Pneumonia Final Copy

8/3/2019 Pneumonia Final Copy

1/68

I. INTRODUCTION

Breathing is the greatest pleasure in life.

~Giovanni Papini

Breath is sometimes used as a metaphor for life itself because it takes

in the oxygen needed by the body and the carbon dioxide out of the body. It

is one of the human persons vital functions to maintain and sustain life. One

of the most common illness that disrupts the normal breathing pattern of a

person is Pneumonia.

Pneumonia is an infection and inflammation of the alveoli in the lungs

that is usually caused by infection with bacteria, viruses, fungi or other

organisms. Pneumonia is a particular concern for older adults and people with

chronic illnesses or impaired immune systems, but it can also strike young,

healthy people. Pneumonia may be of bacterial in origin (pneumococcal,

streptococcal, staphylococcal, or chlamydial) or viral in origin, such as

respiratory synctial virus (RSV). (http://mayoclinic.com; August 27, 2008;

6:45pm )

Worldwide, Pneumonia is the 7th leading cause of death in 1999 and

2000 according to CDC. In the United States, the incidence extrapolations of

pneumonia is 4,800,000 per year, 400,000 per month, 92,307 per week,

13,150 per day, 547 per hour, 9 per minute, 0 per second. In the Philippines,

Pneumonia is the 5th cause of mortality according to the 2003 Philippine

Health Statistics with a rate of15,831 for males and 16, 224 for females or

32, 055 per 100, 000 population. ( http://doh.gov.ph; August 28, 2008;

8:30pm)

A study suggests that antipsychotic drugs increase the risks of

developing pneumonia in the elderly. Elderly patients who use antipsychotic

drugs have a 60 percent increased risk of developing pneumonia compared

to non-users. This risk is highest in the first week following prescription and

decreases gradually thereafter. Antipsychotic drugs are frequently used in

elderly patients for the treatment of psychosis and behavioral problems

1


2/68

associated with dementia and delirium. This study is the first to show that the

development of pneumonia is associated with antipsychotic drug use.

(www.sciencedaily.com; Apr. 16, 2008)

Researchers at Children's Hospital of Pittsburgh of UPMC haveidentified a key protein target that may be a crucial factor in the

development of a vaccine to prevent and new therapies to treat pneumonia,

the leading killer of children worldwide. Identified for the first time is the

importance of a protein known as interleukin 22 (IL-22) in the immune

response to a strain of bacterial pneumonia. In the laboratory, the

researchers were able to effectively treat mice with pneumonia by using

purified IL-22. IL-22 and interleukin 17A (IL-17A) are produced by a recently

discovered lineage of cells known as T Helper Type 17 (Th17). Children'sresearchers found evidence that the Th17 cell lineage and its cytokines IL-22

and IL-17A have evolved to promote host defense against certain infections

in the lung caused by extracellular pathogens. (www.sciencedaily.com;

February 12, 2008)

Much of the learning of student nurses is derived from the exposure in

the hospital setting. Reinforcement in the actual setting is important for

learning to be truly effective. As student nurses, it is important that the care

provided bring satisfaction to patients. To be able to provide outmost care,

knowledge about the disease condition must be well founded. It is one of the

objectives of the group to be familiar with the common disease conditions

that may be encountered in the hospital setting. Knowing that Pneumonia is

one of the common cases evident in the area, which is Medical Surgical, the

group decided to make this as their topic for case study.

2


3/68

II. NURSING ASSESSMENT

A. Personal History

To secure confidentiality, the patient would be referred as Monia

throughout the study. Monia is the primary source of information.

Monia is a 31 year old married Filipina who lives in a barrio in San

Vicente, Magalang Pampanga. She was born on August 2, 1974. She is the 2nd

among five siblings. Monia was admitted on August 12, 2008 at 12:05 pm in a

district hospital in Magalang with complaints of fever, chills and cough. The

admitting diagnosis is Community Acquired Pneumonia and was discharged

on August 16, 2008 with a final diagnosis of CAP.

Monia lives in a barrio which has limited accessibility to the hospital.

She and her family earn a living by planting different plant crops like camote.

Her activities of daily living include cooking, cleaning the house, doing the

laundry, taking good care of her five children and helping her husband in

planting and selling crops. Monia was not able to finish her schooling due to

the location of their place. She was only able to reach grade six because the

school in their barrio only offers elementary schooling and her family cannot

send her to high school due to financial constraints. Monia and her family are

devoted Missionaries. At present, they live in a house which has concrete

walls, sawali for the roof and a flooring which is still not cemented. She

describes her community as a peaceful one and her neighbors are hospitable.

One of the cultural practices done in their community is the practice of using

herbal plants like bayabas, bawang, ginger and ampalaya for medicines.

3


4/68

B. Pertinent Family Health-Illness History

Paternal Side Maternal Side

Lolo89 y/o

Lola

85y/o

Papa67 /o

Lolo

Ulcer

1996

Lola

Stroke

2002

Mama62y/o

MONIA

34y/oCAP

LEGEND:

Male

Female

Deceased

S1 S2 S3 S5 S6 S7 S8 S1 S2 S3 S5 S6 S7 S8

S Sibling

4


5/68

Explanation:

The illnesses present in the in the family tree of Monia are ulcer, which

was the cause of death of her grandfather, and stroke, which caused the

death of her grandmother last 2002 both on the mother side.

On her paternal side, Monia stated that her grandparents are still living

and has no known illness.

Monia has no history of pneumonia on both maternal and paternal

sides.

C. History of Past Illness

When Monia was 3 years old, she had tigdas or measles which her

mother treated with some herbal plants. She also had chickenpox when she

was 25 years old. Monia did not experience any major illness in the past and

was never hospitalized before. She only experienced cough, colds and fever

occasionally especially during cold weather. During these situations, she only

self-medicates and uses herbal plants like oregano and takes drugs like

Biogesic and Neozep.

D. History of Present Illness

On July 29, 2008, Monia is supposed to go with her husband to sell

their root crops but her body malaise prevented her from doing so. The

following day, she experienced fever, which subsides after sweating. Her

fever had became recurrent and caused her to have difficulty sleeping at

night. She also lost her appetite, which led to lost of weight of 6.6 pounds

(from 125.4 lbs to 118.8 lbs). She also had cough, which she said gave her

the difficulty of breathing. She felt that there is mucus in her throat but she

cannot cough it out. Her condition prevented her from doing her usual chores

of helping in the planting and selling of their root crops and taking good care

of her five children.

At first, Monia thought that it is just a usual fever which she got

possibly because of the prevalence of fever and cough in their barrio. But

after two weeks of having fever, she decided to ask her husband to bring her

to the district hospital which she had not thought before because of the

5


6/68

distance of their house to the said medical institution and also because of

financial constraints. While on their way to the hospital, her husband had to

carry her because she cannot walk properly due to body malaise and high

fever. So on August 12, 2008, Monia was admitted with an admitting

diagnosis of Community Acquired Pneumonia and was discharged after 5

days on August 16, 2008 with a final diagnosis of Pneumonia.

E. Physical Examination

2 weeks prior to admission (+) fever

1 week prior to admission (+) cough, productive

2 days prior to admission fever on and off

- low appetite

few hours prior to admission (+) chills and fever

- (+) body weakness

Date: August 12, 2006 (Admission) Lifted from the Chart

pink palpebral conjunctiva

anecteric sclerae

adynamic pericardium

(-) murmurs

flabby abdomen

(+) chills and fever with temperature of 40.50C/axilla

(+) body weakness

(+) cough, nonproductive

First Student Nurse-Patient Interaction

(August 12, 2008)

General Survey:

Received patient wearing a white colored shirt and blue jogging pants,

in high fowlers position, awake and conscious,; with an IVF of #1 D5NM 1L

regulated at 30 to 31 gtts/min. at 550 cc level infusing well on the right hand.

6


7/68

Signs and symptoms include (+) nonproductive cough, (+) difficulty of

breathing, febrile.

Vital Signs:

Temperature 37.80C/axilla

Pulse rate 86 bpm

Respiratory rate 34bpm

Blood pressure 110/70 mmHg

Skin:

Brown in color, no altered pigmentation, no edema or swelling upon

palpation.

Head:

Hair and Scalp: Black in color, slightly thick, silky and

resilient and hair equally distributed on scalp area, No infestation or

infection noted.

Skull: Rounded, smooth skull contour and no masses or nodules noted.

Face: symmetrical facial feature and symmetric facial

movements.

Eyes: Eyebrows and eyelashes evenly distributed; eyelids

have no discharge, no discoloration and lids close symmetrically.

Palpebral conjunctiva is pink in color.

Vision: Client can see objects in the periphery.

Illuminated pupil constricts while non-illuminated dilates.

(+)PERRLA

Ear: Color of the auricles same as the facial skin.

Symmetrical and aligned with outer canthus of eye, mobile, firm

and not tender, pinna recoils after it is folded.

