José Rizal University

80 Shaw Boulevard, Mandaluyong City

College of Nursing

Nursing Care Management of a Client with Pneumonia

Submitted to

Ms. Anabelle Gayoma

(Clinical Instructor – San Lazaro Hospital )

Submitted by:

Arnoco Viclen
Montibon Louanne
Soriano Clier
Zhang Wenxi

Section 41-Group 4

1
 Introduction

Pneumonia is a general term for a wide variety of conditions that cause an inflammation of the
lungs. Pneumonia is most often caused by a bacterial infection(bacterial pneumonia) or a viral
infection(viral pneumonia). However, pneumonia can also be caused by a fungal infection, yeast
infection, trauma, or from inflammation of the lungs due to exposure to toxic substances, such as
poisonous gases.

Inflammation of the lungs by any of these causes leads to symptoms that can include a wet cough
that produces white or yellow phlegm and shortness of breath. Fever can be a symptom of pneumonia
caused by an infection. Pneumonia is a common complication of a variety of diseases and can lead to
more complications, which can be serious, even life threatening. Pneumonia is a frequent cause of
death. For more information about additional symptoms and complications, refer to .
Pneumonia is a common disease that can occur at any time of the year. It is most common in smokers
and people who have chronic lung infections and diseases, such as lung cancer, acute bronchitis,
congestive heart failure, or emphysema. Other people at risk for pneumonia include those who take
drugs that suppress the immune system, such as corticosteroids and chemotherapy. People who have
diseases that result in an impaired immune system, such as HIV/AIDS, are also at risk. In addition, any
person who is chronically ill or very weak and is unable to cough up phlegm from the lungs is also
susceptible to pneumonia.

Making a diagnosis of pneumonia begins with taking a thorough medical history, including
symptoms, smoking history, and exposure to infections and lung irritants. A physical examination is
also performed and includes listening with a stethoscope to the sounds that lungs make during
respiration. Lung sounds that may point to a diagnosis of pneumonia include a bubbling or crackling
sound and decreased lung sounds. A physician or nurse practitioner will also tap on the chest with the
fingers to listen for certain sounds that may also point to a diagnosis of pneumonia.
Diagnostic testing generally includes a chest X-ray. Depending on a person's condition and medical
history, testing may also include lung function tests, such as a spirometry, which measures how much
air is moved in and out of the lungs during breathing. A CT scan of the chest can help to evaluate such
factors as the presence of other lung conditions, including COPD and congestive heart failure.
A sample of phlegm that is coughed up from the lungs may be tested for the presence of bacteria or
other pathogens. The lungs may also be examined in a procedure called a bronchoscopy. In a
bronchoscopy, a flexible tube fitted with a tiny camera is inserted through the mouth and throat to view
the inside of the lungs. Tissue or phlegm samples can also be taken in this procedure and are examined
in the laboratory.

The level of oxygen in the blood is generally tested using a painless device called a pulse oximetry,
which is clipped onto a fingertip. For people who have a severe case of pneumonia with serious, life-
threatening shortness of breath, an arterial blood gas test may be done. Is this test a sample of blood
taken from an artery is measured very accurately for many parameters of effective breathing, including
the oxygen level in the blood. Blood cultures may also be done to check the blood for infection.
It is possible that a diagnosis of pneumonia can be missed or delayed because symptoms may be mild
or attributed to other conditions. Mild cases of pneumonia that do not require hospitalization are often
referred to as walking pneumonia. For information on misdiagnosis and to learn about diseases that can
mimic pneumonia, refer to misdiagnosis of pneumonia.
 The treatment for pneumonia involves a multifaceted approach. Treatment plans vary depending on
the cause, the severity of the symptoms, the presence of complications, general health, and an
individual's medical history. For more information on treatment.

The types and severity of symptoms of pneumonia vary between individuals depending on a variety
of factors, such as age, general health, medical history, and the presence of complications. In generally
healthy adults, pneumonia can be mild in some cases and not even require hospitalization. However, a
strong strain of pneumonia can be fatal to people who have diseases that affect .

One goal of treatment of pneumonia is to control symptoms, such as fever, cough, and shortness of
breath, until a person recovers. Another goal is to minimize the development of serious complications,
such as severe shortness of breath and hypoxia. With treatment, generally healthy adults can often
recover from bacterial pnemonia or viral pneumonia.

A diagnosis of pneumonia may be delayed or missed because some symptoms, such as cough,
shortness of breath, fever, fatigue, and wheezing can be similar to symptoms of other conditions and
diseases. These include upper respiratory tract, influenza, congestive heart failure, COPD, acute
bronchitis, pleural effusion, and cold.
CHAPTER I

A. NURSING HEALTH HISTORY

Biographic Data

Name: Patient B
Address: Manila
Age: 2 years old
Civil Status: Child
Grandfathers name: Mr. X
Occupation: Vendor
Religion: Roman Catholic

Chief Complaint/s

“ Nilalagnat ang apo ko at may ubo't sipon simula pa nungisang linggo” as verbalized by the
grandfather.

