Pneumonia, pneumonia management and treatment

1. Presented by: Dave Jay S. Manriquez, RN.
INTRODUCTION
This is a case of patient JT, 2 yrs old, male, Roman Catholic, Filipino, residing at Balibali, Compostela and born on July 24, 2004 via Normal
Spontaneous Vaginal Delivery (NSVD) at Danao General Hospital, who was admitted for the 1st
time in Cebu Velez General Hospital (CVGH) for complaints of
fever and weakness. The patient was admitted under the services of Dr. Berdin under the Department of Pediatrics with the case number of 92408 and hospital
number of 051458.
The case was chosen by the researcher on December 3, 2007 at around 1pm.
PNEUMONIA
Pneumonia is a general term that refers to an infection of the lungs, which can be caused by a variety of microorganisms, including viruses, bacteria, fungi, and
parasites. Although different types of pneumonia tend to affect children in different age groups, pneumonia is most commonly caused by viruses. Some viruses
that cause pneumonia are adenoviruses, rhinovirus, influenza virus (flu), respiratory syncytial virus (RSV), and parainfluenza virus (the virus that causes
croup).
• Often pneumonia begins after an upper respiratory tract infection (an infection of the nose and throat). When this happens, symptoms of pneumonia
begin after 2 or 3 days of a cold or sore throat.
Types of Pneumonia
1. Community-acquired pneumonia(CAP)
a. Pneumococcal –causative agent: S. pneumonia; incidence are common on elderly, with COPD, CHF, alcoholism
b. Influenzae pneumonia or Haemophilus influenza- CA: H. pneumoniae; I: splenectomy, alcoholics, in chronic care facilities
c. Viral pneumonia (occur in every 2-3 years) – CA: Influenza viruses A and B, adenovirus, parainfluenza, cytomegalovirus. I: adults
d. Aspiration pneumonia- CA: aspiration of food or gastric contents I: children and elderly.
2. Hospital acquired pneumonia
a. Pseudomonas pneumonia – CA: pseudomonas aeruginosa
b. Staphylococcal pneumonia- CA: Staphylococcus aureus
c. Klebsiella pneumonia- CA: Klebsiella pneumonia; I: immunosupressed, IV drug users, complication of epidemic nfluenza
3. In immunocompromised Host
a. Pneumocystic carnii pneumonia (PCP)- CA: Pneumocystis carnii; I: patients with AIDS, immunosupressed patients, recipients of organ transplants

2. b. Fungal pneumonia- CA: Aspegillus fumigates; I: immunosupressed patients, recipients of organ transplants immunosupresse patients, neutopenic
patients
Incubation
The incubation period for pneumonia varies, depending on the type of virus or bacteria causing the infection. Some common incubation periods are: respiratory
syncytial virus, 4 to 6 days; influenza, 18 to 72 hours.
Duration
With treatment, most types of bacterial pneumonia can be cured within 1 to 2 weeks. Viral pneumonia may last longer. Mycoplasmal pneumonia may take 4 to
6 weeks to resolve completely.
Contagiousness
The viruses and bacteria that cause pneumonia are contagious and are usually found in fluid from the mouth or nose of an infected person. Illness can spread
when an infected person coughs or sneezes on a person, by sharing drinking glasses and eating utensils, and when a person touches the used tissues or
handkerchiefs of an infected person.
Signs and Symptoms
Symptoms of pneumonia vary, depending on the age of the child and the cause of the pneumonia. Some common symptoms include:
• fever
• chills
• cough
• unusually rapid breathing
• breathing with grunting or wheezing sounds
• labored breathing that makes a child’s rib muscles retract (when muscles under the rib cage or between ribs draw inward with each breath)
• vomiting
• chest pain
• abdominal pain
• decreased activity
• loss of appetite (in older children) or poor feeding (in infants)