Nose: Centrally located, uniform in color, no discharges noted, not

tender, no lesions and air moves with slight difficulty as the client

breaths through the nares because of presence of nasal

secretions.

Mouth: (+) Mild drying of lips and oral mucosa

7


8/68

Neck:

Head is centered, head movement is coordinated with no discomfort.

No swelling and masses noted and no enlargement of lymph nodes

upon palpation.

Thorax:

No tenderness and masses on the chest skin, skin intact and uniform

temperature. (+) Fast shallow breathing.

Lungs:

(+) Rales heard upon auscultation.

Heart:

Normal rhythm and rate noted upon auscultation, no murmurs.

Abdomen:

Flabby, no pain when palpated.

Upper Extremities:

Intact nail beds, good capillary refill, no deformities, no tenderness or

swelling,

Lower Extremities:

Intact toenail beds, has upright posture and steady gait, walks unaided

and maintains balance.

Second Student Nurse-Patient Interaction

(August 13, 2008)

General Survey:

Received patient wearing yellow colored shirt and brown shorts, in

right side-lying position, sleeping; with an IVF of #3 D5NM 1L regulated at 30

to 31 gtts/min. at 650 cc level infusing well on the right hand.

Vital Signs:

Temperature 380C/axilla

Pulse rate 81 bpm

Respiratory rate 26 bpm

Blood pressure 120/70 mmHg

8


9/68

Skin:

Brown in color, no altered pigmentation, no edema or swelling upon

palpation.

Head:

Hair and Scalp: Black in color, slightly thick, silky and

resilient and hair equally distributed on scalp area, No infestation or

infection noted.

Skull: Rounded, smooth skull contour and no masses or nodules noted.

Face: symmetrical facial feature and symmetric facial

movements.

Eyes: Eyebrows and eyelashes evenly distributed; eyelids

have no discharge, no discoloration and lids close symmetrically.

Palpebral conjunctiva is pink in color.

Vision: Client can see objects in the periphery.

Illuminated pupil constricts while non-illuminated dilates.

(+)PERRLA

Ear: Color of the auricles same as the facial skin.

Symmetrical and aligned with outer canthus of eye, mobile, firm

and not tender, pinna recoils after it is folded.

Nose: Centrally located, uniform in color, no discharges noted, not

tender, no lesions and air moves with slight difficulty as the client

breaths through the nares because of presence of nasal

secretions.

Mouth:(+) Mild drying of lips and oral mucosa

Neck:

Head is centered, head movement is coordinated with no discomfort.

No swelling and masses noted and no enlargement of lymph nodes

upon palpation.

Thorax:

No tenderness and masses on the chest skin, skin intact and uniform

temperature. (+) Fast shallow breathing.

Lungs:

9


10/68

(+) Rales heard upon auscultation.

Heart:

Normal rhythm and rate noted upon auscultation, no murmurs.

Abdomen:

Flabby, no pain when palpated.

Upper Extremities:

Intact nail beds, good capillary refill, no deformities, no tenderness or

swelling,

Lower Extremities:

Intact toenail beds, has upright posture and steady gait, walks unaided

and maintains balance.

10


11/68

F. Diagnostic and Laboratory ProceduresDiagnostic/LaboratoryProcedures

Date OrderedDate Results

In

IndicationsOr

Purposes

Results NormalValues

Analysis andInterpretation

of ResultsHemoglobin Date Ordered:

08/12/08Date Results In:

08/12/08

To evaluate thehemoglobin

content, the ironstatus, and

oxygen carrying

capacity of theblood.

10.2 mg% Male: 13.5 18Female: 12-16

Less thannormal. The

Oxygen carryingcapacity of the

blood is

inadequate dueto the

inflammatoryreaction thatoccurs in the

alveoli,producing

exudates thatinterfere with the

diffusion ofoxygen and

carbon dioxide.

Hematocrit Date Ordered:08/12/08

Date Results In:08/12/08

This is tomeasure thepercentage of

the patients redblood cells in thetotal volume ofblood. It aids inthe diagnosis ofany abnormal

status ofpatients

hydration.

33.0 vol. % Male: 40-54Female: 37-47

Less thannormal. Itindicates

insufficient bloodvolume

composed ofRBCs and an

abnormal statusof patients

hydration due tothe excessive

sweatingexperienced by

11


12/68

the patient aftereach onset of

fever.

WBC Count Date Ordered:08/12/08


To determineinfection or

inflammationand also to

determine and

evaluate thebodys

physiologiccapacity toresist andovercomeinfection

10.750/cu. mm. Adult: 5-10 x103

There ispresence of

inflammation orinfection due tothe invasion of

microorganismsin the lungs.

Platelet Count Date Ordered:08/12/08


To determinethe number ofplatelets in thepatient's bloodand to assist inthe diagnosis of

bleedingdisorders

280/cu. mm. Adult: 150 - 450 Value is withinnormal rangewhich could

indicate that thepatient does nothave bleeding

disorders.

Segmenters Date Ordered:08/12/08


To determineinfection or

inflammation

87% 50-70 Increase in valuecan be a result ofbodys response

to infection.Lymphocytes Date Ordered:

08/12/08Date Results In:

08/12/08

To determineviral infection or

inflammation

13% 25-40 Decreasedcapability of

carrying out theactivities of theimmune system

or there is adecreased ability

to produce

12


13/68

antibodies.

Nursing Responsibilities:

Before

1. Explain the procedure to the SO and the purpose of the procedure.

2. Inform the SO that there is no food/fluid restriction needed.

3. Inform the SO that the test requires blood sample, tell who will do the test and when.

4. Inform that there will be a discomfort from needle puncture and pressure from the tourniquet.

During:

1. Support the patients arm upon insertion of the needle.

2. Be sure the patient remains still upon insertion of needle.

After:

1. Apply pressure to the punctured site.

2. Observe the venipuncture site for bleeding.

3. Explain that some bruising, discomfort, and or swelling maybe experienced at the site. Instruct to apply

warm, moist compress.

4. Send the specimen to the laboratory.

Diagnostic/ Date Ordered Indications Results Normal Analysis and

13


14/68

Laboratory

Procedures

Date Results

In

Or

Purposes

Values Interpretation

of ResultsChest X-Ray Date Ordered:

08/12/08

Date Results In:

08/12/08

This is done

to obtain or

detect

pulmonary

diseases

and the

status of

respiratory

problems or

trauma

There are hazy

infiltrates in the

Right lower lung

zone. The heart

is normal in size

and

configuration.

Diaphragms,

costophrenic

angles &

visualized bones

are intact.

Impression:

Pneumonitis,

Right Lower

Lung

Clear

lung fields

With continuous

formation of

exudates, the

involved lobe

undergoes

Consolidation of

the tissue

caused by filling

w/ exudates. In

chest x-ray, the

lung should

appear as black

because the lung

is not dense and

it permits the

passage of x-

rays. But in

lungs w/

pneumonia,

consolidated

parts become

dense and

14


15/68

appear as white

areas on the

chest x-ray film.


Before:

1.Explain the procedure to the patient, its purpose and how it is done.

2. Inform the patient that there are no foods or fluid restriction.

3. Remove all jewelries and metal objects from the area to the image.

4. Ask the patient to remove her clothes and put on a hospital gown.

5. Assist the patient.

During:

1. Ensure the patients safety at all times.

2. Position the patient for specific views needed.

3. Ensure that the patient will remain motionless during the imaging.

After:

1. Assist the patient in dismounting from the radiography table and getting dressed.

15


16/68

III. ANATOMY AND PHYSIOLOGY

ANATOMY

1. The SINUSES (frontal, maxillary, and sphenoidal) are hollow spaces in the

bones of the head. Small openings connect them to the nose. The functions

they serve include helping to regulate the temperature and humidity of air

breathed in, as well as to lighten the bone structure of the head and to give

resonance to the voice.

2. The NOSE (nasal cavity) is the preferred entrance for outside air into the

respiratory system. The hairs that line the wall are part of the air-cleaningsystem.

3. Air al so enter through the MOUTH (oral cavity), especially in people who

have a mouth-breathing habit or whose nasal passages may be temporarily

obstructed, as by a cold or during heavy exercise.

16


17/68

4. The ADENOIDS are lymph tissue at the top of the throat. When they

enlarge and interfere with breathing, they may be removed. The lymph

system, consisting of nodes (knots of cells) and connecting vessels, carries

fluid throughout the body. This system helps to resist body infection by

filtering out foreign matter, including germs, and producing cells

(lymphocytes) to fight them.

5. The TONSILS are lymph nodes in the wall of the throat (pharynx) that

often become infected. They are part of the germ-fighting system of the

body.

6. The THROAT (pharynx) collects incoming air from the nose and mouth and

passes it downward to the windpipe (trachea).

7. The EPIGLOTTIS is a flap of tissue that guards the entrance to the

windpipe (trachea), closing when anything is swallowed that should go into

the esophagus and stomach.

