I.

Introduction

Pneumonia acute infection of one or both lungs can be caused by a bacterium, usually

Streptococcus pneumonia or by a virus, fungus, or other organism. The causal organisms

reach the lings through the respiratory passages. Usually an upper respiratory infection

precedes the disease. Alcoholism, extreme youth or age, debility, immunosuppressive

disorders and therapy, a compromised consciousness are predisposing factors. When one or

more entire lobes of the ling are involved, the infection is considered a lobar pneumonia. When

the disease is confined to the air spaces adjacent to the bronchi, it is known as

bronchopneumonia. Aspiration pneumonia is the pathological consequence of the abnormal

entry of fluids, particulate matter, or secretions in the lower airways. Pneumonia was once

called the old man’s friend because many ill and elderly individuals died of pneumonia. It was

said to be an easy way to die and escape from suffering for the incurably ill, hence the idea

that it was a friend. It is still more common in the elderly than in the young. It may still be the

final cause of death in the elderly and ill. The symptoms of pneumonia re high fever, chills,

pain in the chest, difficulty in breathing, cough and sputum that is pinkish at first and becomes

rust-colored as the infection progresses. The skin may turn bluish because the lungs are not

sufficiently oxygenating the blood. Complete bed rest and good supportive care are important.

Oxygen helps to relieve severe respiratory difficulty. Immunization for pneumococcal

pneumonia is recommended for children under two years old, adults 65 or older, and others at

risk. Nevertheless, pneumonia is still a serious disease, especially in elderly and debilitated

persons who usually acquire bronchopneumonia or when complicated by bacterial invasion of

the bloodstream, membrane of the heart or the central nervous system. Viral pneumonia,

generally milder than the bacterial form, is the result of lower respiratory infection and has

been the cause of more than 90% of deaths for individuals over 65.

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Pneumocytis carnii pneumonia, which is cause by an organism traditionally thought to a

parasitic protozoan but now suspected to be a fungus, generally only occurs in patients who

have AIDS or leukemia or whose immune system is otherwise suppressed.

II. General Data

Name: Mrs. TTA

Age: 92 years old

Address: 33 P.R Suarez St. Tagbilaran City Bohol

Sex: Female

Case no: 100022602372

Status: Widow

Date of birth: November 10, 1917

Religion: Roman Catholic

Date of Admission: July 23, 2010

Name of Hospital: Chong Hua Hospital

Attending Physician: Dr. Polloso, Tomas Jr.

Final Diagnosis: Community Acquired Pneumonia

III. HEALTH ASSESSMENT

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A.HEALTH HISTORY

A.1 Biological data

Mr. Tata Talaid (father) High school graduate Died due to heart attack
(farmer)

Mrs. Choncha T. High school graduate Died due to Gastric Cancer

Talaid(mother) (house wife)

Mr. Rafael Talaid (1st child) College graduate Died due to Car Accidient
(Engineer)

Mrs. Condita Taria (2nd College Graduate Diaed due to hypertension

child) (Teacher)

Mrs. Cordes Sabandal (3rd College Graduate Died due to heart attack
child) (Teacher)

Mrs. Trafanenia T. Apostol College Graduate Diagnose with CAP

(youngest) (Teacher)

Mr. Patrick Apostol College Graduate Only son of the patient

(NURSE)

A.2 Reason for seeking consultation

>Body weakness, dyspnea and cough

A.3 Past Health History

Mrs. TTA does not have any known illnesses except for the disease that has

been diagnosed to her. She does not have any allergies to food and medicines. She

admitted in the hospital due to complaints of cough, dyspnea and body weakness that

later has been diagnosed to Pneumonia.

A.4 Family History

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 The family of Mrs. TTA had a history of heart attacked and hypertension on the

father side, while in the mother side they had a history of Cancer.

