ANGELES UNIVERSITY FOUNDATION Angeles City COLLEGE OF NURSING S.Y. 2008-2009
A Case Study COMMUNITY-ACQUIRED PNEUMONIA
In Partial Fulfilment of the Requirements in Related Learning Experience
Submitted by: David, Nikki Louise Kina Z. Gutierrez, Mary Joy R. Manalo, Ma. Adrianne V. BSN III-15 Group 57 Submitted to: Ms. Johana L. Dimla, R.N. September 19, 2008 TABLE OF CONTENTS
NURSING ASSESSMENT A. Demographic Data, Socio Economic, Cultural And Environmental Factors
C. Pertinent Family HealthHistory..
D. History of Pastillness
E. History of PresentIllness. F. Physical Examination (IPPA, Cephalocaudal Approach) G. Diagnostic and Laboratory Procedures
ANATOMY AND PHYSIOLOGY
THE PATIENTS ILLNESS A. Synthesis of the disease
1. 2. 3.
Definition of the disease Predisposing and Precipitating Factors Signs and Symptoms
4. Health promotion and preventive aspects of the disease V. THE PATIENT AND HIS/HER CARE Medical Management A. IVFs .
B. Drugs C. Diet. D. Activity and ExerciseNursing Management:
A. Nursing Care Plans B. Actual SOAPIERsVI. CLIENTS DAILY PROGRESS IN THE HOSPITAL
A. Clients Daily Progress Chart B. Discharge Planning.1. 2. General Conditions of the Patient Upon Discharge M.E.T.H.O.D.
CONCLUSION AND RECOMMENDATIONS
DEDICATION We would like to dedicate this fruit of our toiling to our Heavenly Father, our Almighty God, for without Him our case would be unfeasible. To our parents, friends, brothers and sisters in the nursing profession and to every person who has an affinity to this profession, we dedicate this to all of you. Moreover, we offer this to those who strive hard to raise the notch for the development and improvement of the noblest profession on earth the nursing profession.
ACKNOWLEDGEMENT The aim of this study was attained through the help and guidance of the following people who have extended their time, support and encouragements to make this study possible. The researchers would like to express their appreciation and give thanks to the Almighty Father, the source of their talent, now more than ever, and for bestowing upon us patience, strength, wisdom and determination that helped us to materialize this study. To their loving families, for providing all the love and care, for always being there to give guidance and care in times of difficulties and for the support they have given form the start of this study. To Ms. Johana L. Dimla, their clinical instructor, for all the patience, advice and undying support and kindness. Her mere guidance enables us to produce the best result. To their patient and the significant others, for their cooperation and willingness to participate in this study and for providing them essential information about this study and making their doors open. Finally, to many unnamed friends, for their support and serving as their inspiration that helped them believe in their capabilities, we would like to extend our deepest gratitude.
I. INTRODUCTION 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, consciousness, underlying lung disease, intubation, alcoholism, altered and smoking, endotracheal malnutrition,
immobilization. The causative microorganisms influence the symptoms and signs with which the patient presents, how the pneumonia should be treated and the prognosis. Pneumonias can be classified into several ways. Pathologists originally classified them according to the anatomic changes that were found in the lungs during autopsies. As more became known about the microorganisms causing pneumonia, a microbiologic classification arose, and with the advent of x-rays, radiological classification. Another important system of classification is the combined clinical classification, which combines factors such as age, risk factors for certain microorganism, the presence of underlying lung disease and underlying systemic disease, and whether the person has recently been hospitalized. The combined clinical classification, now the most commonly used classification scheme, attempt to identify the persons risk factors when he or she first comes to medical attention. The advantage of this classification scheme over previous systems is that it can help guide the selection of appropriate initial treatments even before the microbiologic cause of pneumonia is known. There are two broad categories of pneumonia in this scheme: community-acquired pneumonia and hospital-acquired pneumonia. A recently introduced type of healthcare-associated pneumonia lies between this two categories.
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.
Incidence rates mentioned above is primarily the reason of the group for choosing this case. The prevalence of community-acquired pneumonia in the local and foreign communities needs attention and through this study, CAP would be known better and would be helpful for the group to effectively play their role as advocates of their patients care and well-being. This will serve as an important tool for them to render proper nursing care, facilitate health promotion and perform appropriate interventions to individuals with such condition. This study aims to provide the group a clear view of the pertinent facts surrounding community-acquired pneumonia, which will lead them to become effective and efficient in the nursing field.
II. NURSING ASSESSMENT
A. Personal History a. Demographic Data Mr. Cap is a 69-year old naturally born Filipino. He was born on February 17, 1939 and is presently residing at Magalang. He was admitted last August 17, 2008 at a district hospital somewhere in Angeles City with a chief complain of difficulty of breathing. His admitting diagnosis was Bronchopneumonia and Acute Gastroenteritis. He had a final diagnosis of community-acquired Pneumonia. He was discharged last August 25, 2008. b. Socio-economic and Cultural Factor Brought by their economic status in life, Mr. Cap had only finished elementary at a public school in Magalang. After graduating in elementary, he started working as a farmer in their own land. He got married at an early age of 17 and became the sole provider of his family by working as a farmer. For many years up to now, he is still the president of the Association of Farmers in Magalang. His last job was in the department of agriculture. He retired last 2004 at the age of 66. At present, his source of income is their land which he tills together with his grandson. He is earning approximately Php 100,000 a year from their harvests, which is equivalent to Php 8, 333 per month. Having this monthly income for the eight members of his family, they are then considered poor. Mr. Cap is a religious member of the Iglesia ni Cristo and never fails to visit their church. He does not believe in hebolarios but uses medicinal plants available in their yard like guava and oregano whenever he has a cough. Mr. Cap is a frequent smoker. He started smoking when he was 16 year old and started taking alcoholic beverages at the age of 27. He starts smoking early in the morning and consumes approximately half pack of cigarettes a day.
c. Environmental Factors Mr. Cap has 13 children, six of which are males and seven are females. All of them already have their own family. Twelve of them are living away from their parents and only one, who is the youngest, lives with her parents in their ancestral home. Mr. Caps family is classi