8. The VOICE BOX (larynx) contains the vocal chords. It is the place where

moving air being breathed in and out creates voice sounds.

9. The ESOPHAGUS is the passage leading from the mouth and throat to the

stomach.

10. The WINDPIPE (trachea) is the passage leading from the throat

(pharynx) to the lungs.

11. The LYMPH NODES of the lungs are found against the walls of the

bronchial tubes and windpipe.

12. The RIBS are bones supporting and protecting the chest cavity. They

move to a limited degree, helping the lungs to expand and contract.

17


18/68

13. The windpipe divides into the two main BRONCHIAL TUBES, one for

each lung, which subdivide into each lobe of the lungs. These, in turn,

subdivide further.

14. The right lung is divided into three LOBES, or sections. Each lobe is like a

balloon filled with sponge-like tissue. Air moves in and out through one

opening -- a branch of the bronchial tube.

15. The left lung is divided into two LOBES.

16. The PLEURA are the two membranes, actually one continuous one folded

on itself, that surround each lobe of the lungs and separate the lungs from

the chest wall.

17. The bronchial tubes are lines with CILIA (like very small hairs) that have

a wave-like motion. This motion carried MUCUS (sticky phlegm or liquid)

upward and out into the throat, where it is either coughed up or swallowed.

The mucus catches and holds much of the dust, germs, and other unwanted

matte that has invaded the lungs. You get rid of this matter when you cough,

sneeze, clear your throat or swallow.

18. The DIAPHRAGM is the strong wall of muscle that separates the chest

cavity from the abdominal cavity. By moving downward, it creates suction in

the chest to draw in air and expand the lungs.

19. The smallest subdivisions of the bronchial tubes are called

BRONCHIOLES, at the end of which are the air sacs or alveoli (plural of

alveolus).

20. The ALVEOLI are the very small air sacs that are the destination of air

breathed in. The CAPILLARIES are blood vessels that are imbedded in the

walls of the alveoli. Blood passes through the capillaries, brought to them by

the PULMONARY ARTERYand taken away by the PULMONARY VEIN.

18


19/68

While in the capillaries the blood gives off carbon dioxide through the

capillary wall into the alveoli and takes up oxygen from the air in the alveoli.

Physiology

The exchange of gases (O2 & CO2) between the alveoli & the blood

occurs by simple diffusion: O2 diffusing from the alveoli into the blood & CO2

from the blood into the alveoli. Diffusion requires a concentration gradient.

So, the concentration (or pressure) of O2 in the alveoli must be kept at a

higher level than in the blood & the concentration (or pressure) of CO2 in the

alveoli must be kept at a lower lever than in the blood. We do this, of course,

by breathing - continuously bringing fresh air (with lots of O2 & little CO2)

into the lungs & the alveoli.

Breathing is an active process - requiring the contraction of skeletal

muscles. The primary muscles of respiration include the external intercostal

muscles (located between the ribs) and the diaphragm (a sheet of muscle

located between the thoracic & abdominal cavities).

19
http://www.sit.wisc.edu/~edrothen/flash/lungs.htmhttp://sorrel.humboldt.edu/~wva1/images%20respiration/lung_anatomy.gifhttp://www.sit.wisc.edu/~edrothen/flash/lungs.htmhttp://sorrel.humboldt.edu/~wva1/images%20respiration/lung_anatomy.gif


20/68

The external intercostals plus the diaphragm contract to bring about

inspiration:

Contraction of external intercostal muscles > elevation of ribs &

sternum > increased front- to-back dimension of thoracic cavity >lowers air pressure in lungs > air moves into lungs

Contraction of diaphragm > diaphragm moves downward >

increases vertical dimension of thoracic cavity > lowers air pressure in

lungs > air moves into lungs:

To exhale:

relaxation of external intercostal muscles & diaphragm > return of

diaphragm, ribs, & sternum to resting position > restores thoracic

cavity to preinspiratory volume > increases pressure in lungs > air is

exhaled

Intra-alveolar pressure during inspiration & expiration

As the external intercostals & diaphragm contract, the lungs expand.

The expansion of the lungs causes the pressure in the lungs (and alveoli) to

become slightly negative relative to atmospheric pressure. As a result, air

moves from an area of higher pressure (the air) to an area of lower pressure

(our lungs & alveoli). During expiration, the respiration muscles relax & lung

volume descreases. This causes pressure in the lungs (and alveoli) to become

slight positive relative to atmospheric pressure. As a result, air leaves the

lungs.

The walls of alveoli are coated with a thin film of water & this

creates a potential problem. Water molecules, including those on the alveolar

walls, are more attracted to each other than to air, and this attraction creates

a force called surface tension. This surface tension increases as water

molecules come closer together, which is what happens when we exhale &

our alveoli become smaller (like air leaving a balloon). Potentially, surface

20
http://sorrel.humboldt.edu/~wva1/images%20respiration/ventilation_diaphragm.gifhttp://sorrel.humboldt.edu/~wva1/images%20respiration/ventilation_diaphragm.gif


21/68

tension could cause alveoli to collapse and, in addition, would make it more

difficult to 're-expand' the alveoli (when you inhaled). Both of these would

represent serious problems: if alveoli collapsed they'd contain no air & no

oxygen to diffuse into the blood &, if 're-expansion' was more difficult,

inhalation would be very, very difficult if not impossible. Fortunately, our

alveoli do not collapse & inhalation is relatively easy because the lungs

produce a substance called surfactant that reduces surface tension.

Pulmonary Surfactant

Surfactant decreases surface tension which:

o increases pulmonary compliance (reducing the effort needed to

expand the lungs)

o reduces tendency for alveoli to collapse

Exchange of gases:

External respiration:

o exchange of O2 & CO2 between external environment & the

cells of the body

o efficient because alveoli and capillaries have very thin walls &

are very abundant (your lungs have about 300 million alveoli

with a total surface area of about 75 square meters)

Internal respiration - intracellular use of O2 to make ATP

occurs by simple diffusion along partial pressure gradients

Partial Pressure

it's the individual pressure exerted independently by a particular gas

within a mixture of gasses. The air we breath is a mixture of gasses:

primarily nitrogen, oxygen, & carbon dioxide. So, the air you blow into

a balloon creates pressure that causes the balloon to expand (& this

pressure is generated as all the molecules of nitrogen, oxygen, &

carbon dioxide move about & collide with the walls of the balloon).

21
http://oac.med.jhmi.edu/res_phys/Encyclopedia/Surfactant/Surfactant.HTMLhttp://oac.med.jhmi.edu/res_phys/Encyclopedia/Surfactant/Surfactant.HTML


22/68

However, the total pressure generated by the air is due in part to

nitrogen, in part to oxygen, & in part to carbon dioxide. That part of

the total pressure generated by oxygen is the 'partial pressure' of

oxygen, while that generated by carbon dioxide is the 'partial pressure'

of carbon dioxide. A gas's partial pressure, therefore, is a measure of

how much of that gas is present (e.g., in the blood or alveoli).

Factors involved in increasing respiratory rate

Chemoreceptors - located in aorta & carotid arteries (peripheral

chemoreceptors) & in the medulla (central chemoreceptors)

Chemoreceptors (stimulated more by increased CO2 levels than by

decreased O2 levels) > stimulate Rhythmicity Area > Result =

increased rate of respiration

22


23/68

IV. THE PATIENTS ILLNESS (Book-Based)

Synthesis of the Disease

Community Acquired Pneumonia

1. Definition of the disease

Community-acquired pneumonia (CAP) is a disease in which

individuals who have not recently been hospitalized develop an infection of

the lungs (Pneumonia). CAP is a common illness and can affect people of all

ages. CAP often causes problems like breathing, fever, chest pains and a

cough. CAP occurs because the areas of the lung which absorb oxygen

(alveoli) from the atmosphere become filled with fluid and cannot work

effectively.

CAP occurs throughout the world and is a leading cause of illness and death.

Causes of CAP include bacteria, viruses, fungi, and parasites. CAP can be

diagnosed by symptoms and physical examination alone, though x-rays,

examination of the sputum and other tests are often used. Individuals with

CAP sometimes require treatment in a hospital. CAP is primarily treated with

antibiotic medication. Some forms of CAP can be prevented by vaccination.

2. Non-modifiable and Modifiable Factors

Non-modifiable Factors:

>Age

Pneumonia is more common among infants, young children, and the

elderly. With age, mucus accumulates within the respiratory passageways.

The mucus-cilia escalator is less able to move the mucus because it becomes

more viscous and the number of cilia as well as their rate of movement

decreases. This leads to increase susceptibility of the elderly to respiratory

infections such as pneumonia.

In children, their immune system is not yet well developed making

them susceptible in acquiring pneumonia.

23


24/68

>Genetic Factors

A number of genetic disorders can predispose a person to pneumonia,

such as: Sickle cell anemia, cystic fibrosis, and Kartageners syndrome.

Modifiable Factors:

>Smoking and second-hand smoking

People who smoke have a much higher risk of developing pneumonia.