A.5 Review of Systems

(See appendix E)

VII. PHYSICAL ASSESSMENT

Assessment:

Skin: Skin is warm to touch, skin color is brown, skin turgor is senile

Hair: Hair color is black with some white hair, evenly distributed without any manifestation

Scalp: there are no dandruff noted, no lumps and tenderness

Nails: Nails color is pinkish with capillary refill of 2-3 sec without lesions

Skull: skull is circular in shape, skull is symmetrical with no masses noted

Face: patient can’t express different emotion because poor hearing and age, with no masses

and no edema noted.

Eyes: Patients pupil is equally round reactive to light and accommodation with a size of 3mm.

Conjuctiva is clear and pale pink. Iris is round.

Nose: Patient has NGT on her right nostril. There are no discharges noted.

Mouth: lips are pale pink and gums are negative for lesion. Her teeth are not complete.

Neck: symmetrical and negative for any lymph node enlargement

Abdomen: patient stomach rises upon inhalation and falls upon expiration.

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Musculoskeletal system: patient can still rotate her hand but she has poor grip strength

because of her age.

Neurologic Screening Assessment: patient is confused; she can’t remember where she was

and what is the date for this day. She can’t perform heel-to-toe walk and shallow knee bends

because of her age.

IV

. A. ANATOMY AND PHYSIOLOGY OF THE SYSTEM INVOLVED

A. RESPIRATORY SYSTEMS:

• Nose -The term nose refers to the visible structure that forms a prominent feature

of the face. Most of the nose is composed of cartilage although the bridge of the nose consists

of bones.

• Nasal Cavity -The nasal cavity or nasal fossa is a large air-filled space above and

behind the nose in the middle of the face. The nasal cavity is important in warming and

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cleaning the air it is inhaled. The nasal cavity also contains organs involved in olfaction

sensory smelling.

• Pharynx -The pharynx is the common passageway of both the respiratory and

digestive systems. It receives air from the nasal cavity and air, food and water from the mouth.

• Larynx -The larynx or voice box is an organ in the neck of mammals, involved in

protection of the trachea and sound production. The larynx houses the vocal cords, and is

situated just below where the tract of the pharynx splits into the trachea and the esophagus.

Sound is generated in the larynx, and that is where pitch and volume are manipulated. The

strength of expiration from the lungs also contributes to loudness, and is necessary for the

vocal cords to produce speech. During swallowing, the larynx (at the epiglottis and at the

glottis) closes to prevent swallowed material from entering the lungs; the larynx is also pulled

upwards to assist the process. Stimulation of the larynx by ingested matter produces a strong

cough reflex to protect the lungs. The vocal folds can be held close together (by adducting the

arytenoids cartilages), so that they vibrate. The muscles attached to arytenoids cartilages

control the degree of opening. Vocal fold length and tension can be controlled by rocking the

thyroid cartilage forward and backward on the cricoids cartilage, and by manipulating the

tension of the muscle within the vocal folds. This causes the pitch produced during phonation

to rise or fall.

• Trachea -is a common biological term for an airway through which respiratory air

transport takes place in organisms.

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• Vertebrate trachea -in terrestrial vertebrates, such as birds and humans, the trachea

lets air move from the throat to the lungs.

• Invertebrate trachea -in terrestrial invertebrates, such as onychophorans and

insects, trachea conduct air from outside the organism directly to all internal tissues.

Bronchi -A bronchus is a caliber of airway in the respiratory tract that conducts air into the

lungs. No gas exchange takes place in this part of the lungs.

• The trachea divides into main bronchi: the left and the right, at the level of the

sterna angle. The right main bronchus is wider, shorter, and more vertical than the left main

bronchus. The main bronchi subdivides into two or three secondary bronchi that each serves

the left and right lungs, respectively. The lobar bronchi divide into tertiary bronchi. Each of the

segmental bronchi supplies a bronchopulmonary segment. A bronchopulmonary segment is a

division of a lung that is separated from the rest of the lung by a connective tissue septum.

