General Objective:

We the group 6-B develop this case study to help us enhance our knowledge about the
disease process and also to manage the treatment of the disease.
Specific Objectives
This case study significantly identifies the factors that gave rise for our client to have the
diagnosed problem. The following are the identified objectives for the case study.

To develop a comprehensive assessment of the client.

To establish a Pathophysiology for the disease of the client.
To develop a nursing care plant appropriate for the clients diagnosed problem
To be able to teach the significant others of the client for proper health

maintenance.
To lessen the risk of infection and development of complications of the client.
To be able to provide an environment conducive for health.
To enhance the care that will be given for other clients with the same diagnosis.

Introduction
1

Pneumonia is an infection of the lower respiratory tract caused by bacteria,

viruses, fungi, protozoa, or parasites. It is the eighth leading cause of death in the
United States. The incidence and mortality of pneumonia are highest in the elderly. Risk
factors for pneumonia include advanced age, immunocompromise, underlying lung
disease, alcoholism, altered

consciousness, smoking, endotracheal

intubation,

malnutrition, and immobilization. The causative microorganisms influence the symptoms

and signs with which the patient presents, how the pneumonia should be treated and
the prognosis.
Community-acquired pneumonia develops in people with limited or no contact
with medical institutions or settings. CAP tends to be caused by different
microorganisms than those infections acquired in the hospitals. The characteristics of
the individual are important in determining which etiologic microorganism is likely. For
example, immunocompromised persons tend to be susceptible to opportunistic
infections that are uncommon in normal adults. In general, nosocomial infections and
those affecting immunocompromised individuals have higher mortality rate communityacquired pneumonias.
The most common community-acquired pneumonia is caused by Streptococcus
pneumoniae, which has a relatively low mortality rate, although it is higher in the elderly.
Mycoplasma pneumoniae is a common cause of pneumonia in young people especially
those living in group housing such as dormitories and army barracks. Influenza is the
most common viral community-acquired pneumonia in adults. Legionella species, which
also cause CAP, can contaminate cooling systems and water supplies leading to
outbreaks of disease. Signs and symptoms of CAP are fever, cough, dyspnea,
tachypnea and tachycardia. Diagnosis is based on clinical presentation and chest x-ray.
Treatment is with empirically chosen antibiotics. Prognosis is excellent for relatively
young and healthy patients, but many pneumonias, especially when caused by
Streptococcus pneumoniae and influenza virus, are fatal in older, sicker patients.

According to the World Health Report by the World Health Organization, lower
respiratory infections, which include community-acquired pneumonia, ranks ninth
among the leading causes of mortality on individuals aging 15 to 59 worldwide and
ranks fourth on individuals aging 60 and over, and that it is the leading killer of children
worldwide.
CAP is one of the most common entities seen in Filipino adults. It is the most
common infectious disease prompting hospitalization and the first and fifth leading
cause of morbidity and mortality in the Philippines, respectively.
Pneumonia was the top common disease in all ages groups in the 16 health
districts of Davao City between January and February this year based on statistics
prepared by the CHO (city health office). Pneumonia ranked first among the top three
common diseases in 11 districts, with 1,428 cases in Agdao districts as the highest. The
World Health Organization has stated that pneumonia is among the leading causes of
death in children under five years old. There were 6,335 cases of community acquired
pneumonia (CAP) in the 16 health districts from January to December 2011.
(www.edgedavao.net)
For our client Mr. X who is 43 years old and a lawyer. At his young age of 16 he
started smoking and drinking alcoholic beverages. He can consume half pack of
cigarettes a day. On the day of his confinement he already develops some signs and
symptoms of the disease but did not mind it until it got more complicated.

Definition of Terms
3

Community Acquired Pneumonia a long term treatment and it is acquired

outside the hospitals.

Immunocompromised having the immune system impaired or weakened ( as

by drugs or illness ).
Goblet Cells Is a glandular, modified simple columnar epithelial cell whose

function is to secrete gel-forming mucins, the major components of mucus.

Mucociliary clearance mucus ciliary clearance also referred to as mucociliary
apparatus or mucus ciliary clearance (MMC) derived from mucus, cilia (cilia of
the tracheal surface epithelium in the respiratory tract) and clearance describe

the cell clearing mechanism of bronchi.

Bradykinin Is an inflammatory mediator. It is a peptide that causes blood

vessels to dilate (enlarge), and therefore cause blood pressure to fall.

Leukotriene Are family of eicosanoid inflammatory mediators produce in
leukocytes by the oxygenation of arachidonic acid by the enzyme arachidonate

5- lipoxygenase.
Thermoregulatory center Hypothalamos , is the ability of an organism to keep
its body temperature within certain boundaries, even when the surrounding
temperature is very different.

Comprehensive Assessment
PATIENTS PROFILE
4

Name: Mr. X
Age:
Sex: Male
Address:
Birthday:
Birthplace:
Civil status: Married
Religion:
Nationality: Filipino
Admission date: Dec. 01, 2012
Admission Time: 01:52 PM
Attending physician: Dr.
Admitting physician: Dr.
Chief Complaint: Cough and Fever
Diagnosis: CAP ruled out TB; Parotitis

I.

