SPURTHY COLLEGE OF NURSING

BANGALORE
CASE STUDY ON

PNEUMONIA

SUBMITTED TO: SUBMITTED BY:

SUBMITTED ON:
IDENTIFICATION DATA:
 Name of the child : B/O Sheetal
 Name of the mother : Sheetal Sharma
 Sex : Male
 Age : 5 days
 IPD NO : 667878
 Developmental age : Early infancy
 Religion : Hinduism
 Address :Bangalore.
 Birth weight : 2.5 kg
 Care started on : 14-05-2024
 Care ended on :17-05-2024
 Diagnosis : Pneumonia
CHIEF COMPLAINTS ON ADMISSION:
B/o Sheetal was admitted in NICU with the following chief complaints:
 Wheezing sound x 2 days
 Fever x 2 days
 Cyanosis: acrocyanosis present x from birth
 Mild respiratory distress x 1 day
PRESENT HISTORY OF ILLNESS:
 Present medical history: Baby was apparently well last 2 days back, then there is
sudden fever and mild respiratory distress. Then the physical examination was done
by the physician and blood investigations was sent to rule out the condition and then
the baby was diagnosed with pneumonia. Now he is under observation in NICU for
further treatment.
 Present surgical history:
No surgical intervention was carried out for the baby
PAST HISTORY OF ILLNESS:
Past medical history: There is no past medical history
Past surgical history: There is no past surgical history

FAMILY HISTORY:
Type of family: Nuclear
Number of family members:5
Family history of any illness: There is no family history of DM, HTN, Communicable disease
and congenital anomalies in the family.
Family Pedigree:
Number of Age/Sex Relation Education Occupation Health status
family with patient
members
Rajesh 50 yrs./Male Grandfather Matric Retired Hypertensive
Kumar passed
Lata devi 48 Grandmother 8th passed Housewife Healthy
yrs./Female
Pardeep 26 Father Graduate Private job Healthy
Kumar years/Male
Sheetal 23 Mother Matric Housewife Healthy
yrs./Female passed

Family Tree:

grandfather Grandmother
Rajesh Kumar Lata devi

Father Mother
Pardeep Kumar Sheetal

Patient

MOTHER’S PAST HISTORY AND ANTENATAL HISTORY:

Personal history of mother
Age : 24 years
Blood group : AB +ve
Diabetes millitus : Not detected
Hypertension : No signs of pre eclampsia
Renal disease :Not present
Cardiac disease : Not present
Malaria : Not present
Drug abuse : No history of drug abuse
Medication history of mother
Glucorticosteroids : Not taken
Tocolytic agent : Not taken
Antibiotic agent : Not given
History of present labour
Foetal distress : No foetal distress present at time of birth
Presentation : Vertex presentation
Mode of delivery : normal vaginal delivery with episiotomy at 38 weeks of gestation
Duration of rupture of membrane : 2 hours
Duration of labour : 16 hours
Intrauterine growth retardation : weight of new born was appropriate according to period of
gestation
Amniotic Fluids
Volume : Adequate
Colour : Clear
Lungs maturity : Attain lung maturity
Sexual transmitted diseases
Herpes : Not reactive
HIV : Not reactive
TORCH Screen : Negative
Previous obstetrics history of mother
She is primi-gravida mother
BIRTH HISTORY OF THE CHILD:
Prenatal history: Pregnancy was confirmed at 4th weeks of pregnancy. Pre natal care
initiated at 12 weeks of gestation and continued throughout the pregnancy. Nothing
uneventful was reported during pregnancy. Three antenatal visits were done by the
mother.TT immunization was taken by the mother.
Intranatal history: delivery done at 38 weeks of gestation by normal vaginal delivery with
episiotomy in SMGS Hospital,Jammu. No any abnormalities during the intra natal period.
Post-natal history: No complaints reported during the post-natal period by the mother.
Lochia rubra was present. Birth weight of baby is 2.5 kg and length was 45 cm, baby cried
immediately after birth. APGAR scores is 8 and 9.
DIETARY PATTERN OF CHILD:
Type of feeding: The baby is being given breastfeed.
Current diet: Breastfeeding is given to the baby every 2 hourly.
PHYSICAL ASSESSMENT OF NEONATE:
APGAR SCORE: One minute Apgar score was 8 and 5 minutes score was 9
Chest circumference 33 cm
Weight: 2.5 kg
Height : 45cm
VITAL SIGNS:
Temperature Respiration Pulse Blood pressure
100 degree F 56 b/min 150 b/min 105/85 mmhg
99.6 degree F 50 b/min 148 b/min 124/76 mmhg
99.2degree F 43 b/min 140 b/min 109/70 mmhg
99 degree F 40b/min 138 b/min 111/66 mmhg

