I. INTRODUCTION

This is a case of a 62 year old man who was diagnosed with Community Acquired Pneumonia.

Pneumonia is an inflammation or infection of the lungs most commonly caused by a bacteria or virus. Pneumonia can also be caused by inhaling vomit or other foreign substances. In all cases, the lungs' air sacs fill with pus , mucous, and other liquids and cannot function properly. This means oxygen cannot reach the blood and the cells of the body.

Most pneumonias are caused by bacterial infections.The most common infectious cause of pneumonia in the United States is the bacteria Streptococcus pneumoniae. Bacterial pneumonia can attack anyone. The most common cause of bacterial pneumonia in adults is a bacteria called Streptococcus pneumoniae or Pneumococcus. Pneumococcal pneumonia occurs only in the lobar form.

An increasing number of viruses are being identified as the cause of respiratory infection. Half of all pneumonias are believed to be of viral origin. Most viral pneumonias are patchy and the body usually fights them off without help from medications or other treatments.

Pneumococcus can affect more than the lungs. The bacteria can also cause serious infections of the covering of the brain (meningitis), the bloodstream, and other parts of the body.

Community-acquired pneumonia develops in people with limited or no contact with medical institutions or settings. The most commonly identified pathogens areStreptococcus pneumoniae, Haemophilus influenzae, and atypical organisms (ie, Chlamydia pneumoniae,Mycoplasma pneumoniae, Legionella sp). Symptoms and signs are fever, cough, pleuritic chest pain, 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 or healthy patients, but many pneumonias, especially when caused by S. pneumoniae or influenza virus, are fatal in older, sicker patients.

II. PATIENT PROFILE

Name: E. S.

Age: 62 years old

Sex: Male

Religion: Roman Catholic

Date Admitted: October 1, 2015 at exactly 11:15 AM

Admission diagnosis: COPD not in exacerbation

Final diagnosis: Community Acquired pneumonia (CAP)moderate Risk

III. PATIENT HISTORY

Chief Complaint: Difficulty of Breathing

General Data:

This is a case of a 62 year old male Filipino, presently residing in Malinta, Valenzuela who was admitted in Valenzuela Medical Center on October 1, 2015.

History of Present Illness:

5 days prior to admission, patient had positive signs and symptoms of cough, yellowish pleghm, persistent fever and back pain. Knowing that these signs and symptoms were just forms of little discomforts, he self-medicated with Paracetamol. However, he noticed no changes and experienced difficulty of breathing so he sought medical consultation.

IV. PHYSICAL ASSESSMENT

Vital Signs:

Blood Pressure: 110/60

Temperature: 35.7 C

Pulse rate: 78bpm

Respiratory rate: 26 breaths/min

General appearance:

The patient is awake, lying on bed, conscious and coherent with an oxygen cannula running at 2LPM

V. ANATOMIC AND PHYSIOLOGY OVERVIEW

The Lungs

The lungs are paired, cone-shaped organs which take up most of the space in

our chests, along with the heart. Their role is to take oxygen into the body, which

we need for our cells to live and function properly, and to help us get rid of

carbon dioxide, which is a waste product. We each have two lungs, a left lung

and a right lung. These are divided up into 'lobes', or big sections of tissue

separated by 'fissures' or dividers. The right lung has three lobes but the left lung

has only two, because the heart takes up some of the space in the left side of our

chest. The lungs can also be divided up into even smaller portions, called

'bronchopulmonary segments'.

These are pyramidal-shaped areas which are also separated from each other by

membranes. There are about 10 of them in each lung. Each segment receives its

own blood supply and air supply.

Air enters your lungs through a system of pipes called the bronchi. These pipes start from the bottom of the trachea as the left and right bronchi and branch many times throughout the lungs, until they eventually form little thin-walled air sacs or bubbles, known as the alveoli. The alveoli are where the important work of gas exchange takes place between the air and your blood. Covering each alveolus is a whole network of little blood vessel called capillaries, which are very small branches of the pulmonary arteries. It is important that the air in the alveoli and the blood in the capillaries are very close together, so that oxygen and carbon dioxide can move (or diffuse) between them. So, when you breathe in, air comes down the trachea and through the bronchi into the alveoli. This fresh air has lots of oxygen in it, and some of this oxygen will travel across the walls of the alveoli into your bloodstream. Travelling in the opposite direction is carbon dioxide, which crosses from the blood in the capillaries into the air in the alveoli and is then breathed out. In this way, you bring in to your body the oxygen that you need to live, and get rid of the waste product carbon dioxide.

