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

The Nursing Process: Care of a 3 year old Patient with Bilateral Pneumonia
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The Nursing Process: Care of a 3 year old Patient with Bilateral Pneumonia
Assessment
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. 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. 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
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 (McIntosh, 2002). 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.
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 (McIntosh, 2002).
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. influenza (McIntosh, 2002). 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. 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.
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 that 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 ja...