Pneumonia

Medical Surgical Ward

Submitted by:

Group 3
Fatima Love Ariate
Siena Marie Lundang
Juan Paulo Manuel
Tricia Kaye Micarsos
Floriza Mondejar
Anne Moralizon
Jim Isaac Reyes
Rona Grace Ulitin
Mary Grace Umali




Introduction
Pneumonia is a form of acute respiratory infection that affects the lungs. The lungs
are made up of small sacs called alveoli, which fill with air when a healthy person breathes.
When an individual has pneumonia, the alveoli are filled with pus and fluid, which makes
breathing painful and limits oxygen intake.Pneumonia is the single largest cause of death in
children worldwide.
Every year, it kills an estimated 1.4 million children under the age of five years,
accounting for 18% of all deaths of children under five years old worldwide according to
World Health Organization 2012. It is the 5
th
leading cause of mortality on the Philippines
(2006) according Department of Health.

Typical symptoms
chest pain
cough
fever
DOB

Types of Pneumonia
Community acquired: occurs outside of the hospital and other health care setting.
Hospital acquired: some people catch pneumonia during a hospital stay for
another illness higher risk if on a ventilator.
Health care setting: other health care setting like nursing homes dialysis center,
outpatients clinics.
Bacterial: affect people who have weak immune system like old age, or
malnutrition.
Fungal: complications experienced by aids patients.
Viral: common forms; flu virus, herpes simplex virus, rhino virus, adenovirus.
Mycoplasma: possess of both bacteria and virus.
Aspiration: occurs when inhaled foreign materials.










Objectives
This case presentation has the main goal of explaining the causes of Pneumonia
and its different possible complications. It also emphasizes the proper nursing
interventions that are applicable for this type of medical condition.

Rationale for choosing the case
This case was chosen by the group for the following reasons:
To better understand the whole concept of Pneumonia and to identify the possible
complications that may arise and affect the patient.
To be able to enhance the groups knowledge regarding the proper nursing
interventions needed in this particular medical condition.

Significance of the study
This study will greatly aid the students in broadening their knowledge regarding this
particular medical condition and will promote the proper nursing interventions that
are needed in this particular case.

Scope and Limitation
The study contains the following; a brief discussion of the condition and its causes,
possible complications and proper treatment, a pathophysiology to better understand
the connection of the condition to the persons over-all health, a nursing care plan
that would present a nursing analysis and diagnosis about the condition, including a
plan and intervention to assist in an enhance recovery.













Patients Profile

Patient name: Patient X
Address: 75 M Leonor St. San Pablo City, Laguna
Religion: Roman Catholic
Nationality: Filipino
Birthdate: March 2, 1930
Age: 82 years old
Admitting Doctor: Dr. Tamucheen Galadari
Attending Physician: Dr. Haydee Sarmiento
Admission: August 1, 2012
Chief Complain: Cough and Difficulty of breathing


History of Present Illness
Dyspnea
Upper GI bleeding
Ischemic heart disease

Past Medical History
Hypertension
5
th
and 8
th
left rib fracture

Initial Vital Signs

August 1, 2012
Blood Pressure 150/80 mmHg
Pulse Rate 107 bpm
Respiratory Rate 32 cpm
Oxygen Saturation 92 %
CBG 108

Initial Intake and output:
Intake:580
Output:400




Gordons Functional Health Pattern

1. Health Perception / Health Management
Patient is cooperative and is quick in compliance to medication regimen.
Patient is aware of his condition and possible outcome.

2. Nutritional and Metabolic Pattern
Patients main meal in the hospital was lugaw, gelatin, and crackers but at home he
eats chicken, rice, fish and vegetables.
Frequently skip meals

3. Elimination Pattern
Patient has trouble in defecating and is positive for melena and has no problems
upon urination.

4. Activity / Exercise Pattern
Patient can walk before with assistance, but now is bed ridden. No activities and
hobbies.

5. Sleep / Rest Pattern
Patient gets adequate amount of sleep of 8 hours a day, but in the hospital, there
was frequent disturbances due to close monitoring.

6. Cognitive and Perceptual Pattern
Patient is conscious and coherent and is able to talk but with slurred speech. Hes
aware of what is going on around him and is aware of the treatment being done to
him.

7. Self-perception / Self-concept Pattern
Patient knows that his disease is normal for his age. He is slightly depressed
because he is unable to perform ADL by himself.

8. Role-relationship Pattern

Patient has good relationship with family and friends. He is not the bread winner of
the family.
9. Sexuality / Reproductive Pattern
He has no wife and children and is sexually inactive.

10. Coping / Stress Tolerance
The patient avoids stress by watching TV and eating. Also talking to his family and
conversing with friends.

