TRINITY UNIVERSITY OF ASIA

ST. LUKE’S COLLEGE OF NURSING

CASE STUDY (OPD)

NAME: Marie Deborah Kay B. Chakas

CASE: Pneumonia (Pedia)

James, a 4-year-old boy was brought to the OPD for evaluation of productive

cough and difficulty of breathing. Initial oxygen saturation showed hypoxia (SpO2

84% on room air). Five days prior to admission, he started to have fever and

vomiting. The vomiting resolved but the fever persisted, reaching a temperature of

39.9 C. Few hours prior to admission, he awoke complaining of right upper quadrant

pain.

James was then handed off to the ER for initial treatment which included CT

scan of the abdomen and Chest X-Ray. CT Scan showed normal interpretation while

X-Ray revealed right lower lobe effusion. Laboratory tests furthered showed

metabolic acidosis. A blood culture was also obtained. His past medical history was

significant only for allergic rhinitis and eczema, and his immunizations were up-to-

date. There had been no recent travel, animal exposure or known sick contacts. His

family and social history was unremarkable.

James then went into mild respiratory distress with a respiratory rate of 44 bpm,

SPo2 94% to 98% on 2L O2 via nasal cannula and right-sided splinting. Lung sounds

revealed decreased breath sounds in lower lung fields bilaterally with the right side

greater than the left side. He had no retractions or nasal flaring. He continued to

have fever and respiratory distress, thus, admission.

1. What is Pneumonia?

Pneumonia is a form of acute respiratory infection that affects the lungs. When an

individual has pneumonia, the alveoli are filled with pus and liquid, which makes

breathing painful and limits oxygen intake. Pneumonia is caused by a number of

infectious agents, including viruses, bacteria and fungi. In children viruses are the

main cause of pneumonia in older infants and toddlers between 30 days and 2 years

old. In children 2 to 5 years old, it is the Respiratory syncytial virus (RSV) that is often

seen. In fact, pneumonia is the single largest infectious cause of death in children

worldwide.

2. What are these risk factors of a pediatric patient for having pneumonia?

 Weak immune system- while most healthy children can fight the infection with

their natural defenses, children whose immune systems are compromised are at

a 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- ongoing health problems such as asthma, cystic fibrosis

and symptomatic HIV infections can increase the child’s risk of contracting

pneumonia

 Unfavorable environment- living in crowded homes and indoor air pollution

caused by cooking and heating with biomass fuels, as well as secondhand

smoking also increase a child’s susceptibility to pneumonia.

3. What are the signs and symptoms of pneumonia?

Symptoms of pneumonia may be a bit different for each child. They may also

depend on what is causing the pneumonia, however the symptoms of viral

pneumonia may be more numerous than that of bacterial pneumonia. Bacterial

pneumonia happens with cough that produces mucus, cough pain, vomiting or

diarrhea, loss of appetite, fatigue and fever. Early symptoms of viral pneumonia are

the same as those of bacterial pneumonia, but with the viral one, the breathing

problems happen slowly. The child may wheeze and the cough may get worse. Viral

pneumonia may make a child more at risk for bacterial pneumonia. In addition to

those symptoms, the child may have chills, tachypnea, headache and fussiness.

Very severely ill infants may be unable to feed or drink and may also experience

unconsciousness, hypothermia, hyperventilation and convulsions.

4. What are the assessment data in the case that will point to a pneumonia

diagnosis?

 Productive cough

 Difficulty of breathing

 Fever (39.9)

 Vomiting

 RUQ pain

 Right lower lobe effusion

 Metabolic acidosis

 Mild respiratory distress (44 bpm)

 Decreased breath sounds in lower lung fields bilaterally with the right side

greater than the left side

5. What is metabolic acidosis?

Metabolic acidosis is generally defined by the presence of a low serum bicarbonate

concentration (normal range 22-28 mEq/L), although occasionally states can exist
where the serum bicarbonate is normal with an elevated anion gap. In general,

metabolic acidosis is associated with a low urine pH but depending on the presence

or absence of a respiratory alkalosis. Metabolic acidosis starts in the kidneys instead

of the lungs. It occurs when they can’t eliminate enough acid or when they get rid of

too much base. There are three major forms of metabolic acidosis: hyperchloremic,

lactic, and renal tubular.

6. What is/are the complications of pneumonia?

 Bacteremia- bacteria that enter the bloodstream from the lungs can spread the

infection to other organs, potentially causing organ failure.

 Difficulty of breathing- if the case is severe, enough oxygen would still not

suffice.

