INTRODUCTION

A. Pneumonia is an inflammation of the lung that is most often

caused by infection with bacteria, viruses, or other organisms.
Occasionally, inhaled chemicals that irritate the lungs can cause
pneumonia. Healthy people can usually fight off pneumonia infections.
However, people who are sick, including those who are recovering from the
flu (influenza) or an upper respiratory illness, have weakened immune
systems that make it easier for bacteria to grow in their lungs.

Aspiration is defined as the inhalation of either oropharyngeal or

gastric contents into the lower airways. Inhalation of these contents can
lead to aspiration pneumonia. Aspiration pneumonia results from chronic,
usually unwitnessed, inhalation of small amounts of oropharyngeal
contents leading to an infectious process.

Substances other than bacteria may be aspirated into the lung,

such as gastric contents, exogenous chemical contents, or irritating gases.
This type of aspiration or ingestion may impair the lung defenses, cause
inflammatory changes, and lead to bacterial growth and a resulting
pneumonia.
 This inflammation causes an outpouring of fluid in the infected part
of the lungs, affecting either one or both lungs. The blood flow to the
infected portion of the lung (or lungs) decreases, meaning oxygen levels in
the bloodstream can decline.

The body attempts to preserve blood flow to vital organs and

decrease blood flow to other parts of the body such as the GI tract. The
effects of pneumonia are widespread even though the infection is localized
to the lung. The complications of pneumonia in the elderly can be life-
threatening, from low blood pressure and kidney failure to bacteremia, an
infection that spreads to the bloodstream.

Elderly people are more susceptible to pneumonia for several

reasons. Often they already suffer from co-morbid conditions such as heart
disease, which means they don’t tolerate infection as well as younger
people. Age also causes a decrease in an older person’s immune system
response, so his defenses are weaker. Some virulent organisms can cause
infection in younger people, but the infections can be worse in older people.
Common pathogens are Streptococcus pneumoniae. Other causes
include Haemophilus influenzae, and Streptococcus aureus.
 B. (Incidence and Prevalence rate)

Incidence Rate for Pneumonia: approx 1 in 56 or 1.76% or 4.8 million

people in USA

Extrapolation of Incidence Rate for Pneumonia to Countries and

Regions: The following table attempts to extrapolate the above
incidence rate for Pneumonia to the populations of various countries
and regions. As discussed above, these incidence extrapolations for
Pneumonia are only estimates and may have limited relevance to the
actual incidence of Pneumonia in any region:
 Country/Region Extrapolated Incidence Population Estimated Used

Pneumonia in North America (Extrapolated Statistics)

USA 5,182,154 293,655,4051

Canada 573,668 32,507,8742

Pneumonia in Europe (Extrapolated Statistics)

Austria 144,260 8,174,7622

Belgium 182,616 10,348,2762

Britain (United Kingdom) 1,063,600 60,270,708 for UK2

Czech Republic 21,991 1,0246,1782

Denmark 95,530 5,413,3922

Finland 92,020 5,214,5122

France 1,066,309 60,424,2132

Greece 187,897 10,647,5292

Germany 1,454,551 82,424,6092

Iceland 5,187 293,9662

Hungary 177,041 10,032,3752

Liechtenstein 590 33,4362

Ireland 70,051 3,969,5582

Italy 1,024,543 58,057,4772

Luxembourg 8,165 462,6902

Monaco 569 32,2702

Netherlands (Holland) 287,968 16,318,1992

Poland 681,641 38,626,3492

Portugal 185,720 10,524,1452

Spain 710,837 40,280,7802

Sweden 158,583 8,986,4002

 Switzerland 131,485 7,450,8672

United Kingdom 1,063,600 60,270,7082

Wales 51,494 2,918,0002

Pneumonia in the Balkans (Extrapolated Statistics)

Albania 62,555 3,544,8082

Bosnia and Herzegovina 7,193 407,6082

Croatia 79,356 4,496,8692

Macedonia 36,001 2,040,0852

Serbia and Montenegro 191,045 10,825,9002

Pneumonia in Asia (Extrapolated Statistics)

