INTRODUCTION Pediatric community-acquired is diseases in which individuals who have not recently been hospitalized develop on infection of the

lungs(pneumonia). PCAP is a common illness that affects infants and children. PCAP often causes problems like difficulty in breathing, fever, chest pain and cough. PCAP occurs because the atmosphere or the areas of the lungs which absorb oxygen (alveoli) from the atmosphere become filled with fluid and cannot work effectively.

CAP is a common illness in all parts of the world. It is a major cause of death among all age groups. In children, the majority of deaths occur in the newborn period, with over two million worldwide deaths a year. In fact, the WHO estimates that one in three newborn infant deaths are due to pneumonia. Mortality decreases with age until late adulthood; elderly individuals are particularly at risk for CAP and associated mortality .Although viral pneumonias are common in school-aged children and adolescents and are usually mild and self-limited, these pneumonias are occasionally severe and can rapidly progress to respiratory failure, either as a primary manifestation of viral infection or as a consequence of subsequent bacterial infection Despite a broad armamentarium of antimicrobials available to treat the disease, pneumonia remains the seventh leading cause of death in the United States. According to WHO and BTS criteria, severe CAP was present in 57 (50%) and in96 (85%) cases, respectively; 29 (26%) were aged less than 1 year. The median age (months)w a s 2 2 ( m e a n 2 4 1 4 , r a n g e 2 5 8 ) . O v e r a l l , r a d i o g r a p h i c f i n d i n g w a s r i g h t - s i d e d i n 7 7 (68%) cases and the upper lobe was compromised in 36 (32%) cases. By analyzing data stratified to age, the frequency of upper lobe involvement was significantly higher among severe cases (W HO criteria) only for those patients aged 1 year (13/35 [ 3 7 % ] v s . 7 / 4 5 [16%], P = 0.03, OR [95% CI] 3.2 [1.1-9.2]). The specificity and positive predictive value of upper lobe involvement for severity among the latter group of patients were 84% (95% CI70-93%) and 65% (95% CI 41-84%), respectively. No association was found by using the BTS criteria. The admission chest radiography was useful to predict severity of children aged 1 year hospitalized with CAP. National Regional 1= Lorma Medical Center = It is due to the motive to learn and apply our knowledge and incaring the patient with pediatric community acquired pneumonia (PCAP). skills

II. OBJECTIVES a. G E NE R AL O BJ EC TI VE S After this case study, we will be able to know what are Pneumonia, how it is acquired and prevented, its prevention and treatments of its occurrence. b.SPECIFIC OBJECTIVES Define what is Pneumonia Trace the pathophysiology of Pneumonia Enumerate the difference signs and symptoms of pneumonia Formulate and apply nursing care plans, utilizing the nursing process To learn new clinical skills as well as sharpen our current clinical skills required in the management of the patient with Pneumonia To develop our sense of unselfish love and empathy in rendering nursing care to our patient so that we may able to serve future clients with higher level of holistic understanding as well as individualized care. III. PATIENTS PROFILE: Name : Mondido, Princess Address: P-4 Narra St. Bermudez, Apokon Tagum City Birth date: December 7,2010 Age: 8 months Civil status: Child Mothers name: Mondido, Maribel Occupation: House Wife Educational attainment: High School Graduate Fathers name: Mondido, Reynaldo Occupation: Fisher Man Educational attainment: High School Graduate Religion: Roman Catholic B. CHIEF COMPLAINT The patient was admitted due to the chief complaint of high grade fever, 38.6 C via axilla, productive cough and difficulty of breathing. C. HISTORY OF PRESENT ILLNESS The present condition started 3 days prior to admission when thepatient had dry cough with associated difficulty of breathing. No othera s s o c i a t e d s i g n s a n d s y m p t o m s s u c h a s d i a r r h e a a n d v o m i t i n g . N o con sultation done or medication taken.2 days prior to admission, the above condition persisted associated with neither fever, still no consultation done nor medication taken. F e w h o u r s p r i o r t o a d m i s s i o n , d u e t o p e r s i s t e n c e o f t h e a b o v e condition, she was then brought in the institution and was then admitted on July 31, 2010 at 9:40PM with