 Pleural effusion- pneumonia may cause fluid to build up in the thin space

between alyers of tissue that line the lungs and pleura. If the fluid becomes

infected, there may be a need to have it drained through a chest tube or

removed with surgery.

 Lung abscess- an abscess occurs if pus forms in a cavity in the lung. An abscess is

usually treated with antibiotics. Sometimes, surgery of drainage with a long

needle or tube placed into the abscess is needed to remove the pus.

7. What is/are the diagnostic test to confirm pneumonia?

 Chest X-Ray- identifies structural distribution; may also reveal multiple

abscesses/infiltrates, empyema; scattered or localized infiltration; or

diffuse/extensive nodular infiltrates. In mycoplasmal pneumonia, chest x-ray

may be clear

 Fiberoptic bronchoscopy- may be both diagnostic (qualitative cultures) and

 therapeutic (re-expansion of lung segment)

 ABGs/pulse oximetry- abnormalities may be present, depending on extent of

lung involvement and underlying lung disease.

 Gram stain/cultures- sputum collection; needle aspiration of empyema, pleural

and transtracheal or transthoracic fluids; ung biopsies and blood cultures may

be done to recover causative organism. More than one type of organism may be

present.

 Complete Blood Count- leukocytosis is usually present, although a low white

blood cell vount may be present in viral infection, immunosuppressed conditions

such as AIDS, and overwhelming bacterial pneumonia. Erythrocyte

sedimentation rate is elevated.

 Serologic studies- assist in differential diagnosis of specific organism

 Pulmonary function studies- volumes may be decreased; airway pressure may

be increased and compliance decreased. Shunting is present.

 Electrolytes- sodium and chloride levels may be low

 Bilirubin- may be increased

8. What is/are the pharmacological management for pneumonia?

Treatment should be targeted to a specific pathogen that is based on

information obtained from history and physical exam.

If bacterial pneumonia is suspected, treat empirically with antibiotics, keeping in

mind significant history and bacterial pathogens that are common to specific age

groups.

 Neonates- ampicillin plus aminoglycoside or third-generation cephalosporin,

however not ceftriaxone, as it can displace bound bilirubin and lead to

 kernicterus

 1-3 months old- should have additional coverage with erythromycin or

clarithromycin

 Older than 5 years old- macrolide antibiotics for first-line therapy

Special attention should be given to children with chronic illnesses, as these might

alter choices for antibiotics

 Children with sickle cell anemia- cefotaxime, macrolide, vancomycin

 Children with cystic fibrosis- piperacillin or ceftrazidime plus tobramycin

If viral pneumonia is suspected, pharmacological treatment will depend on the virus

identified.

 Varicella- acyclovir

 RSV- ribavirin

 With HIV- sulfamethoxazole/trimethoprim and orednisone

 Cytomegalovirus-ganciclovir and gamma globulin

9. What is/are the non-pharmacological management for pneumonia?

Non-pharmacological management for pneumonia include the following

 promoting rest

 having a humidifier in the patient’s room

 administering IV fluids if patient is unable to drink well

 oxygen therapy

 frequent suctioning of the child’s nose and mouth to help get rid of thick mucus

 breathing treatments as ordered by the child’s health care provider

 thoracentesis

 thoracostomy
 Image-guided abscess drainage
10. Create 3 NCP based on the data provided in the case and priority problems for pneumonia.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
independent
Objective data: Ineffective Breathing Short-term goal:  Assessed, These are early Short-term: Goal

 RR- 44 bpm Pattern r/t After 8 hours of monitored and warning signs of met. After 8 hours of

 SPO2 @ 84% respiratory distress nursing intervention, recorded impending nursing intervention,

(room air) patient’s respiratory respiratory rate respiratory the patient’s

 Difficulty of rate and oxygen and depth difficulties. respiratory rate was

breathing saturation will  Assessed ABG This monitors decreased to 35bpm,

 Decreased improve towards levels oxygenation and with his oxygen

breath sounds reaching normal ventilation status. saturation up to 90%

over left lung limits  Monitored O2 It is a useful tool to in room air.

Long-term goal: saturation detect changes in Long-term: Goal met.

After 24 hours of oxygenation early on. After 24 hours of

nursing intervention,  Assessed for To determine activity nursing intervention,

the patient will dyspnea at rest tolerance. the patient’s

continue to show versus with respiratory rate was

improvement in his activity and note within normal limits

respiratory rate and changes at 28 bpm, with his

oxygen saturation  Noted muscles The accessory oxygen saturation at

and will manifest used for muscles of inspiration 95%. The patient has

ease in breathing. breathing are not usually also manifested ease

involved in quiet in breathing.

breathing.