Also, those who regularly exposed to second-hand smoking are at risk for

pneumonia. In the case of the patient, she is exposed to second hand

smoking due to her husband who is a smoker.

>Alcohol and Drug Abuse

Alcohol and drug abuse makes a person more susceptible to

pneumonia.

>Crowded Living Conditions

The risk of pneumonia is increased among people living in crowded

conditions just like the area where the patient is exposed.

>Environmental Factors

Occupation exposure to toxic chemical fumes and smoke can weaken

the lungs defenses making a person susceptible in acquiring pneumonia.

Monia is exposed to smoke because of her husband who is a smoker.

3. Signs and Symptoms

>Fever and chills

An increase in body temperature accompanied by chills is due to the

invasion of microorganisms in the lungs that causes inflammation. The body

increases its temperature in order to kill the microbes. Monia experienced

recurrent fever and chills from July 30, 2008 to August 14, 2008.

>Pleuritic chest pain

24


25/68

This is due to the constant irritation of the pleural membrane brought

about by inflammation, which stimulates the release of prostaglandin (pain

mediator) that acts on the pain receptors that causes pain.

>Cough and sputum production

There is an increase production of mucus due to the constant

inflammation of the epithelial lining of the bronchi and alveoli. Coughing is

the bodys mechanism to get rid of microorganisms and excess mucus. The

patient experienced cough from July 30, 2008 to August 15, 2008.

>Hemoptysis

Forceful coughing brought about by constant irritation of the

respiratory tract and consolidated alveolar exudates; damage the capillaries

in the lungs causing the production of blood-tinge sputum.

>Dyspnea

Difficulty in breathing is due to inflamed and fluid filled alveolar sacs

cannot exchange oxygen and carbon dioxide effectively. The patient

experienced dyspnea from July 30, 2008 to August 15, 2008.

>Headache

Impairment of oxygen and carbon dioxide exchange results in a

decrease in oxygenation in the brain that causes headache.

>Fatigue

Accumulation of lactic acid in tissues and muscles due to poor oxygen

perfusion brought about by impaired gas exchange in the lungs. The patient

experienced fatigue from July 29, 2008 to August 14, 2008.

4. Prevention and Health Promotion

Immunization against influenza and increasingly resistant pneumococci

can play a critical role in the prevention of pneumonia, particularly in

25


26/68

immunocompromised and older adults. The influenza vaccine is formulated

and administered annually. Also, it is recommended that the vaccine be

offered to persons aged > 50 years; residents of chronic-care facilities;

patients who have chronic heart or lung disorders, and patients with chronic

metabolic diseases (including diabetes mellitus), renal dysfunction,

hemoglobinopathies, or immunosuppression.

Consequently, to prevent the development of pneumonia, one should

live a healthy lifestyle. Elimination of smoking habits, alcohol and drug abuse;

wearing of PPEs (such as mask) for persons who are exposed in smoke and

other chemicals; and adapting a regular exercise regimen are indeed a great

help in minimizing the incidence of pneumonia.

Stopping smoking is the best way to prevent pneumonia. Some

pneumonia can be prevented by vaccination. Oseltamivir or zanamivir

can be given to prevent influenza in household contacts of people who have

influenza and in people with heart or lung disorders who have not been

vaccinated because these people would be at risk of severe pneumonia if

they developed influenza.

(http://mayoclinic.com/health/pneumonia)

(http://www.lungusa.org/site)

26


27/68

27


28/68

V. THE PATIENT AND HIS CARE

A. MEDICAL MANAGEMENT

a. IVF

Medical

Management/

Treatment

Date Ordered

Date Performed

Date Changed

General

Description

Indications

Or

Purposes

Clients Response

to Treatment

D5NM 1L x 30 to 31

gtts/min

D.O: 08/12/08

D.P: 08/12/08

D.C: 08/15/08

It is a hypertonic

solution and it

contains Dextrose 5

gm NaCl 234mg,

Potassium Acetate

128mg, Sodium

Bisulfate 30mg.

Multiple electrolyte

maintenance

solution for use in

routine daily IV

therapy. It is given

to Monia in amount

sufficient to meet

her ordinary daily

water needs. It is

also a route of

administration of

her IV medicines.

Monias hydration

status was

maintained and

there were no signs

and symptoms of

hypersensitivity.


Before:

1. Verify the doctors order.

2. Explain the procedure to the patient.

3. Obtain necessary materials. Acquaint the SO and patient with the requirements needed for IV infusion.

28


29/68

During

1. Check IV level.

2. Check for patency of tubing as well as infiltrations.

3. Check if the IVF is infusing well.

4. Practice aseptic technique.

After1. Adjust rate of flow of fluids appropriate to patients needs as prescribed.

2. Monitor IVF flow and patients response.

3. Monitor patient for evidence of local IV complications such as pain, swelling and tenderness.

4. Check for the presence of air in the tubing.

5. Record all procedure done.

b. Drugs

Name of

Drugs:

Date Ordered

Date

Route of

Administration

Indications

Or

Specific Foods

taken

Clients

Response to

29


30/68

Generic Name

Brand Name

Performed

Date Changed

, Dosage and

Frequency of

Administration

Purposes the Meds with

Actual Side

EffectsGeneric Name:

Cefuroxime

Brand Name:

Ceftin

Date Ordered:

August 12, 2008

Dates Taken:

August 12-14,

2008

200 mg IV q 12

hours

Cephalosporin

antibiotics. - It

works by

stopping the

growth of

bacteria which

invades the

lungs causing

pneumonia.

Rice, fish,

vegetable,

meat, banana,

water.

The patient did

not show any

allergic

reactions. After

taking the drug

for 3 days,

Monia was

relieved from

productive

cough which

can be a sign

that the

bacteria that

invades the

lungs was

inhibited.


Before:

1. Explain the action of the drug to the client

30


31/68

2. Check doctors order for the time, dosage and route of the drug.

3. Perform skin testing before administration

4. Obtain specimen for culture and sensitivity test.

During:

1. Re-check doctors order

2. Observe sterile technique3. Slowly push the medication to avoid irritation of the IV line.

After:

1. Educate client about the possible side effects

2. Document the action done

3. Observe for signs and symptoms of adverse or allergic reactions

Name of

Drugs:

Generic Name

Brand Name

Date Ordered

Date

Performed

Date Changed

Route of

Administration

, Dosage and

Frequency of

Indications

Or

Purposes

Specific Foods

taken

Clients

Response to

the Meds with

Actual Side

31


32/68

Administration EffectsGeneric Name:

Paracetamol IV

Acetylcysteine

Brand Name:

Parvolex, Lysox

Date Ordered:

August 12,

2008

Date Taken:

August 12,

2008

Date Changed:

August 13,

2008 (shifted to

tab)

300 mg IV Analgesic and

Antipyretic. -

Thought to

produce

analgesia by

blocking pain

impulses by

inhibiting

synthesis of

prostaglandin in

the CNS or other

substances that

sensitize pain

receptors to

stimulation. The

drug may

relieve fever

through central

action in the

hypothalamic

heat regulatory

center.

This is indicated

for mild pain

and fever

experienced by

the patient.

The patient

responded

positively to the

medication. The

patients

recurrent fever

decreased from

40.50C to 37.80C

to 37.20C on

August 12,

2008.

Generic Name:

Paracetamol,

Date Ordered:

August 13,

500 mg/tab Analgesic and

Antipyretic. -

This is indicated

for mild pain

The patient

responded

32


33/68

Acetaminophen

Brand Name:

Tylenol, Tempra

2008

Dates Taken:

August 13-14,

2008

Thought to

produce

analgesia by

blocking pain

impulses by

inhibiting

synthesis ofprostaglandin in

the CNS or other

substances that

sensitize pain

receptors to

stimulation. The

drug may

relieve fever

through central

action in the

hypothalamic

heat regulatory

center

and fever

experienced by

the patient.

positively to the

medication. The

patients

recurrent fever

decreased from

380C to 37.30C

on August 13,2008 and from

380C to 36.90C

on August 14,

2008.


Before:

1. Obey the 10 rights of giving medications

33


34/68

2. Check the physicians order on the patients chart

3. Identify the patient

4. Warn the patient or SO that high doses or unsupervised long term use can cause liver damage

During:

1. Follow standard precautions during administration of the medication

2. Observe proper sterile technique

3. Administer right dose

After:

1. Check for the presence of adverse reactions such as vomiting, abdominal pain, drowsiness, rash and

urticaria

2. Record all procedures done and time of drug administration

3. Monitor temperature q 15 minutes after administration

Name of

Drugs:

Generic

Name

Brand Name

Date Ordered

Date

Performed

Date

Changed

Route of

Administration

, Dosage and

Frequency of

Administration

Indications

Or

Purposes

Specific Foods

taken

Clients

Response to

the Meds with

Actual Side

Effects

34


35/68

Generic Name:

Ambroxol

Brand Name:

Seropram

Date Ordered:

August 12,

2008

Date Taken:

August 12-15,

2008

30 mg/tab A mucolytic

agent. - Which

hasantioxidant

properties and

stimulates the

release of

pulmonarysurfactant,

against

influenza-virus

proliferation in

the airwaywas

investigated in

mice.

