Anemia2sepsis2bronchopneumonia

A Case Study

Presented to the Faculty of

The Ateneo de Davao University

College of Nursing

A Case Study on

Anemia 2 o to Sepsis 2 o

Bronchopneumonia

Submitted by:

Kristi Ann Cabonita
Marie Allexis Campaner
Francis Thomie Caranay
Rico Janrev Castañeda
Rashed Eduard Ceniza
Joanna Paula Concepcion

Submitted to:

Loreen S. Marcelo, RN

September 25, 2010

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TABLE OF CONTENTS

i. Acknowledgement.……………………………………………………………………………. 2
I. Introduction……………………………………………………………………………………. 3
II. Objectives (General & Specific)………………………………………………………………. 5
III. Patient’s Data………………………………………………………………………………….. 8
IV. Genogram……………………………………………………………………………………… 13
V. Health History…………………………………………………………………………………. 14
VI. Developmental Data…………………………………………………………………………… 17
VII. Physical Assessment…………………………………………………………………………... 20
VIII. Complete Diagnosis…………………………………………………………………………… 27
IX. Anatomy and Physiology……………………………………………………………………… 30
X. Etiology……………………………………………………………………………………….. 39
XI. Symptomatology……………………………………………………………………………… 54
XII. Pathophysiology……………………………………………………………………………… 62
XIII. Doctor’s Order……………………………………………………………………………….. 66
XIV. Diagnostic Examination………………………………………………………………………. 93
XV. Drug Study……………………………………………………………………………………. 109
XVI. Nursing Theories……………………………………………………………………………… 184
XVII. Nursing Care Plans……………………………………………………………………………. 192
XVIII. Prognosis ……………………..………………………………………………………………. 217
XIX. Discharge Planning ……………………..……………………………………………………. 222
XX. Recommendation …………………………………………………………………………….. 224
XXI. Bibliography …..……………………………………………………………………………… 225

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ACKNOWLEDGMENT

In accomplishing great things, we must not only think, but believe in the power of our

cognition; not only aim but make our visions tangible; and at the end of the day, not only smile

at the thought of accomplishment, but look back to where the strength to achieve such success

came from.

The proponents would like to extend their warmest gratitude to all the people who

helped make the success of this undertaking a reality.

First and foremost, to our parents, for giving us support and encouragement every day,

for making us feel loved and cared for.

To our Clinical Instructor, Mrs.Loreen Marcelo RN, for her invaluable time and effort

rendered to us; for her guidance all throughout the our ward exposure. For being a friend and

companion in the area.

And lastly, to the Almighty Father, for His unceasing love and blessings; for giving us

enough power and fortitude to face all the hardships in the making of this work. To Him be all

glory and praise!

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INTRODUCTION

Anemia is a common problem among acutely ill patients, especially those who develop

sepsis. There are many factors contributing to the development of anemia in these patients,

including blood sampling and other losses, decreased RBC synthesis and possibly increased

RBC destruction. Increased RBC uptake may be due to changes in RBC morphology during

inflammatory processes. Anemia is common in sepsis in part because mediators of sepsis (TNF-

α and interleukin-1β) decrease the expression of the erythropoietin gene and protein. Although

treatment with recombinant human erythropoietin decreases transfusion requirements, its use in

randomized, controlled trials failed to increase survival. Erythropoietin takes days to weeks to

induce red-cell production and thus may not be effective. Sepsis is a severe illness caused by

overwhelming infection of the bloodstream by toxin-producing bacteria. Microorganisms

invading the body cause infections. Sepsis is also called Systemic inflammatory response

syndrome (SIRS). Sepsis can also be triggered by events such as pneumonia,

With more than 750,000 new cases a year in the United States and a mortality rate of up to

50 percent, sepsis is a serious problem. The condition kills more than 1,400 Americans a day,

making it the leading cause of mortality in the ICU. There are approximately 1, 000,000 cases

of sepsis a year in the Asia,7 and the frequency is increasing, given an aging population with

increasing numbers of patients infected with treatment-resistant organisms, patients with

compromised immune systems, and patients who undergo prolonged, high-risk surgery

(University of British Columbia, Critical Care Medicine, St. Paul's Hospital, Vancouver, BC,

Canada.)

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The significance of studying this case is to enhance or broaden our knowledge as well as the

patient’s who are suffering this disease and also to those people who are in high risk of having

this disease for us to share our knowledge for the primary prevention and simple interventions

of the disease. Thus they are in a pursuit for knowledge to be able to impart it to others. It can

be alarming since many people are confused and unaware of the symptoms presented. With this

study, the student nurses hope to apply their learning in taking care not only of their patients but

also of themselves.

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OBJECTIVES

After 3 days of data gathering, research and analysis, the student nurse shall have

devised objectives that will guide them for the proper understanding and fair interpretation of

the case of their chosen patient.

GENERAL OBJECTIVES

Cognitive

The student nurse’s first main goal is to gain knowledge through the completion of the

case study and to impart this learning to the patient, and to those directly and indirectly involved

with the completion of this case.

Specific Objectives under Cognitive aspect

Within the 3 days span of duty, the student nurses will be able to:

- Gather significant data from the patient’s chart which includes the doctor’s order, labo-

ratory exams and etc. to have complete information about the patient’s current condition.

- Research on the anatomy and physiology of the client’s affected system.

- Research on the possible causes and also the symptoms the patient experienced that may

suggest the current condition of the patient.

- Research and understand the disease process of the patient’s illness.

- Determine and interpret the medical management employed including laboratory and di-

agnostic procedures.

- Identify and study the drugs prescribed to the patient which affects the patient’s current

situation.

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Psychomotor

- In this aspect, the student nurse’s goal is to apply all what they have learned during the

process of completing this case study to improve nursing care that will meet the patient’s

need for the improvement of her general welfare.

Specific Objectives under Psychomotor aspect


- Conduct a thorough physical assessment and to interpret the assessment in order to give

the care the patient need

- Formulate nursing care plans and apply them to satisfy the patient’s needs and give ap-

propriate nursing interventions.

- Make a discharge plan for the patient using M.E.T.H.O.D and validate the patient’s

prognosis according to categories.

Affective

- With the knowledge gained and through the application of this knowledge, another goal

is that the student nurses will be able to empathize with the current situation of the pa-

tient and to gain some values like the value of patience and calmness which is important

for a them to have in order to become better nurses in the future.

Specific Objectives under Affective aspect


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- Establish rapport and therapeutic communication in order to gain information about the

patient which includes the medical and family health history, expectations of her condi-

tion, gather significant data from the patient’s chart and to her family and etc.; and for

the betterment of nursing care.

- Assume the role of being the patient’s advocate.