11. Values / Belief Pattern
Patient is a Roman Catholic, he values his family.
Patients values and beliefs does not conflict with his medical treatment.



























Physical Assessment

Head
o Normocephalic
o Thinning white hair
o Evenly distributed hair
Eyes
o Asymmetrical blinking,
o strabismus,
o (-) PERLA, eye crust on both eyes
Ears
o Symmetrical
o Patent ear canal
o Good hearing acuity
Mouth
o Absence of teeth
o Poor mouth hygiene
Neck
o Normal neck length
o Abnormal mass on right side
o Visible pulsation on right carotid artery
Chest
o Abnormal breathing pattern
o Arrhythmias upon auscultation
o No lumps upon palpitation
o (+) crackles on both lung fields
Abdomen
o Loose skin on abdomen
o Normal bowel sounds
o No abnormal mass upon palpitation
o (+) melena
Arms
o Loose flabby skin
o Muscle weakness fair skin tone
Hands
o Clubbing of nails
o Poor hand hygiene
o Uncut nails long
o (+) edema 3cm
Genitalia
o (+) diaper
o normal urinary function
o sexually inactive
Legs
o (+) distended veins on both legs
o abnormal skin color (freckles)
Feet
o Clubbing of nails
o abnormal bone structure on left toe
o abnormal skin tone
o (-) edema.


Anatomy and Physiology























Laboratory Examination

August 3, 2012
CBC RESULT FLAGS UNITS NORMAL
RANGE
Interpretation
WBC 12.65 + 10^3/uL 4 - 10
Increased in polycythemia
vera,myelofibrosis and
infection
HGB 126 - g/L 120 160
Decreased in various
anemias, severe or prolonged
hemorrhage and with
excessive fluid intake
HCT 0.36 - 0.37 0.47
Decreased in severe anemias,
acute massive blood loss
PLT 74 - 10^3/uL 150 - 450
Risk for bleeding
NEUT% 0.82 + 0.5 0.7
Increased with acute infection,
trauma or surgery, leukemia,
malignant disease, necrosis
LYMPH% 0.05 - 0.2 0.4
Decreased with aplastic
anemia, immunodeficiency
including AIDS
MONO% 0.12 0 0.14
Normal
EO% 0 - 0.01 0.03
Decreased with stress, use of
some medication(ACTH,
epinephrine,thyroxin)
BASO% 0.01 0 0.01


RBC
Indices


RBC 3.78 10^6/uL 2.5 5.5
Normal
MCV 79.40 - fL 81 - 99
Decreased in microcytic
anemia
MCH 29.90 Pg 27 - 31
Normal
MCHC 37.70 + g/dL 33 - 37
Hereditary spherocytosis and
immune hemolysis









August 10, 2012 ( 12:47nn)
CBC RESULT FLAGS UNITS NORMAL
RANGE
Interpretation
WBC 8.28 10^3/uL 4 - 10
Normal
HGB 113 - g/L 120 160
Decreased in various
anemias, severe or prolonged
hemorrhage and with
excessive fluid intake
HCT 0.30 - 0.37 0.47
Decreased in severe anemias,
acute massive blood loss
PLT 222.00 10^3/uL 150 - 450

NEUT% 0.91 + 0.5 0.7
Increased with acute infection,
trauma or surgery, leukemia,
malignant disease, necrosis
LYMPH% 0.03 - 0.2 0.4
Decreased with aplastic
anemia, immunodeficiency
including AIDS
MONO% 0.06 0 0.14
Normal
EO% 0 - 0.01 0.03
Decreased with stress, use of
some medication(ACTH,
epinephrine,thyroxin)
BASO% 0 0 0.01
Normal

RBC
Indices


RBC 4.42 10^6/uL 2.5 5.5
Normal
MCV 80.50 - fL 81 - 99
Decreased in microcytic
anemia
MCH 28.50 Pg 27 - 31
Normal
MCHC 35.40 + g/dL 33 - 37
Hereditary spherocytosis and
immune hemolysis














August 10, 2012 (6 pm)
CBC RESULT FLAGS UNITS NORMAL
RANGE
Interpretation
WBC 9.02 10^3/uL 4 - 10
Normal
HGB 115 - g/L 120 160
Decreased in various
anemias, severe or prolonged
hemorrhage and with
excessive fluid intake
HCT 0.33 - 0.37 0.47
Decreased in severe anemias,
acute massive blood loss
PLT 222.00 10^3/uL 150 - 450

NEUT% 0.85 + 0.5 0.7
Increased with acute infection,
trauma or surgery, leukemia,
malignant disease, necrosis
LYMPH% 0.06 - 0.2 0.4
Decreased with aplastic
anemia, immunodeficiency
including AIDS
MONO% 0.08 0 0.14
Normal
EO% 0.01 0.01 0.03
Normal
BASO% 0 0 0.01
Normal

