UNIVERSITY OF SOUTHERN PHILIPPINES FOUNDATION

Salinas Drive, Lahug, Cebu City

COLLEGE OF NURSING

Care of a Client with:

Neonatal Pneumonia

Submitted to:

Dr..Ivy Villaceran, RN, MAN

Submitted by:

Darah Lynn Y. Mendoza

BSN-III
 TABLE OF CONTENTS

I. Introduction

II. General Information or Patient’s Profile

III. Pertinent Nursing Health History

History of Present Illness

Developmental Task
Genogram
Gordon’s Functional Health Pattern
Physical Assessment
Diagnostics and Laboratory Exams
IV. Anatomy and Physiology

V. Pathophysiology

VI. Summary of Significant FIndings

VII. Nursing Care Management: Nursing Care Plans

VIII. Drug Studies

IX. Discharge Plan

X. Health Teaching Plan

XI. Bibliography
 INTRODUCTION

Pneumonia is the most common invasive bacterial infection after primary sepsis. Early-

onset pneumonia is part of generalized sepsis that first manifests at or within hours of birth.

Late-onset pneumonia usually occurs after 7 days of age, most commonly in neonatal ICUs

among infants who require prolonged endotracheal intubation because of lung disease (called

ventilator-associated pneumonia).

Neonatal pneumonia is lung infection in a neonate. Onset may be within hours of birth

and part of a generalized sepsis syndrome or after 7 days and confined to the lungs. Signs may

be limited to respiratory distress or progress to shock and death. Diagnosis is by clinical and

laboratory evaluation for sepsis. Treatment is initial broad-spectrum antibiotics changed to

organism-specific drugs as soon as possible.

Worldwide neonatal pneumonia is estimated to account for up to 10% of childhood

mortality, with the highest case fatality rates reported in developing countries (3,4). It´s impact

may be increased in the case of early onset, prematurity or an underlying pulmonary condition

like RDS, meconium aspiration or CLD/bronchopulmonary dysplasia (BPD), when the pulmonary

capacity is already limited. It is estimated that 3.9 million of the 10.8 million deaths in children

annually world wide occur in the first 28 days of life. More than 96% of all neonatal deaths

occur in developing countries, and pneumonia accounts for a substantial proportion of these.
 The Millennium Development Goal 4 (MDG 4) of the United Nations aims to achieve

reduction in child mortality by two-thirds by 2015 from the 1990 level. However, many

developing countries are not on track with achieving MDG4. Pneumonia is one of the factors

hindering the achievement of MDG4, because it remains to cause 1.4 million deaths of children

under the age of 5 years annually, accounting for 18% of overall mortality in this age group

globally. The estimated incidence rate of pneumonia in children less than 5 years of age in the

Western Pacific region is 110 per 1,000 person-years. The Philippines is a middle-low income

country in the Western Pacific region. According to the annual reports from its Department of

Health (DOH), pneumonia is ranked as the 1st leading cause of death in children aged 1–4

years.

As stated by Philstar Global, the Cebu City Health Department (CHD) has identified

cardiovascular disease as the leading cause of death in the city last year with 984 deaths

followed by Pneumonia with 877 deaths. She further said that for infants, pneumonia was the

leading cause of death with 57 cases, followed by premature birth (36), sepsis (34), and

diarrhea (21).

I chose this case to present a comprehensively formulated case analysis that will provide

essential knowledge and skills in delivering quality health care to patients diagnosed with

pneumonia. I wanted to share this study to my classmates

 PEDIATRIC ASSESSMENT

CLIENT IN CONTEXT:

Name: Baby D.B

Age: 24 days

Sex: Male

Date of Birth: January 4, 2020

Birthplace: Cebu City

Religion:

Nationality: Filipino

Date of Admission: January 28, 2020

Address: Umapad, Mandaue City, Cebu

Informant: Parent

Medical Diagnosis: Neonatal Pneumonia

HISTORY OF PRESENT ILLNESS:

Onset of complaint prior to admission: 1 day prior to admission, productive cough noted
associated with fever 38c.

