left main bronchus. The right main bronchus subdivides into three lobar bronchi
while the left main bronchus divides into two. The lobar bronchi divide into
tertiary bronchi, also known as segmental bronchi, each of which supplies a
bronchopulmonary segment. A bronchopulmonary segment is a division of a lung
that is separated from the rest of the lung by a connective tissue septum.. This
property allows a bronchopulmonary segment to be surgically removed without
affecting other segments. There are ten segments per lung, but due to anatomic
development, several segmental bronchi in the left lung fuse, giving rise to eight.
The segmental bronchi divide into many primary bronchioles which divide into
terminal bronchioles, each of which then gives rise to several respiratory
bronchioles, which go on to divide into 2 to 11 alveolar ducts. There are 5 or 6
alveolar sacs associated with each alveolar duct. The alveolus is the basic
anatomical unit of gas exchange in the lung.
There is hyaline cartilage present in the bronchi, present as irregular rings in the
larger bronchi (and not as regular as in the trachea), and as small plates and
islands in the smaller bronchi. Smooth muscle is present continuously around the
bronchi.
In the mediastinum, at the level of the fifth thoracic vertebra, the trachea divides
into the right and left primary bronchi. The bronchi branch into smaller and
smaller passageways until they terminate in tiny air sacs called alveoli.
The cartilage and mucous membrane of the primary bronchi are similar to that in
the trachea. As the branching continues through the bronchial tree, the amount of
hyaline cartilage in the walls decreases until it is absent in the smallest
bronchioles. As the cartilage decreases, the amount of smooth muscle increases.
The mucous membrane also undergoes a transition from ciliated pseudostratified
columnar epithelium to simple cuboidal epithelium to simple squamous
epithelium.


The alveolar ducts and alveoli consist primarily of simple
squamous epithelium, which permits rapid diffusion of oxygen
and carbon dioxide. Exchange of gases between the air in the
lungs and the blood in the capillaries occurs across the walls
of the alveolar ducts and alveoli

The Lungs

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. 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.


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 the pleural 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 alveoli 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.






CONCEPT MAP








DIAGNOSTIC TESTS








DRUG STUDY

GENERIC
NAME
BRAND
NAME
INDICATION GENERAL
ACTION/
MECHANISM
OF ACTION
SIDE EFFECTS
& ADVERSE
REACTIONS
NURSING
IMPLICATION
Ambroxol

3/1/14
30mg 5ml
BID p.o
Mucosolvan Adjuvant
therapy in
patients with
abnormal,
viscid, or
inspissated
mucous
secretions in
acute and
chronic
bronchopulm
onary
diseases, and
in pulmonary
complication
s of cystic
fibrosis and
surgery.
It makes
phlegm in
the airways
thinner and
less sticky
Mild GI
effects and
allergic
reactions
Monitor
S&S of
aspiration of
excess
secretions,
and for
bronchospas
m
Report
difficulty
with clearing
the airway or
any other
respiratory
distress
GENERIC
NAME
BRAND
NAME
INDICATION GENERAL
ACTION/
MECHANIS
M OF
ACTION
SIDE
EFFECTS &
ADVERSE
REACTIONS
NURSING
IMPLICATIO
NS
Cefuroxime

3/1/14
500mg q 6h
IVTT ANST
Aerginox It is effective
for the
treatment of
penicillinase
-producing
Neisseria
gonorrhea.
Effectively
treats bone
and joint
infections,
bronchitis,
meningitis,
respiratory
tract
infections
Bactericidal:
Inhibits
synthesis of
bacterial cell
wall, causing
cell death.
GI:
Diarrhea,
nausea,
antibiotic-
associated
colitis
Skin: Rash,
pruritus,
urticaria
Urogenital:
Increased
serum
creatinine,
and BUN
decreased
creatinine
clearance
Determine
history of
hypersensiti
vity
reactions to
cephalospor
ins,
penicillins,
and history
of allergies,
particularly
to drugs,
before
therapy is
initiated.
Monitor
I&O rates
and pattern
GENERIC
NAME
BRAND
NAME
INDICATION GENEREAL
ACTION/
MECHANIS
M OF
ACTION
SIDE
EFFECTS &
ADVERSE
REACTIONS
NURSING
IMPLICATIO
N
Cetirizine Zyrix

3/5/14
5ml BID P.O
prn for
itchiness
Treatment
of chronic
idiopathicur
ticaria
pruritus,ecz
ema
dermatitis
as adjuvant
with therapy
with
hydrocortiso
ne external
preparation,
seasonal
Long lasting
non-
sedating
antihistamin
e that
selectively
inhibits
peripheral
H1
receptors
Fatigue,
dizziness,
coughing,
epistaxis,
bronchospas
m, sore
throat,
drowsiness,
headache

