Loraine Pneumonia

8/8/2019 Loraine Pneumonia

1/11

Introduction

Pneumonia is an inflammation of the lungs caused by an infection. It is also called

Pneumonitis or Bronchopneumonia. Pneumonia can be a serious threat to our health.

Although pneumonia is a special concern for older adults and those with chronic

illnesses, it can also strike young, healthy people as well. It is a common illness that

affects thousands of people each year in the Philippines, thus, it remains an important

cause of morbidity and mortality in the country.

There are many kinds of pneumonia that range in seriousness from mild to life-

threatening. In infectious pneumonia, bacteria, viruses, fungi or other organisms attack

your lungs, leading to inflammation that makes it hard to breathe. Pneumonia can affect

one or both lungs. In the young and healthy, early treatment with antibiotics can cure

bacterial pneumonia. The drugs used to fight pneumonia are determined by the germ

causing the pneumonia and the judgment of the doctor. Its best to do everything we can

to prevent pneumonia, but if one do get sick, recognizing and treating the disease early

offers the best chance for a full recovery.

A case with a diagnosis of Pneumonia may catch ones attention, though thedisease is just like an ordinary cough and fever, it can lead to death especially when no

intervention or care is done. Since the case is a toddler, an appropriate care has to be done

to make the patients recovery faster. Treating patients withpneumonia is necessary to

prevent its spread to others and make them as another victim of this illness.


2/11

ANATOMY AND PHYSIOLOGY

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 andreleasing 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 sideof 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.


3/11

NURSING PROFILE

a. Patients Profile

Name: R.C.S.B.

Age: 1 yr,1 mo.

Weight:10 kgs

Religion: Roman Catholic

Mother: C.B.

Address: Valenzuela City

b. Chief Complaint: Fever

Date of Admission: 1st admission

Hospital Number: 060000086199

c. History of Present Illness

2 days PTA (+) cough

(+) nasal congestion, watery to greenish

(+) nasal discharge

Tx: Disudrin OD

Loviscol OD

Few hrs PTA - (+) fever, Tmax= 39.3 C

(+) difficulty of breathing

(+) vomiting, 1 episode

Tx: Paracetamol

Sought consultation at ER: Rx=BPN, Salbutamol neb.

IE: T = 38.3C, CR= 122s, RR= 30s


4/11

(+) TPC

SCE, (-) retractions, clear BS, (-) cyanosis, (-) edema

d. Past Illness

(-) asthma

(-) allergies

e. Family History

PMHx: (+) asthma (mother)

f. Activities of Daily Living

Sleeping mostly at night and during afternoon

Usually wakes up early in the morning (5AM) to be milkfed.

Eats a lot (hotdogs, chicken, crackers, any food given to her)

Active, responsive

BM (1-2 times a day)

Urinates in her diaper (more than 4 times a day)

Likes to play with those around her

g. Review of Systems

Neuromuscular: weakness of muscles

Integumentary: (-) cyanosis

Respiratory: tavhypnea; (+) DOB; (+) coarse crackles, (+) wheezes,

Digestive: food aversion, vomits ingested milk


5/11


6/11

Salbutamol Ventolin

Syrup

2

adrenoceptor

agonistacts on the 2

adrenoceptors ofbronchial

muscle, with

little or no action

on the -1

adrenoceptors of

the heart.1 tbsp

3x a day

Bronchospasm &

excessive

secretions of

tenacious mucus

(e.g. bronchial

asthma, chronicasthma, chronic

bronchitis)Hypokalemia,

tachycardia, tremor,

muscle cramps

> Administer medicine at

the time specified or as

close to that time as

possibleif there is a

delay, document it.> Evaluate client's

condition and medication

compatibility

Paracetamol Omol Syrup Anti-pyretic

Analgesic

reducing the

activity of the

cyclooxygenase(COX)

enzyme; this

enzyme

participates in

the production of

prostaglandins

which in turn are

involved in thepain and fever

processes.125/vol

5ml every

6 hrsRelief of pain &

for rapid lowering

of fever in

bronchitis

Allergic reactions, GI

disturbances

> Administer medicine at

the time specified or asclose to that time as

possibleif there is a

delay, document it.


7/11


8/11

CUES NURSING

S> Nahihirapan yatasyang huminga saka

lagi na lang sumusukang plema, as

verbalized by the Pts

grandmother.

O> (+) sputumproductionRapid, shallow

breathing(+) crackles,

Nsg Dx

Ineffective

AirwayClearance

related toinability to

maintain clear

airway ascharacterized

by (+) sputum,(+) crackles,

rapid & shallow

breathing

Sci Ex

Bacterial

microorganismenter the airwaysInflammation ofthe lung/sAir sacs filledwith pus & otherliquidsPresence ofobstructions in theairways

Inability to

breathe properly

Plan

After 8 hours ofNursing

Intervention, thePts breathing

will have no

moreadventitious

sounds present(crackles/gargles)

when auscultated

nsg. Int

Monitorrespiratory patterns,including rate, depth,and effort.> Assist withclearing secretions

from pharynx byoffering tissues andgentle suction of theoral pharynx ifnecessary> Provide posturaldrainage, percussion,and vibration as

ordered> Administer

medications such asbronchodilators or

inhaled steroids asordered.

Rat

With secretions in theairway, the respiratoryrate will increase> It is preferable for theclient to cough upsecretions. Gentle

suctioning of theposterior pharynx may

stimulate coughing andhelp remove secretions> Chest physicaltherapy helps mobilize

bronchial secretions> Bronchodilatorsdecrease airwayresistance secondary to

bronchoconstriction

Eval

After 8 ours of

Nursing Intervention,the Pts breathing had

no more adventitioussounds

(crackles/gargles)

present whenauscultated


9/11


10/11


11/11

Documents

Loraine Pneumonia