RBC
Indices


RBC 4.11 10^6/uL 2.5 5.5
Normal
MCV 79.80 - fL 81 - 99
Decreased in microcytic
anemia
MCH 29.70 Pg 27 - 31
Normal
MCHC 37.20 + g/dL 33 - 37
Hereditary spherocytosis and
immune hemolysis

Lipid Profile
August 2, 2012
Result Normal Value Interpretation
CHOL 137 0-200
Normal
HDL 52.5 40-60
Normal
TRI 88 0-150
Normal
LDL 66.9 0-100
Normal
GLUCOSE 94 70-105
Normal




August 3, 2012
Result Normal Value Interpretation
INR 1.19 1.0 There is increasing possibility of
bleeding
% Activity 60.9
Prothrombin Test 14.2 sec 9.8-12.7 Liver disease, Malabsorption, Vitamin
K deficiency
APTT 39.1 sec 26-37 Liver disease, Malabsorption, Vitamin
K deficiency


August 4, 2012
Result Normal Value Interpretation
Potassium 4.2 mmol/L 3.5-5.1
Normal

Conventional
Result Normal Value Interpretation
Potassium 3.2
low
3.60-5 Gastrointestinal losses, Diuretic
administration



Fecalysis Form
Character: soft
Color: brown
Occult blood: + (positive)
Pus: none seen
RBC: none seen
Parasite or ova: neither ova nor parasite seen






Diagnostic Examination

Chest X-Ray
Aug 1, 2012-Aug 5, 2012

Chest AP with obliquity
Follow up study dated 08-05-12 compared with previous study dated 08-01-12
shows development of opacities in the right perihilar area and both lower lobes likely
due to pneumonia.
The bronchovascular markings are prominent with no definite active parenchymial
infiltrates.
The heart is enlarged
The aorta is tortous and calcified at its knob.
Diaphragm and sulci are intact.
There are old healed fractures of the 5
th
-8
th
posterior ribs.
Impression:
-Cardiomegaly
-Atheromatous Aorta
-Old rib fractures, left





















Pathophysiology
































Predisposing factors:
-Age
-Gender
-Race
Precipitating
Factors:
-Alcoholism
-Environment
-Lifestyle
-Sleeping Habits
Staphylococcus
Pneumoniea
Entry of Microorganism
through nasal passages
Activation of Defense
Mechanism
Increase Neutrophils
Accumulation & Bacterial
Replication in the Alveoli
Loss effectiveness of the
defense mechanism
INFECTION/INFLAMMATION
Vasoconstriction
Accommodation of
Edematous Fluid
Exposure to a certain
environment
Elevated White Blood Cells



































Impaired Oxygen and
Carbon Dioxide Exchange
DOB
Cough and Crackles

Nursing Care Plan

Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective:
Objective:
- RR 30
- Use of
accessor
y
muscles
(nasal
flaring)
- (+)
crackles
on both
lungs
upon
auscultat
ion.
- With
nasal
cannula
at 2l/min
- Po2 92%
- Thick
greenish
secretion
s with
foul
odor.
Ineffective
airway
clearance
related to
increase
production of
secretions
and increased
viscosity.
After a series of
nursing
interventions
patients
Short term goal of
8hrs
- Airway
secretions
will be
lessened
as
evidenced
by not
using
accessory
muscles
such as
nasal
flaring.
Long term goal of
1week.
- Airway
secretions
will be
absent as
evidenced
by normal
RR ranging
from 16-
20, and
absence of
crackles
upon
auscultati
on.
Independent
- Further
establish
rapport.
- Position
patient semi
fowlers
position.
- Encourage fluid
intake unless
contraindicate
d
- Perform chest
tapping

- Suction
patients
secretions
- Encourage
patient to
perform deep
breathing
exercise.
- Health
teaching
(Proper deep
breathing
exercise,
disease
process,
prevention of
complications
and control of
the disease.)
Dependent
- 0xygen
administration.






Independent
-To gain trust
of patient.

-For better
lung
expansion.

-To liquefy
secretions.


-To loosen
secretions.

-To lessen
secretions.

-To facilitate
clear airway.
Brunner


-For
management
of disease.








Dependent
-to improve
clinical signs
and
symptoms,
patient
comfort and
adequate
oxygenation.
After a series of
nursing
intervention
patients..
short term goal of
8hours.
- Airway
secretions
were
lessen as
evidenced
by not
using of
accessory
muscles.
(Goal met)
Long term goal 1
week.
- airway
secretions
was
absent as
evidenced
by
lowered
RR from
33 to 25,
And
absence of
crackles.


