Christ the King College

9014 Gingoog City

Pediatric Case Study

“Pediatric Community Acquired Pneumonia”

Table of Contents

I. Introduction

II. Nursing Health History

Biographic Data

Family health history

Personal history

Past medical history

Life style

Social history

Physical assessment

Assessment Data

Assessment Vital Signs

III. Laboratory Results

IV. Anatomy and Physiology

V. Pathophysiology

VI. Nursing care plan

VII. Drug study

VIII. Discharge plan

IX. Evaluation

X. Bibliography

I- Introduction:

Pediatric community-acquired Pneumonia is a disease which individuals who have not

recently been hospitalized develop on infection of the lungs. PCAP is a common illness

that affects infants and children. PCAP occurs because the atmosphere or the areas of

the lungs which absorb oxygen from the atmosphere become filled with fluid and cannot

work effectively.

PCAP occurs throughout the world and is a leading cause of illness and death. The

cause of PCAP includes bacteria, viruses, fungi and parasites. PCAP can be diagnosed

by symptoms and physical examination alone, through x-rays, examination of sputum

and other tests are often used. Individuals with PCAP are primarily treated with

antibiotic medication in the hospital some forms of PCAP can be prevented by

vaccination.

PCAP usually acquired via inhalation or aspiration of pulmonary pathogenic organism

into a lung segment or lobe. Less commonly, PCAP results from secondary bacteria

from a distant source, such as Escherichia coli urinary tract infection and or bactericidal.

PCAP is due to aspiration of oro-pharyngeal content is the only form of PCAP involving

multiple pathogens. The proportion of children with pneumonia who are diagnosed with

specific etiology is low. Unlike adults, children usually do not produce adequate sputum

specimens for Gram stain and culture. Blood cultures have a yield of less than 10% in

patients with bacterial pneumonia. “Lung puncture” studies that are conducted in

developing countries are obviously not met with enthusiasm in general pediatric

practices. Prospective studies that have employed sensitive antibody test and

polymerase chain reaction techniques have suggested that in up to 20% of pediatric

community acquired pneumonias, the infection is “mixed” (i.e., both S. Pneumonia and

M. and C pneumonia); in these cases, the primary pathogen is not clear. Authors of

these studies have also suggested that mixed infection with bacteria and respiratory

viruses is likely to become as well.

Many studies have looked at causes of pediatric pneumonia as it relates to

certain readily available laboratory measurements. Many clinicians consider S.

pneumonia to be likely cause of the lower respiratory infection if the picture is

characterized by acute onset of high fever, pneumonia on chest radiograph,

leukocytosis, and a rapid response to B-lactam antibiotics. Numerous studies have

found that chest radiographs do not readily distinguish between bacterial, a typical

bacterial, and viral pneumonia. A variety of laboratory test have been used in attempt to

distinguish bacterial from viral pneumonia, including C-reactive protein and absolute

neutrophil counts. One problem in using “screening” test is that specific cut off levels

have often not been established.

A recent study done in Europe found that although white blood cell count and C-reactive

proteins were statistically higher in patients with pneumococcal infections, other clinical

and laboratory and radiographic studies were of little value. Given the clinical,

epidemiologic, and laboratory difficulties in pinpointing the cause of pediatric

pneumonia, an additional approach is to divide patients by age. The primary bacterial

pathogen in neonatal pneumonia is group B streptococci, although Escherichia coli and

Listeria mono cytogeneses have also been reported

The mechanism is similar to that in neonatal sepsis, where colonization from the mother

results in neonatal colonization and breakthrough infection. Chlamydia trachomatis is

the most common sexually transmitted infection in the United States. The organism may

reside in the genital tract of pregnant women and be transmitted in about 60% of cases

to infants at the time of delivery. About one half of infants who acquire the organism

develop conjunctivitis, and 20% eventually develop lower respiratory disease

REASON FOR CHOOSING THE CASE:

It is due to the motive to learn and apply our knowledge and skills

incaring the patient with pediatric community acquired pneumonia (PCAP). 

This is a rare case since the patient is only 3 years old

Family Centered Objectives:

Our family centered objectives would remain to be our most significant motive in

conducting this case study. They are as follows:

• The parents of the patient will be able to understand the causes and

therapeutic management regimen 

• The parents will be able to consider and demonstrate the proper way of breastfeeding

and guidelines for the condition.

• The parents will be able to verbalize the importance of increase fluid intake.