Bangladesh 2,494,243 141,340,4762

Bhutan 38,568 2,185,5692

China 22,920,840 1,298,847,6242

East Timor 17,986 1,019,2522

Hong Kong s.a.r. 120,972 6,855,1252

India 18,795,363 1,065,070,6072

Indonesia 4,207,993 238,452,9522

Japan 2,247,052 127,333,0022

Laos 107,084 6,068,1172

Macau s.a.r. 7,857 445,2862

Malaysia 415,102 23,522,4822

Mongolia 48,552 2,751,3142

Philippines 1,521,912 86,241,6972

Papua New Guinea 95,652 5,420,2802

Vietnam 1,458,755 82,662,8002

Singapore 76,833 4,353,8932

Pakistan 2,809,347 159,196,3362

North Korea 400,545 22,697,5532

South Korea 851,184 48,233,7602

Sri Lanka 351,267 19,905,1652

Taiwan 401,467 22,749,8382

Thailand 1,144,685 64,865,5232

Pneumonia in Eastern Europe (Extrapolated Statistics)

Azerbaijan 138,853 7,868,3852
Belarus 181,950 10,310,5202

Bulgaria 132,670 7,517,9732

Estonia 23,676 1,341,6642

Georgia 82,833 4,693,8922

Kazakhstan 267,241 15,143,7042

Latvia 40,699 2,306,3062

Lithuania 63,668 3,607,8992

Romania 394,509 22,355,5512

Russia 2,540,718 143,974,0592

Slovakia 95,710 5,423,5672

Slovenia 35,496 2,011,473 2

Tajikistan 123,733 7,011,556 2

Ukraine 842,330 47,732,0792

Uzbekistan 466,066 26,410,4162

 Pneumonia in Australasia and Southern Pacific (Extrapolated Statistics)

Australia 351,408 19,913,1442

New Zealand 70,479 3,993,8172

Pneumonia in the Middle East (Extrapolated Statistics)

Afghanistan 503,182 28,513,6772

Egypt 1,343,248 76,117,4212

Gaza strip 23,382 1,324,9912

Iran 1,191,233 67,503,2052

Iraq 447,788 25,374,6912

Israel 109,394 6,199,0082

Jordan 99,021 5,611,2022

Kuwait 39,839 2,257,5492

Lebanon 66,656 3,777,2182

Libya 99,380 5,631,5852

Saudi Arabia 455,222 25,795,9382

Syria 317,944 18,016,8742

Turkey 1,215,775 68,893,9182

United Arab Emirates 44,539 2,523,9152

West Bank 40,785 2,311,2042

Yemen 353,380 20,024,8672

 Pneumonia in South America (Extrapolated Statistics)

Belize 4,816 272,9452

Brazil 3,248,843 184,101,1092

Chile 279,246 15,823,9572

Colombia 746,660 42,310,7752

Guatemala 252,010 14,280,5962

Mexico 1,852,228 104,959,5942

Nicaragua 94,583 5,359,7592

Paraguay 109,259 6,191,3682

Peru 486,075 27,544,3052

Puerto Rico 68,787 3,897,9602

Venezuela 441,483 25,017,3872

 Pneumonia in Africa (Extrapolated Statistics)

Angola 193,739 10,978,5522

Botswana 28,927 1,639,2312

Central African Republic 66,043 3,742,4822

Chad 168,327 9,538,5442

Congo Brazzaville 52,906 2,998,0402

Congo kinshasa 1,029,124 58,317,0302

Ethiopia 1,258,880 71,336,5712

Ghana 366,300 20,757,0322

Kenya 582,037 32,982,1092

Liberia 59,834 3,390,6352

Niger 200,480 11,360,5382

Nigeria 313,241 12,5750,3562

Rwanda 145,388 8,238,6732

Senegal 191,508 10,852,1472

Sierra leone 103,833 5,883,8892

Somalia 146,551 8,304,6012

Sudan 690,849 39,148,1622

South Africa 784,384 44,448,4702

Swaziland 20,633 1,169,2412

Tanzania 636,543 36,070,7992

Uganda 465,710 26,390,2582

Zambia 194,571 11,025,6902

Zimbabwe 64,797 1,2671,8602

There are 25 million cases of
pneumonia world wide are reported
each year and about 63,500 people
died from the disease.
 II. OBJECTIVES

General:
I should be able to able to make use of the knowledge, skills, and
attitude I have built up in myself as a preparation for this clinical
exposure. In the process, I should be able to improve these three
domains and motivate our patient to the road of recovery.