Physical Examination
A. INTEGUMENTARY
5

Physical Exam Findings

SKIN
Color: Patient has dark skin complexion; no discoloration
Texture: Has smooth skin but his palm of his hands is rough as well as his soles in
the feet
Turgor: Has good skin turgor as we pinched his skin is goes back immediately in
place.
Scaling; No scales noted
Hair distribution: Thin, short, black hair
Infestation: No infestation noted
Comments: No abnormalities noted upon assessing the skin.
STOMA [/] Not Applicable
[ ] clean, dry [ ] redness [ ] chronic redness [ ] drainage [ ] chronic drainage [ ]
prolapsed
FINGERNAILS & TOENAILS
[/] color, shape, cleanliness good [/] no problems deviations assessed
[ ] irregularities in surface: No irregularities in surface
[ ] inflammation of the nails: No inflammation around the nails
[ ] fungal problem: No fungal problem
B. HEAD AND NECK
Physical Exam Findings
HEAD & NECK
Head motion: Able to move/ flex head without difficulty
[ ] asymmetric head position: Symmetric head position
[/] shrugs shoulder [ ] unable to support head midline & erect [ ] dull, puffy, yellow
skin
[ ] periorbital edema [ ] lymph node enlargement [ ] thyroid enlargement
[ ] tracheal displacement
Comments: No problem noted during assessment of the head and neck.
6

NOSE & SINUSES

[ ] nasal drainage [ ] inflamed [ ] tender [ ] polyps/lesions [ ] edema
[ ] altered nasal mucosa
[ ] absence of frontal sinus glow [ ] right nostril occluded [ ] left nostril occlude
Comments: No pain or lesion noted
MOUTH & PHARYNX
[ ] altered oral mucosa membrane: No altered oral mucous found
[ ] inflammation: No inflammation noted
[ ] hoarseness [ ] bruxism (grinds teeth) [/] loose teeth [ ] decay [ ] halitosis [ ]
excessive salivation
[/] lips dry, cracked [ ] lip fissures [] lip bleeding [ ] gums inflamed [ ] gums bleed [ ]
gum retraction [ ] thick tongue [ ] tongue dry, cracked [ ] tongue fissures [ ] tongue
bleeds
Inspected the following [/] inner oral mucosa [/] buccal mucosa [/] floor of mouth [/]
tongue [/] hard palate [/] soft palate
Deviations: has normal color of the tongue as noted
[ ] lesions, vesicles: no lesions and vesicles noted
[ ] gag reflex absent [ ] gag reflex hyperactive [ ] poor denture fit or not using [ ]
chewing problem [ ] missing teeth
Comments: Mr. X has no lesions found of the any said inspected areas. Normal
findings upon assessment on gag reflex.
C. EYES & EARS
Physical Exam Findings
EYES
7

Visual acuity: Can see objects in a distance

Visual fields/ peripheral: Can see objects on the peripheral sides
Eye tracking presents: [/] up [/] down [/] [/] right [/] left
[/] corneal light reflex aligned [ ] light reflex misaligned [ ] nystagamus
External eye structures: external eye structures is round and symmetrical.
No lesions, edema noted.
Abnormalities: No abnormalities noted
Blink reflex: Has normal blink reflex. Able to blink without difficulty.
Pupil & iris direct light response: Pupil and iris respond to the direct light
Pupil & iris consensual light response: Pupil constrict on light
EARS
External ear structure: The ear structure are symmetry in shape. Ear lobes are bean
shaped, parallel and symmetrical
External ear structure abnormalities: No abnormalities noted
Comments: No abnormalities noted upon assessing the ears. There is no pain nor
tenderness upon touching the auricles. No discharges or lesions noted in the ear
canal
D. CARDIOPULMONARY
HEART & VASCULAR
Auscultated heart sounds:
Apical pulse: 89 bpm
Jugular venous distention [ ] present [ ] absent capillary refill [ ] >1 second [/]
2seconds [/] PMI palpable- 5th intercostals space to medial to left midclavicular line
[ ] PMI not palpable
[ ] edema: No edema noted
Blood pressure: 120/80 mmHg
Peripheral pulses: 87 bpm
Comments: Clients heart sound characteristics is regular and strong in rhythm.
8

THORAX & LUNGS

Inspected: [/] posterior thorax [/] lateral thorax [/] anterior thorax
List thorax deviations: No abnormalities noted upon assessing the thorax
Diminished sounds: Diminished sounds noted
Respiratory rate: 25 cpm
Comments: breath sound has abnormalities (rales) on left upper lobe upon
auscultation.
E. GASTROINTESTINAL
ABDOMEN
Bowel sounds: [/] present in all quadrants [ ] absent: LUQ, LLQ, RLQ, RUQ
[ ] Hypoactive [/] hyperactive [ ] tympanic
Abdomen: [/] flat [/] soft [] firm [ ] distended [ ] rounded [ ] obese [ ] asymmetry [ ]
pain [ ] rebound tenderness
Skin: The skin is intact
Comments: Theres no abnormalities noted
NUTRITIONAL/ METABOLIC PATTERNS
Height: cm weight: kg [ ] within Ideal body weight [ ] less than [ ] more than IB
N/A
Body Mass Index Ranges

