The Nursing Process: Care of a 3 year old Patient with Bilateral Pneumonia Assessment

Write Nursing Process Paper Based on the Patient/Patient Information……….

Answer:

Data collection

Description of the child and family

The patient, MR, is a three year old female born on January 11, 2009. She was admitted to Akron Children’s Hospital on February 2, 2012 complaining of a running nose, cough, decreased appetite and fever for a week accompanied by three episodes of vomiting. A diagnosis of bilateral Pneumonia was made. MR has a seven year old sister and a five year old sister. She resides in Akron, Ohio, at her parent’s home. She lives with her parents who have been married for the last nine years. The patient’s family smokes, though not in the house. She is insured by Medical Mutual of Ohio through her parents. She has had one previous admission at the age of three weeks when she was treated for meningitis.

Developmental assessment

The patient is 95 cm (37.4 inches) tall. This puts her at the 58th percentile for height. The child weighed 14kgs (30.865) pounds, which puts her at the 52th percentile for weight. Body mass index (BMI), though not a useful measure in children is calculated using the formulae: weight in kilograms divided by height in meters squared (Ball, Bindler, & Cowen, 2010). She has a BMI of 15.5, which is the 45th BMI percentile. This means that if we took a hundred children of MR’s age and sex and ranked them her BMI would be 45th. According to Ball et al. (2010), MR is healthy. She is neither overweight nor underweight. Her weight and height are appropriate for her age and sex. According to Pressley and McCormick (2007), the age of 3 to 6 years coincides to the Phallic stage of psychosexual development, as proposed by Sigmoid Freud and at this stage reproductive organs become very important to the child (p. 137). Despite her illness, she was noted to be fascinated with her genitals, just as is expected at her age. Her language is totally normal, nothing out of what is expected of a three year old. She could speak in three to five word sentences. She was up and about, quite active sometimes. The mother reports that prior to her illness she was always exploring her environment, sometimes climbing on things. She was able to draw simple shapes and was quite good at following commands. Her mother reports that she was sleeping for 10 to 12 hours at night. I find her social, emotional, gross motor, fine motor and cognitive development in order.

Nutritional assessment

According to Price and Gwin (2007), “good nutrition and good general health are instrumental in promoting linear growth” (p. 16). This is to say that for a child to grow well, his or her nutritional needs must be well taken care of. Prior to her malady MR was a healthy child with a good nutritional status. However, upon getting sick things took a negative turn with her reduced appetite being compounded upon by episodes of vomiting. She was however still in fair nutritional status, as none of her metric values are outside the normal range.

Pathophysiology

Pneumonia is an infectious/inflammatory disorder of the lung parenchyma in which the patients typically present with fever, chills, pulmonary symptoms such as cough, dyspnea, sputum production and pleuritic chest pain and one or more infiltrates or opacities on a chest X-ray (Cunha, 2010, p. 2).

Pneumonia is classified in two ways: depending on the causative agent or depending on the area of the lung affected. Lobar pneumonia affects one lobe while bronchopneumonia affects more than one lobe in a patchy way. Community acquired pneumonia is a lung infection acquired away from the hospital while hospital acquired pneumonia develops 48 hours after admission into a hospital (Madara and Denino, 2007, p.246-247).

There are four stages which are involved in the pathophysiology of pneumonia namely congestion, red hepatization, grey hepatization and resolution. Congestion usually lasts for the first 24 hours, and is marked by engorgement of the capillary bed with blood and leakage of a serous fluid into the alveoli. The red hepatization stage is so called because of the reddish gross appearance of the lungs at this stage. Red blood cells and fibrin enter the alveoli to create affirm consolidated lung (Madara and Denino, 2007). Grey hepatization occurs when disintegrating red blood cells and fibrin accumulate in the affected lung area. Resolution stage is a cleaning up process which starts within 8 to 10 days of the illness. If resolution does not occur serious complications may occur (Ball et al., 2010).

