A CASE STUDY ON PEDIATRIC

COMMUNITY ACQUIRED
PNEUMONIA-D

In partial fulfillment of the requirements

in RLE
in the Pediatric ward
PERSONAL DATA
 NAME: LEPTING, Lenny Mae Bagano
AGE: 1 year and 7 months old
SEX: Female
BIRTHDATE: January 1, 2015
ADDRESS: Colong, Ampusong, Bakun, Benguet
RELIGION: Wesleyan
DATE OF ADMISSION: August 13, 2016
CHIEF COMPLAINT/S: The patient had
difficulty of breathing, intermittent fever, and
I.HEALTH
HISTORY
 A.PRESENT ILLNESS
About 4 days prior to admission (PTA) (August
9, 2016), patient had febrile episode,
undocumented. Two days prior to admission
(August 11, 2016), patient had coughing
episode, still with associated fever. This
prompted consult at nearby district hospital
and was admitted. One day prior to admission
(August 12, 2016), patient was noted to have
fast breathing with progression of cough.
Patient was discharged upon request and was
 B. PAST HISTORY
The patient was born with Down syndrome
and has no OTHER chronic diseases/illnesses.
She is fully immunized. No history of allergies.
Patient had two times history of fall with
consent.
She was previously hospitalized on December
2015 and recently on July 19 to August 3,
2016. The recent hospitalization is due to
PCAP-C, PDA and Down syndrome and she
was maintained on furosemide.
 C. FAMILY HEALTH HISTORY
With regards to Down syndrome history, the
mother stated that there are no known cases
in the family that is similar to the patients
condition. The mother has Hypertension and
the rest of the family members have no
reported diseases/illnesses.
II.DEVELOPMENTAL
DATA
 ERIKSONS STAGES OFDEVELOPMENT
Early childhood=18 months-3 years old
Autonomy vs. Shame and Doubt
HAVIGHURTSTS AGE PERIODS AND
DEVELOPMENTAL TASKS
Infancy and Early Childhood
FRUEDS STAGES OF DEVELOPMENT
Anal=1 year and 6months-3 years old
III.ASSESSMENT
 A.PSYCHOSOCIAL STATUS
The patient is a 1-year old Kankana-ey female
born with Down syndrome. She responds with
smiles and laugh whenever someone is
playing or talking with her. She is Wesleyan in
religion. All the needs of the patient are being
provided by the mother.
 B.MENTAL AND EMOTIONAL
STATUS
Patient was seen awake and alert with no
signs of distress. She is not well oriented to
her surroundings. During our shift, patient
seems to be slightly irritable and intolerant of
a crowd. She expresses her ________ through
crying.
 C.ENVIRONMENTAL STATUS
The patients bed is along the hallway; with
bed side rails. The hallway is not that spacious
enough for them to move freely. There was an
adequate ventilation and lighting. The floor
was well-maintained and non-slippery. A clean
comfort room with sufficient water supply was
available. There are occasional noises heard
because some patients were crying. Bed
sheets were observed to be clean with enough
blankets.
 D.SENSORY STATUS
a. Visual status
Patient has Mongolian eyes slant common
with Down syndrome patients. Her eyes move
towards sounds/voices.
b. Auditory Status
Upon assessment, no visible lumps or lesions
noted. Corrective devices used as hearing aids
and discharges were not noted.
a. Olfactory status
Patients nose was seen to be symmetrical,
proportionate and no lesions seen.

b. Gustatory Status
Patient has no difficulty in masticating and
swallowing but with decreased appetite.
a. Tactile Status
Facial sensations are intact and symmetrical
on both sides. She is able to perceive heat,
cold and pain sensations.

b. Language Perception and Formation

The patient does not talk.
 E. MOTOR STATUS
Patient can sit with support and stands with
support. No tremors and deformity noted on
both upper and lower extremities. Upper
extremities are symmetrical as the lower
extremities. Peripheral pulses were present
such as radial. Extremities are warm to touch.
 F. NUTRITIONAL SATUS
The patient eats solid foods and on
breastfeeding. The patient had decreased
appetite; during our shift she consumed 40%
of the food that was served. The patient is
small for her age. Parents see foods as a
source of energy. Patient has no known food
allergies and favors eating potatoes. Abdomen
is globular upon inspection, hard and taut to
the touch.
 G.ELIMINATION
Patients frequency of urination is estimated
to be 2 times per shift at approximately 200
cc.
H.FLUID AND ELECTROLYTE STATUS
Patient is able to consume about 200 cc of
water and is breastfed at least 2 times per
shift for 10-15 minutes. Patients skin is fair
and has pinkish nail beds. No signs of
dehydration noted as well as edema.
 I.TEMPERATURE STATUS