Underweight: BMI is less than 18.5

Normal weight : BMI is 18.5 to 24.9

Overweight: BMI is 25 to 29.9

Obese: BMI is 30 or more

F. GENITOURINARY(GYNECOLOGICAL & BREAST)

Deviation assessed in: [ ] size [ ] symmetry [ ] contour [ ] shape [ ] skin color

[ ] texture
9

Nipple deviations: [ ] retractions [ ] discharge [ ] bleeding [ ] nodules [ ] edema [ ]

ulcerations
Comments: No abnormalities noted upon assessing the breast of the client.
G. MUSCULOSKELETAL
[ ] gait abnormalities: No gait abnormalities
[ ] posture abnormalities: No posture abnormalities
[ ] impaired weight bearing stance: No impaired weight bearing stance
[ ] bilateral symmetry: No bilateral symmetry
[ ] asymmetry: No asymmetry noted
[ ] bilateral alignment: No bilateral alignment noted
Comments: No decrease of ROM noted, no tenderness and misalignment noted. All
things are normal.
H. NEUROLOGIC SYSTEM
[/] alert [/] aware of environment [ ] impaired consciousness [ ] Glasgow coma scale
score:
[/] changed level of consciousness [ ] unchanged level of consciousness
[/] able to communicate [/] vocalizes sounds [ ] limited verbalization [ ] non-verbal [ ]
changed in communication pattern
[ ] unchanged communication pattern
Comments: The client is responsive he was able to interact and socialize with other
people
CRANIAL NERVE (CN) FUNCTION
CN I- Olfactory

[/] intact [ ] impaired [ ] unknown

CN VI- Trigeminal

[/] intact [ ] impaired

CN VII- Facial

[/] intact [ ] impaired

CN VIII- Acoustic

[/] intact [ ] impaired

CN IX- Glossopharyngeal

[/] intact [ ] impaired

CN X- Vagus

[/] intact [ ] impaired

10

CN XI- Spinal accessory

[/] intact [ ] impaired

CN XII- Hypoglossal

[/] intact [ ] impaired

SENSORY FUNCTION
Touch

[/] intact [ ] impaired

Pain

[/] intact [ ] impaired

REFLEXES
Patellar reflex: [ ] 0 no response [ ] 1+ low
[/] 2+ normal, visible muscle twitch and extension of lower leg

ANATOMY AND PHYSIOLOGY

Respiratory System
11

The respiratory system functions to deliver the oxygen to the blood -- the
transport medium of the cardiovascular system -- and to remove oxygen from the blood.
The actual exchange of oxygen and carbon dioxide occurs in the lungs.
The respiratory centers in the brain stem (pons and medulla) control respiration's
rhythm, rate, and depth. Primary controlling factors include 1) the concentration of
carbon dioxide in the blood (high CO2 concentrations initiate deeper, more rapid
breathing) and 2) air pressure within lung tissue. Expansion of the lungs stimulates
nerve receptors (vagus nerve X) to signal the brain to "turn off" inspiration. When the
lungs collapse, the receptors give the "turn on" signal, termed the Hering-Breuer
inspiratory reflex. Other regulators are: 3) an increase in blood pressure, which slows
down respiration; 4) a drop in blood acidity, which stimulates respiration; and 5) a
sudden drop in blood pressure, which increases the rate and depth of respiration.
Voluntary controls -- "holding one's breath" -- can also affect respiration, but not
indefinitely. Carbon dioxide build-up soon forces an automatic start-up.

The respiratory system consists of two tracts: The upper respiratory tract includes
the nose (nasal cavity, sinuses), mouth, larynx, and trachea (windpipe). The lower
respiratory tract includes the lungs, bronchi, and alveoli.
The two lungs, one on the right and one on the left, are the body's major
respiratory organs. Each lung is divided into upper and lower lobes, although the upper
lobe of the right lung contains a third subdivision known as the right middle lobe. The
right lung is larger and heavier than the left lung, which is somewhat smaller in size
because of the predominately left-side position of the heart.
A clear, thin, shiny coating -- the pleura -- envelopes the lungs. The inner,
visceral layer of the pleura attaches to the lungs; the outer, parietal layer attaches to
12

the chest wall (thorax). Pleural fluid holds both layers in place, in a manner similar to
two microscope slides that are wet and stuck together. The lungs are separated from
each other by the mediastinum, an area that contains the heart and its large vessels,
the trachea (windpipe), esophagus, thymus, and lymph nodes. The diaphragm, the
muscle that contracts and relaxes in breathing, separates the thoracic cavity from the
abdominal cavity.

The chart of the respiratory system shows the intricate structures needed for
breathing. Breathing is the process by which oxygen in the air is brought into the lungs
and into close contact with the blood, which absorbs it and carries it to all parts of the
13

body. At the same time the blood gives up waste matter (carbon dioxide), which is
carried out of the lungs when air is breathed out.
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-cleaning system.
3. Air also 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.
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.