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PATIENT’S DATA

Name: Trudis

Age: 4 months old

Address: Purok 2 Salvacion, Panabo City

Civil status: child

Nationality: Filipino

Religion: Roman Catholic

Birth Place: Panabo City

Birthdate: 5/15/10

Name of Father: Michael Visperas

Name of Mother: Shiela Mae

Admitting Diagnosis: Anemia secondary to sepsis secondary to pneumonia

Admitting physician: Dr. Evangeline Arnaiz

Date of Admission:

Hospital: Southern Philippines Medical Center

Informant: Mother

History record:

Immunization: I BCG, I DPT

(-) HPN (-) CA

(-) DM (-) Leukemia

(-) PTB

Chief Complaint: Fever

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History of Past illness:

Patient has no other past illness as verbalized by the mother. Trudis was born healthy

with a normal delivery. She has already been immunized with I BCG and I DPT.

History of present illness:

Six days prior to admission patient has intermittent high grade fever, (+) cough- non-

productive. She was first admitted at Carmen District hospital and at the same day she was

immediately referred to SPMC. The mother medicated ,the child with paracetamol and with a

herbal medicine called calabong. Three days PTA patient defecated soft stool for four times

approximately 2 tbsp per episode. Day of admission (+) for vomiting.

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FAMILY BACKGROUND AND HEALTH HISTORY

Family Background

The patient's parents; Shiela and Michael has been married for eight years. The couple

lives at Panabo city with their 4 children. Michael works as a truck driver for a businessman for

almost 5 years, where he earns 6,000 a month. On the other hand Shiela only stays at home to

take care of their children.Shiela's youger sister, also lives with them and helps them to look

after the children. The couple also owns a small sari-sari store at their house where they gain

2000-3000 a month. Tessa is the youngest among the four siblings. The oldest child in the

family is aged 8 years old, who studies at a public school near their place. The second child is

aged 5 years old who is still at playschool at a day care center. Their third child is aged 2 years

old who still doesn't go to school. The family belongs to the lower class. Shiela is a gravida 4

para 4. She stated that she has completed the prenatal check-ups needed with all the pregnancy

she had. She also claimed to be fully immunized with tetanus toxoid. Shiela gave birth to all her

children at the local government hospital in Carmen.

Lifestyle and Diet:

Shiela wakes up at around 5 a.m to prepare food for the children and her husband. Their

usual meals include fish, meat and vegetables. In the morning their eldest child is sent to school.

While Shiela stays at home and takes care of the other 3 children and at the same time watches

over their, with the help of her sister.

Effects/ Expectation of illness:

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Shiela verbalized that it was the first time that a child of hers was admitted to a hospital.

Because of this she stated to take better care of her children. She has learned to immediately

seek help to prevent further complications of her child's condition. She and her husband expects

their youngest child to recover after the treatment and management done to Trudis.

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GENOGRAM

Grandpapa Grandmama Grandaddy Grandmommy
∆
†∆♥

Francis Marie

Tudis
Camille Ж
Mikko Candice
DEVELOPMENTAL DATA

Legend:

Erikson's Stages of Psychosocial Development
Male = Female=
† = Deceased
Ж = Has Anemia 2o to Sepsis 2o
Bronchopneumonia
♥ = Hypertension
∆ = Diabetic

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Erikson's eight stages reflect both positive and negative aspects of the critical life periods. Erikson envisions life as a sequence

of levels of achievement. Each stage signals a task that must be achieved. The resolution of the task can be complete, partial, or

unsuccessful. Erikson believes that the greater the task achievement, the healthier the personality of the person; failure to achieve a

task influences the person's ability to achieve the next task. These developmental tasks can be viewed as a series of crises, and

successful resolution of these crises is supportive to the person's ego. Failure to resolve the crises is damaging to the ego.

Stage Description Result Justification
The first stage of Erik Erikson's

Infants theory centers around the infant's ACHIEVED The parents of the baby always see to it

basic needs being met by the that the baby is comfortable. They
(0 to 18
months) parents. The infant depends on the provide everything that the baby needs.

parents, especially the mother, for Trudis is breastfed on demand and
Trust vs. food, sustenance, and comfort. The safety of the baby is the top priority of
Mistrust child's relative understanding of the parents. The baby has everything

world and society come from the that she needs like blankets and

parents and their interaction with clothings which is provided by the

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the child. If the parents expose the parents. The parents are warm towards

child to warmth, regularity, and their baby as shown by them carrying

dependable affection, the infant's the baby. They always think of the needs

view of the world will be one of of the baby especially if it comes to

trust. Should the parents fail to health. They see to it that the baby gets

provide a secure environment and the proper health care needed.

to meet the child's basic need a

sense of mistrust will result.

According to Erik Erikson, the

major developmental task in

infancy is to learn whether or not

other people, especially primary

caregivers, regularly satisfy basic

needs. If caregivers are consistent

sources of food, comfort, and

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affection, an infant learns trust-

that others are dependable and

reliable. If they are neglectful, or

perhaps even abusive, the infant

instead learns mistrust- that the

world is in an undependable,

unpredictable, and possibly

dangerous place.

Piaget's Phases of Cognitive Development

Piaget concluded that there were four different stages in the cognitive development of children. The first was the Sensory

Motor Stage, which occurs in children from birth to approximately two years. The Pre-operational Stage is next, and this occurs in

children aged around two to seven years old. Children aged around seven to eleven or twelve go through the Concrete Operational

stage, and adolescents go through the Formal Operations Stage, from the age of around eleven to sixteen or more.


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Sensory Motor
Piaget's ideas surrounding the The client had achieved this
Stage (Birth - ACHIEVED
Sensory Motor Stage are stage since the client, as what we
2yrs)
centred on the basis of a have observed is able to recognize

'schema'. Schemas are mental thing around her. The client was

representations or ideas about also able to follow dangling toy,

what things are and how we which her parents have, from side to

deal with them. Piaget deduced side and tries to get them. She also

that the first schemas of an turns her head to the sound around

infant are to do with movement. her especially to the voice of her

Piaget believed that much of a parents. Her motor development is

baby's behaviour is triggered by also good as she could held her head

certain stimuli, in that they are up in a prone position for a long

reflexive. A few weeks after time.

birth, the baby begins to
Trudis is positive for reflexes like

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sucking, yawning and many more.
understand some of the
She begin to learn things as
information it is receiving from
evidenced by her laughing when
it's senses, and learns to use
ever her mother or father makes
some muscles and limbs for
faces in front of her. She knows and
movement. These
recognize her mother and father.
developments are known as

'action schemas'.

Babies are unable to consider

anyone else's needs, wants or

interests, and are therefore

considered to be 'ego centric'.

During the Sensory Motor

Stage, knowledge about objects

and the ways that they can be

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manipulated is acquired.

Through the acquisition of

information about self and the

world, and the people in it, the

baby begins to understand how

one thing can cause or affect

another, and begins to develop

simple ideas about time and

space.

Babies have the ability to build

up mental pictures of objects

around them, from the

knowledge that they have

developed on what can be done

with the object. Large amounts

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of an infant's experience is

surrounding objects. What the

objects are is irrelevant, more

importance is placed on the

baby being able to explore the

object to see what can be done

with it. At around the age of

eight or nine months, infants

are more interested in an object

for the object's own sake.