IMMUNIZATION HISTORY:
S.NO. Vaccine Dose Route
1. BCG 0.05 ml ID
2. Hepatitis B 0.5 ml IM
3. OPV 2 drops Oral

SOCIO-ECONOMIC HISTORY:
Baby of Neelam belongs to a low-income status family
The monthly income of father 20,000/month
Housing: The patient lives in 5 rooms Pukka house with separate bathroom and toilet. The
ventilation and lighting is adequate in the house and uses tube and bulb as the source of light
in the night. Water supply from the municipal corporation taps. The disposable of waste is
done in the open area.

DEVELOPMENTAL MILESTONES:
Physical Fine motor Social and Intellectual Language
development Emotional development development
development
 Lies in  Closes  Bonds  Beginning  Cries
foetal eye to with to develop vigorousl
position bright mother concepts y
with light. not yet e.g.  Respond
knees  Opens develop becomes to high-
tucked eye ed. aware of pitched
up. when physical tones by
 Unable held in sensations moving
to raise an such as his limbs
head. upright hunger.
Head position  Explores
falls . using his
backwar senses.
ds if  Cry to
pulled to indicate
sit. need.
 Reacts
to
sudden
sound.

PHYSICAL EXAMINATION
SKIN:
Cyanosis : Present at the time of birth
Jaundice : Present i.e. yellow discoloration of skin
Petechial : Not seen
Birth marks : Present on lower back
Haemangioma : Not present
Subcutaneous fat : Present
HEAD:
Head circumference: 32 cm
Caput succedaneum : Not present
Cephalhematoma : Not present
Encephalic : Not present
Microcephaly : Not present
Encephalopathy : Not present
Size of fontanel : Normal , not depressed
Forceps marks : Not present
EYES:
Size : Appropriate for age
Shape : Normal
Placement : Aligned in the same plane
Symmetry : Symmetrical
Sclera : Shiny and yellow in colour
Pupil : Equal, round, reactive to light and accommodation
Discharge : None
Vision : Not checked
Movement : Normal eye movement in all directions
EARS:
Pinna : Normal in shape
Position : equal alignment
Cartilage : Cartilage present
Auditory canal : not assessed
Hearing : Normal i.e. baby react towards loud voices
NOSE:
Shape of nose : Aligned properly
Potency of nostril : Adequate
Septum : None
Nasal mucosa : Pink and moist
Discharge : None
MOUTH:
Size of oral cavity : Small cavity
Opening of oral cavity : Normal
Cleft lip : Not present
Cleft palate : Not present
NECK:
Goitre : not present
Thyroglossal : not present
Bronchial arch: Normal
Lymph nodes: Not palpable
Range of motion: Movement is adequate

CHEST:
Size: Normal range
Shape: Round
Symmetry: symmetrical
Nipples and breast: Spacing normal and no discharge
Scapula symmetry: Appear symmetrical
Inspection: Round in shape
Auscultation: Normal s1 and s2 sound is heard
Palpation: No tenderness, tumour or growth
Respiratory rate: 40 breath/minute
Breath sounds: wheezing sounds are heard
ABDOMEN:
Inspection: no scar present, normal healthy cord is present
Palpation: liver margin not palpable
Auscultation: Bowel sounds present
Percussion: no fluid accumulation
Umbilicus: hernia absent
EXTREMITIES:
Symmetry of extremities: symmetrical
Joints: no pain, tenderness
Range of motion: full range of motion
MALE GENITALIA:
Scrotum: normal
Testes: both testes descended
Penis: normal in size, urethral opening present at the glans penis
RECTUM:
Haemorrhoids: absent