14

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.
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.
15

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 ARTERY
and taken away by the PULMONARY VEIN. 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.

16

Pathophysiology of Community-Acquired Pneumonia

Precipitating Factors:
Age above 50 for
Filipinos
Inhalation of microorganisms

Predisposing Factors:
Lifestyle such as:
- smoking
- alcoholic
Nature of his work
Exposure to
bacteria agents

Invasion of foreign bodies in the URT

Activation of the upper airway defense mechanism, cough reflex,
mucociliary clearance and nasopharyngeal defense
Pathogens begin to colonize
Pathogens enter the lower
Damage occurs to mucous membrane
Activation of the inflammatory process,
released of chemical mediators

17

Histamine

Bradykinin

Prostaglandin

Leukotriene

Increase in
Vascular

Stimulates goblet cells

to increase mucus
production

Stimulate muscle spasm

Chemotaxis

Permeability

that contributes to
bronchoconstriction

Migration of WBC to
the site of injury

Accumulation of mucus

Narrowing of airway

Leaking of fluids and fluid

shifting resulting to
accumulation of fluid in

secretions in the airway

Release of pyrogens

the alveolar sacs

contributing to the
narrowing of airway

Crackles

Productive

Stimulates the thermoregulatory This accumulation of fluids

Dyspnea

center of the body to reset

impairs gas exchange

body temperature

resulting to ventilation-

Nasal flaring

perfusion mismatch
Fever
Tachypnea

Pallor Chest Pain

Malaise

18

Narrative Pathophysiology
Community Acquired Pneumonia mostly caused by aging especially 50 above for
Filipinos, also lifestyle those who are smokers and alcoholic can easily get this type of
disease. It will start with inhalation of the microorganism which is staphylococcus
pneumonea through airbore or droplet, then once it will invade our body it will activate
our 1st line of defense which are the reflexes such as the cough reflex, nasopharyngeal
defense, mucociliary clearance, also the sneezing. It will stay longer in our upper
respiratory system and start to colonize, slowly pathogens will enter now the lower
respiratory system which are the lungs, bronchi and aveoli. It will start damaging the
mucous membrane. Once that happened our body will now release some chemical
mediators to stop the disease such as histamine which will stimulate the goblet cells to
increase mucus production, bradykinin which wil cause muscle spasm that contributes
to have bronchoconstriction, prostaglandin will cause chemotaxis or migration of white
blood cells to fight of bacteria inside our body, and leukotriene which will cause increase
of vascular permeability. If the disease is not treated well it will cause more damage and
will result to have a fever, tachypnea, pallor, chest pain, dyspnea, and also body
malaise. Good prognosis with right treatment will cure the patient. Bad prognosis can
lead to meningitis or death.

19

Course in the Ward

Doctors Order Notes

7/6/15 (8:20pm)
- History of on and off cough

- give paracetamol torplanadine

whitish phlegm

( norgesic forte tab ) 1 tab

- (-) HPN , (-) DM, (+) BA, (+)

Allergies: NSAIDS
- HCL PRC (+) left pre auricular
pain (+) fever

- facilitate labs and relay

- 1 d PTA right submandibular

Initial CXR receiving c/o MPG

area
- A S, PPC
(+) tender lymphocecyoclay
Submandibular auricular
area
(-) wheezing
6:40 PM
Temp 38.8
PR 81

- Please admit under the service of Dr. Ybiernas

RR 21
Meds: 1) Ampicillin Sulbactam (silgram)
1.5 g q8 ANST Start ASAP
2) Orofar gargle TID
3) Hydrocortisone 100 g q8 IV
4) Alloprinol 300 g 1 tab OD
5) Paracetamol 500 g 1 tab for PRN for fever
IVF PNSS 1 L @ 100 cc/hr
I and O q shift
20

BP 120/80
Ht. 163 cm
Wt. 67.9 kg
7/7/15 ( 6pm )
- awake, comfortable

- Noted pulmonites will relay to HP

- dyspnea

- Decreased hydrocortisone to q12 H

- chest pain

- Hold PPT, URIC, ALT and crea

- hemophysis

- Facilitate AFB X2

- clear BS
- Stable VS
-(-) Fever

21

Laboratory results
Examination

Result

Unit

Range

High
/Low Remarks

Hemoglobin

137.00

g/L

140-179

Hematocrit

0.43

Red Blood Cell

4.64

^10812/L

4.5-6.0

White Blood Cell

6.00

^1089/L

5.0 10.0

Platelet Count

253.00

^1089/L

140 - 440

Nuetrophils

0.75

0.65 0.65

Lymphocyte

0.46

0.35 0.45

Monocyte

0.08

0.06 0.12

Eosinophil

0.01

0.02 0.04

Basophil

0.00

0 - 0.02

0.40-0.60

Absolute Neutrophil

^1058/L

1.8 7.8

Absolute lymphocyte

1.28

^1059/L

1.0 4.8

Absolute Monocyte
Absolute Eosinophill

0.64
0.08

Absolute Basophil

MCV

^1059/L
^1059/L

0.0 0.80
0.0 0.45

^1059/L

0.0 0.20

92.10

^1/L

80 - 97

MCH

29.60

^pg

MCHC

321.00

RDW

13.40

27.0 31.2
318 - 354
11.5 14.5

Drug Study
Drug Name

Mechanism of

Indication

Action

Contraindicatio

Adverse

Reactions

Dosage

Nursing

Rationale

Intervention

Generic

Sulbactam

Treatment of

Hypersensitivity

Rash

Actual:

Name:

inhibits

skin and skin

to penicillins.