Manner of Onset: Acute

Progress of Condition: Unchanged

Medication given to alleviate condition: None

 NEWBORN/INFANT HEALTH HISTORY

A. Prenatal History

Prenatal check-up done at what AOG: 8 weeks

Frequency of Prenatal check-up: every month when reached trimester

Prenatal done in/by: Health Center

Illness incurred during course of pregnancy: UTI (23 weeks gestation)

Medications taken during pregnancy (OTC or prescribed): Multivitamins, Antibiotic

B. Obstetric History

G: 3 T: 2 P: 1 A: 1L: 2

Use of Tobacco: None Use of Alcohol: NoneUse of Drugs: None

C. Labor and Delivery

AOG during labor: 30 weeksDuration of labor: 1 hour Type of Delivery: NSVD

Type of Anesthesia: None Place of Delivery: Inside the ambulance

Complications:

Assisted by: Obstetrician

D. Birth History

Respiratory Effort of Newborn: Unassisted

Character of Cry: Loud

Medications Administered:

Presence of congenital anomalies:

Length of baby’s hospital stay:

E. Feeding History

First feeding was started at how minutes/hours after birth: 45 mins- 1 hour
 Method of feeding: Breastfeeding

Type of formula for bottle fed: N/A

Amount and Frequency: N/A

Age of Supplemental feeding started: N/A

Composition of supplemental feeding: N/A

Vitamins taken: N/A

Appetite: Good

Prescribed diet: N/A

F. Health History

Previous illness, injuries, operations: N/A

OTC Medication taken: N/A

Allergies: None

Immunization Received: 1st dose BCG, Hep B

G. Family History (Focus only in the immediate family members)

NAME RELATIONSHIP AGE HEALTH EDUCATION OCCUPATION

STATUS

AmielBaruman Father 32 Highschool Construction

Graduate worker

Honey Baruman Mother 29 Highschool Housewife

Graduate

Maria IvonyBaruman Sister 6 Preschool Student

Family History of: Diabetes Mellitus, Hypertension

H. Developmental Milestone: (write the age when this milestone was achieved.)

Smile ___ Sit with support ___ Stand with support ___ Say first word ___
 Hold head steadily ___ Sit unsupported ___ Stand alone ___

Talk in sentence ___ Roll over ___ Walk around ___ Toilet training ___

Education present grade: ___

General Survey: Please encircle, check or provide additional information as necessary.

Integumentary: Are there any abrasions, lacerations or birthmarks? None

Head and Neck: Are there masses on the head or neck? None

Eyes, Ears, Nose, Mouth and Throat: Is there exudates in the eyes? None

Is the baby blinking? Yes

Does his or her eyes follow an object within 8 inches? No

Is there discharges from the ears, nose and throat or nose congestion? None

Does the newborn respond to sound? Yes

Respiratory Characteristics, Lungs and Breathing: Is the newborn’s lungs congested or grasping
for breath?

Cardiovascular Characteristics: Is there cyanosis? No

Temperature Regulation: Is body temperature maintained? Yes

Hepatic Regulations: Does the newborn have jaundice? No

Gastrointestinal Adaptation: Has the newborn passed stools? Yes

Has she or he vomited? No

Genitourinary Adaptation: Has the baby voided? No

Neurological Characteristics: How are extremities moving? Moving freely

How does cry sound? Strong and loud

Endocrine Characteristics: Is there evidence of fetal or maternal endocrine disease? None

Is the newborn jittery? No

Sleep and Rest Patterns: What is the sleep pattern? Patient sleeps every now and then

Relationships, Psychosocial Profile and Cultural/Ethnic Variations: How are family members
relating to the newborn? Parents

PSYCHOSOCIAL PROFILE. (The psychosocial profile should focus on the child’s health practices
and behaviors that affect health and well-being)

Health Practices

When was the child’s last check-up? Everyday Usual OTC drugs? Folic Acid

Typical Day

What is the child’s typical day like? Patient is always sleeping. When awake, patient’s mother
breastfeeds him and goes back to sleep.