Specific:
Cognitive

9. Learn important information about Pneumonia; its causes, signs

and symptoms, occurrence, diagnostic tests, and treatment.
10.Know what happens to the body once this disease occurs.
11.Formulate an effective nursing care plan to relieve the problems
experienced by the patient and achieved plan goals.
12.Apply the different kinds of interventions performed.
Psychomotor

3. Assess the patient’s condition in a cephalocaudal manner noting

her general physique and patterns of functioning.
4. Perform appropriate interventions to each of the NANDA-
approved diagnoses we have formulated.

Attitude

8. Interview the patient / folks in a therapeutic manner using different

means of therapeutic communication.
9. Successfully establish trust and rapport with the patient
I.ANATOMY AND PHYSIOLOGY
 The respiratory system is situated in the thorax, and is responsible for
gaseous exchange between the circulatory system and the outside world. Air is
taken in via the upper airways (the nasal cavity, pharynx and larynx) through the
lower airways (trachea, primary bronchi and bronchial tree) and into the small
bronchioles and alveoli within the lung tissue.

The lungs constitute the largest organ in the respiratory system. They
play an important role in respiration, or the process of providing the body with
oxygen and releasing carbon dioxide. The lungs expand and contract up to 20
times per minute taking in and disposing of those gases.
Air that is breathed in is filled with oxygen and goes to the trachea, which
branches off into one of two bronchi. Each bronchus enters a lung. There are two
lungs, one on each side of the breastbone and protected by the ribs. Each lung is
made up of lobes, or sections. There are three lobes in the right lung and two
lobes in the left one. The lungs are cone shaped and made of elastic, spongy
tissue. Within the lungs, the bronchi branch out into minute pathways that go
through the lung tissue. The pathways are called bronchioles, and they end at
microscopic air sacs called alveoli. The alveoli are surrounded by capillaries and
provide oxygen for the blood in these vessels. The oxygenated blood is then
pumped by the heart throughout the body. The alveoli also take in carbon dioxide,
which is then exhaled from the body.
Inhaling is due to contractions of the diaphragm and of muscles between the ribs.
 Exhaling results from relaxation of those muscles. Each lung is
surrounded by a two-layered membrane, or the pleura, that under normal
circumstances has a very, very small amount of fluid between the layers. The fluid
allows the membranes to easily slide over each other during breathing.

Each alveolus has a thin membrane that allows oxygen and carbon
dioxide to pass in and out of the capillaries, the smallest of the blood vessels.
When you take a deep breath, the membrane unfolds and expands. Fresh oxygen
moves into the capillaries, and carbon dioxide passes from the capillaries into the
bloodstream, where it is carried out of the body through the lungs.
When air is inhaled through the nose or mouth, it travels down the trachea to
the bronchus, where it first enters the lung. From the bronchus, air goes through
the bronchi, into the even smaller bronchioles and lastly into the alveoli.

Pneumonia may be defined according to its location in the lung:

8.Lobar pneumonia occurs in one part, or lobe, of the lung.

9.Bronchopneumonia tends to be scattered throughout the lung.
 VITAL INFORMATION

Name: E.A
Age: 87 years old
Sex: Female
Address: Cogon, Panitan Capiz
Civil Status: Married
Religion: Roman Catholic
Occupation: ----
Date & Time admitted: August 18, 2009 / 3:29 pm
Ward: IHM – Room 224
Chief Complaint: Cough
Impression/Admitting Diagnosis: Aspiration Pneumonia
Final Diagnosis: Aspiration Pneumonia
Attending Physician: Dr. M. Obligacion and Dr. J.
Arancillo
 V. CLINICAL ASSESSMENT

A. Nursing History
1 month prior to admission, the patient is (+) to CVA but it is
undiagnosed. Mrs. E.A. is (-) to HPN and (-) DM.
1 week prior to admission, E.A. was noted to have cough associated
with fever, undocumented. So she sought consult with AP given
Co.amoxiclav with relief of symptoms.
Day of admission, folks decided to have patient admitted for general
check – up.

B. Past Health Problem/Status

Mrs. E.A has no notable Illness. She sometimes
experiences cough, fever and cold. She is a Non alcoholic and Non
Smoker.