( less than

1.5 gram

patient if

prevent

Ampicillin

plasmid-

structure, intra

2% );

q8 IVTT

allergic to

any

Sodium

mediated beta-

abdominal, and

erythema

ANST (-)

penicillin

allergic

lactamase

gynaecologic

multiforme,

enzymes

infection caused

exfoliative

Brand Name:

commonly

by susceptible

dermatitis,

client on

Sulbactam

found in

microorganisms

urticaria

the side

Sodium

microorganism

Ask

Educate

effects of

s resistant to

the

ampicillin.

medicatio

Classification:

n and

Aminopenicillin

what to
expect

To

reaction
To avoid
anxious
reaction
of the
patient

Drug Name

Mechanism

Indication

of Action

Contraindicatio

Adverse

Reactions

Dosage

Nursing

Rationale

Intervention

Generic

Infections in

Isolated

Actual:

Name:

the mouth and

cases of

gargle 1oz

patient for

baseline

Benzoxonium

throat

skin rash;

TID

signs and

informatio

Cl,Lidocaine

examples:

occasional

symptoms

n during

HCl

pharyngitis or

and

of mouth

treatment

laryngitis, sore

transient

and the

throat with

cases of

colds,

mild local

throat

Assess for

Brand Name:
Orofar - L

aphthous

allergic

irritation.

Classification:

gingivitis.

Antiinfective

Adjuvant in

and antiseptic

tonsillitis.
Dental plaque.

To obtain

To give
immediate
action

reaction:

ulcers,
stomatitis,

Assess

skin rash
Intstruct
patient to
sip water
after
taking the
gargle

To
decrease
dry mouth

Drug Name

Mechanism

Indication

of Action

Contraindicatio

Adverse

Reactions

Dosage

Enters

-replacement

-allergy to any

CNS:

Actual:

Name:

target cells

therapy in

component of

vertigo,

100mg IV

Hydrocortison

and bids to

adrenal

the drug

headache,

Q8

cytoplasmic

cortical
-fungal

contraindication

informatio

paresthesi

9am to mimic

n during

as,

diurnal

treatment

insomnia,

corticosteroid

Brand Name:

many

severe or

seizures,

levels.

Cortef, Solu-

complex

incapacitating

Cortef,

reactions

allergic

Hydrocortone,

that are

conditions

Cortenema

responsible

psychosis,
CV:

doses evenly

hypotensio

throughout the
day

-hematologic

-vaccinia or

n, shock,

inflammator

disorders

varicella

HPN and

Adrenal

immunosup

-ulcerative

cortical steriod

presive

colitis

(glucocortic

heart

-use minimal

-antibiotic-

failure

doses for

resistant

secondary

minimal duration

infections

to fluid

to minimize

retention,

adverse effects.

oid), and
salt

thromboe

retaining

immunosuppres

mbolism,

To give
immediate

-space multiple

for its antiClassification:

To obtain

-give daily before

-allergic states infections

-hepatitis B

baseline

initiates

-amebiasis

Rationale

Intervention
-assess for

Generic

receptor;

Nursing

-do not give IM

action

(mineralocor

sion

thromboph

injections if

ticoid)

lebitis, fat

patient has

actions.

embolism,

thrombocytopeni

Some

cardiac,

c purpura.

actions may

arrhythmia

be

-Taper doses

undesirable

Dermatolo

when

depending

gic:

discontinuing

on drug use.

Thin,

high-dose or long

fragile

term therapy.

skin,
petechiae,

-monitor client for

ecchymos

atleast 30mins

es,
purpura,

-educate client

striae,

on the side

subcutane

effects of the

ous fat

medication and

atrophy

what to expect

EENT:

-instruct client to

Cataracts,

report pain at

glaucoma,

injection site

increased
IOP

-Instruct client to
take drug exactly

Endocrine:
amenorrhe
a, irregular
mens,
growth
retardation
,
decreased
carbohydr
ate
tolerance
and DM,
cushingoid
state, HPA
suppressio
n
systemic,
hyperglyce

as prescribed

mia
GI: peptic
or
esophage
al ulcer,
pancreatiti
s,
abdominal
distention,
nausea,
vomiting,
increased
appetite
and weight
gain
Hematolog
ic: Na and
fluid
retention,
hypocalce
mia,

increased
blood
sugar,
increased
serum
cholesterol
,
decreased
T3 and T4
levels
Hypersens
itivity:
anaphylact
oid or
hypersensi
tivity
reactions
Musculosk
eletal:
muscle
weakness,
steroid

myopathy
and loss of
muscle
mass,
osteoporo
sis,
spontaneo
us
fractures
Other:
immunosu
ppresion,
aggravatio
n or
masking of
infections,
impaired
wound
healing
Nursing Care Plan
Assessment

