AMA Computer Learning CenterSt. Augustine School of Nursing

A Case Study Presented to the faculty of AMA Computer Learning Center

PNEUMONIA

Submitted to:Mr. John Eric T. Salvador B.S.N, R.N

Submitted by:Almario, Jeanette

Cayanan. Gemmalyn JoySantos, Cariza Joy M.

3k-PN

September ‘09

Table of Content Page

Introduction 1

Personal History 2 Family health history Past health history

Complete Physical Assessment 5-11

Neurological Assessment 12

Laboratory Procedure 13-15

Anatomy and Physiology 16

Pathophysiology of Pneumonia 17

Drug Study 18

Diet and Activity 19

SOAPIE (actual) 20

SOAPIE (potential) 21

Conclusion 22

Recommendations 23

Bibliography 24

NCP(actual) 25

NCP (potential) 26

Introduction

Pneumonia is serious infection and/or inflammation of the lung. The air sacs in the lung which are the alveoli are filled with fluid. Oxygen has trouble reaching the blood. If there is too little oxygen in the body, the body can’t work properly. Because of this and spreading infection through the body pneumonia can cause death.

Symptoms of pneumonia caused by bacteria usually come on quickly. They may include productive cough (greenish phlegm), fever and chills, fast breathing and feeling short of breath, chest pain that often feels worse when you cough or breathe in, body weakness and difficulty of breathing.

Pneumonia is not a single disease. It can have over 30 different causes. There are five main causes of pneumonia; bacterial pneumonia (pneumoccocal pneumonia & legionnaires disease) viruses/viral pneumonia, mycoplasmas pneumonia, fungi (pneumocytis carinii) and other various chemical.

Latest Trend(Medication for Pneumonia)

Macrolids such as azithromycin, clarithromycin, erythromycin. Tetracylines, such as doxycycline. Fluoroquinolones, such as gemifloxacin, levofloxacin and moxifloxocin. If you have to go to the hospital, your doctor may use any of the above antibiotics. Other antibiotics that your doctor may use in this situation include: Cepholosporins , such as ceftriaxone, cefotaxime, ceftazidime or cetepime. Penicillins, such as amoxicillin with clavulanate, ampicillin and tacarcillin with clavulanate and vancomycin.

The adult pneumonia shot, Pneumovax (pneumoccocal vaccination), protects against 23 strains of pneumoccocal bacteria.

1.

2. Personal History

Name: Mr. X Address: San Jose, GuaguaAge: 77 yrs. Old Work: Truck Driver

2.

3.

2.1 Past Health History

Mr. X, past illness was diarrhea (last August 26, 2009) and often, on/off fever (last August 28, 2009). But he was never been confined in the hospital before.

2.2 Present Health History

Mr. X, 77 years old, widowed from San Jose was a patient at DPMMH. He was confined last September 1, 2009 because of difficulty of breathing, productive cough and high grade fever 3 days before confinement.

When he was confined in the hospital, Mr. X said that he experienced body malaise and chills whenever he has a high grade fever. His daughter said that it was her first time that he saw her father experienced high grade.fever of 39.4 during our duty hours of 7-3 pm.

3. Lifestyle and Diet

Mr. X admitted that during his childhood days he used to smoke 30-40 pieces of cigarette per day (1 ½ pack/day). And drink alcohol after his work, usually 4-5 bottles per day. Now, at his age Mr. X said that he already stopped smoking but he said he drink occasionally.

Mr. X verbalized also that he likes to eat meat but because of not enough income he just eat what his family prepared.

4.4. Complete Physical Assessment

Date assessed: September 4, 2009Time Assessed: 9:00 A.MInitial Vital Signs:

Temperature: 37.4CPulse Rate: 70bpmRespiratory Rate: 30cpmBlood Pressure: 110/70 mmHg

General Appearance: The pt. is awake, lying on bed, conscious and coherent with an IVF of

D5W regulated @ 10-15 gtts./min. (KVO) 90ml. level infusing well @ right hand.