A discovery by Piaget

surrounding this stage of

development, was that when an

object is taken from their sight,

babies act as though the object

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has ceased to exist. By around

eight to twelve months, infants

begin to look for objects

hidden, this is what is defined

as 'Object Permanence'. This

view has been challenged

however, by Tom Bower, who

showed that babies from one to

four months have an idea of

Object Permanence.

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Freud's Model of psychosexual development

According to Freud’s theory of psychosexual development, the personality develops in five overlapping stages from birth to

adulthood. The libido changes its location of emphasis within the body from one stage to another. Therefore, a particular area has

special significance to a client at a particular stage. If the individual does not achieve a satisfactory progression at each stage, the

personality becomes fixated at that stage.


Oral (Birth to 1 The oral stage begins at Trudis is a 4 months old baby
ACHIEVED
½ year) birth, when the oral who shows pleasure in sucking

cavity is the primary and putting things into her mouth.

focus of libidal energy. She is breastfed on demand by

The child, of course, her mother. Her mother said that

preoccupies himself if Trudis cries, she either checks

with nursing, with the the diaper or breastfed the baby.

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pleasure of sucking and The mother has no problems in

accepting things into the breastfeeding the baby and she is

mouth. The oral equipped with adequate

character who is knowledge on the proper

frustrated at this stage, breastfeeding technique. She is

whose mother refused to very attached to her baby and

nurse him on demand or cares for her a lot. But, she just

who truncated nursing not let the baby put anything on

sessions early, is her mouth. She doesn’t disregard

characterized by the child’s safety which is far

pessimism, envy, more important.

suspicion and sarcasm.

The overindulged oral

character, whose nursing

urges were always and

often excessively

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satisfied, is optimistic,

gullible, and is full of

admiration for others

around him. The stage

culminates in the

primary conflict of

weaning, which both

deprives the child of the

sensory pleasures of

nursing and of the

psychological pleasure

of being cared for,

mothered, and held. The

stage lasts

approximately one and

one-half years.

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Physical Assessment

General Survey

Physical assessment was taken on September 12, 2010 at 11:45am, approximately 120

hours after time of admission. Received lying on bed in supine position, awake, conscious

though visibly tired.

Upon entering the room of a four month old female who lying next to parents with a

height of 61 centimeters and a weight of 6.2 kilograms, head circumference of 39 centimeters,

chest circumference of 41 centimeters and abdominal circumference of 44 centimeters and is

wearing a white colored tank top and a diaper underneath one layer of blue colored underwear.

Appears clean. No noted foul body odor. Appeared relaxed though tired. With occasional

smiling. No noted crying throughout assessment. Noted lesion on right posterior area of the

wrist. Skin on noted parted is significantly darker than that of the rest of the body. Initial vital

signs during time of assessment are:

Cardiac Rate: 139

Temperature: 37.5

Respiratory Rate: 39

Neurologic Status

Is able to smile though with no noted crying throughout the duration of the assessment.

Able to suck and swallow especially evident during breastfeeding. Eye movement in unison.

Blinks when eyes are exposed to light. Turns head when sound is generated. Sucking reflex is

present; Palmar reflex is present; Planter reflex is present.

No noted signs of neurologic disabilities.

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Skin

Skin is generally light brown in color and uniform throughout most of the body; areas of

lighter pigmentation include the palms, lips and nail beds. Noted bruising, dark in color, on right

posterior wrist approximately 3 by 4 centimeters in size. Noted redness on left gluteus maximus.

No noted foul body odor. Upon palpation, noted skin is dry. Skin felt generally warm on areas

under the cover of clothing but cooler on the arms and extremities. No noted significant

birthmarks, bleeding or lesions aside from the aforementioned. With a Temperature of 36.0°C.

Skin has fair skin turgor.

Head

Inspection, the skull is normocephalic and symmetric has smooth skull contour. With a

head circumference of 39 centimeters. Hair is black in color, unevenly distributed, soft and thin.

Has dry hair. No noted change in pigmentation. No noted bruises, lesions, nodules or swelling.

Posterior fontanelle is hard indicating it has closed. Anterior fontanelle is soft and flat. No noted

bulging or depression. Facial movements are symmetrical and is particularly evident when

showing emotions such as smiling.. No presence of infection or infestation was noted.

Eyes

During inspection, eyebrows are evenly distributed, have thin hair that are black in color.

Eyebrows were symmetrically aligned with equal movement. The skin of the eyelids were intact,

no discharges and no discoloration. Lids close symmetrically however with noted infrequent

blinking with a rate of 4 blinks per minute; bilateral blinking. Upon inspection, sclera is

generally white. No noted visible sclera above cornea. When lids are closed, sclera is not visible.

No noted tearing from lacrimal duct and lacrimal sac. No noted discharge. Has brown colored

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iris; pupils are black in color, equal in size of about 2mm. Both pupils constrict when illuminated

and are briskly reactive to light. Both eyes coordinated and move in unison. No noted strabismus,

bleeding or purulent discharge.

Ear

Auricles are aligned with the outer canthus of the eye. Upon palpation, found to be firm and not

tender; no noted pain. No noted tenderness upon palpation of the mastoid process. Pinnea recoils

after it is folded. Upon inspection with a penlight, no noted excessive discharge of cerumen or

blood. Blinking reflex noted when producing loud noise. No noted difficulty in hearing.

Nose

Upon inspection, nose is wide, symmetric straight and uniform in color. Upon palpation,

no noted tenderness or lesions. With noted minimal amount of mucous discharge from the nose.

Upon inspection with a penlight, mucosa is pink; no noted swelling, redness, growth or lesions.

Nasal septum is intact and in the midline between the nasal chambers. No noted nasal flaring.

Mouth

Upon inspection outer lips are dark pink in color; appeared soft, moist and smooth; with

symmetrical contour. No noted dryness and roughness. Inner, lips are pinkish red and uniform in

color; is moist, soft and smooth. Has no teeth. Gums are pink, moist and appear firm. No noted

swelling on gums. Tongue is in central position of the mouth, light pink in color; moist; slightly

rough with noted thin whitish coating in some areas. Able to move side to side. Smooth tongue

base with prominent veins. No noted lesions or dryness. Palate is intact. Soft palate is pink and

smooth. Hard palate is light pink and irregular in texture. Uvula is positioned in midline of

palate.

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Neck

Neck is generally uniform in color. Neck is short with not noted head lag when turning

head. Lymph nodes are not swollen and tender. Thyroid gland is not visible. Trachea is in the

center of the neck.

Chest and Lungs

Has symmetrical anterior chest expansion with a respiratory rate of 39 breaths per

minute. Spine is vertically aligned. Noted productive coughing with green colored sputum. Upon

auscultation, faint crackles can be heared. Noted occasional irregular breathing pattern. Right

and left shoulders are of the same height. Anterior chest wall is intact, no noted tenderness or

masses. Posterior chest has full and symmetric respiratory excursion. Upon percussion of the

posterior chest, sounds resonate; no noted dullness or flatness over lung tissue. Upon

auscultation of the upper chest using a stethoscope, noted faint wheezing. No noted chest

indrawing.

