Pediatric Pneumonia - Case Study Example

Paediatric Pneumonia Case Study Patient History The five month’s old female baby, Megan, is admitted with a three day history of pneumonia and dehydration. The symptoms are fever and cough. The baby is unable to suck mother’s feed and vomits frequently. The initial vomits were milky, but the recent ones contained blood spots. Social Background Megan has a four year old sibling. The family belongs to south western desert lands of South Australia. They are presently visiting Adelaide to attend a funeral. The vaccination details of the baby are not available. Diagnose The patient’s symptoms of cough, fever and vomiting indicate a case of community acquired pneumonia (CAP) accompanied by dehydration. Pneumococcal pneumonia Pneumococcal pneumonia is the primary cause of persistent bacterial infection in infants. It is also a common cause of the CAP. Symptoms like fever and cough are suggestive of pneumonia. Moreover, longevity of presence of these symptoms enhances the likelihood of presence of pneumonia. (Elaine I Tuomanen, et al. Pneumococcal pneumonia in children) Pneumococcal Pneumonia is a lung infection caused by bacteria and is very common in the babies. Babies are highly vulnerable to Pneumococcal Pneumonia with symptoms like cough, fever and even breathing problems. Severe case of pneumonia may require hospitalization also. (http://www.tenderbabycare.com/PNEUMONIA.htm) In case of children especially, patient’s history and physical examination along with chest radiography are the most probable means of determining pneumonia. Also, in very young children, hospitalization may be required if they appear toxic. Determining the cause of pneumonia in children is not an easy task. In most of the studies conducted regarding this, specific cause of pneumonia could not be identified in 40% to 60% of cases. The best predictor of the cause of paediatric pneumonia is age. The table given below lists the probable pneumonia infections according to the age of the child: (source: Taj Jadavji, et al. A practical guide for the diagnosis and treatment of pediatric pneumonia) As cited in the table above, during the first 2 years of a child’s life viruses are most frequently implicated. As the child grows, bacterial pathogens like S. pneumoniae and Mycoplasma pneumoniae, are more likely to cause pneumonia. Further, there is greater complication involved in differentiating between viral and bacterial pneumonia infections. Pneumonia in infants is characterised by cough, tachypnea, and progressive respiratory distress. In some cases it may be accompanied by dehydration also. It is important to note that bacterial pneumonia due to S. pneumoniae, Streptococcus pyogenes, Staphylococcus aureus or Hib can be very severe in infants and toddlers. Such pneumonia is characterised by level one evidence like cough, fever and vomits and further level two evidence like large pleural effusion or lung abscess (level II evidence). Common symptoms considered while diagnosing pneumonia include breathing problems like short breathiness and rapid breathing. Short breathiness and rapid breathing are the most prominent symptoms of pneumonia in infants and small children. In addition, a baby infected with pneumonia may make grunting sounds while breathing. Due to difficulty in breathing, the baby may reduce or stop taking feed. Coughing can also be a Coughing may be a symptom of pneumonia in older babies over 3 months old. However, coughing is also associated with tuberculosis. Persistent cough with chills and fever may be investigated for a susceptible case of tuberculosis as well. Fever again, is a common symptom for pneumonia. It has also been commonly seen that the baby infected with pneumonia may tend to vomit after feeding or have multiple episodes of diarrhoea. Megan has a history of fever accompanied by cough, therefore is a probable case of CAP. Dehydration: Dehydration is the most common complication of pneumonia. Infants can acquire dehydration in pneumonia due to consistent drooling or vomiting. (Synopsis of pediatric emergency medicine, Gary R. Fleisher, Stephen Ludwig, Benjamin K.) In fact vomiting is a common symptom of pneumonia is young children. Dehydration is generally defined as the lack of enough fluid in the child’s body. Dehydration can result from, vomiting, diarrhea, or any combination of these conditions. It can also be caused by reduced breast feeding in infants. Infants and small children are highly vulnerable to get dehydrated as compared to older children or adults, as they tend to lose more fluid at a faster pace. A child who has dehydration along with symptoms of pneumonia is most likely be