• The parents will be able to identify potential complications and how to initiate appropriate

preventive or corrective actions.

II- Nursing Health History:

Biographic Data

Name: Batang X

Address: Barangay 20, Purok 7, Gingoog City

Gender: Male

Status: single/Child

Birthday: April 25, 2009 Age: 3 years and 9 months

Birth place: Cagayan de Oro City

Religion: Roman Catholic

Nationality: Filipino

Room: Pediatric Semi private

Attending physician: Dr. Almero

Chief Complaint: 4 days fever

Date/Time admitted: January 20, 2013

Diagnosis: Pediatric Community acquired pneumonia

Family History:

His paternal side has a genetic history of hypertension, his grandfather

previously Diagnosed for CAP,

One of his aunt in his mother side has DM after pregnancy, no other known

illnesses.

Personal History:

5 days prior to admission the child played under the rain and catches colds afterward, 4

days until Admission the child experienced high fever associated with cough, which

prompted his mother to admit her son to the hospital.

Past medical history:

The mother stated that the patient was hospitalized be fo re s ta ted

D iagnosed Bronco pneumon ia when the ch i ld was s t i l l 4 months o ld

a lso when he was 1 y r . and 5 months he was d iagnosed w i th same

i l l ness . The pa t ien t had no a l le rg ies to d rugs . The mother a lso

claimed that the patient already received complete vaccination

Lifestyle:

They live near the rice field at barangay 20, hot, and humid condition always causes the

cough to her child as the mother stated. The child often plays at the market with the

other kids every time his mother brings him to work.

Social History:

The mother describes her son sociable, and always mingles with other kids much often

plays at the mud bridges on the rice fields. The community knows their family well, they

respect them, and they have a peaceful community, and consider their family at peace

with everyone.

Developmental Task:

Psychosexual Theory

According to Freud’s Psychoanalytic theory the patient is under Anal stage, where he

has a need to control, and his area of pleasure is in the anus or activities related in that

area.

Psychosocial Theory

According to Erickson’s psychosocial theory the patient is under, Autonomy vs. Shame

and doubt, where the child need a degree of freedom inorder to meet his need for

control.

Cognitive Theory

According to Piaget’s cognitive theory the patient is under, Preoperational, the child is

ego centric and relates everything that is presently happening is because of him.

Moral development Theory

According to Kohlberg’s Moral development the child is under pre conventional stage

where in a child will do good inorder to receive reward, and avoid to do wrong action to

avoid punishment.

Physical assessment

Mouth

 The lips are pinkish in color and moist. No ulcerations or lesions noted. The tongue

moves freely and not tender. The client possesses pinkgums

INTEGUMENT:

1 . S k i n

 The skin of the client is moist, pale and has a good skin turgor.Has a fair skin complexion.

2.Hai r  and  Scalp

 The hair are equally distributed with a thin hair strands; wellkept; no lice or dandruff seen/noted.

3 . N a i l s

Client’s nails are normally transparent and convex. Thesurrounding cuticles are intact and without

inflammations noted. Has anormal capillary refill with 1 to 2 seconds.

THORAX and LUNGS

 The chest contour is symmetrical, the spine is vertically aligned. The ches t wa l l i s

in tac t , no tenderness o r no masses no ted . Upon auscultation rales was being

noted.

HEART

 There is no presence of abnormal pulsations when the heart was auscultated. No

murmurs and friction rubs heard upon auscultation.

BREAST

 The b reas ts a re even w i th the ches t wa l l , sk in i s smooth and intact.

Areola is round and bilaterally the same. The nipples are round and equal in size, no

discharge noted. The breast are not tender, no masses or nodules noted.

ABDOMEN

 The abdomen is intact, round and with normal bowel sound heard upon auscultation. No deformities

seen.

 EXTREMITIES:

On the upper extremities no deformities noted. Has a D5IMB½ L at the left hand. While on the lower

extremities, no deformities were noted.

GENITAL AND RECTAL:

Upon inspection there were no deformities, no rashes, no abnormal secretions were present.

Admission data:

Client came from home to the hospital ambulatory, accompanied by his mother, with

fever and productive cough noted.

