2k11 Case Study Jud

LICEO DE CAGAYAN UNIVERSITY

College of Nursing

In Partial Fulfillment of the requirements in NCM501202-Related Learning Experience

A CASE STUDY OF

PNEUMONIA

Submitted By:

Uba, Chrislyn B.

BSN III student

Submitted To:

Clinical Instructor

II. HEALTH HISTORY

A. Patients Profile

Name of Patient: Tatad, Angela

Sex: Female

Age: 1 year old

Birthday: December 08,2009

Address: Upper 20 St. Nazareth, CDOC

Birthplace: Cagayan de Oro City

Religion: Roman Catholic

Mother: Mrs. Tatad

Father: Mr. Tatad

Nationality: Filipino

Date Admitted: January 9, 2011

Time Admitted: 11:00 AM

Temperature: 38. 0 C

Pulse Rate: 105 bpm

Respiration: 45 cpm

Attending Physician: Dr. Estorba

B. Family History and Personal Health History

The patient was born on the eighth of December 2009, she was delivered

in a normal spontaneously vaginal delivery. She has no known food or drug

allergy and she was not been able to received blood in the past. She had been

previously hospitalized due to LBM.

History of Present Illness

2 days prior to admission, their were positive onset of productive cough associated with intermittent fever

Given Amroxol and Paracetamol to patient.

Chief Complaint

The chief complaint of patient is her cough thus, for this condition persisted to admission.

III. DEVELOPMENTAL TASK THEORY

Sigmund Freud’s Theory (Psychosexual Theory)

The psychosexual stages of Sigmund Freud are five different developmental periods during which the individual seeks pleasure from different areas of the body associated with sexual feelings. These stages are as follows:

Oral Birth to 1 yearAnal 2 – 3 yearsPhallic 4 – 5 yearsLatency 6 – 12 yearsGenital 13 – Up

Based on Freud ‘s theory, the patient belongs to the Oral stage. The Mouth is the center of pleasure. FIXATION results in Difficulty in trusting others, nail biting, drug abuse, smoking, overeating, and alcoholism. Feeding produces pleasure and sense of comfort and safety. The oral stage lasts from birth to about 18 months. The focus of pleasure is, of course, the mouth. Sucking and biting are favorite activities.

Erik Erickson’s Theory (Psychosocial Theory)

Erik Erickson envisioned life as a sequence of levels of achievement. Each stage signals a task that must be achieved. He believed that the greater that task achievement, the healthier the personality of the person. Stages of Erikson’s Psychosocial Theory are as follows:

Infancy Birth – 18 months Trust vs. Mistrust

Early Childhood 18 mnths – 3 years Autonomy vs. Shame & Doubt

Late Childhood 3 – 5 years Initiative vs. Guilt

School Age 6 – 12 years Industry vs. Inferiority

Adolescence 12 – 20 years Identity vs. Role

Confusion

Young Adulthood 18 – 25 years Intimacy vs. Isolation

Adulthood 25 – 65 years Generativity vs.

Stagnation

Maturity 65 years to death Integrity vs. Despair

Based on this theory, the patient belongs to early childhood

which is autonomy vs shame and doubt. Autonomy is the independence a

toddler strives for from caregivers. Toddlers’ autonomous behavior is a

way of forming their own identity away from their caregivers . This stage is

a time where a toddler has the “will” to become independent. Shame and

doubt is likely to occur when the toddler is not given any choices or

boundaries because the toddler is determined to become independent.

The strong will of a toddler may cause conflict between child and caregiver

It is in this level that that the child begins to evaluate her own behavior.

The mother does not scold the child whenever she commits mistake but

corrects her because the mother believes that over restriction and over

control of any activity can lead to lack of self confidence of the child when

she grows up. She wants that her child will learn from her own mistakes

and realize good from the bad. Autonomy can be gained for the toddler

when given reasonable choices and proper guidance from the caregiver

Jean Piaget’s Theory (Cognitive Theory)

Cognitive development refers to how a person perceives, thinks, and gains understanding of his or her world through the interaction and influence of genetic and learning factors. This is divided into five major phases:

Sensorimotor Phase Birth to 2 years

Pre-conceptual Phase 2 – 3 years

Intuitive Thought Phase 4 – 6 years

Concrete Operations Phase 7 – 11 years

Formal Operational Phase 12 – adulthood

Based on this theory, the patient belongs to the pre-conceptual phase. It was observed that the child associates words with objects and she learns to explore the environment. The child begins to move towards understanding the world through mental operations rather than purely through actions. The action being manifested by the child is a significant behavior by her age.