3. • in extreme cases, bluish or gray color of the lips and fingernails
Sometimes a child’s only symptom is rapid breathing. Sometimes when the pneumonia is in the lower part of the lungs near the abdomen, there may be no
breathing problems at all, but there may be fever and abdominal pain or vomiting. When pneumonia is caused by bacteria, an infected child usually becomes sick
relatively quickly and experiences the sudden onset of high fever and unusually rapid breathing. When pneumonia is caused by viruses, symptoms tend to appear
more gradually and are often less severe than in bacterial pneumonia. Wheezing may be more common in viral pneumonia. Some types of pneumonia cause
symptoms that give important clues about which germ is causing the illness. For example, in older children and adolescents, pneumonia due to Mycoplasma (also
called walking pneumonia) is notorious for causing a sore throat and headache in addition to the usual symptoms of pneumonia.
In infants, pneumonia due to chlamydia may cause conjunctivitis (pinkeye) with only mild illness and no fever. When pneumonia is due to whooping cough
(pertussis), the child may have long coughing spells, turn blue from lack of air, or make a classic “whoop” sound when trying to take a breath.
Prevention
There are vaccines to prevent infections by viruses or bacteria that cause some types of pneumonia. Children usually receive routine immunizations against
Haemophilus influenzae and pertussis (whooping cough) beginning at 2 months of age. (The pertussis immunization is the “P” part of the routine DtaP
injection.) Vaccines are now also given against the pneumococcus organism (PCV), a common cause of bacterial pneumonia.
When to seek prompt treatment?
Call your child’s doctor immediately if your child has any of the signs and symptoms of pneumonia, but especially if your child:
- is having trouble breathing or is breathing abnormally fast
- has a bluish or gray color to the fingernails or lips
- has a fever of 102 degrees Fahrenheit (38.9 degrees Celsius), or above 100.4 degrees Fahrenheit (38 degrees Celsius) in infants under 6 months of
age
Treatment
Doctors usually make the diagnosis of pneumonia after a physical examination. The doctor may possibly use a chest X-ray, blood tests, and (sometimes)
bacterial cultures of mucus produced by coughing when making a diagnosis. In most cases, pneumonia can be treated with oral antibiotics given to your child at
home. The type of antibiotic used depends on the type of pneumonia.
Children may be hospitalized for treatment if they have pneumonia caused by pertussis or other bacterial pneumonia that causes high fevers and respiratory
distress. They may also be hospitalized if supplemental oxygen is needed, if they have lung infections that may have spread into the bloodstream, if they have

4. chronic illnesses that affect the immune system, if they are vomiting so much that they cannot take medicine by mouth, or if they have recurrent episodes of
pneumonia.
FEVER
Fever is any abnormal elevation of body temperature. A temperature of 38 degree Celsius or higher is significant. Cause by in infection, dehydration,
tumors, and disturbances of temperature regulating centers, drugs or toxins. Fever is not an illness. Far from being an enemy, it is an important part of the body’s
defense against infection. Many infants and children develop high fevers with minor viral illnesses. Feelings of coldness, goosefish, and shivering accompany a
rising temperature, while hot feelings and sweats accompany defervescence. The normal temperature rises during the day and falls during the night. When fever
exaggerates this swing, night sweats occur. Malaise, headache, and pain in the muscles and joints often accompany fever.
There are four characteristics of fever patterns:
1. Intermittent - temperature reaches a peak elevation in the evening and falls to normal during daytime.
2. Remittent – temperature over two to three degree range each day but does not return too normal. Most fever are of this type.
3. Sustained – characterized by persistent elevation without a high and low variation.
4. Relapsing – short febrile periods, lasting one to several days.
Common causes
• Viral and bacterial infections
• Colds or flu-like illnesses
• Sore throats and strep throat
• Ear infections
• Viral gastroenteritis or bacterial gastroenteritis
• Acute bronchitis
• Infectious mononucleosis
• Urinary tract infections
• Upper respiratory infections ( such as tonsillitis, pharyngitis or laryngitis )
• Medications ( such as antibiotics, antihistamines, barbiturates, and drugs for high blood pressure )
• Occasionally, more serious problems like pneumonia, appendicitis, tuberculosis, and meningitis
• Fever can occur in infants who are overdressed in hot weather or a hot environment
• Collagen vascular disease, rheumatoid diseases, and autoimmune disorders
• Juvenile rheumatoid arthritis
• Lupus erythematosus
• Periarteritis nodosa
• AIDS and HIV infection