GI
disturbance:
dry mouth
Assess for
allergic
symptoms:
Rhinitis,
pruritus,
urticaria,
watering
eyes, before
and
periodically
during
treatment
GENERIC
NAME

BRAND
NAME

INDICATION

GENEREAL
ACTION/
MECHANIS
M OF
ACTION

SIDE
EFFECTS &
ADVERSE
REACTIONS

NURSING
IMPLICATIO
N

Ranitidine

3/1/14
25mg q 8h
IVTT
Managemen
t of GI
disorders,
GERD, peptic
ulcer
Inhibits the
action of
histamine at
the H2
receptor site
located
primarily in
gastric parietal
cells, resulting
in inhibition of
gastric acid
secretion has
some
antibacterial
action against
H. pylori
Diarrhea,
dizziness,
tiredness,
headache
and rash,
fever
Instruct
patient not
to take new
medication
without
consulting
the doctor
allow one
hour
between any
antacid and
ranitidine

GENERIC
NAME

BRAND
NAME

INDICATION

GENEREAL
ACTION/
MECHANISM
OF ACTION

SIDE
EFFECTS &
ADVERSE
REACTIONS

NURSING
IMPLICATIO
N

Paracetamol

3/5/14
250mg 7.5ml
q 4h p.o RTC
Fever
Exhibits
analgesic action
by peripheral
blockage of pain
impulse
generation. It
produces
antipyretics by
inhibiting the
hypothalamic
heat-regulating
centre. Its weak
anti-
inflammatory
activity is related
to inhibition of
prostaglandin
synthesis in the
CNS.
Nausea,
allergic
reactions, skin
rashes, acute
renal tubular
necrosis.
POTENTIALLY
FATAL: very
rare, blood
dyscrisias.
(e.g.
thrombocytop
enia,
leucopenia,
neutropenia,
agranulocytosi
s) liver
damage.
: Monitor
Vital signs
accordingly.
: Administer
medications
on time.
: Document
the time
medication
administratio
n.

NURSING CARE PLANS



Problem Identified: Difficulty of breathing

Nursing Diagnosis: Ineffective airway clearance related to
increase tracheobrochial secretions.

Cause Analysis: When a disease interferes with the transfer of
oxygen and carbon dioxide within the lungs, the bodys tissues
begin to suffer and signal their need for more adequate
breathing. Reflexly, the child goes through the motions of
faster and deeper breathing even though the speed up does
not remove the fundamental difficulty. (Modern Medical
Guide Harold Shryock, M.D. pg 201)
Cues:
Subjective:
Nahihirapan huminga ang anak ko, as verbalized by the
patients mother.

Objective:
Wide eyed
Restlessness
Cyanosis
Dyspnea

Expected Outcome
STO:

After 4 hours of nursing intervention, the patient will be able
to maintain airway patency.

LTO:

After 8 hours of nursing intervention, the patient will be able
to demonstrate reduction of congestion as manifested by
absence of cyanosis.
Nursing Interventions
Independent actions:

Monitor respirations and breathe sounds, noting rate and sounds.
Evaluate patients cough or gag reflex and swallowing ability.
Monitor for feeding intolerance, abdominal distention, and emotional
stressors.
Position head appropriate for age and condition.
Suction naso/tracheal/oral as needed.
Elevate head of bed and change position every 2 hours and as needed.

Dependent actions:

Administer oxygenation
Rationale
Independent actions:

To assess indications of respiratory distress and/or accumulation of
secretions.
To determine ability to protect own airway.
It may compromise airway.
To open or maintain open airway in at-rest or compromised individual.
To clear airway when excessive or viscous secretions are blocking airway
or patient is unable to swallow or cough effectively.
To take advantage of gravity decreasing pressure on the diaphragm and
enhancing drainage of ventilation different lung segments.

Dependent actions:

To support for ventilation.
Evaluation
STO:
Goal met, the patient maintained airway patency.

LTO:
Goal met, the patient demonstrated reduction of congestion
as manifested by absence of cyanosis.

References: Daviss Nurses Pocket Guide, pg. 80-84

Problem Identified: Increased body temperature

Nursing Diagnosis: Increased body temperature related to infection
secondary to Pneumonia

Cause Analysis: Optimal conditions of health it is maintained at a
surprisingly constant level by the reflex regulation of heat production and
heat elimination. The body responds to infections and inflammations, as
well as to tissue destruction, by fever which increases the rate at which
the immune system functions. However, when the body produces excess
heat than it can dissipate, it can lead to a faulty thermoregulatory state
that can lead to heat-stroke or severe dehydration. (Modern Medical
Guide Harold Shryock, M.D. pg 217)

Cues
Subjectives:
Dugay na ni iyang lanat sugod pa tong nag pa admit me
diri as verbalized by the s.o.