C. Family History Illness

Mrs. E.A. family is (+) in Hypertension.
OBGyne HX = G10P10
LEGEND:

F.A. Died of
FEMALE E.A 94 Asthma
87

MALE

DISEASED

58 40 18
67 65 60 56 54 52 41

Lung cancer
 VI. BRIEF SOCIAL, CULTURAL, AND RELIGIOUS
BACKGROUND

Educational Background
Mrs. E.A. is a high school graduate.

Occupational Background
Mrs. E.A. is a housewife.

Religious Practices
Mrs. E.A. is a Roman Catholic.

Economic Status

Mrs. E.A. is supported by her children in her daily living.

 VII. CLINICAL INSPECTION

A. Vital Signs

V/S taken upon admission:

T – 36.1 °C P – 89 bmp RR – 18 bmp CR – 92 bmp BP–
130/90mmHg

V/S taken during my care:

T – 36.5 °C P – 83 bmp RR – 21 bmp CR – 86 bmp BP –
120/80 mmHg

B. Height: 152 cm
Weight: 44 kg
BMI: 19.0
Mrs. M.L is in a Normal Weight.
 C. Physical Assessment

General Appearance: Patient is as sleep most of the time, cannot move freely and is
not responsive.
Skin: Moist
Hair: There is no presence of dandruff and no presence of lice.
Nails: She had a short nails.
Head: normocephalic and symmetric; no lesions, lumps, tenderness.
Face: Face symmetric.
Lymphatic: no involuntary movements, symmetric facial movements.
Eyes: Dirty sclera, Pale conjunctiva, Presence of cataract at the left eye.
Ears: Auricles brown in color, symmetrical in size and position; no lesions, tenderness,
scaling, and discharge in palpation. Unable to hear sounds distinctly.
Nose: symmetric in size and position. No lesions, tenderness, scaling, and discharge
on palpation. No nasal congestion observed.
Mouth: lips symmetrical, soft, and dry.
Neck and upper extremities: symmetrical, no masses or swelling.
Chest, breast and axilla: symmetrical; no masses noted.
Respiratory System: symmetrical chest expansion, (+) crackles both LF, (+) rhonchi
both LF.
VIII. Cardiovascular System: cardiac rate is normal and weak.
IX. Gastrointestinal system: bowel movement is regular.
X.Genitor-urinary system: she can micturate well, no pain noted.
XII. Musculoskeletal system: Unable to flex and extend both upper and lower
extremities. No tenderness or swelling on joints or bones. Good hand grip.
 D. GENERAL APPRAISAL

Speech: She cannot speak clearly but able to make sounds.

Language: Bisaya
Hearing: She can’t easily responds when called and claims to hear
well.
Mental status: She is illogical. Cannot respond easily to verbal
command but is not experiencing any mental deficits.
Emotional Status: she is emotionally stable. She is currently not
grieving for anyone.
 VIII. LABORATORY AND DIAGNOSTIC DATA
• Chemistry

Fluid: serum Result Normal Values Significance of the

August 24, 2009 Abnormal Result
16:52:35

Creatinine 28.2 62.0 – 106.0 umol/L renal disease that

affects the
glomerular
filtration rate.

Potassium 3.10 3.50 – 5.10 mmol/L Within Normal

Range
Sodium 136.3 62.0 – 106.0 umol/L Starvation &
diabetic acidosis,
Dehydration

ALT 26
 B. Hematology
Significance of the
Blood Exam Result Normal Values Abnormal Result
August 24, 2009
WBC 3.8 4.5 – 11.0 10^ g/L Within Normal Range
RBC 4.62 M: 4-6 – 6.2 10^ 12/L Within Normal Range
F: 4.2 – 5.4 10^ 12/L
Hemoglobin 135 M: 130 – 180 g/L Within Normal Range
F: 115 – 165 g/L
Hematocrit L 0.41 M: 0.40 – 0.54 vol - fr Within Normal Range
F: 0.37 – 0.47 vol – fr