Treatment

A case management approach of pneumonia has been developed by World Health Organization (WHO). This approach is based on an assumption that the causes of fatal pneumonia in children include S. pneumoniae and H. influenzae (Semba, 2008, p.195). The treatment of pneumonia involves hospitalization if it is severe and other supportive measures alongside administration of antibiotics which are effective against the suspected organisms. Investigations have to be done and attempts to culture organisms must be made. Culture and sensitivity results are important, for they are vital in choosing the right drugs.

Antibiotics that target the two notorious organisms mentioned above should be promptly instituted when bacterial pneumonia is suspected. Supportive measures include antipyretics and adequate rehydration (Fleisher and Ludwig, 2010, p.913). Antitussives have no pivotal role to play.

Amoxicillin, given orally at a dose of 90mg per kg in three divided doses is the mainstay of treatment. However, Ceftriaxone and macrolides can also be used especially in children who are penicillin resistant or those with atypical pneumonia (Fleisher and Ludwig, 2010, p.913).

MR was treated with 180mcg of Albuterol (trade name Ventolin) delivered via a spacer device and mask, 70mg/1.75ml of oral Azithromycin (trade name Zitromax) administered daily and oral Ibuprofen suspension at a dose of 140 mg/7ml. Normal saline (0.9% sodium chloride) was used to dilute some of the medications.

Medications

As outlined above, the child received Albuterol, Azithromycin and Ibuprofen. Albuterol is a bronchodilator which acts by relaxing smooth muscles through stimulatory activity on beta-2 receptors. It is commonly used for asthma. The reason why it was indicated in MR is because there was suspicion that she had a hyper responsive airway. The doses given are the standard doses for her age. Azithromycin is a macrolide antibiotic which can be effectively used for pneumonia. In this case the patient had pneumonia and thus this is a justified treatment modality. In addition, the doses are precise. Ibuprofen is a non steroidal anti inflammatory drug (NSAID) that acts by inhibiting the COX I and COX II, thereby inhibiting production of prostaglandins that are responsible for pain and fever. It has antipyretic activity alongside its usual analgesic properties. It also has anti-inflammatory properties. In this patient it was indicated because of the fever that MR had. It also helped to fight inflammation in the lung. Normal saline is an intravenous fluid tat has a number of uses, including correction of dehydration and electrolyte imbalances. In this patient it was to dilute some of the medications such as Ibuprofen.

Physical assessment

Though pneumonia is primarily a disease of the lungs, a meticulous physical exam must be carried out to ensure that concomitant findings are not missed (Ball et al., 2010). In the physical exam other important findings might be revealed and hence the importance of doing good physical assessments.

When the patient was lying in bed the side rails were up. The patient was usually assessed hourly and when need arose. At the bed side there was oxygen and a functioning suction machine. There was a pulse oximeter with alarms set. A phone was easily within reach.

She had one peripheral intravenous line, gauge 24, inserted on her right arm. There was a dressing covering the insertion site. The line was patent with some intravenous fluid being infused without any problem. No wetness or drainage was noted at the site, which was clean with no pain, swelling or redness. The site was assessed frequently.

She was mildly dehydrated. There was no jaundice, anemia, clubbing, cyanosis, lymphadenopathy, edema, wasting. MR’s skin was however pale, warm but dry. Her lips were dry and cracked. Her skin turgor was reduced. Her temperature was high at 38.7oC. She was said to have been taking Tylenol at home for pain and hotness of body.

In the respiratory system her breathing was little labored. In addition, MR had an increased respiratory rate (tachypnea) of 30 breaths per minute. The chest was rising symmetrically. There were no other signs of respiratory distress such as flaring of the ala nasae, use of accessory muscles of respiration, or chest wall in drawing. Percussion notes were dull. On auscultation diminished breath sounds were heard bilaterally with fine crackles on the bases of both lungs.