The pt. can follow instructions and commands.Area Assessed Technique

UsedNormal Findings

Actual Findings

Analysis

SKINcolor Inspection Tan Pallor Due to DOBTexture Palpation Smooth, soft Smooth, soft NormalTurgor Palpation Skin snaps

back immediatelyWhen pinched

When pinched, it slowly snaps back

Due to aging

Hair Distribution Inspection Evenly distributed

Evenly distributed

Normal

Temperature Palpation Warm to touch Warm to touch NormalMoisture Palpation Dry, skin folds

are normally moist

Dry, skin folds are normally moist

Normal

NAILSColor of Nail bed Inspection Pink and clear Pink and clear NormalTexture Palpation Smooth Smooth NormalShape Inspection Convex

curvatureConvex curvature

Normal

Nail base Inspection Firm Firm NormalCapillary refill time

Blanch test 2-3 seconds 4 sec. Due to DOB

HAIRColor Inspection Black (varies)

Black but slightly going to white

Normal due to aging

Distribution Inspection Evenly distributed

Evenly distributed

Normal

Moisture Inspection Neither Neither Normal

excessively dry nor oily

excessively dry nor oily

Texture Inspection Silky, resilient Silky, resilient NormalHEAD

Scalp symmetry Inspection Symmetrical Symmetrical Normal

Skull size Inspection Normocephalic Normocephalic Normal Shape Inspection

and PalpationRound Round Normal

Nodules/ masses Palpation Absence of nodules and masses

Absence of nodules and masses

Normal

FACESymmetry Inspection

Symmetrical Symmetrical Normal

Facial movement Inspection Symmetrical Symmetrical Normal

Skin color Inspection Tan Pale Due to DOBEYESEyebrows Inspection

Symmetrically aligned, equal movement

Symmetrically aligned, equal movement

Normal

Eyelashes Inspection Slightly curved upward

Slightly curved upward

Normal

Eyelids Inspection Smooth, tan, do not cover pupil as sclera, close symmetrically

Smooth, tan, do not cover pupil as sclera, close symmetrically

Normal

Ability to blink Inspection Blinks voluntarily and bilaterally

Blinks voluntarily and bilaterally

Normal

Frequency of blinking

Inspection 20 blinks per min.

17 blinks per min.

Normal

Ocular movement Inspection Eye moves freely

Eye moves freely

Normal

Position Inspection Drawn from lateral angel

Drawn from lateral angel

Normal

Size Inspection Medium Medium Normal Texture Palpation Mobile, firm and

non-tenderMobile, firm and non-tender

Normal

CONJUCTIVAColor Inspection Transparent

with light colorTransparent with light color

Normal

Texture Inspection Shiny and smooth

Shiny and smooth

Normal

Presence of lesions

Inspection No lesions No lesions Normal

APPARATUS

Cornea

Color Inspection Black Black Normal Texture Inspection Shiny and

smoothShiny and smooth

Normal

PUPILSColor Inspection Black Black NormalReaction to light Inspection Pupils Equally

Round and React to Light Accommodation (PERRLA)

Pupils Equally Round and React to Light Accommodation (PERRLA)

Normal

Size Inspection Equal Equal NormalShape Inspection Round and

constrict brisklyRound and constrict briskly

Normal

Symmetry Inspection Equal in size Equal in size Normal Visual Acuity Inspection Able to real

news printAble to real news print

Normal

Visual Fields Inspection When looking straight ahead, client can see objects in periphery

When looking straight ahead, client can see objects in periphery

Normal

Ocular Inspection Eyes move freely

Eyes move freely

Normal

NOSESymmetry, shape, size and color

Inspection Symmetrical, smooth and tan

Symmetrical, smooth and tan

Normal

Mucosa color Inspection Reddish to pinkish

Reddish to pinkish

Normal

NASAL SEPTUMNares

Inspection Oval, symmetrical

Oval, symmetrical

Normal

Nasal discharge Inspection No discharge No discharge Normal Sinuses Inspection Not tender Not tender Normal MOUTHSecretion Inspection (neutral in

color) without mucus production

Mucus production

Abnormal due to inflammation

LipsColor

Inspection Pinkish to slightly brown

Pinkish to slightly brown

Normal

Symmetry Palpation Symmetrical Symmetrical Normal Texture Palpation Soft, moist,

smoothSoft, moist, smooth

Normal

Moisture Palpation Soft and moist Soft and moist Normal GUMSColor Inspection Pinkish Pinkish Normal Moisture Palpation Moist Moist Normal