During our shift the patients temperature was

an average of 37 degrees Celsius, per axillary
upon the initial vital signs taking. The ward is
adequately ventilated; she had used only a
blanket, with clothes made of cotton not
greatly affecting the clients temperature.
 J.RESPIRATORY
During our shift she had a respiratory rate of---
in average. No use of accessory muscles
noted. Chest wall symmetrically expands with
each respiration and no retractions seen. Non
cyanotic
 K.CARDIOVASCULAR
During our shift the patient had an average of-
--for her pulse rate. She had a normal capillary
refill of 1-2 seconds. No edema, non-cyanotic
and no heart murmurs upon auscultation.
 L. INTEGUMENTARY STATUS
Patients skin is dry, generally fair, without
pigmentations, no pallor, no jaundice, and no
cyanosis noted. She had a good skin turgor.
Inspected no sores or wounds.
Her nail beds were soft when palpated, with
capillary refill of 1-2 seconds. Her hair is dry,
evenly distributed, no parasite infestations,
and well-trimmed.
 M. COMFORT AND REST
The patient experienced occasional sleep
disturbance as verbalized by mother.
 IV.
PATHOPHYSIOLOG
Y
OF
PRESENT ILLNESS
V. MEDICAL TREATMENT
AND MANAGEMENT
INCLUDINGPROCEDURES
AND ITS IMPLICATION
TO NURSING
 1. X-RAY
CHEST:
Follow up study since 7-22-16 shows a
progression in the alveolar opacities in both
lungs. There is emergence of dense opacity in
the right lateral hemithorax extending into the
apex. Thea heart is normal size and
configuration.
Visualized osseous structures are
unremarkable.
 1. X-RAY
CHEST:
Follow up study since 7-22-16 shows a
progression in the alveolar opacities in both
lungs. There is emergence of dense opacity in
the right lateral hemithorax extending into the
apex. Thea heart is normal size and
configuration.
Visualized osseous structures are
unremarkable.
IMPRESSION:
CARDIOMEGALY WITH ALVEILAR EDEMA
PNEUMONIA, BOTH LUNGS WITH
CONSOLIDATION IN THE RIGHT LOWER LOBE
AND LEFT UPPER LOBE
MINIMAL PLEURAL EFFUSION, RIGHT
 Nursing
implications and
procedure:
 Positively identify the patient using at least two unique identifiers before providing
PRE-TEST:

care, treatment, or services.

Inform the caregiver that the procedure assesses cardiopulmonary status.

Obtain a history of the patients symptoms and complaints, including a list of

known allergens.

Obtain a history of the patients cardiovascular and respiratory system, symptoms,

and results of previously performed laboratory tests and diagnostic and surgical
procedures.

Obtain a list of the patients current medications, including herbs, nutritional

supplements, and nutraceuticals.

Review the procedure with the caregiver. Address concerns about pain and explain
that no pain will be experienced during the test. Inform the caregiver that the
procedure is performed in the radiology department and takes approximately 5 to
15 min.

Sensitivity to social and cultural issues, as well as concern for modesty, is

important in providing psychological support before, during, and after the
 Ensure that theINTRA-TEST:
patient has removed all
external metallic objects from the area to be
examined.
Patients are given a gown, robe, and foot
coverings to wear.
Instruct the patient to cooperate fully and to
follow directions. Instruct the
Patient to remain still throughout the
procedure because movement produces
unreliable results.
 Recognize anxiety POST-TEST
related to test results and
be supportive of impaired activity related to
respiratory capacity and perceived loss of
physical activity.
Discuss the implications of abnormal test
results on the patients lifestyle.
Provide teaching and information regarding
the clinical implications of the test results, as
appropriate.
Reinforce information given by the patients
 TEST NAME RESULT REFERENCE RANGE
Hemoglobin
Hematocrit
2. CBC Count
122
0.37
110-160 g/L
0.37-0.54 L/L
WBC Count 11.85 5.0-10.0
DIFFERENTIAL COUNT
Neutrophils 0.59 0.50-0.70 %
Lymphocytes 0.37 0.20-0.40 %
Monocytes 0.02 0.0-0.10%
Eosinophils 0.02 0.0-0.7%
Basophils 0.00 0.0-0.01%
Total 1.00
RBC COUNT 4.12 4.04-5.48 1012/L
Platelet Count 169 150-400 109/L
RBC INDICES
MCV 90.60 80-100fL
MCH 29.60 27-31 pg
MCHC 327.00 310-360 g/L
RDW-CV 14.80 11-16 %
RDW-SD 56.80 35-56 fL
Nursing Implications
and procedures:
 PRE-TEST