Back and Extremities

Upon inspection upper extremities are grossly proportional to body shape for age, equal

in size on both sides of the body. Noted bruise on right posterior wrist. No noted deformities or

edema on upper extremities. No noted tremors or palpable nodules. Clavicles are intact, no

lumps noted; No noted variation in size of hands; Has five phalanges on each hand; No noted

deformities or unusual length of fingers; Two prominent palmar creases are visible and do not

completely transverse the palm; No noted single transverse or Simian crease. Nails of upper

extremities are trimmed and cleaned. Noted capillary refill of approximately 3 seconds. Lower

extremities are grossly proportional to body shape for age, equal in size and length on both sides

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of the body. Toenails are trimmed and cleaned. No noted deformities or edema. Unable to

ambulate. Manipulation of the ankles reveals full flexibility in the form of plantar flexion of the

foot. Foot returns to neutral position after manipulation. Joints in upper and lower extremities

have good range of motion; No noted signs of hip dislocation; No noted signs of abnormal

curvature of the spine; No protrusions or deformities noted. Joints move smoothly with no noted

deformities, swelling, pain, tenderness. Spinal column vertically aligned. Spinal column is

straight with no noted protrusions or deformities.

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COMPLETE DIAGNOSIS

Anemia secondary to Sepsis Secondary to Bronchopneumonia

ANEMIA

Anemia is a condition that occurs when the number of red blood cells (RBCs) and/or the amount

of hemoglobin found in the red blood cells drops below normal. Red blood cells and the

hemoglobin contained within them are necessary for the transport and delivery of oxygen from

the lungs to the rest of the body. Without a sufficient supply of oxygen, many tissues and organs

throughout the body can be adversely affected. Anemia can be mild, moderate or severe

depending on the extent to which the RBC count and/or hemoglobin levels are decreased. It is a

fairly common condition, affecting both men and women of all ages, races, and ethnic groups.

P. 769 Brunner & Sudddarths Textbook of Medical Surgical Nursing 7th edition J.B Lippincott

Company

Anemia is a medical condition in which the red blood cell count or hemoglobin is less than

normal. The normal level of hemoglobin is generally different in males and females. For men,

anemia is typically defined as hemoglobin level of less than 13.5 gram/100ml and in women as

hemoglobin of less than 12.0 gram/100ml. These definitions may vary slightly depending on the

source and the laboratory reference used.

P. 336 Rick Randle Contemporary Medical Surgical Nursing 2007

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Anemia is a condition in which your blood has a lower than normal number of red blood cells.

Anemia also can occur if your red blood cells don't contain enough hemoglobin Hemoglobin is

an iron-rich protein that gives blood its red color. This protein helps red blood cells carry oxygen

from the lungs to the rest of the body.

Hopper P.D., Williams, L.S. ; Understanding Medical Surgical Nursing 3rd edition

SEPSIS

Sepsis is any adverse medical conditions due to the presence of any microorgansim in the blood.

Usually, the layperson using the term blood poisoning is referring to the medical condition that

arise when bacteria or their products reach the blood.

Mosby’s Pocket Dictionary of Medicine, Nursing & Health Professions 5th edition

Sepsis is a serious infection usually caused by bacteria which can originate in many body parts,

such as the lungs, intestines, urinary tract, or skin that make toxins that cause the immune

system to attack the body's own organs and tissues

Infection that progress to the blood stream causing systemic infection is called sepsis. It results

from the presence of microorganism in the blood stream.

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P,1482 Brunner & Sudddarths Textbook of Medical Surgical Nursing 7 th edition J.B Lippincott

Company

Bronchopneumonia

Bronchopneumonia occurs as a diffuse pattern of infection in both lungs more often in the lower

lobes. One or Several species if microorganisms cause the infection beginning in the bronchial

mucosa and spreading into the local alveoli the inflammatory exudates form in the alveoli

interfering with oxygen diffusion. Onset tends to insidious with mild fever, cough and rales.

Congestion causes productive cough and purulent sputum.

P.382 Gould B, Patho physiology for Health Professions 3rd edition, Saunders

Bronchopneumonia or bronchial pneumonia or "Bronchogenic pneumonia is the acute

inflammation of the walls of the bronchrioles. It is a type of pneumonia characterised by multiple

foci of isolated, acute consolidation, affecting one or more pulmonary lobes.

Smeltzer, Suzzane C. and Brenda G. Bare. Medical Surgical Nursing. Volme 2. 10 th

Edition. Lippincott Williams & Wilkins: Philadelphia. Copyright © 2004.

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Bronchopneumonia is a type of pneumonia that is characterized by an inflammation of the lung

generally associated with, and following a bout with bronchitis. This is really a specific type of

pneumonia that is localized in the bronchioles and surrounding alveoli.

P. 464 Brunner & Sudddarths Textbook of Medical Surgical Nursing 7 th

edition J.B Lippincott Company

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ANATOMY AND PHYSIOLOGY

Respiratory System

The respiratory system consists of all the organs involved in breathing. These include the

nose, pharynx, larynx, trachea, bronchi and lungs. The respiratory system does two very

important things: it brings oxygen into our bodies, which we need for our cells to live and

function properly; and it helps us get rid of carbon dioxide, which is a waste product of cellular

function. The nose, pharynx, larynx, trachea and bronchi all work like a system of pipes through

which the air is funneled down into our lungs. There, in very small air sacs called alveoli, oxygen

is brought into the bloodstream and carbon dioxide is pushed from the blood out into the air.

When something goes wrong with part of the respiratory system, such as an infection like

pneumonia, chronic obstructive pulmonary diseases, it makes it harder for us to get the oxygen

we need and to get rid of the waste product carbon dioxide.

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The Upper Airway and Trachea

When you breathe in, air enters your body through your nose or mouth. From there, it

travels down your throat through the larynx (or voicebox) and into the trachea (or windpipe)

before entering your lungs. All these structures act to funnel fresh air down from the outside

world into your body. The upper airway is important because it must always stay open for you to

be able to breathe. It also helps to moisten and warm the air before it reaches your lungs.

The Lungs

Structure

Air travels to the lungs through a series of air tubes and passages. It enters the body

through the nostrils or the mouth, passing down the throat to the larynx, or voice box, and then to

25

the trachea, or windpipe. In the chest cavity the trachea divides into two branches, called the

right and left bronchi or bronchial tubes, that enter the lungs.

In the adult human, each lung is 25 to 30 cm (10 to 12 in) long and roughly conical. The

left lung is divided into two sections, or lobes: the superior and the inferior. The right lung is

somewhat larger than the left lung and is divided into three lobes: the superior, middle, and

inferior. The two lungs are separated by a structure called the mediastinum, which contains the

heart, trachea, esophagus, and blood vessels. Both right and left lungs are covered by an external

membrane called the pleura. The outer layer of the pleura forms the lining of the chest cavity.