In the cardiovascular system, the pulses were strong and the capillary refill was less than two seconds. The pulses were regular in rhythm and the rate was appropriate for gender and age. The apex beat was not displaced.

She was moving all the four limbs spontaneously. When asleep, she was easily aroused. Her abdomen was not distended. It was soft, with no enlarged organs. Bowel sounds were heard in all the four quadrants.MR was voiding normal amounts of clear urine with no evidence of pain while micturating.

Her ear, nose and throat exam revealed a dry throat with no bleed. Her nose and ears were normal. In summary, the major findings were in the respiratory system as all the other systems were normal.

Lab values and diagnostic tests

Though pneumonia can be a clinical diagnosis clinched upon using clinical acumen, a number of tests may need to be done in order to confirm the diagnosis. A complete blood count (CBC) revealed leukocytosis of 16,000/mm3, which is higher than the expected upper limits. This is in keeping with an infection.

Culture and sensitivity of the expectorated sputum ought to be done in an attempt to culture the offending organism. Sensitivity results are important in choosing an appropriate regimen (Ball et l., 2010).

Her chest X-ray depicted patchy opacities that were mainly affecting the lower lobes, but without a doubt involved more than one lobe. This is consistent with a picture of bronchopneumonia, which is quite common in the pediatric age group (Ball et al., 2010).

Though sputum is invaluable in culturing the organisms, its use in children is usually limited by the ability of the children to expectorate it. In most cases they tend to swallow the sputum. This presents a huge problem. Bronchoscopy then offers a better alternative, but it is also tedious to perform. In this child the results obtained were non contributory. Arterial blood gases may require to be done to ascertain the oxygenation needs. The oximeter showed she was saturating well.

Normal growth and development

Normally, children with pneumonia have a good future outcome if managed properly and promptly. Though some serious complications can arise (such as pleural effusion and bacteremia) may result, most of the patients resolve without any serious sequel (Fleisher and Ludwig, 2010, p.913). MR is expected to recover and her condition is not expected to slow growth and development. This would however be affected if she gets repeated infections.

Data Grouping, Interpretation, and Nursing Diagnoses

Impaired breathing patterns related to the inflammatory effects of Pneumonia.

Impaired breathing due to pneumonia is a nursing diagnosis that can be applied to MR. To start with, she had some labored breathing and a respiratory rate that was increased. There was a dull percussion note. Breath sounds were diminished bilaterally. There were bilateral crackles heard on auscultation. Though she was otherwise well with no other symptoms of respiratory distress, the above symptoms are indeed significant (Fleisher and Ludwig, 2010). It is also dependent on which stage the patient presents with, high with chances of deterioration if no intervention is made. She had a cough and a running nose which are respiratory symptoms. She also had a fever which commonly accompanies pneumonia. (Ball et al.,2010).

Fluid deficit problem associated with reduced intake

MR came in with complaints of reduced appetite and a few episodes of post-prandial vomiting. On physical examination her skin was pale; her lips were dry and cracked. Her mucous membranes were dry. Her skin turgor was reduced. And she had a fever. Though she was not severely dehydrated, the above are evidence of fluid deficit problems. Vomiting is an annoying phenomenon in which what we eat is indeed regurgitated, thereby depriving the body of the fluid it so much needs. Reduced intake also contributes significantly to dehydration (Ball et al., 2010).

Planning and Implementation Goal

Impaired breathing patterns related to the inflammatory effects of Pneumonia.

Short term goal.

Ensure that MR establishes a normal breathing pattern within the shortest period of time.

Long term goal.

Ensure adherence to practices which are likely to prevent long term complications arising from her breathing problem.

Fluid deficit problem associated with reduced intake

Short term goal.

Ensure that MR’s reduced intake is dealt with promptly with adequate rehydration.

Long term goal.

Ensure that MR’s appetite returns to normal shortly after discharge.

Nursing Interventions and Rationale

Impaired breathing patterns related to the inflammatory effects of Pneumonia.