It is administered

for the breakdown

of acid

mucopolysaccharide

fibers and to make

the sputum thinner

and less viscous andtherefore more

easily removed by

coughing.

Patient

responded well

to treatment

without signs of

adverse

reactions or

complicationssuch as

superinfection.

After taking the

drug for 4 days,

the patient was

relieved from

dyspnea and her

respiratory rate

decreases from

34bpm upon

admission to 26

bpm on August

13 to 24 bpm on

August 14 to 21

bpm on August

15 and 19 bpm

upon discharge.

35


36/68


Before:

1. Obey the 10 rights of giving medications

2. Check the physicians order on the patients chart

3. Identify the patient.

4. Make sure that the patient is not pregnant which is one of the contraindications of the drug.

5. Strictly follow aseptic technique in preparation of IV medication

During

1. Caution to patient that the drug could cause gastric ulceration.

2. Observe proper sterile technique.

After:

1. Check for the presence of adverse reaction such as nausea and vomiting and mild gastric irritation.

2. Record all procedures done and time of drug administration.

c. Diet

Type of diet

Date Ordered

Date

Performed

Date Change

General

Description

Indications or

Purposes

Specific food

taken

Clients

Response and

or Reaction to

the DietDAT D.O: 08/12/08

D.P: 08/12/08

Regular diet

based of the 4

basic food

groups as long

For patients

whose condition

does not

necessitate a

Fish, meat,

bread, fruits,

vegetables, and

water.

The patient was

able tolerate the

diet as the

patient did not

36


37/68

as the patient

can tolerate it.

modified diet developed any

allergies. There

is a boost in the

patients energy

level and

nourishment is

increased asevidenced by

patients ability

to perform her

self-care needs

and absence of

body malaise

and fatigue upon

discharge.Nursing Responsibilities:

Before:

1. Explain the diet or type of diet to patient

2. Feed patient in upright-position to prevent aspiration.

3. Give small frequent feeding.

4. Instruct strict compliance on the diet program given.

37


38/68

d. Activity/Exercise

Type of Exercise

Date Ordered

Date PerformedDate Change

General

Description

Indications or

Purposes

Clients Response

and or Reaction tothe Exercise

Bed Rest Date Ordered:

08/12/08

A type of activity

wherein the patient

is in supine position

with his body lying

flat on bed with the

head raised using

This is indicated to

reduce the patients

oxygen demand, to

facilitate fast

recovery and avoid

complications. Rest

The patient was able

to take adequate

amount of rest and

sleep as evidenced

by absence of body

malaise, fatigue and

38


39/68

pillows as support

to the head.

decreases the

bodys metabolic

rate.

normalization of

respiratory rate

from 34bpm upon

admission to 26

bpm on August 13

to 24 bpm on

August 14 to 21bpm on August 15

and 19 bpm upon

discharge.


1. Check for the doctors order

2. Explain to the SO the type of activity needed by the patient and why it is necessary

3. Ensure safety precautions by instructing SO not to leave patient alone at the bed since side rails are

not present or by putting pillows at the side of the patient to prevent the patient from falling

4. Stretch bed linens

5. Assist the patient in position changes to prevent bed sore formation

Type of Exercise

Date Ordered

Date Performed

Date Change

General

Description

Indications or

Purposes

Clients Response

and or Reaction to

the ExerciseDeep Breathing

Exercise

Date Ordered:

08/12/08

Designed to

improve the

To promote

oxygenation and

Monia was able to

demonstrate Deep

39


40/68

efficiency of

ventilation,

decrease the work

of breathing,

increase of

excursion of the

diaphragm, andimprove the gas

exchange and

oxygenation

prevent respiratory

complications.

Breathing

Exercise/DBE and

had relief of her

difficulty of

breathing as

evidenced by

normalization ofrespiratory rate of

34bpm upon

admission to 26

bpm on August 13

to 24 bpm on

August 14 to 21

bpm on August 15

and 19 bpm upon

discharge


1. Explain the reason and rationale and aims of bed rest.

2. For DBE, have the patient assume a comfortable position and looses constrictive clothing.

3. Instruct the patient to place hands below the anterior costal margin and ask the patient to

breathe slowly and deep through the nose. Have patient keep shoulder related and upper chest

quite allowing the abdomen to rise. Tell patient to practice this three to four times for her to rest.

40


41/68

41


42/68

2. NURSING MANAGEMENT

1. Nursing Care Plan

Problem # 1: Ineffective Airway Clearance r/t Retained Secretions AEB Ineffective or Absent Sputum

Assessment Nursing

Diagnosis

Scientific

Explanation

Planning Nursing

Intervention

s

Rationale Expected

Outcome

Subjective

Cues

>

Objective

Cues

Patient

manifested:

> pursed lip

breathing

> increased

respiratory

rate (34 bpm

on August 12,

2008)

>non-

productive

Ineffective

Airway

Clearance

r/t

Retained

Secretions

AEB

Ineffective

or Absent

Sputum

Pneumonia is an

inflammation of

the lung

parenchyma

caused by

various

microorganisms

including

bacteria and

viruses. It affects

both ventilation

and diffusion.

Areas of the

lungs are not

adequately

ventilated

because of

Short Term:

> After 4

hours of NI,

patient will

demonstrate

behaviors to

improve

airway such

as deep

breathing

and

coughing

Long Term:

> After 1 to

3 days of NI,

patient will

1. establish

rapport

2. monitor

vital signs

3. elevate

head of bed

and change

position every

2 hours.

4. encourage

deep

breathing and

coughing

exercises.

5.provided

TSB

1. to gain

cooperation

2. to obtain

baseline

data

3. to

enhance

drainage

and

ventilation

to different

lung

segments.

4. to

maximize

respiratory

effort.

Short Term:

> patient shall

have

demonstrated

behaviors to

improve

airway such as

deep

breathing and

coughing

Long Term:

> patient shall

have

demonstrated

absence of

congestion

42


43/68

cough

> rales heard

upon

auscultation

> irritability

>

restlessness>hyperthermi

a (380C/axilla

on August 12,

2008)

Patient may

manifest:

> difficulty of

breathing

> altered

chest

excursion

> use of

accessory

muscles to

breathe

> nasal

flaring

secretions. If a

patient is unable

to clear

secretions from

the respiratory

tract, ineffective

airway clearanceoccurs. The signs

and symptoms

include (+) DOB

due to the

presence of

secretions,

nonproductive

cough which

indicates

retained

secretions, high

RR which

indicates the

mechanism of

the body to gain

oxygen and fever

which occurs

demonstrate

absence of

congestion

with breath

sounds clear

and

improvedoxygen

exchange.

6. encourage

increase fluid

intake

7. encourage

warm versus

cold liquids

8.demonstrate

pursed lip and

diaphragmatic

breathing

9. encourage

opportunities

for rest

10. regulate

IVF as ordered

11. administer

meds as

ordered.

5. to lessen

fever.

6. to help

liquefy

secretions

7. to help

liquefysecretions

8. to

improve

airway

9. to

prevent or

lessen

fatigue

10. to keep

the patient

properly

hydrated

11. to

comply with

the

with breath

sounds clear

and improved

oxygen

exchange.

43


44/68

> pale

conjuctiva

and mucous

membranes

> cyanosis

because of the

presence of

microbes in the

body. It acts as

the bodys

defense

mechanism.

therapeutic

regimen.

44


45/68


46/68

cough

Patient

may

manifest:

> difficulty

of

breathing> altered

chest

excursion

> use of

accessory

muscles to

breathe

> nasal

flaring

> pale

conjuctiva

and

mucous

membranes

filled lungs are

being covered

with mucus

secretions

causing the air

flow to be

blocked,therefore

difficulty of

breathing

may appear and

to compensate,

the patient will

exert effort to

breath rapidly

causing more

carbon dioxide

to be inhaled

than oxygen

leading cyanotic

manifestations.

evidence by

diminished

rales on

Lung fields

upon

auscultation

andimproved

respirations.

y

6. Encourage

increase fluid

intake

7. Encourageadequate rest

periods

between

activities

8. Assist

client to learn

breathing

exercises

9. Administer

medications

as ordered

cough

5. To mobilize

secretions

6. To facilitate

hydration

7. To limit

fatigue which

would increase

oxygen demand

8. To facilitate

effective

breathing

pattern

9. For

pharmacological

management

rales on

Lung fields

upon

auscultation

and

improved

respirations.

46


47/68

Problem # 3: Hyperthermia

Assessme

nt

Nursing

Diagnosis

Scientific

Explanation

Planning Nursing

Interventions

Rationale Expected

OutcomeSubjective

Cues

>

Objective

Cues

Patient

manifested

:

> pursed

lip

breathing

>

increased

respiratory

rate (34

bpm on

August 12,

2008)

Hyperthermi

a

Pyrogens are

released in the

inflammation

process.