Mean Cell volume 90.0 78 – 79 fl Folate deficiency,

(MVC) B12 deficiency,
Hereditary spherocytosis
Mean cell Hemoglobin 29.1 27 – 32 pg Within Normal Range
(MCH)
Mean Cell haemoglobin 32.5 30 – 35 g/dl Within Normal Range
concentration(MCHC)
RDW 13.2 11 – 16 % Within Normal Range
Neutrophil 50.0 50-70 % Within Normal Range
Stabs 1.0 2-3
Eosinophil 11.0 0 - 3% Infection,
Inflammation,
Leukemia, Allergic
reaction
Basophil 0.0 0–1% Anaplastic anemia,
Bone marrow
depression,
Pernicious anemia,
Some infectious or
parasitic disease

Lymphocytes 29.0 20 – 45 % Within Normal Level

Monocytes 9.0 0–8% Chronic Infection

 C. ABG analysis

August 24, 2009 Result Normal Values Significance of the

Abnormal Result

pH 7.45 7.35 – 7.45 Within Normal

Value

PCO2 41.3 35 – 45 mmHg Within Normal

Value

PO2 46.0 80 – 100 mmHg Anemia &

Obstructive
Pulmonary disease

HCO2 28.3 22 – 26 mmol/L

TCO2 66.4 Mmol/L

 X-RAY result

Bibasal pneumonia with consolidation with minimal

regression in the Right.
Right upper lobe Pneumonia, no significant interval change
Atheromatons & Tortuous aorta
Bronhiectasis, both lung bases
Dextroscooliosis, thoracic spine
 IX. PATHOPHYSIOLOGY

Liquid or object enters the respiratory system through inhalation of

microorganism
(Infectious Process)

Infection occurs

Immune reaction follows

Under the infection and immune response inflammation process

proceeded.

Vasoconstriction

Release of chemical mediators

 Vasodilatation and increase capillary permeability

Increase blood pressure then formation of heat and redness to

the site

Swelling and pain emerges then led to loss of tissue functions

Increase in local Capillary leaks

Increased permeability of cell members allowing leukocytes and

fibrin to consolidate in involved areas

fibrin and leukocytes stiffen there will be a decrease in lung

compliance & decrease lung vital capacity which decreases gas
exchange that leads to hypoxemia