- Administer
prescribed
medications.
Collaborative
- Coordinate
with radiologist
for chest x-ray
- Coordinate
with dietician
for proper diet.
- Collaborate
with laboratory
for laboratory
results.
Brunner
-to promote
better
wellness.
Collaborative
-























Assessment Diagnosi
s
Planning Intervention Rationale Evaluation
Subjective:
Objective:
- Pitting
edema of
3 cm
upon
palpation
.
- v/s:
BP:
130/90
PR: 64
RR: 30
O2: 92%
- Poor skin
turgor
- Intake:
580
Output:
400


Excess fluid
volume r/t
water/sodiu
m retention
AEB skin
indentation
of 3 cm upon
palpitation
After series of
nursing
intervention
patient
Short term goal of
8hrs
- Excess
fluid will
be
removed
AEB
increased
urine
output.
Long term goal of
1week.
- Patients
fluid will
be
normalize
d AEB
absences
of pitting
edema
and
normal I &
O
Independent
- Further
establish
rapport.
- Record I & O.


- Weigh daily
save the each
day

- Assess difficult
areas for
edema (face,
foot,legs,hand
s,arms)
- Turning of
patient every 2
hours.

- Health
teaching
(disease
process
prevention of
complication
and control.)
Dependent
- Prescribe
meds by
physician
- Restrict or
administer
fluid as
indicated
Collaborative
- Collaborate
with dietician
for proper
diets.
- Collaborate
with
laboratory for
laboratory
results.
Independent
-to gain trust of
patient.

-to record for any
dehydration.

-to check if
weight loss or
weight gain.

- to know extent
of the edema



-to prevent bed
sore and proper
circulation.

-for management
of disease.





Dependent
- to promote
better wellness

- To maintain
equilibrium
on patients
body fluids.

After a series of
nursing
intervention
patients..
Short term goal
of 8hrs.
- Excess
fluid as
removed
by intake
of 500
and
increased
urine
output of
720.
(Partially
Met.)
Long term goal
- Patient
fluid was
normaliz
ed by
absence
of pitting
edema
after I &
O and
weighing.
(Goal
Met.)


Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective:
Objective:
- (+) blood
in stool
AEB
fecalysis
- Hgb
115g/L
- Pale skin
- Black
tarry
stool
- Weak in
appearan
ce
- Blood
type O+
Impaired
gastrointestinal
tissue
perfusion r/t
Excess gastric
acid
manifested by
black tarry
stool.
After a series of
nursing
intervention
patient
Short term goal of
8hrs.
- Patients
bleeding
will
prevented
as
evidenced
by absence
of black
tarry stool
Long term goal of 1
week
- Good
gastrointest
inal
perfusions.
As
evidenced
by (-) blood
in stool.
Independent
- Further establish
rapport
- Monitor I & O



- Monitor v/s and
possible GI
bleeding


- Health Teaching
(Disease process,
Prevention of
complication and
control.)
Dependent
- Monitor meds
prescribed by
physician
Collaborative
- Collaborative
with lab with
laboratory
result.
- Collaborate with
dietician for
proper diet.
Independent
-to gain trust
of patient.

-to monitor
for any
dehydration.

- To monitor
any change in
health status
of the
patients.
-for
management
of disease.



Dependent
- to promote
better
wellness

After a series of
nursing
intervention
patient
Short term goal of
8hrs.
- Patient
bleeding
was lessen
as
evidenced
by stool
color
consistenc
y.
(Goal
Partially
Met)
Long term goal of 1
week
- Patient
gastrointes
tinal
perfusion
was good
as
evidenced
by. (-)
blood in
stool.












Discharge Planning

Take the entire course of any prescribed medications. After a patients
temperature returns to normal, medication must be continued according to the
doctors instructions, otherwise the pneumonia may recur. Relapses can be far more
serious than the first attack.
Get plenty of rest. Adequate rest is important to maintain progress toward full
recovery and to avoid relapse.
Drink lots of fluids, especially water. Liquids will keep patient from becoming
dehydrated and help loosen mucus in the lungs.
Keep all of follow-up appointments. Even though the patient feels better, his lungs
may still be infected. Its important to have the doctor monitor his progress.
Encourage the guardians to wash patients hands. The hands come in daily
contact with germs that can cause pneumonia. These germs enter ones body when
he touch his eyes or rub his nose. Washing hands thoroughly and often can help
reduce the risk.
Tell guardians to avoid exposing the patient to an environment with too much
pollution (e.g. smoke). Smoking damages ones lungs natural defenses against
respiratory infections.
Give supportive treatment. Proper diet and oxygen to increase oxygen in the blood
when needed.
Protect others from infection. Try to stay away from anyone with a compromised
immune system. When that isnt possible, a person can help protect others by
wearing a face mask and always coughing into a tissue.