admitted to the hospital for continued IV fluid replacement. Also, infants and toddlers who are diagnosed with bacterial infections are prescribed antibiotics, though viral infections in kids may not require a specific antibiotic therapy. Also, while treating children with vomits, they are never prescribed to drugs to stop vomiting, called antiemetics or antidiarrheals as this type of treatment would usually prolong the diarrhea. Pathphysiology pf Pneumonia Pathophysiologic process and manifestations: Organisms may enter the respiratory tract through inspiration or aspiration of oral secretions; staphylococcus and Gram-negative bacilli may reach the lungs through circulation in the bloodstream. Though the usual normal pulmonary defense mechanisms such as cough reflex, mucocilliary transport, and pulmonary macrophages tend to protect against infection, yet in some susceptible hosts, these defenses either get suppressed or are overwhelmed by the invading organism. As the invading organism multiplies and releases damaging toxins, causing inflammation and edema of the lung parenchyma; this results in accumulation of cellular debris and exudates. As the lung tissue get fills with exudates and fluid, it changes from an airless state to consolidated state. In case of viral pneumonia, the ciliated epithelial cells get damaged. The severity of symptoms depends on the extent of pneumonia present. Symptoms include: Fever Chills Malaise Cough Pleuritic pain Increased tactile fremitus on palpitation Rales and ronchi on auscultation Dyspnea Overview of nursing interventions While nursing a patient of pneumonia, it is important to administer antibiotics specific for the causative organism, as prescribed and confirmed by culture and sensitivity. Then. Effort must be made to control fever with acetaminophen as ordered. Assessment of vital signs and monitoring respiratory status, pulse oximetry, exercise tolerance and breath sounds is critical in patients of pneumonia, especially children. Additionally, in the case of pneumonia accompanied with dehydration, it is important to encourage adequate fluid intake and provide bronchial hygiene. Along with performing chest physiotherapy (CPT) as indicated, O2 therapy needs to be administered as ordered. (Source: http://www.scribd.com/doc/11635320/Pathophysiology-of-Pneumonia) The Focal Points: Oxygenation and fluid, electrolyte and acid balance are the key considerations in this case study for deriving a definite conclusion. Oxygenation, fluid imbalance and electrolyte imbalance: Oxygenation is the amount of oxygen in a usually liquid form present in the blood. When a child is infected with pneumonia, the air spaces in lungs get filled with mucus. This bars the entry of oxygen into the bloodstream and therefore reduces the oxygen level in the blood. In the case of Megan, her oxygenation level needs to be determined through a blood test or via pulse oximetry. In fact, Pneumococcal pneumonia commonly begins when the bacteria find their way deep into the lungs, to the area called the alveoli, or air sacs. Alveoli are the primary functional part of the lungs where oxygen is absorbed into the blood. When the pneumonia hits alveoli, the bacteria tend to grow and multiply rapidly. Consequently, alveoli get filled with fluid, and fail to function properly, thereby thwarting the oxygen supply to the bloodstream. This fluid filling of the lungs is also a common definition of Pneumococcal pneumonia. ( http://www.faqs.org/health/topics/16/Pneumococcal-pneumonia.html) Pneumonia can also lead to fluid imbalance in the body. Children diagnosed with pneumonia with dehydration, as in the case of Megan, are highly susceptible to have fluid imbalance occurring due to diarrhea or rapid vomiting. Replacing fluids to meet the body demand adequately in this case is crucial. (http://www.healthcentral.com/ency/408/001187.html) In addition, the reduced intravascular, interstitial, and/or intracellular fluid results in dehydration. A typical form of fluid volume deficit called hypovolemia is common in children patients of pneumonia and dehydration. This type of fluid imbalance occurs from a loss of body fluid or the shift of fluids into the third space, or from a reduced fluid intake. (http://www.csmc.edu/8885.html) Dehydration due to vomiting can further complicate into an electrolyte imbalance in the child’s body. Electrolyte imbalance commonly occurs when the level of electrolytes in the body gets disturbed. Euvolemic hyponatremia or a decrease in total body water is common in patients of hypothyroidism, tuberculosis and pneumonia. Investigating oxygenation, fluid imbalance and electrolyte imbalance in case of pneumonia