Uploaded by Kelly Andres

PCAP 2020

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PCAP T/C BFS
A Case Abstract
Presented to the Faculty of Nursing
In Partial Fulfilment of the Requirements in
INP
Presented by:
Andres, Kelly Queenie D.
Submitted to:
Judith B. Lutrania MAN,LPT,RN
Clinical Instructor
February 2020
Table of Contents
TITLE PAGE
TABLE OF CONTENTS
CHAPTERS:
I.INTRODUCTION
II.BIOGRAPHIC DATA
III.NURSING HEALTH HISTORY
IV.ANATOMY AND PHYSIOLOGY
V.PATHOPHYSIOLOGY
VI.COURSE IN THE WARD
VII.NURSING CARE PLAN
CHAPTER I
INTRODUCTION
Pneumonia
Pneumonia arises from inflammation and infection of the lungs,
specifically in the bronchioles and alveoli, which causes
consolidation and interferes with gas exchange. Consolidation
can be seen on both a chest x-ray as shadowing, and heard when
auscultating the lungs as these alveolar spaces are filled with
fluid instead of air (Better Health Channel 2015; Dunn 2005).
Signs and symptoms
General malaise
Fever
Persistent cough Chest pain
Increased respiratory rate
Breathing difficulties
Decreased appetite
Abdominal pain
Headache
Treatment
Antibiotics
Pneumonia treatment depends on the severity of the pneumonia. A
person may need oral antibiotics and can be treated in the
community setting, or for more severe cases they may need
admission to hospital and treatment with intravenous
antibiotics, oxygen therapy and chest physiotherapy (Dunn 2005).
Oxygen Therapy
Another important aspect of pneumonia treatment is oxygen
therapy and maintaining adequate oxygen saturation levels.
Depending on the patient, oxygen saturation levels should be
above 93% with the oxygen concentrations also varying depending
on the patient, their comorbidities and severity of the
pneumonia. Humidified oxygen therapy can also be used in order
to assist the patient with expectoration (Watson 2008).
Pain Management
It is also important to remember that the patient with pneumonia
may also be in pain. And if a patient with pneumonia is in pain,
their lung expansion may be compromised which can further
exacerbate their condition. Often this pain can be described as
a pleuritic-type chest pain (Farrell & Dempsey 2013; Watson
2008).
Hydration
Other treatments for pneumonia should focus on ensuring the
patient is adequately hydrated and if not, ensure IV fluids are
commenced. Adequate hydration is important for the expectoration
of secretions and will also help with any associated
hypotension. The individual may also have an increased fluid
loss occurring if they are febrile and continue to have an
increased respiratory rate, therefore urinary output should also
be monitored as this can flag deterioration in the patients
condition (Dunn 2005; Watson 2008).
Chapter II
DEMOGRAPHIC DATA
Name: Patient A.S
Age: 2yrs old
Address: Rizal, Diffun, Quirino
Birth Date: April 7, 2016
Gender: Male
Religion: Roman Catholic
Nationality: Filipino
Date of Admission: February 19,2020
Admitting Diagnosis: PCAP T/c BFS
Chief Complaint:
Seizure
Chapter III
NURSING HEALTH HISTORY
A. HISTORY OF PRESENT ILLNESS
A day before admission, the patient has fever, cough, and colds. At
midnight he had a seizure.
B. PAST HEALTH HISTORY
Previous Admission : April 7, 2016 – April 14, 2016
Mother denies any accidents or injuries.
Immunizations : Complete
Chronic Illness : Asthma
Allergies : sea food and chicken
C. FAMILY HEALTH HISTORY
His father has asthma. Maternal grandparents had diabetes, cancer and
hypertension. Paternal grandparents had hypertension.
CHAPTER IV
ANATOMY AND PHYSIOLOGY
The Respiratory System
Upper Respiratory Tract
The major passages and structures of the upper respiratory tract
include the nostrils, the nasal cavity, the pharynx, the
epiglottis, and the larynx. The upper respiratory tract is lined
a mucous membrane. Mucus helps to trap smoke, dust and other
small particles. The membrane is lined with cilia (hair-like
structures that move the mucous upwards only the upper
respiratory tract). The lining of the tract and the close laying
blood vessels (especially in the nose) help to warm and moisten
air as it passes.
The pharynx, commonly called the throat, is a passageway that
extends from the base of the skull to the level of the sixth
cervical vertebra. It serves both the respiratory and digestive
systems by receiving air from the nasal cavity and air, food,
and water from the oral cavity. Inferiorly, it opens into the
larynx and oesophagus.
The larynx, commonly called the voice box or glottis, is the
passageway for air between the pharynx above and the trachea
below. It extends from the fourth to the sixth vertebral
levels. The larynx plays an essential role in human speech.
During sound production, the vocal cords close together and
vibrate as air expelled from the lungs passes between them.
The epiglottis acts like a trap door to keep food and other
particles from entering the larynx.
Lower Respiratory Tract
The major passages and structures of the lower respiratory tract
include the trachea, the right & left bronchus, the bronchioles,
and the lungs containing the alveoli. Deep in the lungs, each
bronchus divides into secondary and tertiary bronchi, which
continue to branch to smaller airways called the bronchioles.
The bronchioles end in air sacs called the alveoli. Alveoli are
bunched together into clusters to form alveolar sacs. Gas
exchange occurs on the surface of each alveolus by a network of
capillaries carrying blood that has come through veins from
other parts of the body.
The trachea, commonly called the windpipe, is the main airway to
the lungs. It divides into the right and left bronchi at the
level of the fifth thoracic vertebra, channeling air to the
right or left lung. The cartilage in the tracheal wall provides
support and keeps the trachea from collapsing. The mucous
membrane that lines the trachea is similar to that in the nasal
cavity. Mucus traps airborne particles and microorganisms, and
the cilia propel the mucus upward, where it is either swallowed
or expelled.
The alveoli are grouped together like a lot of interlinked
caves, rather than existing as separate individual sacs. The
alveoli have a structure specialised for efficient gaseous
exchange: the alveoli walls are extremely thin.
CHAPTER V
PATHOPHYSIOLOGY
CHAPTER VI
COURSE IN THE WARD
DATE/TIME
DOCTOR’S
DOCTOR’S ORDER
PROGRESS NOTE
2-19-20
 Admit to Pedia
1 15 am
Ward
 Secure consent
 DAT & SAP
 IVF : 1L D5d3 NaCl
@ 66cc/hr
Dx
 CBC
 CXR AP
 U/A
Tx
 Paracetamol 240mg
IV Q$ RTC for now
 Ampicillin 800mg
IV Q8
 Diazepam 7mg IV
PRN for seizure
2-19-20
 Continue meds
 Continue IVF
RATIONALE
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