This property allows a bronchopulmonary segment to surgically remove without affecting other

segments. The segmental bronchi divide into many primary bronchioles which divide into

terminal bronchioles, each of which then gives rise to several respiratory bronchioles, which go

on to divide into 2 to 11 alveolar ducts. There are 5 or 6 alveolar sacs associated with alveolar

duct. The alveolus is the basic anatomical unit of gas exchanges in the lung.

• Lungs -The lungs are the essential respiration organ in air-breathing vertebrates.

Its principal function is to transport oxygen form the atmosphere into the bloodstream, and to

excrete carbon dioxide form the bloodstream into the atmosphere. This exchange of gases is

accomplished in the mosaic of specialized cells that form million of tiny, exceptionally thin-

walled air sacs called alveoli. The lungs also have non-respiratory functions.

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V. CONCEPTUAL FRAMEWORK OF THE PATHOPYSIOLOGY OF THE DISEASE

Aspiration of streptococcus bacteria

Release of endo-bacterial toxin

Inflammatory response of neutrophil; release of inflammatory mediators; accumulation

of fibrinous exudates, red blood cells and bacteria.

Red hepatization and consodolidation of lung parenchyma

Leukocyte infiltration

Gray hepatization and deposition of fibrin on pleural surfaces; phagocytosis in alveoli

Resolution of infection: macrophages in alveoli ingest and remove degenerated

neutrophils, fibrin, and bacteria.

8
VI. DISSCUSSION OF PATHOPHYSIOLOGY

The symptoms of infectious pneumonia are causes by the invasion of the lungs by

microorganisms and by the immune system’s response to the infection. Although over one

hundred strains of microorganism can cause pneumonia, only a few of them are responsible

for most cases. The most common causes of pneumonia are viruses and bacteria. Less

common causes of infectious pneumonia include fungi and parasites.

Viruses must invade cells in order to reproduce. Typically, a virus reaches the lungs when

airborne droplets are inhaled through the mouth and nose. Once in the lungs, the virus invades

the cells lining the airways and alveoli. This invasion often leads to cell death, either when the

virus directly kills the cells or through a type of cell self-destruction called apoptosis. When the

immune system responds to the viral infection, even more lung damage occurs. White blood

cells, mainly lymphocytes, activate a variety of chemical cytokines which allow fluid to leak into

the alveoli. This combination of cell destruction and fluid-filled alveoli interrupts the normal

transportation of oxygen into the bloodstream.

In addition to damaging the lungs, many viruses affect other organs and thus can disrupt many

different body functions. Viruses also can make the body more susceptible to bacterial

infections; for this reason, bacterial pneumonia often complicates viral pneumonia.

Viral pneumonia is commonly caused by viruses such as influenza virus, respiratory syncytial

virus (RSV), adenovirus and metapneumovirus. Herpes simplex virus is a rare cause of

pneumonia except in newborns. People with immune system problems are also at risk for

pneumonia caused by ctymegalovirus (CMV)

Bacteria typically enter the lung when airborne droplets are inhaled, but they can also reach

the lung through the bloodstream when there is an infection in another part of the body. Many

9
bacteria live in parts of the upper respiratory tract, such as the nose, mouth, and sinuses, and

can easily be inhaled into the alveoli. Once inside the alveoli, bacteria may invade the spaces

between cells and between alveoli through connecting pores. This invasion triggers the

immune system to send neutrophils, which are a type a defensive white blood cell, to the

lungs. The neutrophil engulf and kill the offending organisms, and they also release cytokines,

causing a general activation of the immune system. This leads to the fever, chills, and fatigue

common in bacterial and fungal pneumonia. The neutrophils, bacteria, and fluid from

surrounding blood vessels fill the alveoli and interrupt normal oxygen transportation.

The bacterium Streptococcus pneumonia, a common cause of pneumonia, photographed

through an electron microscope.

Bacteria often travel from an infected lung into the bloodstream, causing serious or even fatal

illness such as septic shock, with low blood pressure and damage to multiple parts of the body

including the brain, kidneys, and heart. Bacteria can also travel to the area between the lungs

and the chest wall (the pleural cavity) causing a complication called an empyema.