5. • Inflammatory bowel disease
• Regional enteritis
• Ulcerative colitis
• Cancer
• Leukemia
• Neuroblastoma
• Hodgkin’s disease
• Non-Hodgkin’s Lymphoma
When trying to reduce a fever:
• Do not bundle up someone who has the chills.
• A lukewarm bath or sponge bath may help cool someone with a fever. This is especially effective after medication is given, otherwise the temperature
might bounce right back up.
• Do not use cold baths or alcohol rubs. These cool the skin, but often make the situation worse by causing shivering, which raises the core body
temperature.
• Remove excess clothing or blankets. The environment should be comfortably cool. For example, one layer of lightweight clothing, and one lightweight
blanket to sleep. If the room is hot or stuffy, a fan may help.
• Drink cool liquids, as tolerated.
Stages and management of fever:
1. Chill Stage
• Rest and adequate nutrition
• Oxygen inhalation if available
• Provides extra blankets; increase room temperature
• Encourage oral fluid to replace fluid loss
2. Febrile Stage
• Encourage oral fluid 3 liters or 8 glasses per day; provide proper oral hygiene
• Tepid sponge bath
• Reduced external covering to increases heat loss through radiation and conduction
• Keep bed linens and clothing’s dry
• Cool circulating air
• Limit physical activity
• Herbal; the use of Lagundi
3. Resolution Stage
• Characterized by sweating

6. Types:
A. Lysis – gradual decrease in temperature
B. Crisis – sudden decrease in temperature
When to seek consultation:
1. Fever lasts more than three days.
2. Child is less than three months old.
3. Fever does not respond to any intervention done.
Cough – To expel air suddenly and violently from the lungs after deep inspiration and closure of the glottis; a protective reflex caused by irritation of the
laryngeal, tracheal, or bronchial mucosa. A single instance of such an expulsion of air. A condition, transient or chronic, in which persistent irritation of
respiratory mucosa gives rise to episodes of coughing.
Coryza – Inflammation of the mucous membranes of the nose, usually marked by sneezing, nasal airway congestion, and discharge of watery mucus; acute
rhinitis.
Anorexia – Absence of appetite.

7. DISCHARGE PLAN
MEDICATIONS:
• Advised SO to give the following medications at the right time, right dose, right frequency and right route.
1. Amoxicillin (Amoxil) 250/5ml 4ml three times a day per orem
2. Paracetamol (Tempra) 250/5ml syrup 2.5 ml per orem every 4 hours
3. Ranitidine (RABLOC) 25 mg IVTT every eight hours
4. Cefalexin (Eliphorin) 250/5 suspension 5ml three times a day
ENVIRONMENT:
• Encouraged to maintain a safe home free from any healthy hazards such as sharp objects, chemicals and matches
• Encouraged to provide adequate lighting on stairs and bathrooms to avoid injury
• Encouraged to maintain cleanliness of the house and surroundings
• Encouraged to provide a well ventilated area
• Encouraged to listen to soft music for relaxation
TEACHINGS:
• Encouraged SO to give child a good sleeping time and adequate nutrition
• Reminded SO to always assess patient needs
• Reminded to have a follow up check-up at attending physician’s clinic one week after discharge
HEALTH TEACHINGS:
• Encouraged SO to do chest tapping to facilitate mobilization of secretions
• Encouraged SO to change patient’s position regularly to facilitate drainage and mobilization of secretions
• Instructed SO to observe proper hygiene such as bathing the baby daily to keep the baby from infection