The branches of the bronchi eventually narrow down to tubes of less than 1.02 mm (less

than 0.04 in) in diameter. These tubes, called bronchioles, divide into even narrower tubes, called

alveolar ducts. Each alveolar duct ends in a grapelike cluster of thin-walled sacs, called alveoli (a

single sac is called an alveolus). From 300 million to 400 million alveoli are contained in each

lung. The air sacs of both lungs have a total surface area of about 93 sq m (about 1000 sq ft),

nearly 50 times the total surface area of the skin.

In addition to the network of air tubes, the lungs also contain a vast network of blood

vessels. Each alveolus is surrounded by many tiny capillaries, which receive blood from arteries

and empty into veins. The arteries join to form the pulmonary arteries, and the veins join to form

the pulmonary veins. These large blood vessels connect the lungs with the heart.

The lungs are paired, cone-shaped organs which take up most of the space in our chests,

along with the heart. Their role is to take oxygen into the body, which we need for our cells to

26

live and function properly, and to help us get rid of carbon dioxide, which is a waste product. We

each have two lungs, a left lung and a right lung. These are divided up into ‘lobes’, or big

sections of tissue separated by ‘fissures’ or dividers. The right lung has three lobes but the left

lung has only two, because the heart takes up some of the space in the left side of our chest. The

lungs can also be divided up into even smaller portions, called ‘bronchopulmonary segments’.

These are pyramidal-shaped areas which are also separated from each other by

membranes. There are about 10 of them in each lung. Each segment receives its own blood

supply and air supply.

Blood Supply

The lungs are very vascular organs, meaning they receive a very large blood supply. This

is because the pulmonary arteries, which supply the lungs, come directly from the right side of

your heart. They carry blood which is low in oxygen and high in carbon dioxide into your lungs

so that the carbon dioxide can be blown off, and more oxygen can be absorbed into the

bloodstream. The newly oxygen-rich blood then travels back through the paired pulmonary veins

into the left side of your heart. From there, it is pumped all around your body to supply oxygen

to cells and organs.

The Pleurae

27

The lungs are covered by smooth membranes that we call pleurae. The pleurae have two

layers, a ‘visceral’ layer which sticks closely to the outside surface of your lungs, and a ‘parietal’

layer which lines the inside of your chest wall (ribcage). The pleurae are important because they

help you breathe in and out smoothly, without any friction. They also make sure that when your

ribcage expands on breathing in, your lungs expand as well to fill the extra space.

The Diaphragm and Intercostal Muscles

When you breathe in (inspiration), your muscles need to work to fill your lungs with air.

The diaphragm, a large, sheet-like muscle which stretches across your chest under the ribcage,

does much of this work. At rest, it is shaped like a dome curving up into your chest. When you

breathe in, the diaphragm contracts and flattens out, expanding the space in your chest and

drawing air into your lungs. Other muscles, including the muscles between your ribs (the

intercostal muscles) also help by moving your ribcage in and out. Breathing out (expiration) does

not normally require your muscles to work. This is because your lungs are very elastic, and when

your muscles relax at the end of inspiration your lungs simply recoil back into their resting

position, pushing the air out as they go.

The Cardiovascular System

28

The Blood

Blood is denser and

more viscous than water,

which is part of the reason it flows more slowly than water. The temperature of blood is about

38°C, which is slightly higher than normal body temperature, and it has a slightly alkaline pH

ranging from 7.35 – 7.45. Blood constitutes about 8% of the total body weight. The blood

volume is 5 - 6 liters in an average-sized adult male and 4 – 5 liters in an average-sized adult

female. Several hormonal negative feedback systems ensure that blood volume and osmotic

pressure remain relatively constant. Especially important systems are those involving

aldosterone, antidiuretic hormone, and atrial natriuretic peptide, which regulate how much water

is excreted in the urine.

Components of Blood

29

Whole blood is composed of two components: blood plasma, a watery liquid that

contains dissolved substances, and formed elements, which are cells and cell fragment.

Blood Plasma

When formed elements are removed from blood, a straw-colored liquid called

blood plasma is left. Plasma is about 91.5% water and 8.5% solutes, most of which are proteins.

Some of the proteins in plasma are also found elsewhere in the body, but those confined to blood

are called plasma proteins. Among other functions, these proteins play a role in maintaining

proper blood osmotic pressure, which is an important factor in the exchange of fluids across

capillary walls.

Plasma proteins:

- Albumins (54% of plasma proteins)

- Globulins (38%)

30

- Fibrinogen (7%)

Formed Elements:

RBC or Red Blood Cell

Red blood cells or erythrocytes contain the oxygen-carrying protein hemoglobin, which is

a pigment that gives whole blood its red color. A healthy adult male has about 5.4 million red

blood cells per microliter of blood, and a healthy adult female has about 4.8 million. To maintain

normal quantities of RBCs, new mature cells must enter the circulation at the astonishing rate of

at least 2 million per second, a pace that balances the equally high rate of RBC destruction.

Red blood cells are biconcave discs with a diameter of 7-8 micrometers and are highly

specialized for their oxygen transport function. Each one contains about 280 millions

hemoglobin molecules. A hemoglobin molecule consists of a protein called globin.

Red blood cells live only about 120 days because of the wear and tear their plasma

membranes undergo as they squeeze through blood capillaries.

WBC or White Blood Cell

31

Unlike red blood cells, white blood cells or leukocytes have a nucleus and do not contain

hemoglobin. WBCs are classified as either granular or agranular, depending on whether they

contain conspicuous chemical-filled cytoplasmic vescicles that are made visible by staining.

Granular leukocytes include neutrophils, eosinophils, and basophils; agranular leukocytes

include lymphocytes and monocytes.

In a healthy body, some WBCs, especially lymphocytes, can live for several months or

years, but most live only a few days. During a period of infection, phagocytic WBCs may live

only a few hours. WBCs are far less numerous than red blood cells, about 5,000-10,000 cells per

microliter of blood. RBCs therefore outnumber white blood cells by about 700:1. Leukocytosis,

an increase in the number of WBCs, is a normal, protective response to stresses and surgery.

Platelet

32

Besides the immature cell types that

develop into erythrocytes and leukocytes,

hemopoietic stem cells also differentiate

into cells that produce platelets. Under the

influence of the hormone thrombopoietin,

myeloid stem cells develop into

megakaryocyte-colony-forming cells that,

in turn, develop into precursor cells called

megakaryoblasts. Megakaryoblasts transform into megakaryocytes, huge cells that splinter into

2000-3000 fragments. Each fragment, enclosed by a piece of the cell membrane, is a platelet or

thrombocyte. Platelets break off from the megakaryocytes in red bone marrow and then enter the

blood circulation. Between 150,000 – 400,000 platelets are present in each microliter of blood.

They are disc-shaped, 2-4 micrometers in diameter, and exhibit many granules but no nucleus.

Platelets help stop blood loss from damaged blood vessels by forming a platelet plug. Their

granules also contain chemicals that, once released, promote blood clotting. Platelets have a short

life span, normally just 5 – 9

days.