Hypoxia

Triggers the compensatory mechanism

ASPIRATION PNEUMONIA
Name of Generi Action Mechani Indicatio Side Contrain Nursing
Drug with c Name sm of n Effects dication Responsib
Dosage Action s ilities
1.Zantac Ranitidine Histamine Completely - Short term Headache Contraindic -Administer
150 mg 1 tab Antagonist inhibits the treatment Dizziness ated with oral drug with
(BID) action of of active Confusion allergy to meals and at
histamine duodenal Hallucinatio ranitidine, bed time.
at the H2 ulcer n lactation - Decrease
receptors - Skin rash doses in renal
of the and liver
Maintenanc
parietal failure.
e therapy - Provide
cells of the
for concurrent
stomach
duodenal antacid
inhibiting
basal ulcer at therapy to
gastric reduce relieve pain.
acid and dosage - Administer
secretion - Short term IM dose
that is treatment undiluted,
stimulated for benign deep into
by food, gastric large muscle
insulin, ulcer group.
histamine, - Arrange for
cholinergic regular
agonist, follow-up
gastrin and including
penta blood tests,
gastrin. to evaluate
effects.
Name of Generi Action Mechani Indicatio Side Contrain Nursing
Drug with c Name sm of n Effects dication Responsib
Dosage Action s ilities
2. Apo- Anti- Inhibits Acute Dry mouth Contraind - Take full
Metronida Metronid Bacterial infection infection with icated course of
zole azole with with strange with not drug
500 MG 1 Antibiotic suscep- susceptib metallic hypersens therapy;
tab (TID) Flagyl tible le taste itivity to take with
Anti- anaerobe anaerobic metronida food if GI
Noritate Protozoal s, bacteria Nausea zole, upset
Protosta causing pregnanc occurs.
t Amebicid cell Acute Vomiting y. (Do not -Advice the
Vandazo e death, intestinal use for client to
l antiproto amebiasis Diarrhea trichomon avoid
zoal – iasis in 1st drinking
Viaflex trichomo Bacterial trimester ) alcohol to
nacidal, vaginosis avoid
amebicid severe
al. reaction.
3.) Acetylc Mucolyt Used to Acute Increas Effervescen - Dilute the 20
&
Fluimucil ysteine ic reduce the and ed t tab / acetylcysteine
600 mg 1 viscocity of chronic product sachet solution with
tab in ½ Expecto mucous respirator ive Phenylkete either normal
secretions. saline or
glass of rant y tract cough nuris sterile water
water (OD) It has also infection for injection,
been use the 10%
Antivira with Nausea
shown to solution
l agent abundant undiluted.
have - Administer
antiviral mucous GI
the following
Antidot effects in secretion upset drugs
e patients s separately,
Dyspne because they
with HIV are
due to a incompatible
inhibition with
acetylcysteine
of viral solutions.
stimulation - Use water to
by reactive remove
oxygen residual drug
solution on the
intermediat patient’s face
es. after
administration
by face.
- Inform the
patient that
nebulization
may reduce an
initial
disagreeable
odor, but the
odor will soon
disappear.
4) Celeco NSAIDS Analgesic & Acute and Diarrhea Contraindi -Assess
Celebrex xib anti- long-term cated with therapeutic
200mg 1 Analges inflammator treatment Dyspepsi allergies responses:
cap (PRN) ic y activities of signs a to
related to and sulphona 1. Pain
Specific cause the symptom Headache mides, relief
signs and s of
COX-2 celecoxib,
symptoms rheumatoi Upper 2.Decrease
enzyme respirator NSAIDS, d stiffness
associated d arthritis
inhibitor with and y tract or aspirin;
inflammatio osteoarth infection significant 3.Swelling
n; does not ritis renal
affect the Abdomin impairme 4.Reduced
COX-1 Acute al pain nt; grip
enzyme, pain pregnancy strength
which Flatulenc (3rd
protects the Menstrual e trimester), 5. Improved
lining of the pain lactation grip
GI tract and Nausea strength
has blood Lower -If GI upset
clotting and impairme Back pain occurs,
renal nt take with
functions. Dizziness food.
Primary -Avoid
dysmenor Edema aspirin,
rhea alcohol
Rash (increase
risk of GI
bleeding)
5.
Macrobee Macrobe Antianemic Prevention of Take the
with Iron e with s FE-deficiency Macrobee
1 tab (OD) Iron anemia with Iron
Vitamins especially in before meals /
and periods of empty
rapid
Minerals stomach
Adolescent
(Best taken
growth,
pregnancy & between
lactation, meals, maybe
excessive taken with
menstrual meals to
flow, old age reduce GI
discomfort)
Treatment of
FE-deficiency
anemia
associated
with
traumatic or
endogenous
haemorrhage
s, surgery on
the GIT

Malnutrition
 XI. NURSING
Impaired Gas Exchange
MANAGEMENT S/Sx:
-Tachycardia
-Restlessness
Concept Map of -Dyspnea
-Hypoxia
Nursing Problems Therapy: O2 therapy, 2 liters.

Ineffective Airway Clearance Risk for less than body

S/Sx: requirements
-Inability to cough effectively S/Sx:
-Anxiety - Starvation
CC: Cough
-Dyspnea - Diabetic acidosis
Dx: Aspiration
-Dry cough - Dehydration
Pneumonia
Meds: Meds & Diet: OTF (1,500 kilocalories /
Metronidazole day ÷ 6 feedings).
Fluimucil Macrobee with Iron
Celebrex

Activity Intolerance
S/Sx:
-Lethargy
-Verbal reports of weakness
-Fatigue
-Exhaustion
Meds & Therapy:
ZantacRehab / Exercise therapy.
 Ineffective Airway
Clearance

ASSESSMENT
DIAGNOSIS
Subjective:
Ineffective Airway Clearance
“Gina ubo siya”
r/t:
As verbalized by the folks.
-Increased sputum production in response
to respiratory infection.
Objective:
-Decreased energy, fatigue
Inability to cough effectively
Anxiety
Dyspnea
Dry cough
PLANNING
•After 8 hours of nursing intervention the patient will be able to cough effectively
and clear secretions.