REFLEXES:
REFLEXES PRESENT OR NOT
Rooting present
Glabellar present
Moro’s poor
Swallowing and sucking present
Doll’s eye present
Tonic neck present
Palmer grasp present

INVESTIGATIONS:
INVESTIGATION PATIENT’S VALUE NORMAL VALUE REMARKS
DONE
Haemoglobin 11 gm% 12-16 % Mild low
Total leukocyte count 9000/cumm 5000-9000/cumm Normal
Lymphocytes 60% 20-45% High
Monocytes 2% 4-13% Low
Eosinophils 2% 0-14% Normal
Basophils 0% 0-2% Normal
Serum calcium 10mg/dl 8.0-10.4 mg/dl Normal
Albumin 40IU/L 10-45 IU/L Normal
Urea 38 15-45 mg/dl Normal
Na 135 mmol/lit 135-145 mmol/lit Normal
K 3.4 mmol/lit 3.5-5.5 mmol/lit Normal
Ca 1.09 1.0-1.3 Normal
HCT 23.6% 10.5-13.5 Normal
MCV 71 32-44 High
Ph 7.584 7.34-7.44 High
Pco2 22.3 mmhg 35-45 Normal
Po2 193.3 mmhg 75-100 High
Hco2 21.2 mmol/l 20-28 Normal
Spo2 98.2% 90-100 Normal
Total bilirubin 15.0 mg% 0.0-5.0 High
Direct bilirubin 2.5 mg% 0.1-0.4 High
S. Pharmaceutical/ Dose Action Indications Contra Side Nursing
No Trade and Indi- effects responsibilities
Name Route cations
1. Injection 50/mg/k Semisynthe Third Hyper Hypersens Observe site for
cefotaxime g/dose tic, third generation sensiti itivity phlebitis
generation cephalosp vity to Phlebitis Record volume
Vial:1g cephalospor orin. It is cephal Diarrhea on iv fluid chart-
Week:1( in active ospori Nephrotox large drug volume
12 against ns icity
hourly) both gram Leukopeni
Week2- +ve and a
4:(8 gram -ve
hourly) organisms.
It is used
Route: in the
IV treatment
IM of
infection
when
sensitivity
testing
indicates
susceptibil
ity.
TREATMENT:

S. Pharmaceutical/ Dose Action Indications Contra Side Nursing

No Trade and Indi- effects responsibilities
Name Route cations
2. Injection 6mg/kg To treat serious Hypers Heada Perform c &s
Netilmicin IV Aminogly bacterial ensitivi che tests prior to
coside infections ty to Visual initiation of
antibiotic Blood netilmi disturb therapy.
Anti- Stomach cin and ances Monitor high
infective Soft tissues myasth Rashes risk patient
Urinary tract enia Hearin loosely
Intestine gravis g Repeat
Bone and joints is a impair bacterial
etc. contrai ment susceptibility
ndicati Nausea tests if
on. and therapeutic
vomiti effectiveness
ng is not evident
Kidney within 3-5
impair days.
ment
 DISEASE CONDITION
PNEUMONIA
INTRODUCTION
Pneumonia is a form of acute respiratory infection that affects the lungs. The lungs are made
up of small sacs called alveoli, which fill with air when a healthy person breathes. When an
individual has pneumonia, the alveoli are filled with pus and fluid, which makes breathing
painful and limits oxygen intake.
DEFINITION
Lung inflammation caused by bacterial or viral infection, in which the air sacs fill with pus
and may become solid. Inflammation may affect both lungs(double pneumonia) or only
one(single pneumonia).
INCIDENCE
Pneumonia and other lower respiratory tract infections are the leading cause of death
worldwide. The WHO Child health Epidemiology Reference Group estimated the median
global incidence of clinical pneumonia to be 0.28 episodes per child year. This equates to an
annual incidence of 150.7 million new cases, of which 11-20 million (7-13%) are severe
enough to require hospital admission. Ninety-five percent of all episodes of clinical
pneumonia in young children younger than 5 years worldwide, accounting for approximately
10-20 million hospitalizations.