Pyrogens are

chemicals that

stimulate fever

production.

Pyrogens affect

the body

temperature-

regulating

mechanism in

the

hypothalamus

of the brain. As

a

consequence,

heat

Short Term:

>After 3-4

hours of NPI,

patient will

be able to

maintain

body

temperature

within

normal range

Long Term:

>After 5

days of NPI,

patient will

be free from

development

of possible

complication

1. Establish

rapport

2. Monitor vital

signs

3. Ascertain

understanding

of individual

nutritional

needs

4. Explain diet

modifications

such as:

increase protein,

carbohydrates

and vitamin C,

small frequent

1. To gain

patients

confidence and

cooperation in

treatment

regimen

2. Provides

comparative

baseline

3. To determine

what

information to

provide to SO

4. To promote

adequate

nutritional

Short Term:

Patient shall

have been

able to

maintain

body

temperature

within normal

range

Long Term:

Patient shall

have been

free from

development

of possible

complication

s

47


48/68

>non-

productive

cough

Patient

may

manifest:

> difficultyof

breathing

> altered

chest

excursion

> use of

accessory

muscles to

breathe

> nasal

flaring

> pale

conjuctiva

and

mucous

membrane

s

production and

conservation

increase, and

body

temperature

increases.

Feverpromotes the

activities of the

immune

system, such

as

phagocytosis,

and inhibits the

growth of some

microorganism

s. In the

presence of

infection, fever

is concomitant

especially

when it has

become

systemic.

s feedings,

avoidance of

solid foods that

may lead to

indigestion

5. Promotepleasant/relaxin

g environment,

including

socialization

when possible

6. Note

presence and

absence of

sweating as

body attempts

to increase heat

loss by

evaporation,

conduction and

diffusion

intake

5. To promote

rest which

decreases the

metabolic

demand

6. Evaporation is

decreased by

environmental

factors of

humidity and

high ambient

temperature as

well as body

factors

7. To lower body

temperature

8. To facilitate

hydration status

48


49/68

7. Promote

surface cooling

by tepid sponge

baths

8. Discuss

importance ofadequate fluid

intake

9. Administer

medications as

ordered

9. For

pharmacological

management

49


50/68

Problem # 4: Risk for infection r/t to inadequate primary and secondary defenses

Assessme

nt

Nursing

Diagnosis

Scientific

Explanation

Objectives Nursing

Interventions

Rationale Expected

OutcomesS> O

O> Pt.

manifeste

d:

>hyperthe

rmia

>non-

productive

cough

>dyspnea

Patient

may

manifest:

Risk for

infection r/t

to

inadequate

primary and

secondary

defenses.

Pneumonia

involves the

inflammation of

the lung

parenchyma

which

eventually

leads to

decreased

cilliary action

and may

further lead to

stasis of

respiratory

secretions the

client is at risk

for spread of

Short Term:

After 4-6 of

NI the

patient will

be able to

prevent/

reduce risks

of spread of

infection.

Long Term:

After 3 days

of NI the

patient will

achieve

timely

>establish

rapport

>monitor and

recorded V/S

>encourage

proper hand

washing

techniques by all

caregivers

between

therapies/ clients

>provide for

isolation as

>for patient

cooperation

>serve as

baseline data

> a first line

defense against

nosocomial

infections

> reduces risk

of cross

contamination

Short Term:

After 4-6 of

NI, patient

shall have

prevented/

reduced risks

of spread of

infection.

Long Term:

After 3 days

of NI, patient

shall have

achieved

timely

50


51/68

>

irritability

>

restlessne

ss

infection since

the continuous

production of

mucous

secretions is a

perfect

breeding placefor

microorganism.

The secondary

defense

mechanism of

the immune

system is also

inadequate

since the client

is suffering

from a

deceased

hemoglobin

level.

Resolution

of current

infection.

indicated

>change position

every 2 hours

>encourageintake of foods

rich in Vit. C such

as oranges.

>encourage

increase of fluid

intake

>administer/mon

itor medication

regimen

> to facilitate

secretion

movement and

drainage

>to help boost

the immunesystem

>To liquefy

secretion and

to avoid stasis

>To comply

with the

therapeutic

regimen

resolution of

current

infection

without

complications

.

51


52/68

Problem #5: Deficient diversional activity r/t long term hospitalization AEB clients statement of boredom &

inability to perform ADL

Assessment Nursing

Diagnosis

Scientific

Explanation

Planning Nursing

Interventions

Rationale Expected

OutcomeS> maynip na

ku

O> pt. manifest:

Weakness

Irritability

Decrease

performan

ce

Restlessne

ss

Boredom

With VS as

follow:

T- 37 OC

P- 83 bpm

R- 21 bpm

B.P- 110/70

Deficient

diversional

activity r/t

long term

hospitalizatio

n AEB clients

statement of

boredom &

inability to

perform ADL

Prolong

hospitalizatio

n may cause

boredom

especially for

a person who

is use to

doing chores

or ADLs. Any

life change

that requires

numerous

readjustments

can be

perceived as

stressful. The

emotions &

physiological

arousal

Short Term:

After 4 hr. of

N.I, pt. will

engage in

satisfying

activities

within

personal

limitations

such as

chatting with

SO

Long Term:

After 3 days

of NI, pt. will

recognize

own

psychologica

Establish

rapport

Monitor and

record VS

Acknowledge

reality of the

situation &

feelings of pt.

Provide am and

pm care

Note impact of

illness on life

style by

comparing with

precious/norma

To gain trust

To have

baseline data

To establish

therapeutic

relationship

To provide

comfort

To validate

reality of

environment

al deprivation

Short Term:

After 4 hr. of

N.I, pt. shall

have

engaged in

satisfying

activities

within

personal

limitations

such as

chatting with

SO

Long Term:

After 3 days

of NI, pt.

shall have

recognized

52


53/68

mmHg

Pt. may manifest:

Hostility

Withdrawa

l

Crying

Flat affect

Lack of

interest in

eating

created by

stressful

situation are

highly

uncomfortabl

e &

discomfortmotivates the

individuals to

do something

to alleviate it.

l response &

initiate

appropriate

coping

actions

l activity level

Encourage

diversional

activity like

talking to SO

and readingnewspaper

Encourage the

SO to be with

the pt. within

the whole

process of the

situation

Encourage the

SO to provide

the pt.

adequate rest

periods

To lessen

boredom

To provide

comfort andto ensure

that the pt. is

not alone

To prevent

fatigue and

for the pt. to

gain

maximum

strength

own

psychological

response &

initiate

appropriate

coping

actions

53


54/68

2. Actual SOAPIEs

August 12, 2008

S> maskup ku salu

O> Received patient on high fowlers position with an IVF of #1 D5NM 1L

regulated at 30 to 31 gtts/min at 550cc level; signs and symptoms include:

(+)DOB, (+)nonproductive cough; with vital signs taken and recorded as

follows: T- 37.80C/axilla, PR- 86 bpm, RR 34 bpm, BP 110/70mmHg

A>Ineffective Airway Clearance related to Retained Secretions AEB

Ineffective or Absent Sputum.

P> After 4 hours of NI, patient will demonstrate behaviors to improve airway

such as deep breathing and coughing.

I> establish rapport

>monitor vital signs

>elevate head of bed and change position every 2 hours.

>encourage deep breathing and coughing exercises.

>provided TSB

>encourage increase fluid intake

> encourage warm versus cold liquids

>demonstrate pursed lip and diaphragmatic breathing

>encourage opportunities for rest

> regulate IVF as ordered

>administer meds as ordered

E> Goal met AEB patients ability to demonstrate behaviors to improve

airway such as deep breathing and coughing.

August 13, 2008

S>

54


55/68

O>Received patient in right side-lying position, sleeping; with an IVF of #3

D5NM 1L regulated at 30 to 31 gtts/min at 650cc level; infusing well on the

right hand; with Hemoglobin of 10.2mg%; hematocrit 33.0 vol%,

segmenters 87%, lymphocytes 13% as of 08/12/08; with vital signs taken

and recorded as follows: T - 380C/axilla, PR- 81 bpm, RR 19 bpm, BP

120/70mmHg.

A> Risk for Infection related to Inadequate Secondary Defenses (decresed

Hgb, Hct and Lymphocytes level)

P> After 2hours of NI, patient will identify interventions to prevent or reduce

risk for infection.

I> established rapport

>monitored and recorded vital signs

>encouraged deep breathing exercises

>maintained adequate hydration

>emphasized necessity of taking medications (antibiotic)

>encouraged increase intake of Vitamin C rich foods

>encouraged increase fluid intake

>provided adequate rest periods

>due meds given

>needs attended

>referred accordingly

E> Goal met AEB patients ability to identify interventions to prevent or

reduce risk for infection.