•After 8 hours of duty the patient will display patent airway with breath sounds
clearing, absence of dyspnea.
 INTERVENTION RATIONALE NURSING THEORY
Independent:
a.) Monitor Vital signs a.) To asses baseline Dorothy Johnson
every hours. data of the patient. (Human Behavioral System)
This theory focuses on the
balance to maintain stability in
the system. It also focuses on
the behavior of the patient
threatened with illness.

b.) Position patient in a

moderated high b.) To promote maximal
position or semi lung function. Ida Jean Orlando
fowler’s position. (Nursing Process – ADPIE)
Nurses can help the patient
c.) Turn patient every two c.) For repositioning, it what they cannot do to their self.
hours and PRN. promotes drainage of Exploring the meaning of the
pulmonary secretions need and validating the
and it enhances effectiveness of the action.
ventilation to
decrease potential of
atelectasis.
d.) Provide oral care. d.) Secretions from CAP Virginia Henderson
are often foul tasting (14 components of Nursing
and smelling. Care)
Providing oral care
may decrease - Nurses will do what the
nausea and things that patients cannot
vomiting associated do.
with the taste of -From dependence to
e.) Instruct patient or secretions. independence.
the folks
regarding e.) Promotes prompt Hildegarde Peplau
medications, side identification of (Basic care components)
effects, and potential adverse Orientation, Identification,
symptoms of reaction to facilitate Exploitation & Resolution.
adverse reaction timely intervention.
to report to the
nurse or
physician.
Dependent:

a.)Administer a.) A variety of medications Lydia Hall

medication such as are available to treat specific (Component of
antibiotics and problems. Nursing Care)
expectorants for
productive cough. - Care, Core and Cure.
- Through medicines
b.) Instruct the patient b.) It may indicate bronchial the patient can be
or the folks to notify tubes are blocked with cured and infection can
nurse if the patient is mucus, leading to hypoxia be cured.
experiencing shortness and hypoxemia.
of breath or air hunger.

EVALUATION
GOAL MET
After the end of the shift, the patient is able to cough effectively and clear
secretions.
After the end of the shift, the patient display patent airway with breath sounds
clearing, absence of dyspnea.
 Impaired Gas Exchange

ASSESSMENT DIAGNOSIS

Subjective: Impaired Gas Exchange

“Nabudlayan siya mag ginhawa”
As verbalized by the folks. r/t:
•Altered oxygen-carrying
Objective: capacity of blood / release
•Tachycardia at cellular level
•Restlessness •Altered delivery of oxygen
•Dyspnea (hypoventilation)
•Hypoxia

PLANNING

After 8 hours of duty, the patient will improved ventilation and oxygenation of
tissues by ABGs within patient’s acceptable range and absence of symptoms
of respiratory distress.
 a.) Cyanosis of nail
INTERVENTION beds may
represent NURSING THEORY
Independent:
vasoconstriction
a.) Observe color of Hildegarde Peplau
or the body’s
skin, mucous (Basiccare components)
response to fever
membranes, and Orientation, Identification,
/ chills; however,
nail beds, noting Exploitation& Resolution.
cyanosis of
presence of
earlobes, mucous
peripheral
membranes, and
cyanosis or
skin around the
central cyanosis.
mouth is
indicative of
systemic
hypoxemia.
b.) Assess mental
status.
b.) Restlessness, irritation,
confusion, and
somnolence may Dorothy Johnson
reflect hypoxemia / (Human Behavioral
decreased cerebral System)
c.)Monitor heart rate - This theory focuses on the
oxygenation.
/ rhythm. balance to maintain stability
in the system. It also focuses
c.) Tachycardia is usually on the behavior of the patient
present as a result of
threatened with illness.
fever / dehydration but
 Ida Jean Orlando
d.) Monitor body d.) High fever greatly (Nursing Process –
temperature. Assist with increases metabolic ADPIE)
comfort measures to demands and oxygen
reduce fever and chills. consumption and - Nurses can help the
alters cellular patient what they
oxygenation. cannot do to their self.
e.) Maintain bedrest.
- Exploring the
Encouirage use of e.) Prevents meaning of the need
relaxation techniques and overexhaustion and and validating the
diversional activities. reduces oxygen effectiveness of the
consumption / action.
demands to facilitate
resolution of infection.