Developmental Task Theory of Robert Havighurst

A developmental task is a task which arises at or about a certain period in the life of an individual. Havighurst has identified six major age periods: infancy and early childhood (0-5 years), middle childhood (6-12 years), adolescence (13-18 years), early adulthood (19-29 years), middle adulthood (30-60 years), and later maturity (61+).

Based on this theory, the patient belongs in the early childhood

(0-5 years) wherein she is in the stage of Infancy and late Childhood

periods wherein the patient learns to walk, talk, and takes solid foods. It

was observed that during assessment, the patient is weak, can take semi-

solid foods and can walk with assistance and says ‘no’ as a resistance to

request.

IV. MEDICAL MANAGEMENT

A. MEDICAL ORDERS

Medical Orders Rationale

January 9 ,201111am

Secure consent to care and management

DAT with strict aspiration precaution

Intake and output every shift

TPR every 4h

Watch out and refer if persistent SOB,

cyanosis, and other unusualities

IVTF: D5 0.3% NaCl 500 cc @35 mgtts/min

Providing proper nursing care to patient

Patient is allowed intake of food that he can

tolerate but with strict precaution to avoid

aspiration that may cause airway obstruction

To check and note for imbalances in the intake

and output

To monitor any alterations and deviations in

patients’ vital measurement

To check for signs of inadequate oxygenation

and impaired gas exchange

To replace fluid loss and means to incorporate

Intravenous drugs

LABORATORY RESULTS

Date: January 16, 2011

CBC

TEST RESULT

White Blood Cell Count 30.5

Red Blood Cell Count 4.40

Hemoglobin Count 12.5

Hematocrit Count 37.4

Platelet Count 330,000

Urine Test

Date ordered: January 16, 2011

Color: yellow

Specific gravity: 1.010

Transparency: slightly hazy

Ph reaction: 6.5PH

Sugar: Negative

Albumin: negative

Microscopic Cast: non seen

Pus Cells: +(0-2 HPF)

RBC: + (1-1 HPF)

Epithelium: Squamous-rare

Crystal: none

Bacteria: none

Name of Drug Generic (Brand)

Date Ordered

ClassificationDose/ Frequency

RouteMechanism of Action

Specific Indication (why is ordered)

Contra-IndicationSide Effects/Toxic

Effects

Nursing Precaution

Cefaclor

Anti-infectives

1.5ml TID/q5h

Bind ti bacterial cell wall membrane, causing cell death.

Therapeutic Effects: Bactericidal action

Treatment of Respiratory tract infections.

Contraindicated in Hypersensitivity to cephalosporins and serious hypersensitivity to penicillins.

Date Ordered

Classification Dose/ Frequency Route

Mechanism of Action Specific Indication (why is

Contra-Indication Side Effects/Toxic Effects


ordered)

Nursing Precaution

Salbutamol Sulfate

Ventolin

Bronchodilator

1 neb/ q6h/ steam inhalation

Relaxes bronchial smooth muscle by acting on beta2-adrenergic receptors; improves ventilation

Helps expectorate mucous secretions through dilation.

To patient’s hypersensitive to the drug and its components

Tremor; palpitations; tachycardia; nausea and vomiting; irritation

Perform chest tapping every after nebulization

Date Classification Dose/ Frequency Mechanism of Action Specific Contra-Indication Side Effects/Toxic


Ordered RouteIndication (why is ordered)

Effects

Nursing Precaution

Paracetamol

Biogesic

Non-opioid analgesic;antipyretic

250/mg 1 tsp q4 h, prn

Produces analgesic effect by blocking pain impulses, by inhibiting prostaglandins or pain receptors sensitizers; may relieve fever by acting in hypothalamic heat regulating center

For fever

To patient’s going long-term therapy for chronic noncongestive angle-closure glaucoma; hyponatremia; hypokalemia; hepatic impairment; adrenal gland failure’ hypechloremic acidosis

