CAP Final CP

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    CAPITOL UNIVERSITYCollege of Nursing

    A Case Study

    Presented

    In Partial Fulfillment of the

    Requirement for the Subject

    Related Learning Experience 9

    By:

    Lumbay, Jane FrancesMadroo, Froilan MarieMaglangit, Anthony

    Melecio, Lloyd BryanMerina, Jo Ann

    Monteroyo, JosephMonteroyo, Marelou

    Montes, Jerico ClodualdoNacua, Lovely

    Naduma, Mark JamesonNavaro, ChristineNazareno, Maricel

    Submitted to:Ms. Syvel Jane Mata -Caharian , RN

    Clinical Instructor

    July 15, 2010

    Introduction

    http://www.facebook.com/profile.php?id=1820820179http://www.facebook.com/profile.php?id=1820820179
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    COMMUNITY ACQUIRED PNEUMONIA

    Pneumonia is an infection of the lung parenchyma, usually caused by infection.

    Bacteria, viruses, fungi or parasites can cause pneumonia. Community-acquired

    pneumonia refers to pneumonia acquired outside of hospitals or extended-carefacilities. It can range in seriousness from mild to life-threatening. Pneumonia often is a

    complication of another condition, such as the flu. Antibiotics can treat most common

    forms of bacterial pneumonias, but antibiotic-resistant strains are a growing problem.

    The best approach is to try to prevent infection Pneumonia is a particular concern if

    youre older than 65 or have a chronic illness or impaired immune system. It can also

    occur in young, healthy people.

    Community acquired pneumonia continuous to be a common and serious illness

    both in developed and developing countries in spite of the advent of new and

    sophisticated diagnostic techniques, potent antimicrobials and effective vaccines. It

    remains an important cause of morbidity and mortality for both non-hospitalized adults.

    In the Philippines, it is the fourth leading cause of morbidity and the second leading

    cause of death. AMONG other diseases, pneumonia reportedly ranked first in the Top

    10 causes of death in 80 barangays of Cagayan de Oro, based on the 2009 records of

    the City Health Office.

    One important aspect in the management of community acquired pneumonia is

    the decision to hospitalize a patient. It perhaps the single most important decision

    during the entire course of the illness. However, in patient care does not only entail

    extra cost, but also, it theoretically increases the risk of iatrogenic complications

    associated with hospitalization.

    The group chose this case because of its complexity, in order to identify

    and determine the general health problems and needs of the patient. Since the group

    was able to render 3 days of care over the span of two weeks from June 2, 2010 twodays prior to clients admission at Capitol University Medical City until July 10, 2010; the

    group was able to monitor and participate actively in the management of the disease

    process.

    As nurses our main goal is health promotion and maintenance by preventative

    measures through health education. As student nurses we can contribute to the field of

    nursing by empowering our fellow students with knowledge on how to manage a case

    like pneumonia. By sharing our knowledge we hope to help improve the quality of

    nursing care rendered by Capitolians that will bring pride to our university.

    The following are the specific objectives of this study:

    To raise the level of awareness of the patient and the family regarding the health

    problems that are present.

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    To provide information about pneumonia specifically the disease process and the

    identification of its danger manifestation.

    To motivate the patient and family to continue the health care provided by the

    health workers in Capitol University Medical Center and most especially by the

    students and Clinical Instructor of Capitol University.

    And lastly, to help the lower year level in the nursing department to be more

    knowledgeable in making and conducting a case presentation in the higher

    years.

    This case presentation would also try to develop the critical analysis of each case

    presenter in order to come up with a very good output and a team effort.

    NURSING THEORY

    This case presentation is based on Florence Nightingales

    Environmental Theory. We have chosen this theory as our guide in caring for our patient

    with CAP because as what we have noticed environmental factors have a big impact

    with the cause and the possible prevention of the said disease condition. Nightingales

    theory focuses on changing and manipulating the environment in order to

    put the patient in the best possible conditions for nature to act. She has

    also Identified 5 environmental factors namely fresh air, pure water,

    efficient drainage, cleanliness/sanitation and light/direct sunlight. And she considered a

    clean, well-ventilated, quiet environment is very essential for recovery. Applying this

    theory to care of our patient will be much helpful in a way that patient will be free of the

    risk and avoid things that could worsen his situation.

