Diagnostic and Clinical Reasoning for Pediatric Pneumonia

Subjective Data

Chief complaint The child aged three and in company of her mother presents at the facility with flu-like symptoms of stuffy nose, cough, and fever.

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History of present illness

Onset – the parent notes that the cough manifested about 24 hours ago while the fever manifested the previous night.
Location – the disorder affects the respiratory system
Duration – the approximated duration of the first signs of the ailment is 24 hours
Characteristics – the ailment is characterized by troubled breathing, productive cough, and shivering
Associated factors – chest pain aggravated by deep breathing or coughing
Relieving factors – hydration
Treatment – piriton
Summary – the mother brought the toddler in the early morning hours for medical evaluation. The toddler presents with a cough fever, stuffy nose, and fever indicative of a respiratory disorder. The mother notes that the ill look manifested on the day before worsening in the previous night. She had suspected a cold and given piriton to calm the condition but the condition increased in severity. The disorder is characterized by shivering, breathlessness, and productive cough. Coughing and deep breathing aggravates the situation and hydration seems to provide a relief.

Past medical history: the toddler suffered pneumonia two months after delivery that led to a five days hospitalization. She successfully recovered from ailment without any complication and since then has not suffered any respiratory infection of such magnitude, except two cases of a cold.

Allergies: the toddler has no history of allergy to any medication, food, or pets. She has been brought up with pets ever since she was bone and has not shown any medical reaction to their presence. The mother does not use perfumed cosmetics and notes using non-perfumed jelly and soap on her baby.

Medications: the toddler is currently under no prescribed medication

Social history: Both parents are African American who relocated in the US few years ago. The father, who is an engineer, is an active smoker and even though he does not smoke in the house living area, he mainly does it in his house library where the child likes spending time whenever he is around. Currently, the mother is a stay home mom and plans to look for a job once the child is older enough to join nursery school.

Family history: Her maternal grandmother is asthmatic but her mother has no history of chronic respiratory disorders. Her father suffers frequent bronchitis attacks, which doctors attribute to smoking. Her paternal grandfather develops respiratory reactions during winters, which developed after he became a senior citizen.

Health maintenance: the child has undertaken all immunizations required ever since she was born. Despite her love for sweet snacks, her mother has ensured that she consumes a balanced diet and adequate fluids on a daily basis. At least twice a week, she accompanies her mother to a nearby park where they run and exercise their dog pet.

Review of system

General – ill feeling
Skin – normal
HEENT – headache, runny nose
Neck – normal
Cardiovascular – normal
Lungs – cough, shortness of breath
Gastrointestinal – loss of appetite, nausea, and vomiting
Genito-urinary – normal
Periphery vascular – normal
Musculoskeletal – lethargy
Neurological – irritability
Endocrine – fatigue
Psychological – normal

Objective Data

Vital signs: T– 101.2F, HR– 125, RR– 46, BP – 70/46, decreased oxygen saturation, Wt – 14 kg
General appearance: distressed
HEENT: flaring of nostrils
Neck: normal lymph nodes and use of neck muscles when breathing
CV: normal heart sounds, no rub, no rales, normal hearth expansion
Lungs: increased tactile fremitus on palpation, dullness on percussion, and rhonchi, crackle, vocal fremitus, bronchial breath sounds, and reduced breath sounds on auscultation
Abd: normal abdominal quadrants and use of abdominal muscles when breathing
GU: normal
PV: normal
MSK: normal
Neuro: normal
Psych: normal

Diagnostic tests: rapid strep test and oxygen saturation test

Assessment

Pneumonia

Plan

Diagnostics: chest x-ray, blood test, pulse oximetry, and sputum culture,

Therapeutic:

Educational Plan – good hand hygiene and disinfection of surface to protect baby from respiratory infections and vaccination as well as avoidance of crowds during flu and cold season. In addition, education on the link between pneumonia and cigarette smoke was provided.

Collaboration – collaborated with pediatric pulmonologist during childcare.

Clinical Decision Making

Pathophysiology

The most usual pathway for acquiring pneumonia is inhalation of aerosolized droplets of 5 micrometer because of their capacity to evade the respiratory host defenses, thereby reaching the alveoli (Cillóniz, Cardozo, & García-Vidal, 2018). Normally, the lung can employ alveolar macrophages to filter out substances of 0.5 to 2 micrometer. Disruption of the balance between the systemic and local defense mechanism and the organism inhabiting the inferior respiratory tract results in the inflammation of the lung parenchyma. The usual defense processes encompassed in pneumonia pathogenesis involves accumulation of secretions, impaired cough reflex, mucociliary clearance, and system protective processes like complement-mediated and humoral immunity. The resident macrophages serve to safeguard the lung from intruding organisms. They inundate the disease causing microorganisms and trigger signal compounds or cytokines like IL-1, IL-8, and TNF-a that engage inflammatory cells like neutrophils to the infection area (Jain & Bhardwaj, 2018). The macrophages also act to present the antigens to the T lymphocytes that activate both humoral and cellular protective professes, initialize complement processes and make antibodies against the intruders. This results in lung parenchyma inflammation and render lining capillaries leaky leading to exudate congestion, underlying pathogenesis of the ailment.