the vital signs of T-38.6C, PR-135bpm, RR-68bpm, O2sat-98%, weight-6.4kg, height58.5cm and a BMI of 18.90 kg/m 2 (healthy weight) 22 as ideal with a range of 18.5-25 D. PAST MEDICAL HISTORY The mother stated that the patient was not hospitalized nor had i l l n e s s e s b e f o r e . T h e p a t i e n t h a d n o a l l e r g i e s t o d r u g s . T h e m o t h e r a l s o claimed that the patient already received her BCG and Hepa B vaccines, 1 dose each, 1 week after her birth at the health center, and had her vaccines in DPT and OPV with 1 dose each when she was 6Th week old. E. PEDIA HISTORY The patient was born to a 33 year old mother with a 38-39 weeks ageo f g e s t a t i o n v i a N S D a t h o m e . T h e m o t h e r s t a t e d t h a t t h e r e w e r e n o complications happened nor the mother acquired illnesses during her pregnancy period. F. FAMILY HEALTH HISTORY The mother of the patient claimed that both sides of the patient hash i s t o r y o f a s t h m a . A n d n o o t h e r h e r e d i t a r y i l l n e s s e s p r e s e n t s u c h a s diabetes, cancer and hypertension. G. LIFESTYLE In an interview, mother said that their house is a concrete bungalow, located along the highway and near to other houses. The patient is a pure breastfed baby, the mother verbalized that she didnt introduced any solid foods yet. The family is using firewood in cooking their foods. While their drinking water comes from a well which the mother boils before giving to her children. They are also using dipper in taking a bath and flushing their toilet. The mother also claimed that the patient's uncle who lives with the family is an active smoker. And this can one of the precipitating factors that contributed on the patients case for her lungs are still sensitive since patients still 6 month old. Health teaching was done to the mother by encouraging the mother to advice the uncle to minimize smoking and not to smoke near their house. H. SOCIAL HISTORY T h e m o t h e r a l s o c l a i m e d t h a t , t h e i r f a m i l y a r e a c t i v e a n d c o n c e r n citizen of the community, they also mingles with their neighbors and always active participates in activities, education in their community.J u s t l i k e a t y p i c a l f a m i l y r e l a t i o n s h i p s , t h e r e a r e s o m e misunderstanding experienced by the family but usually it only lasted for a day, they fix the problem in a calm manner. The patient's mother described their family as a traditional Filipinofamily, wherein they eta together, live together and giving respect with one another. I.H EALTH PRACTICES W h e n a m e m b e r o f t h e f a m i l y g o t s i c k , t h e y a l w a y s c o n s u l t t o a me dical doctor. They don't have any private family physician. They also believe in hilot

but they never use any herbal medicines that were being prescribed to them, they only taking medicines which are prescribed only by physician.

A c c or d i ng t o E r ik Er ik s on' s Ps y c h os oc ia l T h eor y o f H u m a n Development, the patient is under Trust vs. Mistrust Stage. Wherein thep a t i e n t a l w a y s d e p e n d a l l h e r n e e d s o n h e r m o t h e r , w h i c h i s t h e mainc a r e g i v e r o f t h e c h i l d . W h e n t r u s t d i d n o t d e v e l o p w e l l i t w i l l r e s u l t t o mistrust which can be developed when the needs of the patient were notgiven attention.From Freuds Psychosexual Theory, the patient is under Oral stage.Wherein, the child cries when she needs something. And during also this stage that mouth or oral is only the means of her satisfaction.A c c o r d i n g t o P i a g e t s C o g n i t i v e T h e o r y , s h e i s u n d e r t h e P r e - operational Stage. The id personality dominates during this age. The infanto n l y w a n t e d t o b e s u p p l i e d w i t h a l l h e r p l e a s u r e s l i k e a t t e n d i n g a n d pampering her all the time. III. PHYSICAL ASSESSMENT I. GENERAL STATISTICS A Filipino female client, conscious and with a normal body built. A.Vital signs RR: 60 bpm TEMP: 36.5 CCR: 142 bpmOXYGEN SAT: 99%B. Height and weight: Height 58.5 cmWeight- 6.4kgBMI- 18.90 kg/m2 (healthy weight)22 as ideal with a range of 18.5-25 II. HEAD AND NECK A. H e a d The head is round with no nodules or masses and depressions. B . E ye s The eyes are symmetrically aligned and eyebrows are even lydistributed with no discharge or discoloration on the eyeli d s . Conjunctiva on both eyes is pinkish in color, and the sclera is normal in color. The pupils are black round and equal in size and are reactive to light and accommodation. C . E ar s The ears are symmetrically aligned and the color is same as the facial skin, it is firm and not tender. No serum and discharges noted. D.Nose The nose is symmetrically aligned with the face, no discharges, with flaring nares. It is the same color with the face. It is not tender and no lesions present. The mucosa is pink. The sinuses are not tender when palpated E.Mouth The lips are pinkish in color and moist. No ulcerations or lesions noted. The tongue moves freely and not tender. The client possesses pink gums with no teeth yet.