    The factors that Florence Nightingale emphasized should come together in order

    for the care to be effective, deficiencies in these 5 factors produce illness or lack of

    health. That is where the family members and significant others come into participate in

    providing this type of care for the patient to help her improve her condition and be free

    of the symptoms of CAP.

    CLIENTS PROFILE

    Patient X is a 79-year-old female, married and presently residing at Valencia,

    Bukidnon. She was baptized under Roman Catholic faith.

    Patient X was diabetic. She had history of hypertension and diabetes, no known

    food and drug allergies, non-asthmatic, non-smoker and non-alcoholic beverage

    drinker. The patient had a family history of hypertension from his both parents.

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    A. Vital Signs

    Upon assessment, the following data was obtained from the Patient X: Blood

    pressure= 130/80 mmHg; Axillary temperature= 39.7oC; Pulse rate = 100 beats per

    minute; Respiratory rate= 34 cycles per minute.

    B. Chief Complaints

    The patient had cough and cold.

    C. Health- Illness History

    Three hours prior to admission patient developed increased sleeping time

    and snoring-vomiting. Patient X is positive for diabetes mellitus, had a fever, had a

    yellow sputum, and positive for hypertension.

    D. Previous Hospitalization/Surgeries

    E. Things done to manage health

    Patient was kept watched and monitored. She frequently consults their

    barangay health center workers. She had her maintenance drugs as prescribed by herphysician.

    F. Statement of Patient General Appearance

    Patient X had a senile skin turgor with fair and some white thin spots which were

    evenly distributed. Nail beds were pallor, short and in convex curvature shape.

    G. Nutritional and Metabolic Pattern

    Patient X was on Osteorized Feeding. Daily fluid consumption was inadequate;about a 230 cc was consumed during 8 hours of duty.

    H. Elimination Pattern

    Catheter in placed with yellowish urine attached to Urobag drain at 200cc.

    I. Activity and Exercise Pattern

    Prior to hospitalization, Patient X usually spent her time watching television. She

    doesnt have a regular schedule for exercise.

    J. Cognitive-Perceptual Pattern

    Upon assessment during the first week (July 2-3, 2010), Patient X was lethargic,

    eye movement responsive to speech stimuli.

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    K. Sleep-Rest Pattern

    Prior to admission the patient often slept at 10pm and usually woke up at 5am in

    the morning. Usually the patient sleeps for 7 to 8 hours.

    Physical Assessment

    Baseline DataArea of Assessment

    Assessment Findings Validation

    I. SKIN

    colortemperatureturgor

    Texturelesionsintegrity

    PaleWarm (39.7C)Senile skin turgorno lesions notedRough skin integrity

    InspectionPalpation

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    II. NAILScolortextureshape

    pallordryconvex

    InspectionPalpation

    III. HAIRcolortexturedistributionquantity

    White with some black hairdry hairfine distributedthick

    Inspection

    IV. HEADshapesizeconfigurationheadacheshead injury

    roundednormocephalicgood configuration(+) headachesno head injury

    InspectionPalpation

    V. EYESLidsPeriorboital regionConjunctiva

    ScleraPupils

    >Reaction to light>Reaction toAccommodation

    Visual AcuityPeripheral Vision

    SymmetricalSunkenPale

    AnictericEqual in size 2mmBriskUniformConstriction/convergenceNearsightedDecreased

    InspectionPalpation

    VI. EARSExternal PinnaeExternal CanalGroos HearingTympanic Membrane

    NormosetNo dischargesNormalIntact

    InspectionPalpation

    VII. NOSE AND SINUSESMucosaSeptumPatencyDischarge

    PinkishMidlinePatentNo discharges

    InspectionPalpation

    VIII. MOUTH AND THROATlipsteethmucosagums

    tongue

    PallorCariesPallor

    PinkishMidline

    Inspection

    IX. NECKTracheaThyroid

    MidlineNon-palpable

    InspectionPalpation

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    X. respiratory statusBreathing patternShape of chestLung expansion

    Vocal/Tactile FremitusPercussion

    Breath sounds

    Cough

    Sputum

    Irregular (34 RR)FlatSymmetricalSymmetricalResonant

    Crackles at right chestProductive cough butcannot expectorateYellowish colored

    InspectionPalpationPer