The Blood Vessels

There are 3 types of

blood vessels: the arteries, the

veins and the capillaries. An

33

artery is a vessel that carries blood away from the heart. It carries oxygenated blood. Small

arteries are called arterioles. Veins, on the other hand are vessels that carries blood toward the

heart. It contains the deoxygenated blood. Small veins are called venules. Often, very large

venous spaces are called sinuses. Lastly, capillaries are microscopic vessels that carry blood

from small arteries to small veins (arterioles to venules) and back to the heart.

The walls of the blood vessels, the arteries and veins have three main layers: tunica

adventitia, tunica media and tunica intima. Tunica adventitia which is a fibrous type of vessel is a

connective tissue that helps hold vessels open and prevents tearing of the vessel wall during body

movement. Tunica media is a smooth muscle, sandwiched together with a layer of elastic

connective tissue. It permits changes of the blood vessel diameter. It allows the constriction and

dilation of the vessels. Last but not the least is the tunica intima. Tunica intima, which in Latin

means inner coat, is made up of endothelium that is continuous with the endothelium that lines

the heart. In arteries, it provides a smooth

lining. However in veins it

maintains the one-way flow of the blood.

The endothelium, which makes up the thin

coat of the capillary, is important because

the thinness of the capillary wall allows

the exchange of materials between the

blood plasma and the interstitial fluid of

the surrounding tissues.

Circulation of the blood in blood vessels

34

There are two circulatory routes of blood as it flows through the blood vessels: the

systemic and the pulmonary circulation. In systemic circulation, blood flows from the left

ventricle of the heart through blood vessels to all parts of the body (except gas exchange tissues

of lungs) and back to the atrium. In pulmonary circulation on the other hand, venous blood

moves from the right atrium to right ventricle to pulmonary artery to lung arterioles and

capillaries where gases exchanged; oxygenated blood returns to the left atrium via pulmonary

veins; from left atrium, blood enters the left ventricle.

Inflammation

Cells damaged by microbes, physical agents, or chemical agents initiate a defensive

response called inflammation. The four characteristic signs and symptoms of inflammation are

redness, pain, heat, and swelling. Inflammation can also cause the loss of function in the injured

area, depending on the site and extent of injury. Inflammation traps microbes, toxins, and foreign

35

material at the site of injury and prepares the site for tissue repair. Thus, it helps restore tissue

homeostasis.

Because inflammation is one of the body’s nonspecific defenses, the response of a tissue

to, say, a cut is similar to the response to damage caused by burns, radiation, or bacterial or viral

invasion. In each case, inflammation has three basic stages: vasodilation and increased

permeability of blood vessels, phagocyte emigration, and ultimately, tissue repair.

Among the substances that contribute to vasodilation, increased permeability, and other

aspects of the inflammatory response are the following:

• Histamine. In response to injury, mast cells in connective tissue and basophils and

platelets in blood release histamine. Neutrophils and macrophages attracted to the site of

injury also stimulate the release of histamine, which causes vasodilation and increased

permeability of blood vessels.

• Kinins. These polypeptides, formed in blood from inactive precursors called kininogens,

induce vasodilation and increased permeability and serve as chemotactic agents for

phagocytes.

• Prostaglandins. These lipids are released by damaged cells and intensify the effects of

histamine and kinins. It may also stimulate the emigration of phagocytes through capil-

lary walls.

36

ETIOLOGY AND SYMPTOMATOLOGY

A. ETIOLOGY

Predisposing Present/
Rationale Justification
Factors Absent
37
Age Present Extremes of age predisposes an individual to pneumonia. The patient is aged 4

Those who are aged 65 and above and those who are very months, by this age, the

young are more susceptible to acquiring pneumonia due immune system is not

to weakened immune system and under developed yet well developed as

immune system respectively. compared to adults and

http://emedicine.medscape.com older children, thus

predisposing the child

to pneumonia.
Congenital Absent Congenital Anomalies such as hereditary dyskinesis of There are no diagnostic

Anomalies the cilia and squamous metaplasia hinder the body’s findings that would

ability to eliminate invading pathogens, thus indicate any congenital

predisposing one to acquiring infections in the respiratory abnormalities in the

tract. child that would

Congenital Abnormalities of the Lung by Karan Madan. predispose her to the

http://www.indiachest.org condition.

Precipitating Present/
Rationale Justification
Factors Absent
Immobility Absent Prolonged immobility causes limited expansion of the The patient did not

lungs immobility changes the distribution of ventilation have immobility.

and blood flow through the lungs and patients are unable

to take a deep breath, also, respiratory muscle weakness

occurs due to limited physical activity and metabolic

changes. It results in an increase in the work of breathing

which causes a decrease in the ability of the patient to

cough. With decreased lung expansion and weakened

respiratory muscles, secretions stagnate and pool which

increases the risk for hypostatic pneumonia.

38

B. SYMPTOMATOLOGY

Symptoms Present/Absent Rationale Justification

Fever Present Is a frequent medical Vital Signs upon admission

symptom that reveal a temperature of 38.6.

describes an increase

in internal body

temperature to levels

that are above

normal. It is

stimulated by

cytokines (IL-1 &

IL-6). These

cytokines send

signals in the

hypothalamus that

serves as our

thermoregulatory

center, thus

prostaglandin is

released. Once

prostaglandin is

39

released, it causes an

increase in the set

point. In response to

this, the

hypothalamus

neurally initiates

shivering and

vasoconstriction that

increases the core

body temperature to

the new set point,

and fever is

established.
Pain in the chest Absent Difficulty of This is not manifested by the

over the affected breathing may lead patient.

lung to chest pain due to a

deprivation of

oxygen circulating in

the lungs and heart.

Chemical mediators

like bradykinin and

prostaglandin also

play a role in the

40

pain felt.
Dyspnea Present The alveoli are the There are occasions within the

main site for oxygen shift that that the patient’s

and carbon dioxide respiratory rate rises above

exchange in the the normal range with

lungs. Once the apparent labored breathing,

exudates are poured indicating dyspnea.

into the alveoli, it

impairs the oxygen-

carbon dioxide

exchange because

the space intended

for air is already

filled with fluid

causing dyspnea or

difficulty in

breathing.

Productive cough Present It is a sudden audible The patient had productive

expulsion of air from cough.

the lungs with

sputum. It is an

essential protective

41

response that serves

to clear the lungs,

bronchi, and trachea

or irritants and

secretions or to

prevent aspiration of

foreign material into

the lungs.
Alterations in Present Hyperthermia or The patient was febril upon

body temperature hypothermia are admission.

characteristic signs

of sepsis, occurring

due to
Decreased red Present A decrease in the Laboratory results show a

blood cells number of red blood decrease in RBCs, and a

cells is called ane- blood transfusion was

mia. Anemia is a ordered.

common problem in

acutely ill patients,

especially in those

who develop sepsis.