III. 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.Hair and Scalp The hair are equally distributed with a thin hair strands; well kept; no lice or dandruff seen/noted. 3. N ai l s Clients nails are normally transparent and convex. The surrounding cuticles are intact and without inflammations noted. Has a normal capillary refill with 1 to 2 seconds.

IV. THORAX and LUNGS The chest contour is symmetrical, the spine is vertically aligned. T h e c h e s t w a l l i s i n t a c t , n o t e n d e r n e s s o r n o m a s s e s n o t e d . U p o n auscultation rales was being noted. V. HEART There is no presence of abnormal pulsations when the heart was auscultated. No murmurs and friction rubs heard upon auscultation. VI. BREAST T h e b r e a s t s a r e e v e n w i t h t h e c h e s t w a l l , s k i n i s s m o o t h a n d 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. VII. ABDOMEN The abdomen is intact, round and with normal bowel sound heard uponauscultation. Has a darken umbilicus. No deformities seen. VIII. EXTREMITIES: On the upper extremities no deformities noted. The has a D5IMB L at the left hand. While on the lower extremities, no deformities were noted. IX. GENITAL AND RECTAL: Upon inspection there were no deformities, no rashes, no abnormal secretions were present.

IV. ANATOMY AND PHYSIOLOGY

Anatomically, the respiratory system structures are divided into: Upper respiratory tract and Lower respiratory tract The upper respiratory tract is located in the head and neck and consists of the:

Nose Pharynx Larynx

NOSE: Regions of the nose include the external nose and the nasal cavity. Air moves from the nostrils to the back of the nasal cavity where it exits through the posterior nares. The function of the nasal cavity is to clean, warm and dampen the air that enters so that it can travel throughout the body. REGIONS OF THE PHARYNX: Air moves into the nasal cavity through the nostrils (nasopharynx). The oropharynx opens into the oral cavity which encloses the lips, teeth, cheek, hard and soft palates, tongue and tonsils. Extending from the tip of thee p i g l o t t i s t o t h e g l o t t i s a n d t h e e s o p h a g u s i s t h e l a r y n g o p h a r y n x a n d positioned in the anterior neck is the larynx. LARYNX The larynx is a passageway between the pharynx and the lower airway structures. It is a short tube made up of supportive cartilage, ligaments, muscle and mucosal lining. The supportive cartilage prevents food and drink from entering the larynx while swallowing. The lower respiratory tract is located in the chest and makes up the: Trachea Bronchial tree Lungs Air passes from the larynx to the lungs (trachea).The trachea divides into the right and left primary bronchi (bronchial tree) and the large pair of spongy organs (lungs) are used for respiration. TRACHEA: Also known as the windpipe, the trachea is a 10-12cm tube that runs through the lower neck and chest. The wall of the trachea is made of hyalinec a r t i l a g e w h i c h e n a b l e s t h e t r a c h e a t o s t a y o p e n s o t h a t a i r c a n b e conducted between the larynx and primary bronchi. BRONCHIAL TREE The bronchial tree consists of a primary, secondary (lobar) and tertiary bronchi (segmental bronchi). The trachea splits into the right and left bronchia t h e l e v e l o f t h e s t e r n a l a n g l e . T h e s e c o n d a r y b r o n c h i f o r m s w h e n t h e primary bronchus enters the lung; and conducts air directly to one of the five lobes within the lung. Tertiary bronchi derive from the secondary bronchi andc o n d u c t a i r t o a n d f r o m t h e b r o n c h i a l s e g m e n t . T h e r e a r e 8 b r o n c h i a l se gments in the left lung and 10 in the right lung. LUNGS: The lungs are paired cone-shaped organs which take-up most of the space in the chest with the heart. Their role is to take oxygen into the body, which we need for the cells to live and function properly, and to help us get rid of carbon dioxide, which is a waste product. There are two division of the l u n g s , t h e l e f t a n d t h e r i g h t l u n g . T h e s e a r e d i v i d e d u p i n t o l o b e s o r b i g secretions of tissues separated by fissures or dividers.