Nursing

Scientific

Diagnosis

Explanation

Planning

Nursing
Intervention

Rationale

Evaluation

Ineffective
Subjective:
dili

Airway

mo Clearance

Community-

Short

Acquired

Term :After 5 respiratory status:

gawas

related to

Pneumonia is the hours

akong

retained

inflammation

plema

secretions in

the

masking

the bronchi

parenchyma

unsaon

and lung

when

respiratory rate,

condition: flaring of

was able to

oxygen

nostrils indicate a

expectorate

significant decline in

mucous as

abnormalities

respiratory status:

evidenced

such as dyspnea,

assessment

by

establishes baseline

productive

cyanosis, use of

and monitor

cough

droplets or saliva by

accessory

response to

effective

in

muscles, flaring of interventions

coughing

nostrils

and

of Nursing
lung Interventions

, the patient saturation, note

the will

offending

ubo

as leading to

organism reaches mucous

by

the n of mucous

patient.

in the alveoli

patterns may signal

The patient

ug inflammation
accumulatio

the

of breath sounds,

> Abnormal breathing Short Term :

worsening of

nako

verbalized

> Assess

expectorate

alveoli
which

via evidenced

goblet productive

as presence of

Objective:

cells produces an cough,

Initial VS:

outpouring

PR=87bpm

into the alveoli. coughing

> Assess anxiety

> Being unstable to

RR =

The

and reassure

breath causes

25cpm

multiply

patient with

anxiety and fear: the

presence

patient needs a

fluid effective

organisms and
in

the breathing

serous fluid and exercise

>with rales

the

infection

on both lung

spread.

lobes upon

organisms

is
The

breathing

calming presence:
anxiety increases the
demand for oxygen

exercise

chest

damage the host

auscultation

by

their

overwhelming

> Place patient in

> Maximize chest

high fowlers

excursion and

> shortness

growth

and

position and

subsequent

of breath

interference

with

support with

movement of air

lung

function

leading

overbed table as

to

needed.

of

> Encourage

> Thickened

> with non-

massive

productive

accumulation

cough

mucus. Disruption

expectoration of

secretions of Cap re

>

of the mechanical

secretions and

more likely to

Restlessnes

defenses

assess the

occlude the airway:

cough and ciliary

viscosity amount

making this

motility leads to

and color of

observation would

the colonization of

secretions

allow for

the

lungs

accumulation

of

and

implementation if

of

measures to thin and

secretions in the

loosen the secretions

alveoli

and

bronchi leading to

> Assist the

> Mobilizes

ineffective airway

patient with

secretions and

clearance

coughing and

prevent atelectasis

as

evidence by non-

deep breathing

productive cough
etc.

alveolar

exudates tend to

> Increase fluid

> Assists with

intake

liquefying secretions

consolidate,

and enhancing ability

increasingly

to clear airways

difficult
expectorate.

to
> Provide for

> Decrease demand

periods of rest

for oxygen

and activity,
assisting with
devices as
needed
> Elevate head of

> To maintain an

bed/ change of

open airway and to

position every 2

take advantage of

hours

gravity decreasing
pressure on the
diaphragm and
enhancing drainage
of secretions.

> Assist

>This causes

respiratory

bronchiodilation to

therapist the

ease breathing

administration of
nebulizer
> Establish

> Ensures a route for

intravenous

rapid- acting

access as

medications

ordered
> Assess arterial

>ABG provide data

blood gases

for treatment

(ABG)

regarding the lungs

ability to oxygenate
tissues

Assessment

Nursing

Scientific

Diagnosis

Explanation

Planning

Nursing
Intervention

Rationale

Evaluation

Subjective:

Activity

The

onset

of Short Term :

> Obtain

>Helps to determine

is

subjective data

the effects of

Short Term :

kapoy man Intolerance

pneumonia

maglakaw-

generally marked After 4 hours from patient

pneumonia on the

The patient

lakaw maam increased

by

patients ability to be

was able to

dali

dyspnea,

active.

perform

ra

related to
ko oxygen

hangakon

demand

as verbalized with activity

by

fever, of

and Interventions

shortness

Objective:
Initial VS

breath and easy is

able

(lack of

may

lead

oxygen

inability

supply w

perform activities without

of daily living.
Due

to

thick

fatigability

mucous

in

alveoli

altering

gas
> non-

oxygen

productive

carbon

as

shortness of activity as

physical activity

hygiene,

breath such required in

causes shortness of

etc.

doing response to

dioxide)

breath, activity

oxygen need of

should be reduced

the body

until oxygenation is

the

and

doing

personal

tenacious hygiene, etc.

exchange

fatigue such

living

of personal

> easy

without

of and exhaustion.
> Reduce level of

living

>If increased

the as

accumulation

daily

monitor for fatigue

to activities
to daily

activities of

to pneumonia;

that perform

PR=87bpm
RR = 25cpm

activities prior to

of , the patient onset of

the and hypoxia fatigability

patient

Nursing regarding normal

adequate.
> Assist with

> Conserves energy

activities as

and reduces oxygen

needed.

demand patients with

cough

between

the

pneumonia lack

alveoli And

enough oxygen

>shortness

reserves to perform

of breath

activities

during

independently.

activities
>Pace activities

>It conserves energy.