Does he or she have a babysitter or go to day care or preschool? If so, does he or she enjoy it?
What kind of day-care situation is it (e.g day-care center, child care in private home, babysitter
in your own home)?N/A

How is the child doing in school? N/A

What subjects does the child like and dislike? N/A

If she or he having problems with a particular subject, has he or she sought help?N/A

How many days of school does she or he usually miss every term? N/A

Nutritional Patterns

Is child still nursing or bottle feeding? If yes, how often? Still on breastfeeding

24-hour diet recall. Breast milk

Ask the child to name her or his favorite foods and snacks:N/A

Eating patterns: ask, “How often do you eat breakfast?” “What do you usually have for lunch?”
N/A

Elimination Patterns

Stool: Frequency: Twice a day Time period of day: every morning and late afternoon
Color: yellow green stoolCosistency: formed soft stool

Urination: Frequency: 4-5 diapers per day Time period of day:________

Color: yellowish

Activity and Exercise Patterns

Is the child very active? No What does he or she enjoy doing?Sleeping

Is he or she supervised during activities? N/A

Ask what the child enjoys doing outside the home: N/A

Does he or she play any sports? If so what? N/A

Does he or she wear protective equipment? N/A

What does the child like to do with his or her friends? N/A

How often does he or she watch TV during the week? N/A

How much time does he or she spend on the computer? N/A

Recreational/Hobbies

Ask about the parents’ hobbies: Parents love watching TV

What does the child do for fun? N/A

What hobbies does he or she have? N/A

Sleep and Rest Pattern

Ask about sleep patterns and naps, bedtime rituals: Patient sleeps every now and then

The child usually goes to bed at: 7pm and she or he awakens at 2 am

Sleep problems: None

How many hours does the child sleep? 8-9 hours

Personal Habits

Ask parents about their and other caregiver’s personal habits. Do they smoke, drink alcohol or
use drugs? Patient’s father drinks alcohol and smokes a lot

If they smoke cigarettes, how many do you smoke in an average day? 6-8 sticks a day
If you use alcohol, how much do you usually drink during the weeks? Every weekend

If you use drugs, what type and what method? N/A

Roles/ Relationship/ Self-Concept

If there are siblings, ask the parent about the relationship: His sibling likes him so much,
sometimes she looks out for him

Ask the child, “Who lives at home with you?”

Sexuality

Sex role irritation observed:N/A Does the child masturbate? N/A

Stress and Coping

Does the child behave aggressively or have temper tantrums? No

Ask the child: “What makes you angry?” N/A

Ask the child: “What do you do when you’re angry?” N/A

Ask the child: “ What do you do to have fun or relax?” N/A

 PERTINENT NURSING HEALTH HISTORY

HISTORY OF PRESENT ILLNESS

Two days prior to admission, patient was noted to have onset of productive cough. No
fever, coryza, changes in elimination, feeding or vomiting noted. No medications given, no
consult sought.
One day prior to admission, onset of fever with temperature maximum of 37.9C was
noted.

HISTORY OF PAST ILLNESS

No past hospitalization or surgeries.

FAMILY HISTORY
The patient has family history of Diabetes Mellitus on paternal side and Hypertension on
both sides.