VI. PATHOPHYSIOLOGY

Virulent Microorganism

Streptococcus Pneumoniae

Microorganism eneters the nose( nasal passages)

Passes through the larynx, pharynx, trachea

Microorganism enters and affects both airway and lung parenchyma

Airway damage Lung invasion

Infiltration of bronchi flattening of epithelial cells

Infectious organism lodges macrophages and leukocytes

Stimulation in bronchioles necrosis of bronchial tissues mucus and phlegm production

Alveolar collapse narrowing of air passage COUGHING

Productive/non-productive

Increase pyrogen in the body DIFFICULTY OF BREATHING

FEVER

Necrosis of pulmonary tissue

Overwhelming sepsis

DEATH

VII. Diagnostic Exam

Chest X-ray Result:

Impression: There are reticolunodular opacities on both lungfields with upward traction of left hilus. There are dilated thick walled bronchi noted on both lower lobes. Heart is not enlarged. Aortic knob is sclerotic other visualized structures are unremarkable. Findings are suggestive of Extensive PTB, Bilateral with cicatrical changes, left upper lobe.Bacteriologic correlation is suggested.

Clinical Chemistry Result:

Sodium: 124.9 mmol/L Normal: 135.0-148mmol/L

Hematology Result:

Hct: 0.29 Normal: 0.37-0.47

WBC: 23.5x10 Normal: 5.0-10.0x10

Segmenters: 0.87

Lymphocytes: 0.13

Urinalysis:

Color: Light Yellow

Transparency: Slightly Hazy

Reaction: (pH) 6.0

Protein: +1

Glucose: negative

Specific Gravity: 1.010

Pus cells: 3-4/HPF

RBC: 2-3/hpf

Crystals: A Urates: Many

Mucus threads: few

Cast: Fine Granular cast : 1-2/HPF

VIII. Drug Study

Generic Name: Acetylcysteine

Brand Name: Fluimucil

Classification: Mucolytic Agent

Dosage:

Pharmacokinetics:

Metabolism: Hepatic; half life 6.25 hrExcretion: Urine (30%)

Indications:Mucolytic Adjuvant therapy for abnormal, viscid, or inspissated mucus secretion in acute and chronic bronchopulmonary disease

(pneumonia,asthma,TB).Contraindications:

Contraindicated with hypersensitivity to acetylcysteine; use caution and discontinue if bronchospasm occurs.Adverse Reaction:

Nausea, rhinorrhea, bronchospasm especially in asthmatics, stomatitis,and urticaria.

Nursing Considerations:1. dilute with normal saline solution or sterile water for injection.

2. Administer the ff drugs separately because they are incompatible with acetylcysteine: tetracyclines, hydrogen peroxide, trypsin.

3. Use water to remove residual drug solution on the patient’s face after administration by face mask.

4. Inform patient that nebulization may produce an initial disagreeable odor, but will soon disappear.

X. NURSING CARE PLAN

Problem: Difficulty of breathing

Diagnosis: Ineffective Airway Clearance related to increased mucus production.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:

“nagrereklamo nga si tatay na nahihirapan siya huminga, dami din kasi plema eh” as verbalized by relative.

Objective:

*RR- 26

*Dyspnea

*(+)non-productive cough

*Use of accessory muscle

Ineffective airway

clearance related to increase mucus

production

Short term goal:

After 3-4 hours of intervention, patient will expectorate secretions effectively and RR will decrease from 26 to normal range of 16-20/min.

Long term goal:

After 3 days of intervention, patient will maintain patent airway as evidenced by normal RR.

Independent:

1.Assessed rate/depth of respiration and chest movement.

2.Elevated head of bed and changed position frequently.

3.Assisted patient with frequent deep breathing exercises.

1.Tachypnea, shallow respiration are usually present.

2.Lowers diaphragm, promoting chest expansion, mobilization and expectoration of secretion.

3.Deep breathing facilitates maximum expansion of

Goal half met.

After 4 hours of nursing

intervention, patient

expectorated secretion and RR decreased from 26/min to

22/min.

4. Encouraged increase in fluid intake.

Collaborative:

5.Administered mucolytics as indicated.

(Fluimucil)

6.Provided supplemental fluids.

(IVF: PNSS)

the lungs and smaller airways.

4.Fluids aid in mobilization and expectorations of secretions

5.Aids in mobilization of secretion.

6.Fluids are required to replace insensible loss and aids in mobilization of secretions.

7.Follows

7.Monitored chest Xray, ABG and pulse oximetry results.

progress and effects of disease process.