PATHOPHYSIOLOGY
Infection to the lung (e.g. Bacteria, virus)

Inflammatory response initiated

Alveolar edema + exudate formation

Alveoli & respiratory bronchioles fill with serous exudate, blood cells, fibrin, bacteria
 Consolidation of lung tissues

TYPES:
The main types of pneumonia are:
Bacterial pneumonia. This type is caused by various bacteria.
Viral pneumonia. This type is caused by various viruses, including the flu(influenza), and is
responsible for about one-third of all pneumonia cases.
Mycoplasma pneumonia.
Other pneumonias.

CAUSES:
Book Picture Patient Picture
Alcohol consumption Absent
Certain medicine Absent
influenza Absent
Streptococcus infection Present
Obstructive jaundice-Extrahepatic Absent
biliary atresia, cholelithiasis,
cholecystitis
Prolong immobility Absent
Haemolytic jaundice-ABO and Rh Rh incompatibility
incompatibility, miss matched blood
transfusion, septicaemia, thalassemia
Excessive destruction of RBCs Excessive destruction of RBCs
Fungal infection Present
Babies who are born too early Absent
(premature) are more likely to develop
jaundice than full-term babies
Many different genetic or inherited Absent
disorders
Infections(sepsis) Present
Low oxygen level (hypoxia) Present
Infections present at birth, such as Absent
rubella, syphilis, and others
Diseases that affect the liver or biliary Absent
tract, such as cystic fibrosis or
hepatitis
Cirrhosis of liver portal hypertension Absent
Viral infections Absent
Hereditary Absent
SYMPTOMS:
BOOK PICTURE PATIENT PICTURE
Pneumonia is a form of acute respiratory Present
infection that affects the lungs. The lungs
are made up of small sacs called alveoli,
which fill with air when a healthy person
breathes. When an individual has
pneumonia, the alveoli are filled with pus
and fluid, which makes breathing painful
and limits oxygen intake.
Feed poorly Present
Low blood pressure present
Poor or absent moro reflex Present
Opisthotonos position Absent
High pitch cry Present
Convulsion Absent

DIAGNOSTIC EVALUATION:
BOOK PICTURE PATIENT PICTURE
History collection done
Physical examination done
Non-invasive assessment of jaundice No
Reticulocyte count No
Complete blood count Done
Coomb’s test No

History collection: history collection about family history of anaemia.

MANAGEMENT:
The management include:
Prevention of Rh isomerization by anti D gamma globulin to Rh negative mother in case of
birth of Rh-positive baby or abortion.
Reduction of enter hepatic circulation by drug therapy.
Intensive neonatal nursing.
BOOK PICTURE PATIENT PICTURE
Penicillin, ampicillin yes
Deriphyllin yes
Paracetamol yes
NURSING MANAGEMENT:
The infant is placed under artificial light in warm, enclosed bed to maintain a constant
temperature.
 The baby will wear only a diaper and special eye shades to protect the eyes.
 Breastfeeding should be continued during if possible.
 In rare cases, the baby may need an intravenous (IV) line to deliver fluids.
 A nurse will come to your home to teach you how to use blanket or bed, and to check
on your child.
 The nurse will return daily to check child’s weight, feedings, skin, and bilirubin level.
 You will be asked to count the number of wet and dirty diapers.
PREVENTION:
The best way to avoid jaundice is to make sure your baby’s is getting enough fluids.
All pregnant women should be tested for blood type and unusual antibodies. If the mother is
Rh negative, follow up testing on the infants cord is recommended. This may also be done if
the mother’s blood type is o+, but it is not needed if careful monitoring takes place.
Careful monitoring of all babies during the first 5 days of life can prevent most complications
of jaundice. This includes:
Scheduling at least one follow-up visit the first week of life for babies sent home from the
hospital in 72 hour.
COMPLICATIONS:
Acute respiratory distress (ARDS) and respiratory failure, which are common complications
of serious pneumonia. Kidney, liver and heart damage, which happens when these organs
don’t get enough oxygen to work properly or when your immune system ponds negatively to
the infection.
Cerebral palsy
Deafness.
THEORY APPLICATION
FAYE GLENN ABDELLAH’S NURSING THEORY:
INTRODUCTION;
As a profession nursing should identify its own unique body of knowledge which is essential
to nursing practice. To identify this knowledge, nurse must develop and recognize concept
and theories which are specific to nursing. “
Theory is defined as a system or ideas that is proposed to explain a given phenomenon or
event.” It provides professional autonomy by guiding the nursing practice, education and
research function.
BIO GRAPHY OF FAYE GLEN ABDELLAH
Abdellah was born in New York city. In 1942 she received diploma in nursing from Fitkin
Memorial Hospital, School of nursing. She received B.S, M.A and B.ED from Teacher’s
college at Columbia University and She completed her doctoral work in 1955.
The nursing theory developed by Faye Abdellah etal emphasized upon delivering nursing
care for the whole person to meet the physical, emotional, Intellectual, social and spiritual
needs of the client and family.