is important as these are critically associated with functioning of lungs as well as dehydration. In fact dehydration associated with pneumonia, as in the case of Megan, can result deficiency of electrolytes, sodium and potassium in particular. Suggestive Medication Considering the severity of symptoms associated with pneumonia in case of Megan, the following medication is advisable: Azithromycin: Azithromycin is a Food and Drug Administration (FDA) approved drug prescribed for children 6 months of age and older suffering from community-acquired pneumonia. (Marcia L. Buck, Pharm.D. , Pediatric Therapy Update: Azithromycin) Azithromycin is generally well tolerated. However, some common side effects of this drug include diarrhoea or loose stools, nausea, abdominal pain, and vomiting. Since Megan already has vomiting, it needs to be monitored that administration of Azithromycin does not pronounce the vomits as a side effect. Paracetamol: Paracetamol is a common drug prescribed for children for common illness like fever and pain relief. high dose-usage which is greater than 2,000 mg per day enhances the risk of pper gastrointestinal complications such as stomach bleeding. Since Megan’s vomit has been found to contain blood spots, it needs to be investigated if there is possibility of stomach bleeding due to high dose of paracetamol. Salbutamol and ibruprofen: Salbutamol is administered to reduce respiratory distress in kids and facilitate breathing. ibrufen is a popular pain killer administered to kids and adults for pain relief. The most common side effects of Salbutamol include headache, muscle cramps, dry mouth, and palpitation. A high dose of salbutamol can cause hypokalaemia or low potassium levels, thereby leading to electrolyte imbalance. The common side effects of these medications include gastrointestinal distress, allergic reaction and skin rashes. In case of Tuberculosis: Pathphysiology of Tuberculosis The presence of blood spots in vomits of Megan encourage investigation for tuberculosis as well. However, if TB is diagnosed, the Pathophysiologic process and manifestations would be different from pneumonia. Tuberculosis is caused by the bacteria Mycobacterium tuberculosis and mainly infects the lungs of the patient like pneumonia. The pathphysiology of tuberculosis is given below: (source: http://www.scribd.com/doc/9064917/Pathophysiology-of-Tuberculosis) Predisposing Factors: Precipitating Factors: Age - Occupation (e.g Health Workers) Immunosuppression - Repeated close contact w/ infected persons Prolonged corticosteroid therapy - Indefinite substance abuse via IV Systemic Infection: - recurrence of infection Diabetes Mellitus End-stage Renal Disease HIV or AIDS infection Exposure or inhalation of infected Aerosol through droplet nuclei (exposure to infected clients by coughing, sneezing, talking) Tubercle bacilli invasion in the apices of the Lungs or near the pleurae of the lower lobes Bronchopneumonia develops in the lung tissue (Phagocytosed tubercle bacilli are ingested by macrophages) bacterial cell wall binds with macrophages arrest of a phagosome which results to bacilli replication Necrotic Degeneration occurs (production of cavities filled with cheese-like mass of tubercle bacilli, dead WBCs, necrotic lung tissue) drainage of necrotic materials into the tracheobronchial tree (eruption of coughing, formation of lesions) Initial symptoms of tuberculosis and pneumonia are similar. However, once tuberculosis is diagnosed, the pharmacology would be different from that of pneumonia. Medication administered in case of tuberculosis would include: Isoniazid Rifampin (one brand name: Rifadin) Ethambutol (brand name: Myambutol) Pyrazinamide Conclusion: The symptoms present in the child patient are indicative of pneumonia. The presence of blood spots in the vomit may be suggestive of tuberculosis and lab examination may be conducted to investigate this possibility. Since the vaccination history of the child is not presented, it cannot be determined if the baby has been vaccinated for preventing pneumonia, the preventive vaccination may be administered. The medication administered in this case is FDA approved and suitable for the baby. Sources: 1. Elaine I Tuomanen, MD Sheldon L Kaplan, MD, Pneumococcal pneumonia in children. 2. http://www.tenderbabycare.com/PNEUMONIA.htm 3. Taj Jadavji, et al. A practical guide for the diagnosis and treatment of pediatric pneumonia 4. Synopsis of pediatric emergency medicine, Gary R. Fleisher, Stephen Ludwig, Benjamin K. 5. http://www.faqs.org/health/topics/16/Pneumococcal-pneumonia.html 6. http://www.healthcentral.com/ency/408/001187.html 7. http://www.csmc.edu/8885.html) Read More