>Inability to

and encourage

perform

periods of rest

physical

and activity during

activities

the day.

>physical

> Monitor VS and

> Use the result to

exhaustion

oxygen saturation

indicate when the

before and after

activity may be

activity.

increased or

decreased.

phy
> Gradually

> Activities should be

increase activity

increased gradually,

as tolerated and

as tolerated, to avoid

share guidelines

over taxing the

for progression

patient.

with patient.
> Discuss with

> Physical activity

the patients

increases endurance

activities that

and stamina;

would be

following pneumonia,

appropriate once

return to normal

at home that

activity may take

would be within

time.

the patients
activity tolerance.
> Inform the

> This indicate

patient to stop

intolerance to activity

any activity that

and the level of

produces

activity should be

shortness of

evaluated.

breath.
> Encourage

> Iron has a role in

intake of foods

oxygen transport and

high in iron and

increases energy

good source of

level.

energy such as
lean meat,
legumes which
are rich in protein.
> Assist patient to

>To prevent injuries.

learn and
demonstrate
appropriate safety
measures.

Assessment

Nursing

Scientific

Diagnosis

Explanation

Planning

Nursing
Intervention

Rationale

Evaluation

Subjective:

Ineffective

Community-

usahay naga breathing

Acquired

lisod

disease

kog pattern

is

Short Term :
a

> Assess

> Any of this

respiratory

abnormalities would

process After 4 hours system by noting

hinga kanang related to

involving

mo

inflammation

of Interventions

lung

It , the patient expansion, breath

grabe thick

akong
as

ubo tenacious

verbalize secretions

by the patient

of

tissue.

typically

Nursing respiratory rate,

results shall have a sounds, arterial

in the

when

normal

bronchi

microorganisams

respiratory

due to

enter the normally rate, rhythm,

Objective :

inflammati

sterile lungs from depth

Initial VS:

on of lung

the nasopharynx reports

PR= 87bpm

tissue

and

RR= 25cpm

depth chest

blood gases, etc.

the

of breath

and > Assist Patient

a in assuming a
as position or

lung evidence by position of choice

The patient

of the respiratory

has normal

system and

respiratory

progression of

rate,

disease; also

rhythm,

establishes a

depth of

baseline comparison

breathing

such as leaning

>maximizes thoracic

from

cavity space,

shortness of

decreases pressure

breath as

from diaphragm and

evidence by

abdominal organs

decreased

and facilitates use of

RR from 25

accessory muscles

cpm to 16-

>difficulty of

parenchyma.

breathing

Because of the RR from 25 forward or over

>use of

inflammation

supraclavicul

the

ar muscles

filed with fluid and

> Increase oral

hydration status and

for respiration

mucus

fluids to 2000-

decrease secretions.

alveoli

decrease

indicate the studies

and relief

produces shortness of high- fowlers

inflammation

of cpm to 16- bed table

are 20 cpm
and

Short Term :

20 cpm
>help to improve

as well as

oxygen

and

shoulder

carbon

dioxide

muscles

exchange cannot

3000 ml/day as
tolerated
> mobilizes thick

take place at a

> Provide chest

secretions, and

> non-

alveolar capillary

physiotherapy,

facilitates clearing of

productive

cellular

bronchial tapping,

lung fields.

cough

membrane

level

vibration, etc.

due to blood flow

> with

decreases

>Assist with

>patient with

presence of

(deceased

activities of daily

pneumonia may lack

rales on both

perfusion of blood

living as required

sufficient oxygen

lung lobe

in the lungs)and

reserves to perform

upon chest

leukocytes

activites; even eating

auscultation

fibrin consolidate

may cause severe

in

dyspnea

the

and

affected

part of the lung

due

to

> Teach patient

> Knowing how to

decreased blood

how to decrease

control shortness of

Patient may

flow there is a

shorthness of

breath will help cope

manifest the

decreased supply

breath by

and have optimal

following :

of oxygen to other

restructuring

functioning

tissues leading to

activities

>severe

ineffective

dyspnea

breathing pattern

>Teach

> Preventing spread

pulmonary

of infection and

hygiene;

subsequent

>Abnormal

prevention of

hospitalization

blood gases

spread of
infection

> abnormal
inspiratory

>Administer

>Enhances

or/and

bronchodilators

expectoration of

expiratory

and expectorants

secretions of

ration

previously ineffective
cough

> pursed lip

breathing
> Administer

>Helps to prevent or

> altered

antibiotics as

eradicate infections

chest

ordered

to reduce secretions

excursion

and to end to
inflammation

>hypoxia
(Confusion,

restlessness,
decreased
vital capacity)