NURSING PROBLEM
Basic to all patients :-
 To maintain good hygiene and physical comfort.
 To promote optimal activity, exercise, rest and sleep.
 To promote safety through prevention of accident, injury or other trauma and through
the prevention of the spread of infection.
 To maintain good body mechanics and prevent and correct deformities.

Sustainable care needs:-

 To facilitate the maintenance of a supply of oxygen to all body cells.
 To facilitate the maintenance of nutrition to all body cells.
 To facilitate the maintenance of elimination.
 To facilitate the maintenance of fluid and electrolyte balance.
 To recognize the physiological response of the body to disease conditions-
physiological and compensatory.
  To facilitate the maintenance of regulatory mechanisms and functions.
 To facilitate the maintenance of sensory function.
Remedial care needs :-
 To identify and accept positive and negative expressions and feelings.
 To identify and accept interrelatedness of emotions and organic illness.
 To facilitate progress towards achievement of personal spiritual goal.
 To promote the development of productive interpersonal relationship.
 To facilitate progress towards achievement of personal spiritual goal.
 To create and maintain a therapeutic environment.
 To facilitate awareness of self as an individual with varying emotional , physical and
developmental needs
Restorative care needs:-
 To accept the optimum possible goal in the light of limitation, physical, emotional.
 To use community resources as an aid in resolving problems arising from illness.
 To understand the role of social problems as influencing factors in the cause of
illness.

 From this theory all complaints applied on my client. Once the person gets disease
condition ,then all disturbance comes & cannot get proper nutrition, rest, sleep etc.
There for this theory is applicable to my patient care.
 NURSING DIAGNOSIS:

 Ineffective breathing pattern related to excessive mucous production as evidenced by

vital signs.
 Altered sleeping pattern and disturbance related to stuffy nose as evidenced by
checking the baby vital signs.
 Altered body comfort related to infection as evidenced by eye irritation, dehydration ,
and temperature instability or skin breakdown.
 Interrupted family processes related to child’s illness, hospitalization and medical or
therapeutic regimen as evidenced by verbal statements.
 Altered body temperature less than body requirements related to disease condition
 Knowledge deficit related to disease condition as evidenced by frequently asked
questions.

Assessment Nursing Expected Planning Rationale Implementation Evaluation

Diagnosis Outcome
Subjective Ineffective Maintain Assess the Obtain the Assessment Fluid and
data: breathing the condition of baseline data was done by electrolytes
Mother said pattern breathing the child auscultation of balance was
that during related to pattern of chest maintained as
sleeping there excessive baby. evidenced by
is breathing mucous lab
and wheezing production Provide the Maintain the O2 therapy is investigations.
sound in as O2 therapy to breathing provided to
baby. evidenced the patient pattern of patient
by vital patient
signs.

Provide Maintain the Every 2 hourly

breast feed to nutritional breast feed was
the baby status of the given to the
Objective baby baby
data:
Wheezy
sounds
during Administer Maintain Administered
sleeping, IV fluids to fluid and as per ordered
nose the baby as electrolytes
congestion. per doctors balance in
ordered the body

Continuous Early Continuous

monitoring of assessment monitoring was
foetal of any done for the
condition complication baby
 Nursing Nursing Expected Planning Rationale Implementation Evaluation
assessment Diagnosis outcome
Subjective Altered Improve Assess the To help in Sleep pattern of Sleeping
Data: sleeping the sleeping assessing the baby is assessed. pattern of baby
Mother said pattern and sleeping pattern of patient is gradually
that my baby disturbance pattern of the patient condition facilitated.
is not sleeping related to baby
at night. stuffy nose
as evidence
by Provide It helps in Comfortable
checking noise free providing environment is
the baby’s and comfort to provided to the
sleep comfortable the baby patient
pattern. environment
to patient.