Pharmacology

Gentamicin is a broad spectrum antibiotic in the class aminoglycoside, principally utilized to treat infections caused by gram-negative pathogens. Typically, this formulation is utilized in combination with other agents that are active against gram-positive pathogens. Gentamicin provides antimicrobial effects against the etiological pathogen by irreversibly binding to 16S rRNA and 30S- subunit protein. Particularly, this drug binds to four nucleotides of a single amino acid of protein S12 and 16S rRNA. The action affects the decoding site in the locale of nucleotide 1400 in 16S rRNA of 30S subunit. This area interrelates with the wobble base in the anticodon of tRNA resulting in intrusion with the initiation multiplex. This misleads the mRNA causing insertion of incorrect amino acids into the polypeptide resulting in toxic or nonoperational peptides and the disintegration of polysomes into nonfunctional monosomes. For efficacious treatment of pneumonia, gentamicin is combined with amoxicillin, a bactericidal penicillin that interrupts the generation of cell wall mucopeptides during active replication.

Clinical Diagnostic Reasoning

The diagnoses examined in this scenario include pneumonia, asthma, bronchitis, and bronchiolitis. The differentiating elements from the physical exam included intensity of breath sounds, egophony, and ear and eye involvement. The key assessment finding that led to pneumonia diagnosis include, lack of history of allergic reactions, the absence of otitis media, the absence of conjunctivitis, and reduced intensity of breath sounds. Ordering for a complete blood count was to help identify the etiological pathogen, pulse oximetry to assess the saturation of oxygen in gore, and sputum culture to identify the cause of infection. X-ray was imperative to diagnose pneumonia and establish the location and extent of the infection (Stephen, Sain, Maduh, & Jeong, 2019). Worth a note, C-reactive protein and procalcitonin tests were not relevant in this diagnosis because the radiological and clinical findings were clear (Jain & Bhardwaj, 2018). Antibiotic prescription using gentamycin and amoxicillin, which is accordance with WHO guidance for pneumonia treatment in under 5, was imperative to treat the infection and prevent further complications (Malla, Perera-Salazar, McFadden, & English, 2017). Education on hand hygiene and disinfection of surfaces was imperative in order to eliminate the pathogen in the immediate surrounding thus reducing the exposure of the child to the microbes.

Diagnostic and Clinical Reasoning for Pediatric Pneumonia

Ethical and or Cultural Concerns

The first nursing ethical code observed in this patient care includes “practicing with respect and compassion for the distinctive attributes, worth, and inherent dignity of all persons” (Haddad & Geiger, 2018). The idea of human dignity is among the most essential professional value in nursing practice (Parandeh, Khaghanizade, Mohammadi, & Mokhtari-Nouri, 2016). This entails bracing the right to dignity by acclaiming the values and demands of the toddler and parent. By setting aside potential prejudices and biases, I was able to create a patient relationship grounded on trust, including supporting family choices and acclaiming their decisions. Guaranteeing that the patient received appropriate care, regardless of socioeconomic status braced the nursing goal of enabling patient live with the highest sense of well-being. Comprehending the patient’s moral and legal rights, and giving the parent essential information for informed medical resolution helped maintain the patient’s right to self-determination. Collaborating with the pediatric pulmonologist and preserving good relationship with staff helped create a compassionate, ethical, and medical efficacious environment. Guaranteeing cultural competent nursing care by observing sensitivity, patient position, nonverbal cues, and ensuring culturally acceptable terminologies was imperative in the preservation of cross-cultural communication. Adopting perspectives that boosted transcultural nursing care, including demonstrating a caring outlook, concern, and respect increased the patient and family confidence to care. Showing empathy gave the patient and family a sense of security, understanding that their cultural ways were comprehended and valued. Openness showed the patient and family that their particular ways were examined and flexibility reassured them that their care was patient centered.