VI. CLIENTS DAILY PROGRESS IN THE HOSPITAL

1. Clients Daily Progress Chart

Days Admission

August 12

August 13 August 14 August 15 Discharge

August 16Nursing ProblemsIneffective

55


56/68

Airway

Clearance r/t

Retained

Secretions AEB

Ineffective or

Absent SputumIneffective

Breathing

Pattern r/t

Presence of

secretions

secondary to

Pneumonia

Hyperthermia Deficient

diversional

activity r/t long

term

hospitalization

AEB clients

statement of

boredom &

inability to

perform ADL

Risk for

infection r/t to

inadequate

primary and

secondary

defenses.

56


57/68

Vital SignsTemperature 40.50

C

37.80

C

380C 380C 36.80C 36.90C

Pulse Rate 88bpm 81bpm 83bpm 90bpm 81bpmRespiratory

Rate

34bpm 26bpm 24bpm 21bpm 19bpm

Blood Pressure 110/70mmHg 120/70mmH

g

110/70mmH

g

110/80mmH

g

120/70mmH

gDiagnostic

and

Labora

tory

Proced

uresHemoglobin

Male: 13.5 18

Female: 12-16

10.2 mg%

57


58/68

Hematocrit

Male: 40-54

Female: 37-47

33.0% vol.

WBC Count

Adult: 5-10 x103

10.750/cu.

mm.

Platelet Count

Adult: 150 - 450

280/cu. mm.

Segmenters

50-70%

87%

Lymphocytes

25-40%

13%

Chest X-Ray Medical

Manag

ementD5NM 1L x 30

to

31gtts/

min

DrugsAmbroxol Paracetamol IV Shifted

Cefuroxime Paracetamol

tab

DietDAT ExerciseBed Rest Deep Breathing

VII. DISCHARGE PLANNING

a. General Condition Upon Discharge

58


59/68

Patient was not seen upon discharge on August 16, 2008 at 9:00 in the

morning.

b. METHOD

M>

E> Encouraged to perform deep breathing and coughing exercises, prevent

patient from engaging in strenuous activity or those that may cause fatigue.

T>

H> Instructed patient to wear loose clothes to prevent excessive sweating

> Imposed proper hand washing before and after eating

> Instructed patient to do chest tapping and postural drainage to mobilize

secretions

>Encouraged patient to eat foods rich in Vitamin C

>Encouraged patient to increase fluid intake

>Encouraged patient to always keep the back dry

> Encouraged patient to have adequate rest periods between activities

O> Advised patient to come back 1 week after discharge (August 23, 2008)

at the OPD Department

D> Encouraged patient to eat foods rich in protein such as meats, eggs and

beans.

> Encouraged patient to Include vitamin C in diet such as orange juice,

calamansi and mangoes

> Encouraged increase fluid intake

VIII. CONCLUSION

Learning is not attained by chance, it must be sought for with ardor

and attended to with diligence.

59
http://www.quotationspage.com/quote/3072.htmlhttp://www.quotationspage.com/quote/3072.htmlhttp://www.quotationspage.com/quote/3072.htmlhttp://www.quotationspage.com/quote/3072.html


60/68

-Abigail Adams-

Knowledge is not achieved by a mere snap of the fingers. There is so

much to learn learning that is very much important to be able to accomplish

responsibilities and in one way or another, encourage one to be committed in

his chosen profession. The pursuit for knowledge is every persons

responsibility. As student nurses, well-founded background knowledge is

essential so as to be able to render quality care to every patient.

With the completion of this case study, the group has learned a lot

about Pneumonia, which is a very prevalent disease in Philippines justified by

the statistics conducted by different organizations. It is an illness that could

be prevented if precautionary measures are practiced. The group also

learned that pneumonia can be a complication of other respiratory diseases

like tuberculosis.

Early detection and prompt management may drastically lessen the severity

of the disease condition.

There are preventive measures which the group recommends to lessen

the occurrence of pneumonia. The primary prevention is being vaccinated

with pneumococcal vaccine although this vaccine does not offer absolute

protection especially to people with low immunity. Proper hand washing

should also be practiced especially before eating and after using the

bathroom. A daily diet that includes foods rich in antioxidants, such as fresh-

dark-colored fruits and vegetables and other nutrients help boost a persons

immune system. Brisk walking and other aerobic exercises should be

practiced to help increase the lung capacity and breathing exercises which is

the taking of slow, deep, relaxed breaths and exhalation through pursed lips,

may also be helpful. Lastly, a person should avoid smoking.

IX. BIBLIOGRAPHY

Seeley, Rod, et. Al. Essentials of Anatomy and Physiology, 6th ed.

McGraw-Hill Companies, Inc. New York.

60


61/68

Patton, Kevin T. Anatomy and Physiology, 5th ed. Mosby Inc. St. Louis,

Missouri. 2003.

Black, Joyce, and Hawk Jane Hokanson (2005) Medical-Surgical

Nursing

Yuan, Dr. Sara (2004), Hand Book of Diseases 3rd Edition

Professional guide to diagnostic tests, Lippincott Williams and Wilkins

Nurses quick check diagnostic tests, Lippincott and Wilkins

http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=22576

http://people.eku.edu/ritchisong/RITCHISO/301notes6.htm

http://www.childbirths.com/cypress/ivtherapy.htm

http://search.live.com/results.aspx?

q=decreased+hemoglobin+and+hematocrit&FORM=AWRE2

http://www.childbirths.com/cypress/ivtherapy.htm

http://search.live.com/results.aspx?

q=decreased+hemoglobin+and+hematocrit&FORM=AWRE2

http://www.diagnosis.com/p/pneumonia/prevalence.htm

http://doh.gov.ph/data_stat/html/mortality.htm

http://www.sciencedaily.com/releases/2008/02/080213090516.ht

http://www.wddty.com/03363800369751974858/alternative-treatments-for-

pneumonia.html

http://mayoclinic.com/health/pneumonia/DS00135

X. APPENDICES

Appendix A

MORTALITY

61


62/68

Ten Leading Causes of Mortality by Sex

Number, Rate/100,000 Population & Percentage

Philippines, 2003

Cause Male Femal

e

Both SexesNumber Rate Percent*

1. Heart Diseases38,67

729,019 67,696 83.5 17.1

2. Vascular System Diseases29,05

422,814 51,868 64.0 13.1

3. Malignant Neoplasm20,63

418,664 39,298 48.5 9.9

4. Accidents

27,72

0 6,246 33,966 41.9 8.6

5. Pneumonia15,83

116,224 32,055 39.5 8.1

6. Tuberculosis, all forms18,36

78,404 26,771 33.0 6.8

7. Symptoms, signs and

abnormal clinical, laboratory

findings, NEC

10,74

010,623 21,363 26.3 5.4

8. Chronic lower respiratory

diseases

12,99

8 5,907 18,905 23.3 4.8

9. Diabetes Mellitus 6,823 7,373 14,196 17.5 3.6

10. Certain conditions

originating in the perinatal

period

8,397 5,725 14,122 17.4 3.6

Source: The 2003 Philippine Health Statistics

* percent share from total deaths, all causes, Philippines

Last Update: January 11, 2007

Appendix B

Antipsychotic Drugs Increase Risk Of Developing Pneumonia In

Elderly, Study Suggests

62


63/68

ScienceDaily (Apr. 16, 2008) Elderly patients who use antipsychotic drugs

have a 60 percent increased risk of developing pneumonia compared to

non-users. This risk is highest in the first week following prescription and

decreases gradually thereafter. Antipsychotic drugs are frequently used in

elderly patients for the treatment of psychosis and behavioral problems

associated with dementia and delirium. This study is the first to show that

the development of pneumonia is associated with antipsychotic drug use.

The risk of developing pneumonia is not associated with long-term use, but

is the highest shortly after starting the drug, say Drs. Rob van Marum and

Wilma Knol, authors of the study. They caution that all antipsychotic drugs

may be associated with pneumonia in elderly patients.

In nursing homes, up to 40 percent of residents may be prescribed

antipsychotics, according to the study. It has been suggested that, for

residents of nursing homes who receive antipsychotic therapy, more than

half are prescribed for inappropriate reasons.

Although literature shows limited efficacy and effectiveness for

antipsychotic drug use in the treatment of behavioral problems in dementia

patients, these drugs are frequently used for this purpose. In the last few

years it has become clear that the use of antipsychotic drugs in elderlypatients is also associated with an increased risk of death and morbidity.

The underlying mechanism for the association remains unclear. The authors

stress that clinicians may need to monitor patients for sedation after

initiation of antipsychotic medication and that a careful weighing of the

possible risks is recommended before starting antipsychotic treatment in

elderly people.

This study is published in Journal of the American Geriatrics Society.

Adapted from materials provided by Wiley-Blackwell.