The right lung has three lobes but the left lung has only two, it is because the heart takes up some of the space in the left side of the chest. The lungs can also be divided up into even smaller portions, called bronchopulmonary segments. These arep y r a m i d a l shaped areas which are also separated from each other bym e m b r a n e s . T h e r e a r e a b o u t 1 0 o f t h e m i n e a c h l u n g . E a c h s e g m e n t receives it's own blood supply and air supply. Air enters the lungs through a system pipes called the bronchi. Theses pipe start from the bottom of the trachea as the left and right bronchi and branch many times through out the lungs, until they eventually form little thin-walled air sacs or bubbles, known as the alveoli. The alveoli are important in the gas exchange where it takes place between the air and the blood. Covering alveolus is a whole network of little blood vessel called capillaries, which are very small branches of the pulmonary arteries. It is important that the air in the alveoli and the blood inthe capillaries are very close together, so that oxygen and carbon dioxidecan diffuse between them. Mechanics of Breathing To take a breath in, the external intercostals muscles contract, moving t h e r i b c a g e u p a n d o u t . The diaphragm moves down at the same time, creating negative pressure w i t h i n t h e t h o r a x . T h e l u n g s a r e h e l d t o t h e thoracic wall by the pleural 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 them e c h a n i s m b e h i n d l u n g c o l l a p s e i f t h e r e i s a i r i n t h e p l e u r a l s p a c e (pneumothorax).

Physiology of Gas Exchange

little blood vessel called capillaries, which are very small branches of the pulmonary arteries. It is important that the air in the alveoli and the blood inthe capillaries are very close together, so that oxygen and carbon dioxide can diffuse between them. Mechanics of Breathing To take a breath in, the external intercostals muscles contract, movingt h e r i b c a g e u p a n d o u t . T h e diaphragm moves down at the same time,creating negative pr essure w i t h i n t h e t h o r a x . T h e l u n g s a r e h e l d t o t h e thoracic wall by the pleural membranes, and so expand outwards as well. This creates negative pressure within the lungs, and so air rushes in throughthe upper and lower airways.Expiration is mainly due to the natural elasticity of the lungs, whichtend to collapse if they are not held against the thoracic wall. This is them e c h a n i s m b e h i n d l u n g c o l l a p s e i f t h e r e i s a i r i n t h e p l e u r a l s p a c e (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 m i l l i o n s o f a l v e o l i i n e a c h l u n g , a n d t h e s e a r e t h e a r e a s r e s p o n s i b l e f o r gaseous exchange, presenting a massive surface area for exchange to occur o v e r ..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 d i f f u s i o n a l o n g c o n c e n t r a t i o n g r a d i e n t s . CO2moves into the alveolus as the concentration is much lower in thea l v e o l u s t h a n i n t h e b l o o d , a n d O 2m o v e s o u t o f t h e a l v e o l u s a s t h e continuous flow of blood through the capillaries prevents saturation of theblood with O2and allows maximal transfer across the membrane. V. DISEASE ENTITY/ PATHOPHYSIOLOGY