Confusion; anorexia; aplastic anemia; rash; renal calculi

Report signs of fluid and electrolyte imbalance

Name of Drug Generic

Date Ordered



Specific Indication (why is ordered)


Effects

Nursing Precaution

(Brand)

Cefaclor

Name of Drug

Date Ordered



Specific Indication (why is


Effects

Nursing Precaution

Generic (Brand)

ordered)

Cefaclor

NURSING SYSTEM REVIEW CHART

Name: Angela Tatad Date: January 09, 2011

Vital Signs

Pulse: 160bpm RR: 36cpm BP: N/A Temp: 38.0 C Height: Weight: 8.7kg

INSTRUCTIONS: Place an [X] in the area of abnormality. Comment at the space provided. Indicate the location of the problem in the figure using [X].

EENT:

□ impaired vision □ blind

□ pain □ reddened □ drainage _____________________

□ gums □ hard of hearing □ deaf FEBRILE = 38.0 C________

□ burning □ edema□ lesion □ teeth Productive cough _______

þ Asses eyes, ears, nose with whitish sputum_____

□ throat for abnormality þ no problem crackles upon ausculation

□ asymmetric □ tachypnea ____________________

□ apnea □ rales □cough □ barrel chest ____________________

□ bradypnea □ shallow □ rhonchi _____________________

□ sputum □ diminished □ dyspnea _____________________

□ orthopnea □ labored □ wheezing _____________________

□ pain □ cyanotic _____________________

þ Asses resp, rate, rhythm, depth, pattern, _____________________

breath sounds, comfort þ no problem _____________________

CARDIO VASCULAR _____________________

□ arrhythmia □ tachycardia □ numbness

□ diminished pulses þ edema þ fatigue _____________________

□ irregular □ bradycardia □ murmur _____________________

□ tingling □ absent pulses □ pain _____________________

þ Asses heart sounds, rate rhythm, pulse, blood _____________________

pressure, fluid retention, comfort _____________________

□ no problem _____________________

GASTRO INTESTINAL TRACT _____________________

□ obese □ distention □ mass _____________________

□dysphagia □ rigidity □ pain _Weak body __________

þ Asses abdomen, bowel habits, swallowing, _____________________

bowel sounds, comfort □ no problem Fatigue_______________

GENITO-URINARY and GYNE _____________________

þ pain □ urine color þ vaginal bleeding _____________________

□ hermaturia þ discharge □ nocturia _____________________

þ Asses urine freq., color, control, odor, comfort/ _____________________

Gyn-bleeding, discharge □ no problem _____________________

NEURO _____________________

□ paralysis □ stuporous □ unsteady □ seizures _____________________

□ lethartic □ comatose □ vertigo □ tremors _____________________

□ confused □ vision □ grip _____________________

þ Asses motor function, sensation, LOC, strength, _____________________

Grip, gait, coordination, orientation, speech,

þ no problem _____________________

MUSCULOSKELETAL and SKIN _____________________

□ appliance □ stiffness þ itching □ petechiae _____________________

□ hot □ drainage □ prosthesis □ swelling _____________________

□ lesion □ poor turgor □ cool □ deformity _____________________

□ wound □ rash □ skin color □ flushed _____________________

□ atrophy þ pain □ ecchymosis _____________________

□ diaphoretic □ moist _____________________

þ Asses mobility, motion. gait, alignment, joint function _____________________

/skin color, texture, turgor, integrity □ no problem _____________________

Nursing Assessment II SUBJECTIVE OBJECTIVE

Communication:[ ] hearing loss [ ] visual changes[ ] denied

Comments: no subjective cues since patient is a child

[ ] glasses [ ] language [ ] contact lens [ ] hearing aide R LPupil size : 2 mmReaction: pupil equally round reactive to light & accommodation[ ] speech difficulties

Oxygenation:[ ] dyspnea[ ] smoking history [ ] cough [ ] sputum[ ] deniedComments: no subjective cues since patient is a child

Respiratory [] regular [ x] irregular

Describe: symmetrical lung expansionR right lung is symmetrical to left lungL left lung is symmetrical to right lung

Circulation:[ ] chest pain [ ] leg pain[ ] numbness of extremities[ ] deniedComments: no subjective cues since patient is a child

Heart Rhythm [x] regular [ ]irregularAnkle Edema: nonePulse Car. Rad. DP. Fem.*R + + + + L + + + +Comments: all pulses are palpable