Assessment vital signs:

Temperature: 38.6

Pulse: 120 bpm

Respiratory Rate: 26cpm

Height: 3’2”

Weight: 12 klg

Allergies: No known allergy

III. Laboratory Assessment

Components Normal Values Result Clinical Significance

WBC 4,500–11,000/mm3 9.6 normal

Hemoglobin 12-16 g/dL 14.1 Normal

Hematocrit 36-46 % 42.4 Normal

Platelet 150,000-350,000/

mm3

234, 000

Differential Count:

Normal Values Result

Segmenters 45% - 70% 53

Lymphocytes 18%-45% 39

Monocytes 4-8% 8

IV. Anatomy & Physiology 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. 

Move the pointer over the coloured regions of the diagram; the names will appear at the

bottom of the screen)

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.

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 thepleural 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 alveloi 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.

Significant Parts and organs involved:

The nose consists of the visible external nose and the internal nasal cavity. The

nasal septum divides the nasal cavity into right and left sides. Air enters two

openings, the external nares (nostrils; singular, naris), and passes into the

vestibule and through passages called meatuses. The bony walls of the

meatuses, called concha, are formed by facial bones (the inferior nasal concha

and the ethmoid bone). From the meatuses, air then funnels into two (left and

right) internal nares. Hair, mucus, blood capillaries, and cilia that line the nasal

cavity filter, moisten, warm, and eliminate debris from the passing air.

The pharynx (throat) consists of the following three regions, listed in order through

which incoming air passes:

The nasopharynx receives the incoming air from the two internal nares. The

two auditory tubes that equalize air pressure in the middle ear also enter

here. The pharyngeal tonsil (adenoid) lies at the back of the nasopharynx.

The oropharyrnx receives air from the nasopharynx and food from the oral

cavity. The palatine and lingual tonsils are located here.

The laryngopharynx passes food to the esophagus and air to the larynx.

The larynx receives air from the laryngopharynx. It consists of several pieces of

cartilage that are joined by membranes and ligaments, shown in Figure 2:

The epiglottis, the first piece of cartilage of the larynx, is a flexible flap that

covers the glottis, the upper region of the larynx, during swallowing to

prevent the entrance of food.

The thyroid cartilage protects the front of the larynx. A forward projection of

this cartilage appears as the Adam's apple (anatomically known as the

laryngeal prominence).

The paired arytenoid cartilages in the rear are horizontally attached to the

thyroid cartilage in the front by folds of mucous membranes. The upper

vestibular folds (false vocal cords) contain muscle fibers that bring the folds

together and allow the breath to be held during periods of muscular pressure

on the thoracic cavity (straining while defecating or lifting a heavy object, for

example). The lower vocal folds (true vocal cords) contain elastic ligaments

that vibrate when skeletal muscles move them into the path of outgoing air.

Various sounds, including speech, are produced in this manner.

The cricoid cartilage, the paired cuneiform cartilages, and the paired

corniculate cartilages are the remaining cartilages supporting the larynx.

The trachea (windpipe) is a flexible tube, 10 to 12 cm (4 inches) long and 2.5 cm

(1 inch) in diameter (Figure 2).

The mucosa is the inner layer of the trachea. It contains mucus-producing goblet

cells and pseudostratified ciliated epithelium. The movement of the cilia sweeps

debris away from the lungs toward the pharynx.

The submucosa is a layer of areolar connective tissue that surrounds the mucosa.

Hyaline cartilage forms 16 to 20 C-shaped rings that wrap around the submucosa.

The rigid rings prevent the trachea from collapsing during inspiration.

The adventitia is the outermost layer of the trachea. It consists of areolar

connective tissue.

The primary bronchi are two tubes that branch from the trachea to the left and

right lungs.

Inside the lungs, each primary bronchus divides repeatedly into branches of

smaller diameters, forming secondary (lobar) bronchi, tertiary (segmental)

bronchi, and numerous orders of bronchioles (1 mm or less in diameter),

including terminal bronchioles (0.5 mm in diameter) and microscopic

respiratory bronchioles. The wall of the primary bronchi is constructed like

the trachea, but as the branches of the tree get smaller, the cartilaginous

rings and the mucosa are replaced by smooth muscle.

Alveolar ducts are the final branches of the bronchial tree. Each alveolar

duct has enlarged, bubblelike swellings along its length. Each swelling is

called an alveolus. Some adjacent alveoli are connected by alveolar pores.

The respiratory membrane consists of the alveolar and capillary walls. Gas

exchange occurs across this membrane. Characteristics of this membrane follow:

Type I cells are thin, squamous epithelial cells that constitute the primary cell

type of the alveolar wall. Oxygen diffusion occurs across these cells.