BUCCAL MUCOSAColor Inspection Glistening pink Glistening pink Normal Texture Palpation Soft Soft Normal Moisture Palpation Moist Moist Normal TOUNGEColor Inspection Pinkish Pinkish Normal

Size Inspection Medium Medium Normal Symmetry Inspection Symmetrical Symmetrical Normal Mobility Inspection Moves freely Moves freely NormalUVULALocation Inspection At the midline At the midline Normal Symmetry Inspection Symmetrical Symmetrical Normal TONSILSColor Inspection Pinkish Pinkish NormalDischarges Inspection No discharges No discharges Normal TEETHColor Inspection Ivory/yellowish Yellowish NormalNumber of teeth Inspection 32 28 Due to tooth

decay (teeth extraction)

NECKPosition Inspection Head-centered Head-centered Normal Movement Inspection Moves freely Moves freely Normal Range of motion Inspection Full range Full range NormalConsistency Inspection No enlargement No enlargement Normal HEARTHeart rate Auscultation 60-100bpm 70bpm Normal Heart sounds Auscultation Clear, without

cracklesCrackling Due to the

presence of phlegm and increased mucus production

Lung field Auscultation Resonant With crackles Due to secretions

THORAX & LUNGS POSTERIOR THORAXSymmetry Inspection Symmetrical Symmetrical Normal

Respiratory rate Inspection 12-20cpm 30cpm Due to blockage of secretions

Spinal Alignment Inspection Spine vertically align

Spine vertically align

Normal

Skin integrity Inspection Skin intact Skin intact Normal ANTERIOR

THORAXBreathing pattern Auscultation Breathing is

automatic and effortless, regular and even and produces no noise

Breathing is with effort, produces noise when breathing

Due to secretions in the lungs

Lung/ breath sounds

Auscultation Bronchia-vesicular

crackles Due to the constriction of the bronchus

ABDOMENContour Inspection Flat Flat NormalTexture Palpation Smooth Smooth Normal Frequency and character

Auscultation Audible; soft gurgling sound occur irregularly and rages from 5-30 mins

Audible; soft gurgling sound occur irregularly and rages from 5-30 mins

Normal

UPPER EXTREMITY Skin color Inspection Tan Pale Due to

decrease oxygen

Size (arms) Inspection Equal Equal Normal Symmetry Inspection Symmetrical Symmetrical Normal Hair distribution Inspection Evenly

distributedEvenly distributed

Normal

LOWER EXTREMITY

Skin color Inspection Tan Pale Due to decrease oxygen

Size (legs) Inspection Equal Equal Normal Symmetry Inspection Symmetrical Symmetrical NormalHair distribution Inspection Evenly

distributedEvenly distributed

Normal

NEUROLOGICALLevel of consciousness

Interview Can follow instructions and commands

Can follow instructions and commands

Normal

Behavioral and appearance

Interview Makes eye contact with the examiner

Makes eye contact with the examiner

Normal

Mood Interview Expresses feelings which corresponds to the examiner

Expresses feelings which corresponds to the examiner

Normal

MANNERISMS &

ACTIONS LANGUAGEVoice inflection Interview Clear and

strongClear and strong

Normal

Tone Interview Fluent and articulated

Fluent and articulated

Normal

Manner and speech

Interview Can give appropriate answer to questions

Can give appropriateanswer to questions

Normal

MENTAL STATUSOrientation Interview Oriented with

timeOriented with time

Normal

TIMERecall recent and remote memory

Interview Recall events readily, immediate recall of remote information

Recall events readily, immediate recall of remote information

Normal

Judgments and thoughts

Interview Can make logical decisions

Can make logical decisions

Normal

11.