Nutrition: DAT with aspiration precaution[ ] recent change in weight, appetite[ ] swallowing difficulty [ ] deniedComments: no subjective cues since patient is a child

[ ] dentures [x] none Full Partial With PatientUpper [ ] [ ] [ ]Lower [ ] [ ] [ ]

Elimination: Usual bowel pattern Urinary frequency Once a day 4-5/day constipation remedy [ ] urgency NONE [ ] dysuriaDate of last BM [ ] hematuria January 8 ,2011 [ ] incontinenceDiarrhea character [ ] polyuria Not applicable [ ] foley in place [ ] denied

Bowel sounds: hyperactiveAbdominal Distention Present [ ] yes [x] noUrine* (color, consistency, odor)The color of the urine is yellow*if they are in place

Comments: patient changes diaper 2-3 times

Management of Health and Illness:[] alcohol [ x] denied(amount, frequency)Comments: Not applicable[ ] SBE Last Pap Smear: Not applicableLMP: Not applicable

Briefly describe the patient’s ability to follow treatments (diet, meds, etc.) for chronic health problems (if present). The mother is strictly following the treatment required of her child.

SUBJECTIVE OBJECTIVE

Skin Integrity:[ x] dry [] itching [ ] other [ ] deniedComments: no subjective cues since patient is a child

[ x] dry [ ] cold [ ] pale [ x] flushed [ x warm [ ] cyanotic*rashes,ulcers, decubitus (describe size, location, drainage) The patient’s skin is dry,warm and flushed

Activity/ Safety:[ ] convulsion [ ] dizziness[ ] limited motion of jointsLimitation inability to:[ ] ambulate [ ] bathe self[ ] other [ ] deniedComments: no subjective cues since patient is a child

LOC and orientation:Patient is consciousGait: [ ] walker [ ] cane [ ] other[ ]sensory and motor losses in face or extremities sensory and motor losses in face or extremities.[ ]ROM limitations: no limited range of motion.

Comfort/ Sleep/ Awake[ ] pain (location, frequency, remedies)[ ] nocturia[ ] sleep difficulties [ ] deniedComments: no subjective cues since patient is a child

[ x] facial grimaces[ ] guarding[ ] other signs of pain: [ ] siderail release None

Coping:Occupation: not aplicableMembers of household: 3 members Most supportive person: parents: Mr. & Mrs.Tatad

Observed non- verbal behavior:Patient was playful.

The person and his phone number that can be reached any time: not given

DateOrdered

Diagnostic/laboratoryExams

DateDone

DateOrdered

I.V.Fluids/blood

DateDisc.

1/16/11 Urine exam 1/16/11 1/9/11 D5 0.3%Nacl @35 mgtts/min

Ongoing

SPECIAL PATIENT INFORMATION (USE LEAD PENCIL) n/a Daily Weight: n/a PT/OT n/a ______ BP q Shift: n/a Irradiation n/a Neuro VS: n/a Urine Test ________ n/a CVP/SG. Readin: n/a 24h urine collection

VII. NURSING MANAGEMENT

1. Ineffective Airway Clearance RT excessive mucous secretions and ineffective

coughing

Interventions Rationale

Independent:

1. Position head appropriate for

age(midline)

2. Elevate head of bed/ change

position every 2 hours and prn

3. Increase fluid intake within cardiac

tolerance

4. Dicourage use of oil-based

products around nose

To open or maintain open airway in at-

rest

To enhance ventilation to different lung

segments

Hydration can help liquefy viscous

secretions and improve secretion

clearance

To prevent vomiting and aspiration

to lungs

Dependent:

1. Administer prescribed medications as

ordered (bronchodilators)

To help maintain open airway

2. Impaired gas exchange with the collection of secretions affecting oxygen exchange across

alveolar membrane


Independent:

1. Elevate head of bed/ position client

appropriately

2. Encourage adequate rest and limit

client’s activity within client

tolerance

3. Keep environment allergen/

pollutant free

4. Increase fluid intake within cardiac

tolerance

5. Discourage use of oil-based

products around nose

6. Provide adequate food intake

Dependent: Administer medications as

ordered(bronchodilators, antibiotics)

To open or maintain open airway in

at-rest

Helps limit oxygen needs/

consumption

To reduce irritant effect of dust

Hydration can help liquefy viscous

secretions and improve secretion

clearance

To prevent vomiting and aspiration

to lungs

Helps in improving stamina and

reducing the work of breathing.