Type II cells are cuboidal epithelial cells that are interspersed among the

type I cells. Type II cells secrete pulmonary surfactant (a phospholipid bound

to a protein) that reduces the surface tension of the moisture that covers the

alveolar walls. A reduction in surface tension permits oxygen to diffuse more

easily into the moisture. A lower surface tension also prevents the moisture

on opposite walls of an alveolus or alveolar duct from cohering and causing

the minute airway to collapse.

Alveolar macrophage cells (dust cells) wander among the other cells of the

alveolar wall, removing debris and microorganisms.

A thin epithelial basement membrane forms the outer layer of the alveolar

wall.

A dense network of capillaries surrounds each alveolus. The capillary walls

consist of endothelial cells surrounded by a thin basement membrane. The

basement membranes of the alveolus and the capillary are often so close

that they fuse.

V. Pathophysiology of PCAP

Predisposing Precipitating

Age, weather, genetics Environment

Aspiration of microbes

Failure of Defenses

Invasion of lower respiratory tract

Activation of b-cells

Release of antibodies

Antigen- Antibody Reaction

Antigen Antibody Complex Adhere to the Mucosal Lining of the lower respiratory tract

Initiation of Immune system

Mucosal Irritation

Vasodilation

Increase blood flow

Vaso-congestionIncrease mucus production

Accumulation of mucus

Productive Cough

Increase plasma Hydrostatic Pressure

Increase capillary permeability

Ineffective airway clearance

Escape of plasma Escape of RBC Serum and Fibrin

Transportation of phagocyting cells

Edema

Narrowing of airways

Exudate formation

Filling of bronchi and alveoli

Consolidation of lung

Decrease lung inflation

Use of accessory muscles

Increase respiration

Asymmetrical chest expansion

Ineffective Breathing pattern

Engulfing of Antigen

Cell becomes infected

Detection of the infected cell by the T-cells

Effector T-cells destroys antigen

Regulatory T-cell Strengthen Act of effector

cells

Effector and Regulatory Cells Synthesize and release cytokinase

Altered Temperature Regulating Mechanism in

the Hypothalamus

Hyperthermia

VIII. Discharge Planning

Medication Advise patient to take home medication

Encourage patient S.O to continue

medication Salbutamol syrup, 5 ml TID, as

prescribed

Exercise Instruct and teach client to exercise as can

be tolerated.

Health teaching Eat nutritious food (green leafy

vegetables).

Encourage ambulation and adequate fluid

intake.

Diet Advise the client to eat nutritious food

especially those have vitamin C (for fast

healing against infection.)

Advise the client drink plenty of water and

limit caffeine.

Spiritual Encourage the client to continue religious

activity( e.g. Attending mass)

Outpatient ( checkup) •Advice to make follow-up one week after

or when the medication is stopped, report

for any unusalities,

Treatment •Instruct the client to do the following

measures.

Observing hand hygine

Avoiding playing under the rain or under

the heat of the sun

Diet Analysis

Food Group

Meat, Fowl, or Fish

Vegetables

Fruits

Breads, Cereals, Rice, Pasta

Milk

Fats, Oils, Sweets

Additional Fluid

Quantities

2-3 servings daily

3 servings daily

2 servings daily

4-7 servings daily

2-5 glasses (8-oz) daily

1 serving daily

3-4 glasses daily

IX. Evaluation

Time consuming, Energy draining, brain busting, this is how I describe a Case Study.

For a novice point of view it is very hard to make such work, though we have complete

sources of information, we still learning how to get the right information out of those

sources.

But such task worth such effort, the knowledge and experience I gained was worth it. I

learned time management, that is very important in my course.

By doing this Case study It gave me more understanding about the disease process by

which was a very big question mark back when I was still on my fresh years.

Time worth Spent, Energy drained reasonably, and Brain busted in exchange for a

better one, this is what this case study left me,

XI. Bibliography

1) Blackwell’s Nursing Dictionary Second Edition (2005), Blackwell’s Publishing Ltd.

2) Maternal & Child Health Nursing Sixth Edition (2010),Adele Pillitteri, Lippincott

Williams & Wilkins

3) Fundamentals of Nursing Eight Edition, Kozier & Erb’s, Pearson, Prentice Hall

4) Nurses Pocket Guide, Diagnoses Prioritized Interventions, and rationales,

Marilynn E.Doenges,Mary Frances Moorhoouse,Alice C. Murr, 12th edition.

5) Lippincott’s Nursing Drug Guide, Amy M. Karch, 2011