There are many fac-

tors contributing to

42

the development

of anemia in these

patients, including

blood sampling and

other

losses, decreased red

blood cell (RBC)

synthesis, and possi-

bly increased

destruction. In-

creased RBC uptake

may be due to

changes in RBC

morphology

and the RBC

membrane during

inflammatory

processes.

Anemia in sepsis:

the importance of

red blood cell

membrane changes

43

Micheal Piagnerelli,,

MD, Et al.

Tachycardia Absent Tachycardia is This was not manifested by

characterized by the patient.

rapid beating of the

heart. Heart rate

considered as

tachycardia is above

120 in newborns,

above 180bpm in 6

month old infants,

more than 160bpm

in 1 year old clients

and above 130 in

two-year olds.

RN Notes. 2nd

Edition, by Ehren

Myers, RN.

Since there is an

impaired exchange

of gases in the lungs,

and oxygen transport

44

to tissues is

inefficient, the heart

compensates by

pumping fast.

Crackles Present Crackles (or rales) Upon auscultation, crackles

are caused by fluid were heard on both lung

in the small airways fields.

or atelectasis.

Crackles are referred

to as discontinuous

sounds; they are

intermittent,

nonmusical and

brief. Crackles may

be heard on

inspiration or

expiration. The

popping sounds

produced are created

when air is forced

through respiratory

passages that are

45

narrowed by fluid,

mucus, or pus.

Crackles are often

associated with

inflammation or

infection of the small

bronchi, bronchioles,

and alveoli. Crackles

that don't clear after

a cough may indicate

pulmonary edema or

fluid in the alveoli.

This is common in

pneumonia.

Tachypnea Present Also known as fast There are occasions within the

breathing. For shift that that the patient’s

pediatric clients, respiratory rate rises above

breathing is the normal range with

considered fast when apparent labored breathing.

it reaches the rate of

above 30cpm in ages

1 to 4 years, above

46

35cpm in those aged

6-11 months and

above 60cpm in

newborns to

5months.

RN Notes. 2nd

Edition, by Ehren

Myers, RN.

. A decrease in

oxygen would cause

the body to

compensate to

increase the oxygen

supply in the body.

This results to the

increase in the

respiratory rate.

47

WBC changes Present White blood cells are Laboratory results show

responsible for the elevated levels of white blood

defense system in cells.

the body. White

blood cells fight

infections and

protect our body

from foreign

particles, which

includes harmful

germs and

bacteria.Thus,

elevated WBC

counts indicate

infection.
Decreased blood Absent Due to the cascade This is not manifested by the

pressure of interactions patient.

between WBCs and

48

component of WBC,

neutrophils, release

nitric oxide in the

process, a potent

vasodilator. Thus

causing a decrease in

blood pressure.
Easy Fatigability Absent A decrease in This is not manifested by the

circulating red blood patient.

cells impairs the

transport of oxygen

in the different areas

in the body.

Decreased oxygen

delivery to the

musculoskeletal

tissues cause easy

fatiguability.
Respiratory Absent Respiratory acidosis No ABG results would

Acidosis is acidosis indicate respiratory acidosis.

(abnormally

49

decreased ventilation

of the pulmonary

alveoli, leading to

elevated arterial

carbon dioxide

concentration. In

cases of pneumonia,

respiratory acidosis

occur as a result of

the impaired gas

exchange in the

lungs.
Pallor Present Pallor is due to a The baby was reported to be

reduced amount of pale.

oxyhemoglobin in

skin or mucous

membrane, a pale

color which is

caused by anemia. It

is more evident on

the face and palms.

50

Pathophysiology
(Community Acquired Pneumonia)

Predisposing Factors: Precipitating
Age Factors:

Causative agent
gains access to Through aspiration or
the reparatory inhalation
tract

Penetrates
the LRT

Irritation of the
site occurs

Alveolar macrophages (primary
defense) in the site fights off the
microorganisms

Bacteria adheres to
the alveolar
macrophages

Phagocytosis (cell eating
mechanism) occurs

Engulfed microorganisms will
be removed

51

Weakened immune system
due to predisposing factors

Microorganism
become virulent and is
present in large
number

Overwhelms the
alveolar macrophages

Activation of the
inflammatory response

Release of multiple
inflammatory mediators

Cause pain Bradykinin Histamine Prostaglandin Cause pain
and fever

Causes
vasodilation

Increase capillary
permeability

Extravasation of fluid into
tissues and cavity

Plasma enters into the
inflammatory site
(bronchioles and alveoli)

52

Terminal bronchioles
are filled with debris
and exudates

Cytokines send
signal in the
hypothalamus Exudates in Exudates in
the alveoli the alveoli
cause irritation
Prostaglandin
is released Impairs oxygen-
Increase mucus
production by carbon dioxide
dyspnea
goblet cells exchange in the
Increase set alveoli
point in the
hypothalamus
Body attempts
to expel out
Hypothalamus foreign
neurally initiates substances
shivering and and fluid out of
Body
vasoconstriction the lungs
compensates

Increase in the Stimulation of
core body the cough Increase in tachypnea
temeprature reflex respiratory rate

Chills and fevers Productive cough

53

Continuous inflammation of
the alveoli and bronchioles
occur

Bacterial Exudation of fluids
dissemination into the cavity

Conditions
exacerbate and
bacterial spread
becomes systemic
Fluids accumulate and
consolidate

Sepsis
Fluids consume a lot
of space in the lungs

Decreased lung
expansion

Dyspnea

54

Outer membrane component of
Continuous inflammation of
microorganisms trigger the release of
the alveoli and bronchioles chemical mediators
occur

Bacterial Cytokines, tumor-necrosis factor, platelet-activating factors,
Exudation of fluids
dissemination interleukin, prostaglandins and leukotrines are released
into the cavity

Conditions
exacerbate and
bacterial spread
Increased RBC
becomes systemic
destruction Fluids accumulate and
consolidate Production of adhesion
Mediators damage endothelial lining
molecules and neutrophils
Sepsis

anemia Fluids consume a lot
of space in the lungs

Neutrophilic endothelial
Decrease in the oxygen carrying Decreased lung reaction leads to further
capacity of the blood
expansion endothelial injury
Neutrophil components
release nitric oxide
Tissue hypoxia Dyspnea

Septic shock

musculoskeletal skin CNS Circulatory

pallor
Confusion, dizziness High pulse rate,
Easy fatigability,
increased
weakness

55

If treated: If not treated: Complications
Antibiotics Heart Problems
Iron Supplements Nerve Damage
Dietary Modifications Impaired Mental Function

Bad Prognosis

Good Prognosis

DOCTOR’S ORDER

DATE ORDER RATIONALE REMARKS

09/07/10 Admitting orders
Please admit to IMCU For close monitoring of the patient Admitted

under Pedia 3 service and proper management of his

level 3 condition
BF with SAP Mothers are encouraged to give their Mother

newborns breastmilk because of the informed

benefits of Breastfeeding such as

nutritional, immunological,

emotional and psychological. A

strict aspiration precaution if ordered

when patient is at risk for aspiration,

because of this, feeding would be

strictly watched.
Start venoclysis with D5 Intravenous lines provide easy Started

0.3 NaCl 500 cc @ 25 access for drug administration

cc/hr intravenously (IVTT). Intravenous

solutions containing dextrose and

sodium chloride are indicated for

parenteral replenishment of fluid,

minimal carbohydrate calories, and

sodium chloride as required by the

clinical condition of the patient.
Labs:
WT = 6.2  CBC with PC CBC with PC determines the Done

kL quantity of each quantity of blood

cell in a given specimen of blood,

often including the amount of

hemoglobin, hematocrit, and the

proportion of various white blood

cells. This is done to know any

condition of the client that may

affect his medical management.