DISCHARGE PLAN
M> Patient will continue its ordered medication by the physician.
E> Deep Breathing Exercises
> Coughing Exercises
> Limit activities and have rest periods.
T> Continue medications as order.
H> Encourage d to keep environment allergen free.
> Encouraged warm versus cold liquids as appropriate.
> Provided information about the necessity of raising and expectorating
secretions versus swallowing them.
> Encouraged to have rest periods and limit activities to level of respiratory
tolerance.
> Encouraged to have a monthly check-up.
> Encouraged to stop smoking.
> Demonstrated pursed lip or diaphragmatic breathing techniques.
> discussed rationale for and encourage continuation of successful
interventions.
O> Advised patient to have a Follow-up check-up after one week.
D> Increased oral fluid intake.
> High calorie, high protein diet of soft foods.
E= Goal Met AEB patient verbalized understanding of the health teachings give

CONCLUSION
Community- Acquired Pneumonia is one of the most common infectious diseases
addressed by clinicians cause of morbidity and mortality worldwide
In the case of Mr. X, the disease was caused primarily by personal and
environmental factors such as cigarette smoking, alcohol, job exposure to pathogens,
and other factors. This lead to the development of the disease and lack of action on the
part of the caretakers. Mr. X manifested difficulty of breathing, non productive cough,
and rales on both lung fields.
Through these manifestations different laboratory and diagnostic procedures that
would confirm and support the admitting diagnosis were performed. Different results
have been taken out such as to consider illness such as PTB, AGE and Atelectasis
which have been ruled out and the hospital final diagnosis was Community- Acquired
Pneumonia.
The result played an essential part on the part of the patient. Since the family has
no information about the signs and symptoms of the disease they will now be aware on
those things in order to prevent this illness.
Years have passed and still these diseases are present especially with
developing countries. The solution is simple but needs great discipline to make it
concrete. A clean surrounding will definitely boost our chances of invading such disease
condition.
We the group 6-B strongly recommends that further studies are to be done to
clear out other vague information and misconceptions regarding this disease.

RECOMMENDATIONS
To the community:
The community should be more oriented to this kind of condition and also for the
safety of community to know what are the proper management and how to care patients
with this type of condition.
To the family:
For his family members, they should be more aware on their environment. This
should be an experience for them to not disregard any early signs and symptoms of a
disease especially pneumonia.
To the students:
For the students who are more knowledgeable about community acquired
pneumonia, they should give more information and health teachings to the patients who
experiencing such condition.
To the client:
Mr. X should continue his medication to prevent any multi-resistant disease. Also
accept if there is any changes on his lifestyle such as withdrawal of his smoking and
drinking alcoholic beverages.

BIBLIOGRAPHY
BOOK SOURCES:
Smeltzer, et. al. Medical-Surgical Nursing: 11th Edition. Lippincott Williams and Wilkins.
2011
DeglinHopfer, Valierant, Nazorel. Davis Drug Guide for Nurses: 10 th Edition. F.A. Davis
Company, Philadelphia. 2009
Doenges, et. al. Nurses Pocket Guide: Diagnosis, Prioritized Interactions and
Rationales: 11th Edition. F.A. Davis Company, Philadelphia
McCance, et. al. Pathophysiology: The Biologic Basis for Disease Adul and Children: 5 th
Edition. 2010
Schilling, et. al. Nursing Process Approach To Excellent Care: 5 th Edition. Lippincott
Williams and Wilkins. 2011
ONLINE SOURCES:
http://www.medscape.com/viewarticle/475218
http://www.emedicine.com/MEDtopic3162.htm
http://www.utmedicalcenter.org/encyclopedia/1/000145.htm
http://www.mims.com/
http://www.doh.gov.ph/data_stat/html/mortality.htm
http://www.wrongdiagnosis.com/p/pneumonia/prevalenve.htmtypes
http://www.lungusa.org/site/c.dvLUK900E/b.22576/K.7FFF/Human_Respiratory_System
.htm
http://www.edgedavao.net

Davao Doctors College

General Malvar St. Davao City
BACHELOR OF SCIENCE IN NURSING

Nursing Managements of a patient with

COMMUNITY-ACQUIRED PNEUMONIA

A case study presented to the Nursing Clinical Instructors

of Davao Doctors College

In partial fulfilment of the requirements in

Nursing Care Management 103

Villacorte, Kevin M.,

Subaldo, Lindsay
Santua, Ej Ann
Tutor, Nevia

July 13, 2015

TABLE OF CONTENTS
Objectives................................................................................................1
Introduction..............................................................................................2
Definition of term......................................................................................4
Comprehensive Assessment...................................................................5
Physical Examination...............................................................................6
Anatomy and Physiology..........................................................................12
Pathophysiology schematic......................................................................17
Pathophysiology narrative........................................................................18
Course in the ward....................................................................................20
Laboratory.................................................................................................22
Drug study.................................................................................................23
Nursing care plan......................................................................................31
Discharge plan..........................................................................................43
Conclusion................................................................................................44
Recommendation......................................................................................45
Bibliography...46