8. • Instructed SO to keep the child always clean and dry
• Advised SO to give toys that are big for the mouth so that the patient may not be able to swallow these
• Instructed SO to do hand washing before and after contact with patient
• Instructed SO not to take the patient to crowded places to prevent risk of having infection
• Instructed SO to give medications at the right route, dose and time
OBSERVABLE SIGNS AND SYMPTOMS:
Advised to go to the physician if the following signs and symptoms of pneumonia are observed.
• fever
• chills
• cough
• unusually rapid breathing
• breathing with grunting or wheezing sounds
• labored breathing that makes a child’s rib muscles retract (when muscles under the rib cage or between ribs draw inward with each breath)
• vomiting
• chest pain
• abdominal pain
• decreased activity
• loss of appetite (in older children) or poor feeding (in infants)
• in extreme cases, bluish or gray color of the lips and fingernails
DIETS: Reminded SO to serve the food mentioned to the patient.
• Advised to follow the right vitamin C and multivitamin supplements to be taken
• Encouraged oral fluids at least 8 glasses per day
• Encouraged to eat green leafy vegetables such as “kamungay”, “kangkong”, and “petchay”
• Encouraged to eat high calorie or carbohydrates foods such as rice, bread, and root crops to provide adequate energy and to improve nutrition
SAFETY, SECURITY AND SPIRITUALITY
• Encouraged SO to continue praying to God and to attend mass every Sundays and other days
• Encouraged to put pillows bedside the patient on the bed to avoid injury or falls
• Advised not to leave patient alone and to keep watch at all times
• Instructed to keep sharp objects away from the patient

9. DRUG STUDY
1. Ranitidine (RABLOC) 25mg IVTT every eight hours
Cl: Antiulcer agents, Gastric acid secretion inhibitors
I: Short-term treatment of active duodenal ulcers and bening gastric ulcers. Prophylaxis of duodenal ulcers (at lower doses). Management of
gastroesophageal reflux disease.
A: Inhibits the action of histamine at the H2 receptor site located primarily in gastric parietal cells, resulting in inhibition of gastric acid secretion.
Healing and prevention of ulcers.
C: Hypersensitivity. Some oral liquids contain alcohol and should be avoided in patients with known intolerance.
AR/SE: confusion, nausea, diarrhea
Nursing Considerations:
1. Assess for location and intensity of pain.
2. Encourage to verbalize feelings of pain.
3. Instruct patient to take medication as directed for the full course of therapy.
4. Informed patient that medication may cause drowsiness or dizziness.
5. Advise SO of patient to increase fluid and fiber intake.
6. Advise patient to report onset of black tarry stools, fever, sore throat, diarrhea, dizziness, rash, confusion, or hallucinations to the physician or
other health care provider.
2. Paracetamol (Tempra) 250mg/5ml syrup 2.5 ml per orem every four hours
Cl: Nonopiod analgesic, Antipyretic
I: Mild to moderate pain. Fever
A: Inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever. Analgesia (due to peripheral prostaglandin inhibition).
Antipyretics (lowers fever); due to inhibition of prostaglandins in the CNS.

10. C: Previous hypersensitivity. Products containing alcohol and sugar should be avoided in patients who have hypersensitivity or tolerance to these
compounds.
AR: GI: hepatic necrosis (overdose)
Derm: Rash, urticaria
Nursing Considerations:
1. Take note the temprature of the patient after 3 minutes from giving of medication.
2. Advise patient to consult the physician or other health care provider if discomfort or fever is not relieved by routine doses of this drug.
3. Advise SO to let patient increase his oral fluid intake.
4. Advise SO to let patient wear loose clothing
5. If temperature is still above normal after giving medication try to do tepid sponge bath to patient.
3. Cefalexin (Eliphorin) 250/5 suspension 5ml three times a day.
Cl: Anti-infective (Cephalosporin 1st
generation)
I: Mild to moderate infections of the respiratory and urinary tract, bones, skin and skin structures caused by susceptible organisms.
A: bactericidal or inhibit the growth of susceptible pathogenic bacteria. Treatment and prophylaxis of various bacterial infections.
C: Known hypersentivity to individual agents. Hypersensitivity to cephalosporins.
AR: Nausea, vomiting, diarrhea, abdominal discomfort, allergic reactions, superinfections.
Nursing Considerations:
1. Assess patient for signs and symptoms of infection prior to and throughout course of therapy.
2. Determine previous hypersensitivities in patients receiving cephalosporins.
3. Instruct SO to let patient continue taking medication around clock until finished completely, even if feeling better.
4. Instruct SO to notify physician or other health care provider if fever and diarrhea develop, especially if stool contains pus, blood, or mucus.
5. Instruct So to notify physician if symptoms do not improve.