To treat underlying conditions

3..Fluid volume deficit RT excessive loss of water secondary to amoebiasis as evidenced by dry mucous membrane, poor skin turgor


Independent:

Establish 24 hour replacement needs

and routes to be used.

2.Provide nutritious diet via appropriate

route,give adequate free water with

enteral feedings.

3. Maintain accurate intake and output

4.Bathe less frequently using mild

cleanser and provide optimal skin care

5.Provide frequent oral care,eye care

Dependent:

Administer metrronidazole

Prevents peaks/valleys in fluids level.

To gain energy and prevent fatigue

For comparison purposes and to know

the fluid loss or gain

To maintain skin integrity and prevent

excessive dryness

To prevent injury from dryness.

To kill protozoal microorganism thus

preventing elimination of watery stools

4. Hyperthermia RT physiologic changes and suppressed immune system

secondary to pneumonia and acute amoebiasis

Independent:

Provide tepid sponge bath

Increase fluid intake

Remove unnecessary clothing

Apply petroleum jelly

Provide adequate rest

Dependent:

Administer anti-pyretic medication as

prescribed

Rationale

To reduce body temperature to normal range.

To help cool down the body temp.

To help lessen body temp. due

excessive use of clothing

To avoid crack lips

To prevent fatigue and loss of body

energy

To relieve fever

B. ACTUAL NURSING MANAGEMENT

S No subjective cues since patient is a child

O

Dyspnea rr=45 cpm

Crackles heard upon auscultation

Cough with sputum

A Ineffective airway clearance RT excessive secretions and ineffective

coughing

P Long term: At the end of 3 days, client will manifest patent airway.

Shot term: At the end of 45 minutes, the client will manifest effective

airway clearance and expectorate secretions.

I Independent:

1. Positioned the head midline

2. Elevated head of bed/ change position every 2 hours and prn

3. Increased fluid intake within cardiac tolerance

4. Dicouraged use of oil-based products around nose

5. Performed chest tapping therapy after nebulization, it uses force of

gravity and motion to facilitate secretion removal.

Dependent:

1. Given bronchodilators (Salbutamol ) as ordered, to relax bronchial smooth

muscles thus facilitating airflow.

E After 45minutes, the client’s cough was still productive with lessened mucous

secretions

S

No subjective cues since patient is a child

O

Dyspnea

Tachypnea

Pallor

A Impaired gas exchange with the collection of secretions affecting oxygen exchange across alveolar membrane

P Long Term: At the end of 3 days, the client will be able to maintain a normal body

gas exchange with improve ventilation and absence of respiratory distress.

Short Term:At the end of 30 mins, the client’s will manifest improvement of airway

clearance

I Independent:

Elevated head of bed/ position client appropriately

Encouraged adequate rest and limit client’s activity within client tolerance

Kept environment allergen/ pollutant free

Increased fluid intake within cardiac tolerance

Discouraged use of oil-based products around nose

Provided adequate food intake

E

Goal was partially met. At the end of 30 mins, the client was able to manifest improvement of airway clearance as evidenced by lessened mucous production.

SNo subjective cues since patient is a child

O Temp=38.0 C

Warm, flushed skin

Dry mucous membrane

A Hyperthermia RT physiologic changes and suppressed immune system

secondary to pneumonia and acute amoebiasis

P Long term: At the end of 1 day, client will have stable body temperature.

Short term: At the end of 45 minutes, the client’s temperature will be in normal range

I Independent:

Provided tepid sponge bath Increased fluid intake Removed unnecessary clothing Applied petroleum jelly Provided adequate rest

Dependent:

1. Give antipyretics- to reduce body temperature to normal range

E After 45 minutes, client’s temperature lowered down from 38.9 C to 37.5 C

DISCHARGE PLAN

Medication

Medication should be taken regularly as prescribed, on exact dosage, time and

frequency, making sure that the purpose of medication is fully disclosed by the health

care provider such as:

Paracetamol 1 tsp q4h

Other oral antibiotics

Report any adverse effects and drug/food-drug interactions to the physician.

EXERCISE

2k11 Case Study Jud

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