The most common causes of bacterial pneumonia are Streptococcus pneumoniae, Gram-

negative bacteria and ‘atypical’ bacteria. The term ‘gram-positive’ and ‘gram-negative’ refer to

the bacteria’s color 9purple or red, respectively) when stained using a process called the Gram

staining. The term ‘atypical’ is used because atypical bacteria commonly affect healthier

people, cause generally less severe pneumonia, and respond to different antibiotics that other

bacteria.

The types of Gram-positive bacteria that cause pneumonia can be found in the nose or mouth

of many healthy people. Streptococcus pneumonia, often called “pneumococcus’, is the most

common bacterial cause of pneumonia in all age groups except newborn infants. Another

important Gram-positive cause of pneumonia is Staphylococcus aureus. Gram-negative

10
bacteria cause of pneumonia less frequently than gram-positive bacteria. Some of the gram-

negative bacteria that cause pneumonia include Haemophilus influenzae, Klebsiella

pneumoniae, Escherichia coli, Pseudomonas aeruguinosa and Moraxella catarrhalis. These

bacteria often live in stomach or instestines and may enter the lungs if vomit is inhaled.

“Atypical” bacteria which cause pneumonia include Chlamydophila pneumoniae, Mycoplasma

pneumoniae, and Legionella pneumophila.

Fungal pneumonia is uncommon, but it may occur in individual with immune system problems

due to AIDS, immunosuppressive drugs, or other medical problems. The pathophysiology of

pneumonia caused by fungi is similar to that of bacterial pneumonia. Fungi pneumonia is most

often caused by Histoplasma capsulatum, Cryptococcus neoformans, Pneumocystis jiroveci,

and Coccidioides immitis.

Histoplasmosis is most common in the Mississippi River basin, and coccidioidomycosis is most

common in the southwestern United States. A variety of parasites can affect the lungs. These

parasites typically enter the body through the skin or by being swallowed. Once inside the

body, they travel through the lungs, usually through the blood. There, as in other types of

pneumonia, a combination of cellular destruction and immune response caused disruption of

oxygen transportation. One type of white blood cell, the eosinophil, responds vigorously to

parasite infection. Eosinophils in the lungs can lead eusiniphilic pneumonia. thus complicating

the underlying parasitic pneumonia. The most common parasites causing pneumonia are

Toxoplasma gondii, Strongyloides stercoralis, and Ascariasis.

VII. CLINICAL MANAGEMENT

A. MEDICAL MANAGEMENT

A.1 LABORATORY AND DIAGNOSTIC EXAMINATIONS

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Complete Blood Count Date: JULY/23/2010