Predisposing Factor Age below 5y/o

Precipitating Factor environment, lifestyle

Streptococcal Infection Enters through nose or mouth by inhalation Passes to the pharynx, larynx and trachea Microorganisms enters the affects both the lung parenchyma

Infection lodges and stimulates in the parenchyma Narrowing of air passage

Lung invasion leukocytes increased Mucus and phlegm

Difficulty breathing ineffectively

coughing

Viral infections increase attachment of S. pneumoniae to the receptors on respiratory epithelium. Once inhaled into the alveolus, pneumococci infect type II alveolar cells. They multiply in the alveolus and invade alveolar epithelium. Pneumococci spread from alveolus through the pores of Kohn, thereby producing inflammation and consolidation along lobar compartments. Inflamed and fluid-filled alveolar sacs cannot exchange oxygen and carbon dioxide effectively. Alveolar exudates tends to consolidate, so it is increasingly difficult to expectorate. Bacterial pneumonia may be associated with significant ventilation-perfusion mismatch as the infection grows. Etiology : There are many causes of Pneumonia, including bacteria, viruses, mycoplasmas, fungal agents and protozoa. Pneumonia may also result from aspiration of food, fluidsor vomitus or from inhalation of toxic or caustic

chemicals, smoke, dusts, or gasses. Pneumonia may complicate immobility and chronic illnesses. Pneumonia often follows influenza and together they rank as the 7th leading cause of death in the US, and arethe fifth leading cause in people older than 65.Major risk factors: Advanced age History of smoking Upper respiratory tract infection Tracheal intubation Prolonged immobility Immunosuppressive therapy A non functional immune system Malnutrition Dehydration Homelessness Chronic disease states ( such as diabetes, heart disease, chronic lung disease, and cancer XI. PROGNOSIS Individuals who are treated for PCAP outside of the hospital have a mortality rate less than 1%. Fever typically responds in the first two days of therapy and other symptoms resolve in the first week. The x-ray, however, may remain abnormal for at least a month,e v e n w h e n P C A P h a s b e e n s u c c e s s f u l l y t r e a t e d . A m o n g i n d i v i d u a l s w h o r e q u i r e hospitalization, the mortality rate averages 12% overall, but is as much as 40% inpeople who have bloodstream infections or require intensive care. Factors whichi ncrease mortality are the same as those which increase the need for hospitalization and are listed above.W h e n C A P d o e s n o t r e s p o n d a s e x p e c t e d , t h e r e a r e s e v e r a l p o s s i b l e c a u s e s . A complication of CAP may have occurred or a previously unknown health problem maybe playing a role. Both situations are covered in more detail below. Additional causes include inappropriate antibiotics for the causative organism, a previously unsuspectedm i c r o o r g a n i s m s u c h a s tuberculosiso r a c o n d i t i o n w h i c h m i m i c s P C A P s u c h asWegener's granulomatosis . Additional testing may be performed and may include additional radiologic imaging (such as a computed tomography scan or a procedure such as abronchoscopy or lungbiopsy .

XII. DISCHARGE PLAN AND RECOMMENDATION M-MEDICATION TO TAKE Instruct and explain to the patients mother that the medication is very important to continue depending on the duration that the doctor ordered for the total recovery of the patient. E-EXERCISE Instruct the mother to let her child play but it should be limited to a short period of time only to prevent the occurrence of shortness of breathing. T-TREATMENT Advice the mother to keep her baby relay in order to recover in this present condition, instruct the mother to minimize the patient from exposure to an open environment such as dusty and smoky area which airborne microorganisms are present that can be a high risk factor that cause severity of his condition. H-HEALTH TEACHING Encourage and explain to the patients mother that it is important to maintain proper hygiene to prevent further infection. Instruct the patients mother to bath the baby everyday and explain that bathing early in the morning is not the factor or cause of having pneumonia. Instruct to increase fluid intake to the patients. O-OUT PATIENT FOLLOW-UP Regular consultation to the physician can be a factor for recovery and assess and monitor the patients condition. D-DIET Diet as tolerated, meaning, the patient can eat everything until he can. Diet can plays a big role in fast recovery so that, instruct the mother to give nutritious foods intended for respiratory system.