Positively identify the

patient using at least
two unique identifiers
 INTRATEST:
If the patient has a history of allergic
reaction to latex, avoid the use of
equipment containing latex.
Instruct the patient to cooperate fully and
to follow directions. Direct the patient to
breathe normally and to avoid unnecessary
movement.
Positively identify the patient, and label the
appropriate tubes with the corresponding
 A report of thePOST-TEST:
results will be sent to the
requesting HCP, who will discuss the results
with the patient'.
Nutritional considerations: Instruct caregiver
to let patient consume a variety of foods
within the basic food groups, maintain a
healthy weight, be physically active.
Reinforce information given by the patients
HCP regarding further testing, treatment, or
referral to another HCP.
 Chemistry
SI Unit Conventional Unit

Test Name Result Unit Range Result Unit Range

Sodium 144 mmol/L 136-154

Potassium 5.59 mmol/L 3.5-5.1

Chloride 104 mmol/L 98-107

Total Calcium 2.01 mmol/L 2.12-2.52 8.04 mg/dL 8.5-10.1

 Nursing
implications and
procedures:
 Obtain a historyPRETEST:
of the patients complaints,
including a list of known allergens.
Obtain a history of the patients
cardiovascular, endocrine, gastrointestinal,
genitourinary, immune, and respiratory
systems, as well as results of previously
performed tests and procedures. For related
tests, refer to the cardiovascular, endocrine,
gastrointestinal, genitourinary, immune, and
respiratory system tables.
 INTRATEST:
Direct the patient to breathe normally and to
avoid unnecessary movement. Instruct patient
not to clench and unclench the fist
immediately before or during specimen
collection.
Observe standard precautions and perform a
venipuncture, and collect the specimen in a 5-
mL red- or tiger-top tube.
Label the specimen, and promptly transport it
to the laboratory.
 POST-TEST:
Observe venipuncture site for bleeding or
hematoma formation. Apply pressure
bandage.
Potassium is present in all plant and animal
cells, making dietary replacement simple to
achieve in the potassium-deficient patient.
Observe the patient for signs and
symptoms of fluid-volume excess related to
excess potassium intake, fluid-volume
deficit related to active loss, or risk of injury
 If appropriate, educate patients with low
sodium levels that the major source of dietary
sodium is found in table salt. Many foods,
such as milk and other dairy products, are also
good sources of dietary sodium. Most other
dietary sodium is available through the
consumption of processed foods. Patients on
low sodium diets should be advised to avoid
beverages such as colas, ginger ale, sports
drinks, lemon-lime sodas, and root beer. Many
over-the counter medications including
antacids, laxatives, analgesics, sedatives, and
antitussives contain significant amounts of
 Patients with abnormal calcium values
should be informed that daily intake of
calcium is important even though body
stores in the bones can be called on to
supplement circulating levels. Dietary
calcium can be obtained from animal or
plant sources. Milk and milk products,
sardines, clams, oysters, salmon, rhubarb,
spinach, beet greens, broccoli, kale, tofu,
legumes, and fortified orange juice are high
in calcium. Milk and milk products also
contain vitamin D and lactose, which assist
 Evaluate test results in relation to the patients
symptoms and other tests performed. Related
laboratory tests include aldosterone,
arterial/alveolar oxygen ratio, anion gap,
blood gases, calcium, digoxin, electrolytes,
and osmolality. (Davids Comprehensive
Handbook of Laboratory and Diagnostic Tests
with Nursing Implications, 262, 814, 896)
VI. PRIORITIZATIONOF
NURSING PROBLEMS
1. Ineffective Airway Clearance

2. Risk for Fall

VII. EVALUATION AND
IMPLICATION OF THIS
STUDY TO:
A. Nursing Practice- This study deals greatly on
genetic and respiratory issues. When talking
about the sick, nurses have their therapeutic
duties. Breathing is an essential act for every
human being in order to maintain homeostasis.
In this case it requires the nurses
consciousness because he/she needs to monitor
and respond quickly to respiratory distress
B. Nursing education- In this case a nurse must
be knowledgeable on respiratory system.
Someone who works with respiratory problems
is at risk of catching similar diseases/illnesses.

C. Nursing research-based on the condition of

our patient it took more days for high risk
pneumonia to be treated.
VIII. REFERRAL AND
FOLLOW-UP
 The patient was discharged on august 24,
2016 (Wednesday) and was scheduled for a
follow-up on--