CBC RESULT REFERENCE UNIT

White Blood Cell 6.70 4.8-10.8 10^3/uL

Red Blood Cell 4.28 4.7-6.1 G

Hemoglobin 11.0 ↓ 14.0-18.0 gldL

Hematocrit 33.0↓ 42.0-52.0 %

Platelet 303 130-400 10^3/uL

BLOOD INDICES

MCV 77.1↓ 80-94 fL

MCH 25.7↑ 27.0-31.0 pq

MCHC 33.3 33.0-37.0 g/dL

RDW 14.6 11-16 %

PDW 15.3 9.0-14.0 %

MPV 9.1 7.2-11.1 fL

RELATIVE DIFFERENTIAL COUNT

Neotrophil 77.9↑ 40-74 %

Lymphocyte 14.1↓ 19-48 %

Monocyte 2.9↓ 3.4-9.0 %

Eoisinophil 5.0 0.0-7.0 %

Basophil 0.1 0.0-1.5 %

ABSOLUTE DEFFERENTIAL COUNT

Neotrophil # 5.21 1.9-8 10^3/uL

Lymphocyte # 0.94 0.9-5.2 10^3/uL

Monocyte # 0.19 0.16-1.0 10^3/uL

Eoisinophil # 0.33 0.0-0.8 10^3/uL

Basophil # 0.01 0.0-0.2 10^3/uL

7/23/ 2010
12
 TEST RESULT REFERENCE UNIT

Urea Nitrogen 10.2 7.0-8.0 MG/DL

Cuatine 1.3 0.6-1.5 MG/DL

Uric Acid 4.1 3.0-8.0 MG/DL

SGPT-ALT 28 5.0-50.0 U/L

Albumin 2.2↓ 3.5-5.0 G/DL

Sodium (serum) 132.0↓ 134-148.0 mMOL/L

Potassium 5.1 3.3-5.3 mMOL/L

Arterial Blood Gas July/23/ 2010

TEST RESULT REFERENC UNIT

Ionized Calcium 1.07 1.09-1.33 mMOL/L

Sodium 132.4 135.148 mMOL/L

Potassium 5.24 3.5-5.0 mMOL/L

Temperature 36.6 C

FIO2 21.0 %

pH 7.422 7.35-7.45

PCO2 58.7 35-45 mmHg

pO2 107.3 >80 mmHg

HCO3 38.0 mMOL/L

TCO2 39.9 mMOL/L

BE 10.8 mMOL/L

SO2 98.0 95-98 %

Chest X-ray July/23/ 2010

Reports:
There are nodular, coarse linear and ill-defined denitis in both apical regions.
Nodular are hazy densities are also seen in both lungs bases. The result of the lungs are clear.

13
The heart is magnified. Both hemi diaphragms are intact. Both costophrenic sulci are shallow.
The tracheal air column is at the midline. There is calcification of the tracheobrochial tree.
Aorta is tortuous and sclerotic. The pulmonary vascular markings are within normal limits.
The visualized by bony structure shows generalizes decreased in bone density with thinning of
the cotices.

-CONCLUSION-
1. Mild Gibaral Pneumonia
2.Findings in both apical regions are suggestive of chronic inflammation process. Consider
PTB
3.Bilateral Pleural thickening and/ or minimal effusion
4. Magnified cardiac silhouette
5. Tortuous and athermanous aorta
6. Calcified tracheo bronchial tree
7. Generalized osteoporosis

Specimen; Sputum JULY/24/ 2010

EXAM; Gram Stain
REPORT:
Pus cell = 60.85/ 1pf
Epithelial cells = 15-20/pf
Moderate Yeast cells and hyphae noted

Complete Blood Count Date: JULY/27/2010

CBC RESULT REFERENCE UNIT

White Blood Cell 5.90 4.8-10.8 10^3/uL

Red Blood Cell 3.71 ↓ 4.7-6.1 G

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 Hemoglobin 10.3 ↓ 14.0-18.0 gldL

Hematocrit 31.0↓ 42.0-52.0 %

Platelet 238 130-400 10^3/uL

BLOOD INDICES

MCV 83.6 80-94 fL

MCH 27.8 27.0-31.0 pq

MCHC 32.2 ↓ 33.0-37.0 g/dL

RDW 15.3 11-16 %

PDW 19.3↑ 9.0-14.0 %

MPV 9.9 7.2-11.1 fL

RELATIVE DIFFERENTIAL COUNT

Neotrophil 62.0 40-74 %

Lymphocyte 26.8 19-48 %

Monocyte 3.5 3.4-9.0 %

Eoisinophil 7.5 ↑ 0.0-7.0 %

Basophil 0.2 0.0-1.5 %

ABSOLUTE DEFFERENTIAL COUNT

Neotrophil # 3.66 1.9-8 10^3/uL

Lymphocyte # 1.58 0.9-5.2 10^3/uL

Monocyte # 0.21 0.16-1.0 10^3/uL

Eoisinophil # 0.44 0.0-0.8 10^3/uL

Basophil # 0.01 0.0-0.2 10^3/uL

A.2Treatment and Procedure

15
1. Chest X-ray – is radiology test that involves exposing the chest briefly to

radiation to produce an image of the chest and the internal organs of the chest. It can be used

to define abnormalities of the lungs such as excessive fluid.