Neurological Assessment

Olfactory Nerve (sense of smell) Can smell on both nostrils.

Optic Nerve Without 20/20 vision due to aging.

Occulomotor Nerve PERRLA (test by the used of penlight).

Abducens Nerve Lateral movement

Trochlear Nerve Up & Down gaze

Trigeminal Nerve (+) face sensation

Facial Nerve Can smile, can frown, and roof his /her cheeks.

Acoustic/Vestibulocochlear Nerve Can hear on both ears (clapping the hand)

Glossopharyngeal Nerve Can swallow

Vagus Nerve (+) gag reflex

Spinal Accessory Nerve With a little strength on both shoulder.

Hypoglossal Nerve Can taste sweet, bitter & salty.

12.

5. Laboratory ProceduresLaboratoryProcedure

Date Done

Normal Values

Result Nursing Interpretatio

n

NursingResponsibilities

Hematology September 2,2009

Hemoglobin120-70g/l

153g/l Abnormal due to presence of infection

Pretest:Explain the procedure to the patient.

Instruct the patient to wear easily manipulated clothing to get blood samples easily.

Erythrocyte4.0-5.0 x 10

g/l

5.3 x g/l

Abnormal due to presence of infection

Tell the pt. to relax because the procedure is painless.

Hematocrit0.37-0.54

g/l

0.46 g/l

Normal Intra-test:Instruct the patient to look away when the needle is being inserted.

Leucocytes5-10 x 10

g/l

21.1 x 10 g/l

Abnormal due to infection weakened immune response.

Post-test:Put cotton balls on the puncture site to avoid bleeding.

Platelets150-450 x

10/l

252 x 10/l

Normal Tell the patient to rest after the test.

13.

LaboratoryProcedure

Date Done

Normal Values

Result Nursing Interpretation

NursingResponsibilities

URINALYSIS Sept. 3, 2009

ColorStraw/ yellow amber

Yellow Normal Pre-test:Explain the procedure to the pt. and how he can cooperate.

TransparencyClear

Turbid Due to infection

Provide privacy.

Reaction4.5-8.0

6.0 Normal Intra-test:Instruct the pt. on how to get urine samples (it should be midstream/ sterile technique).

Specific Gravity1.010-1.025

1.010 Normal Tell the pt. that the procedure is painless.

SugarNegative

Negative Normal Post-test:Bring the urine samples in the laboratory.

Albumin Negative

Negative Normal

MicroscopicExamination

Sept. 03, 2009

E cells:None

Few Abnormal due to infection.

Mucus Thread:None

Many Abnormal due to infection.

Red Blood Cell:4.0-5.0 x 10 g/l

0.1 Abnormal due to infection.

PLS Cells 4 Normal

4.5-5.5Bacteria:None

Few Abnormal due to infection.

14.

Diagnostic Procedure

Date Done

Result Impression Nursing Responsibilities

Sept. 4, 2009

There is haziness in right lower lung zone. Nodular densities in the trachea-bronchial region. The heart is in normal size and configuration. Diaphragm, costophrenic angle and the visualized bone are intact.

Pneumonia, right lower lung.

Pretest:Inform the client prior to the exam if you are pregnant, may be pregnant or have an IUD inserted.

Remove all jewelry and wear hospital gown because certain metal or clothing can obscure the image.

Intra-test:Provide privacy.

Post-test:Provide time for the client to change his clothing.

15.

6. Anatomy and Physiology of the Respiratory System

Lungs 

The lungs are the body's major organs of respiration. The two vital parts that make up the lungs are located on each side of the chest within the rib cage. They are separated by the heart and other contents of the mediastinum - the tissues and organs of the middle chest (e.g., the heart and large vessels, windpipe, etc.). The lungs are shaped rather like an upside-down butterfly. The top, or apex, of each lung extends into the lowest part of the neck, just above the level of the first rib. The bottom, or base, of each lung extends down to the diaphragm, which is the major breathing-associated muscle that separates the chest from the abdominal cavity. Each lung is divided into upper and lower lobes, although the upper lobe of the right lung contains another triangular subdivision known as the middle lobe. The right lung is larger and heavier than the left lung, which is somewhat smaller in size because of the position of the heart. At birth, the lungs are pinkish-white in color; however, with age, the lungs darken to gray or mottled black because of deposits of carbon and other particles that are inhaled over the years.