VIII. Pathophysiology Viral infections increase attachment of S. pneumoniae to the receptors on respiratory epithelium. Once inhaled into the alveolus, pneumococci infect type II alveolar cells. They multiply in the alveolus and invade alveolar epithelium. Pneumococci spread from alveolus through the pores of Kohn, thereby producing inflammation and consolidation along lobar compartments. Inflamed and fluid-filled alveolar sacs cannot exchange oxygen and carbon dioxide effectively. Alveolar exudate tends to consolidate, so it is increasingly difficult to expectorae. Bacterial pneumonia may be associated with significant ventilation-perfusion mismatch as the infection grows. Etiology : There are many causes of Pneumonia, including bacteria, viruses, mycoplasmas, fungal agents and protozoa. Pneumonia may also result from aspiration of food, fluids or vomitus or from inhalation of toxic or caustic chemicals, smoke, dusts, or gasses. Pneumonia may complicate immobility and chronic illnesses. Pneumonia often follows influenza and together they rank as the 7th leadng cause of death in the US, and are the fifth leading cause in people older than 65. Major risk factors: Advanced age History of smoking Upper respiratory tract infection Tracheal intubation Prolonged immobility Immunosuppreesive therapy A non functional immune system Malnutrition Dehydration Homelessness Chronic disease states ( such as diabetes, heart disease, chronic lung disease, and cancer) Additional risk factors are dysphagia;exposure to air pollution;altered consciousness (from alcoholism,drug overdose,general anesthesia ,or a seizure disorder);inhalation of noxious substances;aspiration of food,liquid or foreign or gastric

material and residence in institutional settings,where transmission of the disease is more likely. Heredo Familial History There is history of illness in the immediate family. The father of the patient has a history of asthma,in the side of his mother had a hypertension and heart disease. XI. PROGNOSIS Individuals who are treated for PCAP outside of the hospital have a mortality rate less than 1%. Fever typically responds in the first two days of therapy and other symptoms resolve in the first week. The x-ray, however, may remain abnormal for at least a month, even when PCAP has been successfully treated. Among individuals who require hospitalization, the mortality rate averages 12% overall, but is as much as 40% in people who have bloodstream infections or require intensive care. Factors which increase mortality are the same as those which increase the need for hospitalization and are listed above. When CAP does not respond as expected, there are several possible causes. A complication of CAP may have occurred or a previously unknown health problem may be playing a role. Both situations are covered in more detail below. Additional causes include inappropriate antibiotics for the causative organism, a previously unsuspected microorganism such as tuberculosis or a condition which mimics PCAP such as Wegener's granulomatosis. Additional testing may be performed and may include additional radiologic imaging (such as a computed tomography scan or a procedure such as a bronchoscopy or lung biopsy. XII. DISCHARGE PLAN AND RECOMMENDATION M-MEDICATION TO TAKE Instruct and explain to the patients mother that the medication is very important to continue depending on the duration that the doctor ordered for the total recovery of the patient. E-EXERCISE Instruct the mother to let her child play but it should be limited to a short period of time only to prevent the occurrence of shortness of breathing. T-TREATMENT Advice the mother to keep her baby relay in order to recover in this present condition, instruct the mother to minimize the patient from exposure to an open environment such as dusty and smoky area which airborne microorganisms are present that can be a high risk factor that cause severity of his condition. H-HEALTH TEACHING EncoUrage and explain to the patients mother that it is important to maintain proper hygiene to prevent further infection. Instruct the patients mother to bath the baby everyday and explain that bathing early in the morning is not the factor or cause of having pneumonia. Instruct to increase fluid intake to the patients. O-OUT PATIENT FOLLOW-UP Regular consultation to the physician can be a factor for recovery and assess and monitor the patients condition. D-DIET Diet as tolerated,meaning,the patient can eat everything until he can.Diet can plays a big role in fast recovery so that,instruct the mother to give nutritious foods

intended for respiratory system.