2. CBC (complete blood count) – to check white blood cell count; if high this

suggest bacterial infection

3. Gram Stain- is a laboratory test that uses a series of stains to check

for bacteria in a sputum sample. Sputum is the mucous material that comes up

from your air passages when you cough very deeply

4. Bleendedrized feeding 1200 kcal in 1000ml in 6 equally divided

feedings – for nutritional benifiet.

5. Increase feeding to 1800 kcal in 1300 cc/vol in 6 equally divided feedings –

for nutritional benifiet.

6. O2 PRN – this will help patient in breathing when dyspnea occur

A.3 Medications

(APPENDEX B)

A.4 Diet

Mrs. TTA is on Bleededrized feeding

B. Nursing Management

B.1 NURSING CARE PLAN

( SEE APPEMDIX C)
16
 B.2 DISCHARGE PLAN

(SEEE APPENDIX D)

VIII. CONCLUSION

Based from the study that I conducted I conclude that in caring for patients with disease

conditions we should be very careful in observing aseptic technique in order to prevent further

spread of infection. We must be alert on any unusualities. We should be very cautious in any

procedures that we do especially in performing procedures that require aseptic technique. We

should not forge in monitoring the vital signs and the input and output of our patient because it

really plays an important data and servers as a record for our patient. Through establishing

rapport the patient will be able to gain trust in us and in return they will be able to participate in

our nursing intervention that we will give to them. In that way, the patient could possibly

achieve early recovery.

VIII. IMPLICATIONS TO THE STUDY:

A. NURSING EDUCATION

Nursing education is very essential for us student nurses, for nursing as a science evolved in a

very complicated way wherein some of its principles may undergo little changes. With these

ever changing modernized world and eruptions of new technologies, it dramatically altered the

way we extend our care to patients. With these drastic changes, student nurses and soon to

be nurses must keep tract of new health care trends and development so as to be

competitively prepared for a higher level of responsibilities. To achieve such competence,

17
continuing education is needed. Therefore with this care study which I believed to be a part of

nursing education, it enriched my mind and encouraged me more to study to update recent

nursing trends as I adapt to this rapidly changing world.

B. NURSING PRACTICE

The nursing care study helps the students gain positive attitude, adequate knowledge and

develop skills in taking care of the patients who have cesarean delivery. Its recommendation

and suggestions can be of great help to the nursing practice so as to enhance their intellectual

capabilities and be ready to in delivering clinical judgment in higher levels of health care.

C. NURSING RESEARCH

As important for the competent nurse to be alerted to new knowledge that has been

established by research. This research is to develop a questioning and reflective attitude

towards ones practice. Research in nursing lays on its foundation- the students. Therefore as a

part of the foundation, I can contribute my findings in my care study to improve the existing

discoveries and in a way help innovate nursing through research.

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BIBLIOGRAPHY:

• Joyce M. Black et al (2005) Medical Surgical Nursing 7 th edition Elsevier

Suanders

• Smeltzer, S. et. al. (2008). Brunner and Suddarth’s Textbook of Medical-Surgical

Nursing 11 th edition . Philadelphia: Lippincott-Williams & Wilkins

• Spratto, G. and Woods, A. (2008). 2008 Edition PDR ® Nurse’s Drug Handbook.

New York:Thomson Delmar Learning.

• Berman, A. et. al. (2008). Kozier & Erb’s Fundamentals of Nursing: Concepts,

Process and Practice 8 th edition Jurong, Singapore: Pearson Education South

Asia Seely, R., Stephens, T., Tate, P. (2007 ). Essentials of Human Anatomy &

Physiology 6 th edition. New York: McGraw-Hill.

• Van Leeuwen, A., Kranpitz, T., Smith, L., (2006) Davis’s Comprehensive

Handbook of Laboratory and Diagnostic Test with Nursing Implication 2 nd

edition , U.S.A, F.A Davis Company

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