History of Present Illness

One day prior to confinement patient had fever, cough and colds for which he was given
paracetamol (Tmax 39 degrees C) This was accompanied by one episode of vomiting hence consult.
Patient is known (+) asthmatic.
PHYSICAL ASSESSMENT

General Appearance

Normal Finddings Actual Findings Interpretation and

Analysis
Posture The patient who have The patient is crying I: the patient breathing
breathing difficulties and irritated when in is abnormal because he
prefer to sit and may lying position. has breathing difficulties
report feeling of short of in lying position.
breath when lying flat A: The patient is
for even a brief time. experiencing orthopnea.
Ref: Brunner and
Suddhart's Medical-
Surgical Nursing, 11th
edition, Volume 1, page
75.
Skin Color Skin color may varies He has fair skin color. I: the patient skin color
from person to person is in normal.
and ranges from ivory to A:the patient's skin
deep brown to almost color varies from her
pure black. mother.
Ref: Health Care 1
Manual of Norzagaray
College, page 119
Hygiene Clean and nice Sponge bath by his I: the patient has a good
grooming with no grandfather, no hygiene habit.
unpleasant odor. unpleasant odor, wears A:the patient's
shirt without pants. grandfather is
responsible for the
hygiene of his grandson.
Verbal Complies with simple The baby wants to I: the patient is scared to
verbal commands. cuddle by his us (interviewers).
Displays fear of being grandfather and cry A: the patient social
left alone. when put in the bed. development is normal.
Ref: Kozier and Erb's ,
Fundamentals of
Nursing, 8th edition,
volume 1 page 317
Non Verbal Creeps and crawl ,uses The patient is rolling in I: the patient uses pincer
pincer grasp with thumb the bed and grasping grasp with thumb and
and forefinger. what he saw. forefinger
A: the patient motor
development is normal
for his age.
Ref: Kozier and Erb's ,
Fundamentals of
Nursing, 8th edition,
volume 1 page 317
B. Review of Systems

1. Subjective Data

Gordon's Pattern of Functioning

PATTERN BEFORE DURING INTERPRETATION

HOSPITALIZATION HOSPITALIZATION
1.)Health The Grandfather and The Significant others Sufficient knowledge to a
Perception/Health Father of the patient had understood the certain disease will help
Management Pattern describes him as a healthy patients condition and avoid worsening of the
child though he has adapt to the condition and prevent
asthma. They bring the occurrence of the complications
patient to the hospital if disease.
their personal care cannot
treat his sickness when ill.
The patient has no
allergies to any food or
drugs according to them.

2.) Sleep/Rest Pattern The patient had sleep Sleeping disturbances Complete bed rest is very
disturbances with the such as coughing at important for a sick patient
sleeping pattern due to night and asthma for a faster recovery. Thus,
cough and when he has attacks were reduced it should be one of the
asthma attacks, according when the patient priority in giving health
to the significant others. started to comply with care and health teaching to
the medication.. The a patient.
patient usually wakes
up with enthusiasm
and energy.
Anatomy and Physiology

The Lungs

The lungs are paired, cone-shaped organs which take up most of the space in our chests, along
with the heart. Their role is to take oxygen into the body, which we need for our cells to live and
function properly, and to help us get rid of carbon dioxide, which is a waste product. We each have two
lungs, a left lung and a right lung. These are divided up into 'lobes', or big sections of tissue separated
by 'fissures' or dividers. The right lung has three lobes but the left lung has only two, because the heart
takes up some of the space in the left side of our chest. The lungs can also be divided up into even
smaller portions, called 'bronchopulmonary segments'.
These are pyramidal-shaped areas which are also separated from each other by membranes. There
are about 10 of them in each lung. Each segment receives its own blood supply and air supply.
Air enters your lungs through a system of pipes called the bronchi. These pipes start from the
bottom of the trachea as the left and right bronchi and branch many times throughout the lungs, until
they eventually form little thin-walled air sacs or bubbles, known as the alveoli. The alveoli are where
the important work of gas exchange takes place between the air and your blood. Covering each
alveolus is a whole network of little blood vessel called capillaries, which are very small branches of
the pulmonary arteries. It is important that the air in the alveoli and the blood in the capillaries are very
close together, so that oxygen and carbon dioxide can move (or diffuse) between them. So, when you
breathe in, air comes down the trachea and through the bronchi into the alveoli. This fresh air has lots
of oxygen in it, and some of this oxygen will travel across the walls of the alveoli into your
bloodstream. Travelling in the opposite direction is carbon dioxide, which crosses from the blood in the
capillaries into the air in the alveoli and is then breathed out. In this way, you bring in to your body the
oxygen that you need to live, and get rid of the waste product carbon dioxide.

Pathophysiology
DISCHARGE PLAN

M - Medication

Instruct and explain the patient's caregiver that the medication is very important depending on the
duration that the doctor ordered for the total recovery of the patient.

E – Exercise

Instruct the caregiver to let his grandchild play but it should be limited to a short period of time only to
prevent the occurences of shortness of breathing.

T – Treatments

Advise the caregiver to keep the patient relax in order to recover to his present condition. Instruct the
caregiver to minimize the exposure to an open environment such as dusty and smoky area, which
airborne microorganisms are present that can be a high risk factor that may cause severity of his
condition.

H – Health Teaching

Encourage and explain to the patient's caregiver that it is important to maintain proper hygiene to
prevent further infection. Instruct the caregiver to bath the patient everyday and explain that bathing
early in the morning is not a factor or cause of having pneumonia. Instruct to increase fluid intake of
the patient.

O – Out Patient Follow Up

Regular consultation to the physician can be a factor for recovery and assess and monitor the patient's
condition.

D – Diet

Diet as tolerated, diet plays a big role in fast recovery so that instruct the caregiver to give nutritious
foods intended for respiratory problem.