Objective
Data:
By Tap baby It helps in Tapping on back
observation , back for providing of baby for good
the baby has good sleep comfort and sleep
disturbed to facilitate
sleep due to the sleep of
stuffed nose baby

Provide It helps in Steaming and

steam and reliving nasal drops are
nasal drops nasal provided to the
to the congestion patient
patient

Nursing Nursing Expected Planning Rationale Implementation Evaluation

assessment Diagnosis outcome
Subjective Altered To promote Assess the To obtain the Assessment Comfort level
Data: body the body discomfort baseline data was done by of the baby is
Mother said comfort comfort level of the observing the maintained to
that my child related to baby baby some extent as
has fever infection evidenced by
evidenced nursing
by eye observation
irritation,
dehydration, Provide To promote Baby is kept
and comfort to the comfort of safely and
Objective temperature the baby the patient frequent
Data: instability position
By taking or skin changing for
vitals, the breakdown the baby
temperature and
of baby was increased
101 degree temperature Apply eye To prevent Eye shield is
Fahrenheit. on vital shield over from bright applied over
monitoring. the eyes light the eyes

Maintain To prevent
the fluid from Exclusive
balance of dehydration breastfeeding is
the baby done for the
baby

Cover the To Prevent Genitalia is

genitalia from infection covered
with diaper properly.
Nursing Nursing Expected Planning Rationale Implementation Evaluation
assessment Diagnosis outcome
Risk of To reduce Assess the To prevent Assessed the The risk of the
Subjective infection the risk of condition of the base line patient’s infection is
Data: related to infection the child data to the condition reduced after
Mother said hospital child doing all the
that I have procedure interventions
no
knowledge Educate the To prevent Educated the
about the mother from mother for
disease before and infection proper hand
condition after washing
touching to
the child
wash hands
properly

Provided the
Objective Provide the To aware the education to the
data: education to parents child parents
I observed the parents regarding the
the mother of the child nosocomial
knowledge infection.
by asking
questions

Maintained in
Maintain To reduce the ward and
hygienic infection around patients
environment surrounding
around the
patient
HEALTH EDUCATION:

DATES TOPICS
14-05-24 HYGIENE:
Educate the mother to maintain the hygiene
of the baby.
Prevent the excessive exposure of the baby
to the outsiders.
Maintain the cord dryness of the baby.
15-05-24 Pneumonia:
Parents were taught about some home
management that can process it more easily.
Place the child in a well lit window for 10
minutes twice a day is often all that is
needed to help cure mild jaundice.
Never place an infant in direct sunlight.
16-05-24 & 17-05-24 Breast feeding:
Mother were taught about the benefits of
breastfeeding and the benefits of exclusive
breast feed to the baby to maintain
nutritional balance of the baby.

CONCLUSION:
The 5 days old male baby of Sheetal admitted in hospital with history of pneumonia. I took
detailed history from the mother about the baby and done the thorough physical examination
of the baby and the comprehensive care is given to the baby i.e. every 2 hourly breastfeed by
the mother, maintain vital signs of the baby, every 2 hourly changing of the position of the
baby and provided nebulization every 4 hourly. So since from last 3 days I provided care and
by providing medication and nursing care, his temperature was normal.
REFERENCES:
 Basvanthapa “Text book of child health nursing” 1st edition, New Delhi. jaypee
brother’s medical publisher (p) LTD,
 Beevi Assuma “the text book of pediatric nursing” 1st edition, ELSEVIR A division of
reed, Elsevier India private limited.
 Dutta parul “pediatric nursing” 2nd edition. New Delhi. Jaypee brother’s medical
publishers (p) LTD, 2009
 Sharma Rimple, Essentials of pediatric Nursing, 1st edition, New Delhi, Jaypee
brother’s medical publisher (p) LTD, 2013