 Continued These signs signify an

observation for increase in

retractions or respiratory effort.

flaring of nostrils

 Positioned If not

patient with contraindicated, a

 proper body sitting position allows

alignment for for good lung

optimal excursion and chest

breathing pattern expansion.

 Encouraged small

frequent meals This prevents

crowding of the

 Educated diaphragm.

patient’s This allows for relief

guardians on and improves

proper breathing ventilation.

and deep

breathing

exercises
dependent
  Administered For management of

oxygen and underlying

prescribed pulmonary conditions

respiratory and respiratory

medications as distress.

indicated by the

physician
independent
Objective data: Ineffective Airway Short-term goal:  Observed the Sputum that is Short-term: Goal

 Productive Cough Clearance r/t After 8 hours of patient’s sputum, discolored, tenacious met. After 8 hours of

 Lobe effusion retention of nursing intervention, noting color, or has an odor may nursing intervention,

seen on Chest X- secretions amb. the patient will have odor and volume increase airway the patient had

ray film decreased breath a reduced congestion resistance and may reduced congestion

 Dyspnea sounds over one side in the airway warrant further in his airway.

 Decreased of the lung intervention.

breath sounds Long-term goal:  Assessed the Tachypnea, shallow Long-term: Goal met.

over left lung After 2 days of rate, rhythm, and respirations and After 2 days of

nursing intervention, depth of asymmetric chest nursing intervention,

the client will be able respiration, and movement usually the client was able to

to maintain airway chest movement because of maintain airway

clearance/patency discomfort of moving clearance/patency.

chest wall and/or

fluid in lung due to

compensatory

response to airway

obstruction.

 Assessed cough Pneumonia may

effectiveness and cause thick and

productivity tenacious secretions

 to patients.

 Assessed and Decreased sounds are

auscultate lung presented in areas

fields. Noted with consolidated

areas with fluid.

decreased

sounds and

adventitious

breath sounds

 Assessed the Airway clearance is

patient’s hindered with

hydration status inadequate hydration

and thickening of

secretions.
 Elevated the This promotes

patient’s head aeration of lung

and changed to segments,

comfortable mobilization and

position expectoration of

frequently. secretions.

 Helped the client This can help increase

breathe deeply sputum clearance

and performed and decrease cough

controlled spasms.

coughing

 Provided oral Reduces the

care incidence of

nosocomial
 pneumonia.

 Promoted Fluids help minimize

increased fluid mucosal drying and

intake maximize ciliary

action to move

secretions.

dependent
 Administered Oxygen has been

oxygen as shown to correct

ordered hypoxemia, which

can be caused by

retained respiratory

secretions.

 Administered To help loosen and

 ordered clear secretions from

medications the airway.

 Performed Suctioning is needed

nasotracheal when patients are

suctioning unable to cough out

secretions properly

due to weakness,

thick mucus plugs, or

excessive or

tenacious mucus

production. It can

also stimulate

coughs.
independent
Objective data: Hyperthermia Short-term goal:  Monitored HR and BP increase as Short-term: Goal
BT- 39.9C After 4 hours of patient’s HR, BP hyperthermia met. After 4 hours of

nursing intervention, and body progresses. nursing intervention,

the patient’s body temperature the patient’s body

temperature will be  Measured and Gives dehydration temperature was

within normal limits recorded clues which prevents within normal limits

at 36.5C-37.5C. patient’s fluid sweating, a factor at 37C.

status needed for

Long-term goal: evaporative cooling. Long-term: Goal met.

After 2 days of  Adjusted Room temperature After 2 days of

nursing intervention, environmental amy be accustomed nursing intervention,

the patient will factors like room to near normal body the patient

maintain an temperature, temperature and maintained his body

established body ventilation, and linens may be temperature within

temperature within bed linens adjusted to regulate normal limits at 37C-

normal limits. temperature of the 37.5C.

patient.

 Removed extra Exposing skin to room

clothing and air decreases warmth

covers and increases

evaporative cooling.

 Administered It helps reducing

tepid sponge body temperature.

bath

 Encouraged Additional fluids help

increased fluid prevent elevated

intake temperature.

 Maintained Promotes clear flow

patient on bed of air in the patient’s

 rest area, one way of

promoting heat loss.

dependent
 Administered Inhibit the

antipyretic prostaglandin that

medications as serve as mediators of

indicated pain and fever.