Objective:
T- 38.5 C
BP- 100/6 0mmHg
Flushed skin
Tachycardia
Expected Outcome
STO:
After 2 hours of nursing intervention, the
patient will be able to maintain core
temperature within normal range.

LTO:
After 8 hours of nursing intervention, the
patient will be able to be free from seizure
activity.
Nursing Interventions
Independent actions:

Monitor core temperature.
Monitor respirations.
Promote surface cooling by warm compress of luke warm water.
Clean the child.
Provide cotton blankets and wrap extremities.

Collaborative actions:

Administer antipyretic, as needed.
Paracetamol 250 mg q 4

Administer replacement fluids and electrolytes.

Rationale
Independent actions:
To evaluate effects and/or degree of hyperthermia.
Hyperventilation may initially be present, but ventilator effort may
eventually be impaired by seizures, hypermetabolic state.
To decrease surface temperature by heat loss by evaporation and
conduction.
To provide comfort.
To minimize shivering.

Collaborative actions:
To alleviate hyperthermia.
To support circulating volume and tissue perfusion.
Evaluation
STO:
Goal, the patient maintained core temperature within normal
range.

LTO:
Goal met, the patient was able to be free from seizure activity.

References: Daviss Nurses Pocket Guide, pg. 439-444


Problem Identified: loss of appetite

Nursing Diagnosis: Risk for imbalanced nutrition: less than
body requirements related to loss of appetite

Cause Analysis: Body tissues are built of the food elements of
the diet. If necessary nutritional elements are lacking in the
diet, the body suffers accordingly. The ability to resist
producing germs depends in part upon the adequacy of the
diet. The outcome of a given infection depends not only upon
the nature of the germs but also upon the quality if the diet. If
the intake is reduced due to poor food quality, quantity or
appetite, nutrition is negatively affected. (Modern Medical
Guide Harold shryock, M.D. pg 98)

Cues
Subjective:
dili niya mahurot ang pagkaon, gamay ra kaau
iyang kaunon, as verbalized by the s.o.

Objective:
Body weight: 24.8 kg
Reported food intake
BMI:15.4
Weakness of muscles
Expected Outcome
STO:
After 6 hours of nursing intervention, the
patients s.o. will be able to identify causative
factors when known and necessary interventions.

LTO:
After 8 hours of nursing intervention, the
patients s.o. will be able to demonstrate
progressive weight gain toward goal.

Nursing Interventions
Independent actions:
Assess weight; measure or calculate body fat
Assess drug interactions, disease effects and allergies.
Note age, activity and rest levels.
Evaluate total food intake. Obtain calorie intake, patterns, and
time of feeding.
Encourage patients s.o. to feed the child nutritious foods,
vegetables and fruits that is rich in vitamin c.
Collaborative actions:
1. administer IV therapy
2.Consult dietician or nutritional team, as needed.
Rationale
Independent actions:
To establish baseline parameters.
That may be affecting appetite, food intake, or absorption.
Helps determine nutritional needs.
To reveal possible cause of malnutrition and changes that
could be made in patients intake.

Collaborative:
To promote fluid balance and prevent dehydration.
To provide diet modifications, as indicated.
Evaluation
STO:
Goal met, the patients mother identified causative factors
when known and necessary interventions.

LTO:
Goal met, the patients s.o. demonstrated progressive weight
gain toward goal.

References: Daviss Nurses Pocket Guide, pg. 564-569


DISCHARGE PLAN
Medications Dosage/Frequency Nursing Instruction
Cetirizine (zyrix)


Nutrizine


5ml 1x a day


5ml 1x a day
take medication exactly as
directed and not to take
more than the
recommended amount.


Shake drug well before
administration.


HEALTH TEACHINGS:

OBJECTIVES:
After 1 and 30 minutes of health teachings:
The mother should be able to provide an environment conducive for child
health.
Be able to enhance the care that will be given for the child
Explain the importance of maintaining a proper hygiene..
The mothers client will be able to follow the schedule of immunizations
for pneumonia.
MATERIALS NEEDED:
Visual aids
Illustrations
Laptop

GENERAL HEALTH TEACHINGS SPECIFIC HEALTH TEACHINGS
ENVIRONMENTAL SANITATION
Instruct grandmother to keep child
away from smoke/ smoke free
because it will make symptoms
worse.
Encourage grandmother to keep
environment clear of potential
allergens.
Encourage grandmother to pay
attention to the weather and take
precautions when weather or
air pollution conditions may affect the
child. .
Encourage mother to provide well-
ventilated area.
Encourage mother to keep child
always clean and dry.
GENERAL HEALTH TEACHINGS