Alveoli

An alveolus (alveoli is plural) is a tiny air sac located within the lungs. The exchange of oxygen and carbon dioxide takes place within these sacs.The basic structure of the respiratory system can be envisioned as an upside-down tree. Air is breathed into the trachea, which is the tree trunk, and thus the broadest part of the respiratory tree. The trachea divides into two major tree limbs, the right and left bronchi, each of which branches off into multiple smaller bronchi, which course through the tissue of the lung. Just as a tree's limbs branch off into ever-smaller branches and twigs, so each bronchus divides into tubes of smaller and smaller diameter, finally ending in the terminal bronchioles. The air sacs of the lung, in which oxygen-carbon dioxide exchange actually takes place, are clustered at the ends of the bronchioles like the leaves of a tree at the ends of the smallest twig-like branches, and are called alveoli.

16.

8. Drug Study

Drugs Date Order

Classification Indication Side Effect

Nursing Responsibility

Generic Name:RoxithromycinBrand Name:Macrol

Sept. 01, 2009

Antibacterial Upper and lower respiratory tract infections and otitis media due to S. Pneumonea, Mycoplasmas Pneumonea, Legionella pneumophila

Nausea, Abdominal pain and Diarrhea

Perform Skin Test

Generic Name:DiphenhydramideBrand Name:Benadryl

Sept. 01, 2009

Antihistamine Preventing or treating symptoms of high fever and other respiratory allergies, common colds and runny nose

Tiredness, Sleepiness and Disturb coordination

Tell the pt about the side effect that he may feel.Assist the pt from sitting position to lying position

Generic Name:ParacetamolBrand Name:Aeknil

Sept. 01, 2009

Antipyretic Pyrexia of unknown origin and for symptomatic relief of fever and pain associated with common disorders like lower and upper respiratory tract infection

Skin Eruption, Leucopenia

Perform TSB to help reduce fever.Instruct the pt to decrease fluid intake

Generic Name:CefuroximeBrand name:Axcef

Sept. 01, 2009

Antibacterial For the treatment of apnea and lower respiratory tract infection

Nausea and vomiting, Erythema Multiforms and Steven Johnson Syndrome

Perform Skin Test before giving antibiotics

Generic Name:AmbroxolBrand Name:Mucoslovan

Sept. 01, 2009

Expectorant Dissolved the phlegm and clear the airways

GastroIntestinal side effects

It is advisable to avoid use during the first trimester of pregnancy

18.

9. Diet and Activity

Activity Date Ordered Indication Nursing Responsibilities

Turn side to side (every 2 hrs.)

September 2, 2009

To mobilize secretions& to

prevent bed sores

Accompany the relative and the pt whenever the pt

feels body malaise

Diet Date Ordered Indication Nursing Responsibilities

Low Fat Low Salt Diet

September 1, 2009

To prevent hypertension.

Instruct the pt. and relative to follow the diet of the pt.

Tell the pt. to eat food rich in vitamins and minerals.

Increase fluid intake.

September 1 , 2009

To liquify secretions.

Tell the pt. and relative about the benefit of drinking water.

Tell the relative to use calibrated bottle to make about intake.

19.

11. SOAPIE (actual)

Subjective“Madalas pa rin akong umuubo at nahihirapqan din akong huminga

parang bumabara ang plema”, as verbalized by the patient.

ObjectiveReceived patient on semi-fowler’s position, conscious and coherent with

on going D5W 1L regulated @ 10-15gtts/min. (KVO) @90 ml. level infusing well @ right hand.