ENVIRONMENTAL/OCCUPATIONAL HISTORY:
The patient’s mother described their house as a single four flat house made up of light
materials like substandard wood and a few portions made out of cement close to the main road
the road where most vehicles pass by. Pests like cockroaches, flies and rodents are present in
their house. They lived in a squatter area where houses are near each other. According to the
patient’s mother, the patient is exposed to irritants such as smoke because some of their
neighbors use wood to cook their meals, also a lot of their neighbors including the patient’s
father smoke cigarettes near their house. Patient is unlikely exposed to second hand smoke.
 DEVELOPMENTAL TASK
Trust vs. Mistrust ( At birth – 18 months of age)

Trust vs. mistrust is the first stage in Erik Erikson's theory of psychosocial development.
This stage begins at birth continues to approximately 18 months of age. During this stage, the
infant is uncertain about the world in which they live, and looks towards their primary caregiver
for stability and consistency of care.
If the care the infant receives is consistent, predictable and reliable, they will develop a
sense of trust which will carry with them to other relationships, and they will be able to feel
secure even when threatened.
If the care has been inconsistent, unpredictable and unreliable, then the infant may
develop a sense of mistrust, suspicion, and anxiety. In this situation the infant will not have
confidence in the world around them or in their abilities to influence events.
Patient D.B depends on his mother’s breastmilk for feeding and both the healthcare
provider and his mother for care. I believe the patient passed this stage because a sense of
trust is already developed, because both the parent and healthcare provider is responsive and
consistent with the basic needs being meet. The need for care and food are met with
comforting regularity this can be observed by the promotion of breastfeeding between the
mother and the patient and continuous monitoring of the patient’s needs by the healthcare
provider.
Success in this stage will lead to the virtue of hope. By developing a sense of trust, the
infant can have hope that as new crises arise, there is a real possibility that other people will be
there as a source of support. Failing to acquire the virtue of hope will lead to the development
of fear.
 GENOGRAM

Paternal Side Maternal Side

DM HPN HPN

PT

LEGEND

DECEASED MALE FEMALE

F- Father M- Mother
DM- Diabetes Mellitus HPN- Hypertension PT- Patient

PHYSICAL ASSESSMENT

GENERAL SURVEY
Received patient D.B. lying on the crib, sleeping with bonnet, with heplock @ R foot,
good sucking noted with the following vital signs: T- 37.2, P- 148 bpm, R- 65cpm.
Posture: Flexed
Head Circumference: _____ Chest Circumference: ______
Abdominal Circumference: _____ Length/ Height: 41 cm
Weight: 170 gm T: 37.2C PR: 148 bpm RR: 65cpm
Skin, Hair, Nails
Skin is intact and warm to touch. No lesions noted. Good turgor noted
Hair is black and has even distribution
Nails are pink in color and cut short, kept clean
Head, Neck, Cervical Lymph Node
Head is hard and smooth. Head size is symmetric, round and in midline with no involuntary
movements.
The neck is symmetric, with head centered and without bulging masses.
There is no presence of lesions in both head and neck
Mouth, Nose and Sinus
Nose is symmetrical with the nasal septum at the midline
Nasal flaring noted
No profuse discharges noted
Lips were pale in color and dry
Gums are intact, pink in color and moist
No lesions and masses noted on the nose
No lesions and ulcerations noted on the mouth
Eye and Ear
The client’s pupils are equally round and reactive to light and accommodation.
Sclera is white, while client’s conjunctiva is pale.
Size of ears are symmetrical and proportional to the head.
Ear canal is pinkish in color
No presence of discharges in both the ears and eyes.
There is no presence of lumps or lesions.
The auricle, tragus and mastoid processes are non-tender
Thoracic and Lungs
The thorax is the same color as the rest of the body with no presence of lesion.
Patient had a respiratory rate of 65 cpm
Equal chest expansion noted
Supraclavicular & intercostal retraction noted
No tenderness, lumps and nodules felt upon palpation
Percussion
Dullness noted upon percussion
Rales on both lung fields noted
Cardiovascular
Distinct heart sounds noted
The patient had a pulse rate of 148 bpm
Breast
Patient’s breast is symmetrical
No lesions and masses noted
Axillary lymph nodes were not palpable
Abdomen
Patient’s abdomen is globular in shape
Masses and pulsation were not noted
 Diagnostic and Laboratory