Short term goal

Though the child was sick, establishing a rapport is a very important intervention. It may be difficult with children, but a little creativity will achieve the goal. The rationale for this is that the child is likely to be more cooperative when it comes to enacting the actual interventions.

Obtaining resting vital signs is of utmost importance because it serves as a baseline for which further interventions will be based on. In this child, the only way to know that her breathing is improving or getting worse is by taking her vital signs, especially the respiratory rate (Ball et al., 2010). Assessing the condition of the patient helps us in knowing whether our interventions are helping or not.

Long term goal

Counseling to the parents of the child is of utmost importance in ensuring that treatment is adhered to, especially in cases where the parents are responsible for administering drugs to the patient and turning the patient while in bed.

Ensuring that the patient is repositioned every two hours is important because frequent reposition stasis and pooling of secretions which are likely to cause long term damage.

Placing the patient in an upright position will help the lungs to expand and at the same time mobilize secretions.

Fluid deficit problem associated with reduced intake

Short term interventions

Replace all the fluid deficits using appropriate fluids such as water or normal saline. The rationale for this intervention is that it will correct the fluid deficit while facilitating faster recovery.

Strictly monitor the fluid intake and output. This will ensure that correct amounts of fluids are given, thus help in avoiding the complications that are related to over hydration (Ball et al.).

Long term interventions

In order to ensure that MR’s appetite returns to normal a number of interventions can be put in place. These include giving her antiemetics, which will prevent her from vomiting. Nausea and vomiting are established causes of a reduced appetite, which in turn adversely affects the nutritional status of the child. The other intervention would be to give her multivitamins which in a big way boost appetite and thus increases output. Parents must be involved at all stages of the treatment because they are the ones who will deal with the child upon discharge. Proper counseling to the parents is important in ensuring revival of the child’s appetite.

Nursing Action

In the nursing care that I provided to MR, we spent about 50 minutes discussing issues of nutrition with the parents while trying to allay their fears, especially the mother’s. We talked extensively on the need for measures which would increase her appetite, alongside telling them what to expect of their young one. I also ensured that the child assumed an upright position whenever possible to facilitate lung expansion. I constantly maintained an input output chart to record the amount of fluid ingested and excreted. I also ensured that her fluid deficit was dealt with through good rehydration practices. A suction machine was available to suck secretions, but luckily for me it was not really necessary to use it.

Evaluation

The short term objectives for breathing patterns were met, with the exception that it was very hard to establish a rapport with the three year old because at the time of doing this she was quite irritable. The patient was eventually able to maintain normal breathing as evidenced by a normal respiratory rate and the disappearance of labored breathing. Measures to prevent long term complications were also effected, though their success cannot be verified since the patient was discharged.

As far as correcting fluid deficits, the short term goals were indeed met. The child’s dehydration status improved greatly. A few days later her mucous membranes were wet and normal while her skin turgor returned to normal. For the long term goal of increasing the appetite, it was hard to assess, for the patient was under my care for four days. But my opinion is that she will eventually regain her appetite following the measures we suggested.

References

Ball, J.W., Bindler, R.C., & Cowen, K.J. (2010).Child health nursing: Partnering with children

& families (2nded.). Upper Saddle River, NJ: Pearson

Cunha, B.A. (2010). Pneumonia Essentials 2010. Sudbury, Jones and Bartlett Learning.

Fleisher, G.R. and Ludwig, S. (2010). Textbook of Pediatric Emergency Medicine (6th ed.). Lippincott Williams & Wilkins. Madara, B. and Denino, V.O. and (2007). Pathophysiology (2nd ed.). Sudbury, Jones and Bartlett Learning. Pressley, M. and McCormick, C. (2007). Child and adolescent development for educators. New York: Guilford Press. Price, D.L. and Gwin, J.F. (2007). Pediatric nursing. Missouri, Saunders Elsevier Semba, R.D. (2008). Nutrition and health in developing countries (2nd ed.). Baltimore, Hamana Press.

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