Has fast and shallow breathing Easily irritable (+) secretions (greenish phlegm) (+) rales upon auscultation Rr 30cpm

Assessment Ineffective airway clearance related to retain secretions as evidenced by

the patient’s statement.

PlanningAfter 4-6 hrs. of N.I, the patient’s respiratory rate decreased from 30 cpm

to 20 cpm.

Interventions Established rapport. Monitored and recorded vital signs. Positioned the patient in semi-fowler’s or orthopneic position. Thought the pt’s relative about PVD (percussion, vibration and postural

drainage). Instructed the patient to increase fluid intake. Provided comfort and safety measures. Medications compliance on time (with the doctor’s permission).

Evaluation Goal met as evidenced by the client’s respiration is improved.

>Pt. Rr is beyond normal>Rr: 20 cpm 20.

SOAPIE (potential)

Subjective

Objective Received pt. on semi-fowler’s position, conscious and coherent with ongoing D5W 1L regulated @ 10-15gtts/min. (KVO) @ 90 ml. level infusing well @ right hand.

Has fast and shallow breathing irritability (+ greenish phlegm) secretions (+) body malaise (+) rales upon auscultation

Assessment Risk for infection related to retained secretions in the lung.

Planning After 5-6 hrs. of N.I the patient verbalized understanding and

demonstrated techniques on how to reduce the risk for infection.

Interventions

Established rapport. Monitored and recorded vital signs. Provided comfort and safety. Instructed the pt. to increase fluid intake. Educated the pt. about proper using and disposing of tissue. Thought the pt. and relative about proper hand washing. Instructed the pt. to avoid cigarette smoking.

Evaluation

Goal partially met as evidence by the client’s respiratory condition became slightly good.

21.

12. Conclusion

We, therefore conclude that pneumonia is a serious disease in the

respiratory system. It may kill more than hundreds of young infant or older

persons with weak immune response. Pneumonia may lead to other chronic

respiratory system, so early detection or signs of the disease are important to

know the right medications to be given by medical professionals.

22.

13. Recommendations

For Health Care Provider

As the cold weather sets in, we are reminded that it is not only time for flu season but or pneumonia season. Pneumonia is one of the common communicable diseases that most of the Filipino people acquired because of weak immune response. And for the protection of health care provider it is important to b vaccinated against pneumonia, proper hygiene (or simply hand washing is very important) and of course, drinking vitamins and eating healthy food can also contribute in good immune response against any disease not only pneumonia.

For the Institutions/Hospitals

For the hospitals especially in the Government Hospitals fighting against the infectious disease Pneumonia must be also prioritized. Pneumonia vaccination must be spread especially in the urban area where the infection can be spread in just a matter of minute. Certain groups of people are more likely to catch pneumonia and to have complications from it. But because of the Pneumovax, there will be big possibilities to avoid these diseases that cause young children hat are more likely to be expose to bacteria and most of the old age people living in a poor ventilated area. And giving also the knowledge about disease and how it may be acquired or how it may not be must be the agendas of some government officials related o health and life of every young Filipinos.

23.

14. Bibliography

National Center for Health Statistics. National Vital Statistics Report. Deaths: Preliminary Data for 2004. Vol. 54, 19 June 2006.

http://search.medicinenet.com/search/search_results/default.aspx?Searchwhat=1&query=platelets

http://search.medicinenet.com/search/search_results/default.aspx?Searchwhat=1&query=Erythrocyte&I1.x=67&I1.y=10

http://www.lungusa.org/site/apps/nlnet/content3.aspx?c=dvLUK9O0E&b=2060321&content_id={71CC3CFD-4B3E-49C8-AA88-D76EAE1FB9F5}&notoc=1

http.www.WebMD.com

http://www.labtestsonline.org/understanding/analytes/urinalysis/faq.html

http://dynamicnursingeducation.com/class.php?class_id=131&pid=18

http://dynamicnursingeducation.com/class_more.php?class_id=131&more=45

http://en.wikibooks.org/wiki/Human_Physiology/The_respiratory_system

http://library.med.utah.edu/WebPath/TUTORIAL/AIDS/AIDS .html

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