January 28, 2020

Microbiology Section
Culture and Susceptibility

Result:
Final Report: Positive for Carbapenemase Producing Escherichia Coli after 12 hrs of
incubation

Table of Susceptibility/Resistance
Ampicillin – R
Amoxicillin/ Clavulanic Acid – R
Piperacillin/ Tazobactam – R
Cefuroxime – R
Cefoxitin – R
Ceftazidime – R
Ceftrazidime – R
Ceftriaxone – R
Cefepime – SDD
Ertapenem – R
Imipenem – R
Meropenem – R
Amikacin – R
Gentamikin – R
Ciprofloxacin – S
Legend:
S- Sensitive, R- Resistant, I- Intermediate. NS- Non Susceptible
Immunology Section

Feb. 13, 2020 1:00 pm

Procalcitonin- POC 0.27 mg/mL

Remarks:
Interpretation: <0.5 mg/Ml = Bacterial Sepsis is not likely (Normal)

Microbiology Section
Culture and Susceptibility Result

Feb 10, 2020

Result:
Final Repost: No growth after 72 hrs of incubation

Clinical Chemistry Section

Test Result Unit Reference

Glucose (CSF) 42 mg/dl 40-70
Protein (CSF) 1.292 H g/c 0.150-0.450

Clinical Microscopy Section

Cell- Count/ Body Fluids Result
Body Fluids Result Unit
Specimen Cerebrospinal Fluid
Color Colorless
Transparency Clear
Approximate Volume 1
 Hematology Section
Feb. 18, 2020
Test Result Reference Interpretation

CBC

WBC COUNT 16.69 H 6.0- 14.0 A high white blood

cell count may
indicate that the
immune system is
working to destroy
an infection. It may
also be a sign of
physical or emotional
stress.

RBC COUNT 2.01 L 3.4- 5.1 A low red blood

count, or anemia, can
cause feelings of
fatigue and
weakness.

HEMOGLOBIN 65.00 L 105-140 usually indicate that

a person has anemia.

HEMATOCRIT 18.90 L 32-42 usually indicate that

a person has anemia.

MCV 94.00 H 72.88

MCH 32.30 H 24-30

MCHC 34.40 32-36

RDW-CV 21.00 H 11.50-14.50

PLATELET COUNT 400 150-450

DIFFERENTIAL
COUNT

NEUTROPHIL 45.70 L 54-62 neutropenia

LYMPHOCYTE 34.30 H 25-33 High lymphocyte

blood levels indicate
your body is dealing
with an infection or
other inflammatory
condition.

MONOCYTE 15.00 H 3-11 High levels of

monocytes may
indicate the presence
of chronic infection,
an autoimmune or
blood disorder,
cancer, or other
medical conditions

EOSINOPHIL 4.90 H 1-3 high levels of

eosinophils in your
blood (blood
eosinophilia) or in
tissues at the site of
an infection or
inflammation (tissue
eosinophilia).

BASOPHIL 0.10 0-1

 DISCHARGE PLAN

Medications:

 Advised the client/SO to continue the prescribed home medications at the right time,
right route, and right dose to ensure optimum recovery.
 Instructed client/SO not to take medications that aren’t prescribed by the doctor.
 Before starting any new medicine, ask physician first.

Environment:

 Instructed SO to clean the surroundings

 Avoid people who are smoking and polluted places

Treatment:

 Instructed SO to assist the client in performing ADL’s and performing passive ROM
exercises as tolerated.
 Instructed SO not to leave client unattended.
 Report to physicians if there are unusualities

Health Teaching:

 Advise patient to perform proper hygiene

 Avoid strenuous activities

Observable Signs and Symptoms:

Call healthcare provider if you have any of the following:

 Fever
  Severe pain

Diet:

 Advised to eat healthy foods like fruits, vegetables, whole-grain breads, fish and low
fat dairy products.

Spiritually:

 Encouraged the family members to continue religious affiliation