 BT Blood typing is a method to tell what Done

specific type of blood you have.

What type you have depends on

whether or not there are certain

proteins, called antigens, on your red

blood cells.
 Urinalysis Urinalysis is performed to screen for Done

urinary tract disorders, kidney

disorders, urinary neoplasm and

other medical conditions that

produce changes in the urine. This

test also is used to monitor the

effects of treatment of known renal

or urinary condition. This test is also

used to monitor the effects of certain

procedures done to patient and to

check if genito-urinary is in normal

state or not.
 Chest X-ray – APL A chest radiograph, commonly Not done

called a chest x-ray (CXR), is

a projection radiograph of

the chest used to diagnose conditions

affecting the chest, its contents, and

nearby structures. Chest radiographs

09/08/10 Dx:
 S/F PBS please give Examination of the peripheral blood Referral form

referral form smear should be considered, along

with review of the results of

peripheral blood counts and red

blood cell indices, an essential

component of the initial evaluation

of all patients with hematologic

disorders. The examination of blood

films stained with Wright's stain

frequently provides important clues

in the diagnosis of anemias and

various disorders of leukocytes and

platelets.
 Follow up all labs This is done since the laboratory Followed up

result now results are needed in the medical

management of the patient’s

condition.
Rx:
 IVF @ same rate This may continuously administer Hooked

parenteral replenishment of fluid,

minimal carbohydrate calories, and


 Meds: Day 1 please give Rx
Ampicillin Ampicillin is a beta-lactam antibiotic Given

Still w/ Gentamycin Gentamicin is an aminoglycoside Given

antibiotic, used to treat many types

of bacterial infections, particularly

those caused by Gram-negative

bacteria. Gentamycin is given

together with ampicillin bcause one

of the concern of giving antibacterial

is the number of bacteria that

become resistant to the drug

necessitating combination therapy or

use of other antibiotics.
febrile VS q 4 hours Vital signs are important for baseline Taken and

episodes assessment and to monitor patients recorded

condition which evaluates the whole

(+) LBM treatment course, especially the

medications he received that could

be a contributing factor in the

variation results of the vital signs.
Refer accordingly This may create a collaborative referred

treatment among the client and the

health care providers; thus it also

makes a good coordination on the

treatment of the client.
Follow up BT result This is done since the laboratory Followed up

result is needed in the medical

management of the patient’s

condition which is blood transfusion.
To secure PRBC 100cc Packed red blood cells (PRBCs), Not done

aliqout and transfuse 70 also called "packed cells," are a

cc to run un 4 hours after preparation of red blood cells that

proper cross matching are transfused to correct low blood

levels in anemic patients. This

increases the amount of hemoglobin

in the blood that can carry oxygen

perfused from alveoli of the lungs to

tissues.
For PBS prior to Blood This is done to have a baseline data Not done

transfusion to determine whether the medical

management given was right.
09/09/10 Dx: S/F PBS give Examination of the peripheral blood DONE

8:20 am request smear should be considered, along

with review of the results of

peripheral blood counts and red

blood cell indices, an essential

component of the initial evaluation

of all patients with hematologic

disorders. The examination of blood

films stained with Wright's stain

frequently provides important clues

in the diagnosis of anemias and

various disorders of leukocytes and

platelets.
Continue IVF with D5 Intravenous lines provide easy Continued




sodium chloride are continuously

given for parenteral replenishment of

fluid, minimal carbohydrate calories,

and sodium chloride as required by

the clinical condition of the patient.
Continue medications: Day 2

(-) fever Ampicillin Ampicillin is a beta-lactam antibiotic Given

(+) pale Gentamycin that has been used extensively to

looking treat bacterial infections. Strict

(+) cough compliance for treatment regimen is

(+) rash very important for proper treatment

and prevent the growth of drug-

resistant bacteria
Gentamicin is an aminoglycoside Given










Continue VS monitoring Vital signs are important for baseline Taken and

q4 hours assessment and to monitor patients recorded


treatment course, especially the



Continue I&O Intake and output helps gauge fluid Monitored

monitoring q4 hours balance in the body of the patient.

This would also check if patient’s

elimination pattern is normal or

impaired.
Refer accordingly if with This may create a collaborative Referred

unusualities treatment among the client and the



Still securing PRBC for Packed red blood cells (PRBCs), Secured

BT also called "packed cells," are a

preparation of red blood cells that

are transfused to correct low blood





tissues.
09/10/10 Dx: PBS result after 10 This is done to allow enough time

7:20 am working days for further testing in case of

inclusive or doubtful results
Continue IVF with D5 Intravenous lines provide easy Continued




sodium chloride are continuously

given for parenteral replenishment of

fluid, minimal carbohydrate calories,

and sodium chloride as required by

the clinical condition of the patient.

(-) fever Continue medications: Day 3
Ampicillin Ampicillin is a beta-lactam antibiotic Given
comfortable
that has been used extensively to
Asleep
treat bacterial infections. Strict
(+) rash
compliance for treatment regimen is

very important for proper treatment

and prevent the growth of drug-

resistant bacteria
Gentamycin Gentamicin is an aminoglycoside










Continue VS monitoring Vital signs are important for baseline Taken and

q4 hours assessment and to monitor patients recorded


treatment course, especially the



variation results of the vital signs.
Continue I&O Intake and output helps gauge fluid Monitored

monitoring q shift, then balance in the body of the patient. and recorded

record This would also check if patient’s

elimination pattern is normal or

impaired.
Refer accordingly This may create a collaborative Referred

treatment among the client and the



9 am Still for PRBC Packed red blood cells (PRBCs), Noted

transfusion also called "packed cells," are a

preparation of red blood cells that

are transfused to correct low blood





tissues.
Please extract blood for Blood Cross Matching refers to the Done

cross matching without complex testing that is performed

fail – c/o clerk on duty prior to a blood transfusion, to

determine if the donor's blood is

compatible with the blood of an

intended recipient, or to identify

matches for organ transplants.
09 /11/10 Dx: F/U PBS result after This is done to allow enough time Noted

7 am 10 working days for further testing in case of

inclusive or doubtful results
Rx:
awake  IVF @ SR This may continuously administer Done

comfortable parenteral replenishment of fluid,

afebrile minimal carbohydrate calories, and



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