Need to cite this story in your essay, paper, or report? Use one of the

following formats:

63


64/68

APA

MLA

Wiley-Blackwell (2008, April 16). Antipsychotic Drugs Increase Risk Of

Developing Pneumonia In Elderly, Study Suggests. ScienceDaily. Retrieved

August 28, 2008, from http://www.sciencedaily.com

/releases/2008/04/080415111640.htm

Possible Target For Prevention And Treatment Of Pneumonia

Identified

ScienceDaily (Feb. 12, 2008) Researchers at Children's Hospital of

Pittsburgh of UPMC have identified a key protein target that may be a crucial

factor in the development of a vaccine to prevent and new therapies to treat

pneumonia, the leading killer of children worldwide.

Research led by Jay K. Kolls, MD, chief of the Division of Pediatric Pulmonary

Medicine, Allergy and Immunology at Children's, identified for the first time

the importance of a protein known as interleukin 22 (IL-22) in the immune

response to a strain of bacterial pneumonia. In the laboratory, the

researchers were able to effectively treat mice with pneumonia by using

purified IL-22.

"Currently there is no vaccine that covers all kinds of pneumonia and

antibiotic treatment is sometimes limited by antibiotic resistance. As acute

respiratory infections are the no. 1 killer of children in the world, progress in

the development of novel vaccines or new, more effective treatments is

critical," said Dr. Kolls, the Neils K. Jerne Professor of Pediatrics and

Immunology at the University of Pittsburgh School of Medicine. "Our results

64


65/68

raise the possibility of developing new protein-based therapies using IL-22 to

limit or prevent pneumonia."

Pneumonia causes almost one in five deaths in children under age 5

worldwide -- more than 2 million children each year, according to the WorldHealth Organization. It kills more children than any other disease -- more

than AIDS and malaria combined.

IL-22 and interleukin 17A (IL-17A) are produced by a recently discovered

lineage of cells known as T Helper Type 17 (Th17). Children's researchers

found evidence that the Th17 cell lineage and its cytokines IL-22 and IL-17A

have evolved to promote host defense against certain infections in the lung

caused by extracellular pathogens.

This is an important discovery because the Children's research team

proposes that by stimulating the Th17 arm of the immune system, they can

more efficiently treat bacterial pneumonia. Furthermore, the researchers

propose that Th17 is a less critical pathway for intracellular bacteria such as

those that cause listeria and tuberculosis -- thus raising the potential to

target this pathway in diseases of chronic inflammation such as rheumatoid

arthritis or inflammatory bowel disease without increasing susceptibility to

these intracellaulr pathogens.

Dr. Kolls' laboratory investigates mechanisms of lung host defenses in

normal and immunocompromised hosts as well as lung immunology in

disease such as cystic fibrosis and asthma. Additional research interests of

Dr. Kolls include gene therapy, lung immunology, lung host defenses, tumor

necrosis factor, pneumocytis carinii pneumonia, ethanol, gene expression,

polymerase chain reaction and molecular biology.

Results of the study are published in the February online issue of Nature

Medicine.

Adapted from materials provided by Children's Hospital of Pittsburgh, via

EurekAlert!, a service of AAAS.

65
http://www.eurekalert.org/http://www.eurekalert.org/


66/68

Need to cite this story in your essay, paper, or report? Use one of the

following formats:

APA

MLA

Children's Hospital of Pittsburgh (2008, February 12). Possible Target For

Prevention And Treatment Of Pneumonia Identified. ScienceDaily. Retrieved

August 28, 2008, from http://www.sciencedaily.com

/releases/2008/02/080211111323.htm

Appendix C

Community-acquired pneumonia

Community-acquired pneumonia (CAP) is a disease in which individuals

who have not recently been hospitalized develop an infection of the lungs

(pneumonia). CAP is a common illness and can affect people of all ages. CAP

often causes problems like breathing, fever, chest pains, and a cough. CAP

occurs because the areas of the lung which absorb oxygen (alveoli) from the

atmosphere become filled with fluid and cannot work effectively.

CAP occurs throughout the world and is a leading cause of illness and death.

Causes of CAP include bacteria, viruses, fungi, and parasites. CAP can be

diagnosed by symptoms and physical examination alone, though x-rays,

examination of the sputum, and other tests are often used. Individuals with

CAP sometimes require treatment in a hospital. CAP is primarily treated with

antibioticmedication. Some forms of CAP can be prevented by vaccination

CAUSES

Typical Bacterial Pathogens in CAP (approximately 85%)

66
http://en.wikipedia.org/wiki/Diseasehttp://en.wikipedia.org/wiki/Hospitalhttp://en.wikipedia.org/wiki/Infectionhttp://en.wikipedia.org/wiki/Lunghttp://en.wikipedia.org/wiki/Pneumoniahttp://en.wikipedia.org/wiki/Breathhttp://en.wikipedia.org/wiki/Feverhttp://en.wikipedia.org/wiki/Chest_painhttp://en.wikipedia.org/wiki/Coughhttp://en.wikipedia.org/wiki/Oxygenhttp://en.wikipedia.org/wiki/Alveolihttp://en.wikipedia.org/wiki/Earth's_atmospherehttp://en.wikipedia.org/wiki/Bacteriahttp://en.wikipedia.org/wiki/Viruseshttp://en.wikipedia.org/wiki/Fungihttp://en.wikipedia.org/wiki/Parasiteshttp://en.wikipedia.org/wiki/Diagnosishttp://en.wikipedia.org/wiki/Symptomhttp://en.wikipedia.org/wiki/Physical_examinationhttp://en.wikipedia.org/wiki/X-rayhttp://en.wikipedia.org/wiki/Sputumhttp://en.wikipedia.org/wiki/Pharmacotherapyhttp://en.wikipedia.org/wiki/Hospitalhttp://en.wikipedia.org/wiki/Antibiotichttp://en.wikipedia.org/wiki/Medicationhttp://en.wikipedia.org/wiki/Preventive_medicinehttp://en.wikipedia.org/wiki/Vaccinationhttp://en.wikipedia.org/wiki/Diseasehttp://en.wikipedia.org/wiki/Hospitalhttp://en.wikipedia.org/wiki/Infectionhttp://en.wikipedia.org/wiki/Lunghttp://en.wikipedia.org/wiki/Pneumoniahttp://en.wikipedia.org/wiki/Breathhttp://en.wikipedia.org/wiki/Feverhttp://en.wikipedia.org/wiki/Chest_painhttp://en.wikipedia.org/wiki/Coughhttp://en.wikipedia.org/wiki/Oxygenhttp://en.wikipedia.org/wiki/Alveolihttp://en.wikipedia.org/wiki/Earth's_atmospherehttp://en.wikipedia.org/wiki/Bacteriahttp://en.wikipedia.org/wiki/Viruseshttp://en.wikipedia.org/wiki/Fungihttp://en.wikipedia.org/wiki/Parasiteshttp://en.wikipedia.org/wiki/Diagnosishttp://en.wikipedia.org/wiki/Symptomhttp://en.wikipedia.org/wiki/Physical_examinationhttp://en.wikipedia.org/wiki/X-rayhttp://en.wikipedia.org/wiki/Sputumhttp://en.wikipedia.org/wiki/Pharmacotherapyhttp://en.wikipedia.org/wiki/Hospitalhttp://en.wikipedia.org/wiki/Antibiotichttp://en.wikipedia.org/wiki/Medicationhttp://en.wikipedia.org/wiki/Preventive_medicinehttp://en.wikipedia.org/wiki/Vaccination


67/68

Streptococcus pneumoniae

Penicillin-sensitive S pneumoniae

Penicillin-resistant S pneumoniae

H influenzae

Ampicillin-sensitive H influenzae

Ampicillin-resistant H influenzae

Moraxella catarrhalis

(all strains penicillin resistant)

Atypical Respiratory Pathogens in CAP (approximately 15%)

Legionella species

Mycoplasma species

C pneumoniae

Rare Bacterial Pathogens in CAP

Klebsiella pneumoniae - Only in those with chronic alcoholism

Staphylococcus aureus - Postviral influenza setting

Pseudomonas aeruginosa - Only in patients with cystic fibrosis or

bronchiectasis

Nonpulmonary Pathogens in Pneumonia

Nonaeruginosa pseudomonads

Stenotrophomonas (Xanthomonas) maltophilia

Citrobacter freundii

Burkholderia (Pseudomonas) cepacia

Citrobacter koseri

Enterobacterspecies

Flavobacterium species

Enterobacter cloacae

Flavobacterium meningisepticum

Enterobacter agglomerans

Enterococcus species

Symptoms

67


68/68

Symptoms of CAP commonly include:

problems breathing

coughing that produces greenish or yellow sputum

a high fever that may be accompanied with sweating, chills, anduncontrollable shaking

sharp or stabbing chest pain

rapid, shallow breathing that is often painful

Less common symptoms include:

the coughing up of blood (hemoptysis)

headaches (including migraine headaches)

loss of appetite

excessive fatigue

blueness of the skin (cyanosis)

Pneumonia Final Copy

Documents

Transcript of Pneumonia Final Copy