SPECIFIC HEALTH TEACHINGS

HYGIENE Encourage and explain grandmother that
it Is important to maintain proper hygiene
to prevent further infection.
Instruct grandmother to bath her grand
daughter everyday and explain that
bathing early in the morning is not a
factor or cause of having pneumonia. .
Encourage the guardians to wash
patient's hands. The hands come in daily
contact with germs that can cause
pneumonia. These germs enter one's
body when she touch her eyes or rub her
nose.
Encourage washing hands thoroughly
and often can help reduce and often can
help reduce the risk.

GENERAL HEALTH TEACHINGS

SPECIFIC HEALTH TEACHINGS

REST AND SLEEP Provide adequate rest and sleep. It
should be 8 hours of sleep and take a nap
in the afternoon.
Have a regular periods of rest everyday.
IMMUNIZATION for pneumonia Encourage mother to visit health center
for immunization of her child.
Explain and give information to mother
the importance of immunization for
pneumonia
OPD VISITS/REFERRALS:
Follow up check-up as needed at Dr. Canoys clinic
DIET:
Diet as tolerated.
Increased intake of fruits and vegetables.
Increased oral fluid intake.
SPIRITUAL CARE:
Encourage to read the Bible, say a prayer to God to give thanks for the
guidance provided throughout the recovery, and to strength faith in God.


MEDICAL MANAGEMENT

Dengue fever is usually a self-limited illness. There is no specific antiviral
treatment currently available for dengue fever.

Supportive care with analgesics, fluid replacement, and bed rest is usually
sufficient. Acetaminophen may be used to treat fever and relieve other
symptoms. Aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and
corticosteroids should be avoided. Management of severe dengue
requires careful attention to fluid management and proactive treatment of
hemorrhage

WHAT TO DO:

Cases of Dengue fever/Dengue Haemorrhagic Fever (DF/DHF)
should be observed every hour.

Serial platelet and haematocrit determinations, drop in
platelets and rise in haematocrits are essential for early
diagnosis of DHF.

Timely intravenous therapy in isotonic crystalloid solution can
prevent shock and/or lessen its severity.

If the patients condition becomes worse despite giving 20ml/kg/hr for one hour,
replace crystalloid
solution with colloid solution such as Dextran or plasma. As soon as improvement
occurs, replace
with crystalloid.
If improvement occurs, reduce the speed from 20 ml to 10 ml, then to 6 ml, and
finally to 3 ml/kg.
If haematocrit falls, give blood transfusion 10 ml/kg and then give crystalloid IV
fluids at the rate of
10ml/kg/hr.
In case of severe bleeding, give fresh blood transfusion about 20 ml/kg for two
hours. Then give
crystalloid at 10 ml/kg/hr for a short time (30-60 minutes) and later reduce the
speed.
In case of shock, give oxygen.
For correction of acidosis (sign: deep breathing), use sodium bicarbonate.


PROGNOSIS

Small children who develop pneumonia and survive are at risk for
developing lung problems in adulthood, including chronic obstructive
pulmonary disease (COPD). Research suggests that men with a history of
pneumonia and other respiratory illnesses in childhood are more than twice
as likely to die of COPD as those without a history of childhood respiratory
disease.
Men with community-acquired pneumonia tend to fare worse than women.
Men are 30% more likely than women to die from the condition, even if the
severity of the illness is the same. Researchers say there may be some
genetic reason for the disparity.
Children have higher risk of acquiring pneumonia because of lack of
immunization and inadequate or absence of breast milk. Caregivers who are
of less interest and have less skills to take care of an infant increases the
chance of acquiring pneumonia.

Treatment is more likely to produce results if the patient and the family are
compliant to the treatment regimen. Discharging against medical advice
decreases the effectiveness of the treatment. It also increases the chance of
relapse, and increases mortality rates.

In the years 2001-2005, Pneumonia was the 5
th
leading cause of death in the
Philippines. An estimated 33,764 people died from the disease. As of 2006,
Pneumonia-related deaths increased to 34, 958 deaths with a rate of 40.2
and remained at the 5
th
spot.

Among children between 1-5 years old, pneumococcal diseases can lead to
death, paralysis, mental retardation, seizures, learning disabilities and
hearing loss.


REFERENCES

Daviss Nurses Pocket Guide

Nursing Drug Handbook by Lippinccott, 2008

Maternal and Child Health Nursing by Adele Pellitteri

Modern Medical Guide by Harold Shryock

Medical Surgical Book

Wongs Pediatric Nursing on Child Illnesses