Barriers to Care

Since the mother is currently not employed, the amount that earned by the father may not be adequate to fully sustain the family. This, combined with high cost of health care can impede the access to care for this family, thus economic barrier to care. The rising costs prescriptions, diagnostics, and other medical services and high deductibles can make medical expensive, impeding affordability of the services. Complexity of the US health care system can create confusion in areas including composite innovation and information networks, contradictory specialist opinions, compliance regime, medical terminology, and insurance billing. Other non-financial barriers to care in this care would include proximity of the facility, hospital stay as well as transportation barriers (Kamimura, Panahi, Ahmmad, Pye, & Ashby, 2018). The social determinants addressed include exposure to cigarette smoke, because cigarette smoke is a risk element for pneumonia (Campagna, Amaradio, Sands, & Polosa, 2016). Densely populated neighborhood would also cause crowding, which is a predisposing element for pneumonia outbreak. Additionally, residing in a crowded city that experiences significant air pollution increases the risk of pneumonia. The Affordable Care Act is one healthcare policy that can positively influence financial barrier to care (Serakos & Wolfe, 2016). This healthcare policy improves healthcare access specifically to persons without a stable healthcare insurance, underinsured, or uninsured.

Evidence Based Practice

Question: treating children below the age of five years, does ethical consideration improve the quality of care?

The rationale for this PICO question is that ethical issues in nursing largely affect care delivery, which affects patient’s outcome. The clinical queries and terms utilized to direct the search include ethical concerns in nursing practice as well as the implication of ethical concerns in nursing care. The resources identified for this elucidation include “Nurses’ human dignity in education and practice” by Parandeh, Khaghanizade, Mohammadi, and Mokhtari-Nouri (2016) as well as “Nursing Ethical Considerations” by Haddad and Geiger (2018). Ethics are a basis for nurse and are of high clinical significance. Every patient has to make their own resolutions based on their values and beliefs (Haddad & Geiger, 2018). Healthcare experts have a responsibility to boost good, minimize harm, and refrain from maltreatment towards patients. Dignified care that acclaims the patient’s values and demands is imperative to provision of quality care. Observing ethical concerns is a care standard that braces the concept of patient-centeredness, which is an imperative element in proof based practice. Involvement of nurses at all stages in ethics reviews can enhance preservation of ethical principles and make it easier for them to advocate for patient rights.

Self-Reflection

Reflecting on the decision-making on patient history, I have realized that I omitted information regarding the patient’s family religion. Besides culture or ethnicity, religion is an imperative element that influences personal values, practices, and beliefs. While not all religions may have issues with modern medicine, some may have queries to areas such as drug use and beliefs towards healing. Not addressing the issue of religion can affect the ethical provisions of patient dignity, values and beliefs. With the mandate given to me as an FNP in ordering and provide, I drove the development of the plan of care for this patient, including medical assessment, diagnostic ordering, prescribing, and advocated for a five days hospital stay to enable close monitoring.

Diagnostic and Clinical Reasoning for Pediatric Pneumonia

Reference List

Campagna, D., Amaradio, M. D., Sands, M. F., & Polosa, R. (2016). Respiratory infections and pneumonia: potential benefits of switching from smoking to vaping. Pneumonia, 8(1), 4.

Cillóniz, C., Cardozo, C., & García-Vidal, C. (2018). Epidemiology, pathophysiology, and microbiology of communityacquired pneumonia. Annals of Research Hospitals, 2(1).

Haddad, L. M., & Geiger, R. A. (2018). Nursing Ethical Considerations. In StatPearls [Internet]. StatPearls Publishing.

Jain, V., & Bhardwaj, A. (2018). Pneumonia, Pathology. In StatPearls [Internet]. StatPearls Publishing.

Kamimura, A., Panahi, S., Ahmmad, Z., Pye, M., & Ashby, J. (2018). Transportation and other nonfinancial barriers among uninsured primary care patients. Health services research and managerial epidemiology, 5, 2333392817749681.

Malla, L., Perera-Salazar, R., McFadden, E., & English, M. (2017). Comparative effectiveness of injectable penicillin versus a combination of penicillin and gentamicin in children with pneumonia characterised by indrawing in Kenya: a retrospective observational study. BMJ open, 7(11), e019478.

Parandeh, A., Khaghanizade, M., Mohammadi, E., & Mokhtari-Nouri, J. (2016). Nurses’ human dignity in education and practice: An integrated literature review. Iranian journal of nursing and midwifery research, 21(1), 1.

Serakos, M., & Wolfe, B. (2016, December). The ACA: Impacts on Health, Access, and Employment. In Forum for Health Economics and Policy (Vol. 19, No. 2, pp. 201-259). De Gruyter.

Stephen, O., Sain, M., Maduh, U. J., & Jeong, D. U. (2019). An Efficient Deep Learning Approach to Pneumonia Classification in Healthcare. Journal of Healthcare Engineering, 2019.

Diagnostic and Clinical Reasoning for Pediatric Pneumonia