f.) Elevate head and f.) These measures

encourage frequent promotes maximal
position changes, deep inspiration, enhance
breathing, and ineffective expectorantion of
coughing. secretions to improve
ventilation.
Dependent:
a.) Follows progress of Dorothy Johnson
a.) Monitor ABGs (Human Behavioral
disease process and
facilities alterations in System)
pulmonary therapy
- This theory focuses on
the balance to maintain
stability in the system. It
also focuses on the
behavior of the patient
threatened with illness.
EVALUATION
GOAL PARTIALLY MET
After 8 hours of duty, the patient was able to improved ventilation and
oxygenation of tissues by ABGs within patient’s acceptable range and
absence of symptoms of respiratory distress.
pH - 7.45 (7.35 – 7.45)
PCO2 - 41.3 (35 – 45 mmHg)
PO2 - 46.0 (80 – 100 mmHg)
HCO2 - 28.3(22 – 26 mmol/L)
TCO2 - 66.4
 Risk for less than body requirements

ASSESSMENT DIAGNOSIS
Subjective: Risk for less than body
“Wala siya mayad nagakaon, requirements
wala gana” as verbalize by the
folks. R/t:
- Increased metabolic needs
Objective: - Abdominal distension / gas
Sodium – 136.3 associated with swallowing air
- Starvation during dyspneic episodes
- Diabetic acidosis
- Dehydration
Height: 152 cm
Weight: 44 kg
BMI: 19.0
PLANNING
After nursing intervention the patient will demonstrate a measurable increase in
appetite and can tolerate her OTF of 1,500 kilocalories per day / 6 (250 cc of
OTF per feeding)
INTERVENTION RATIONALE NURSING THEORY
Independent: Virginia Henderson
a.) Eliminates (14 components of
a.) Provide covered noxious sights,
container for sputum and Nursing Care)
tastes, smells from -Nurses will do what
remove at frequent the patient
intervals. Assist with / the things that
environment and can patients cannot do.
encourage oral hygiene reduce nausea.
after emesis, after
aerosol and postural
drainage treatments, and
before meals.
Ida Jean Orlando
b.) Bowel sounds may (Nursing Process –
b.) Auscultate bowel be diminished /
sounds. Observe / ADPIE)
absent if the infectious
palpate fro abdominal - Nurses can help
process is sever /
distention. the patient what they
prolonged. Abdominal
distention may occur cannot do to their
as a result of air self.
swallowing or reflect - Exploring the
the influence of meaning of the need
bacterial toxins on the and validating the
gastrointestinal tract. effectiveness of the
action.
c.) Evaluate general c.) Presence of Ida Jean Orlando
nutritional state, obtain chronic conditions or (Nursing Process –
baseline weight. financial limitations ADPIE)
can contribute to
malnutrition, lowered - Nurses can help the
resistance to infection, patient what they
and / or delayed cannot do to their self.
response to therapy. - Exploring the
meaning of the need
and validating the
effectiveness of the
action.
EVALUATION

GOAL MET

After nursing intervention the patient were able to demonstrate measurable

increase in appetite and can tolerate her feeding.
 Activity Intolerance

ASSESSMENT DIAGNOSIS

Subjective: Activity Intolerance

“Nagapangluya siya kag indi
siya mayad kahulag” as R/t:
verbalize by the folks. General weakness and imbalance
between oxygen supply and demand.
Objective:
•Lethargy
•Verbal reports of weakness
•Fatigue
•Exhaustion
PLANNING

After nursing intervention the patient will demonstrate a measurable increase in

tolerance to activity with absence of lethargy and excessive fatigue, and vital
signs within client’s acceptable range.
INTERVENTION RATIONALE NURSING THEORY

Independent:
a.) Evaluate client’s a.) Establishes patient’s Dorothy Johnson
response to activity. capabilities / needs and (Human Behavioral
Note reports of facilitates choice of System)
dyspnea, increased interventions. - This theory focuses on the
weakness / fatigue, an balance to maintain stability
changes in vital signs in the system. It also
during and after focuses on the behavior of
the patient threatened with
activities.
illness. Also in the
medicines that the patient is
receiving.
Florence Nightingale
b.)Provide a quite b.) Reduces stress and
(Environment theory)
environmental and limit excess stimulation,
- Organizing and
visitors during acute promoting rest. manipulating environment
phase as indicated. (physical, social, and
Encourage use of stress psychosocial) in order to put
management and the person in the best
diversional activities as condition alleviate
appropriate. unnecessary pain and
suffering.
c.) Explain importance of c.) Bed rest is maintained Dorothy Johnson
rest in treatment plan during acute phase to (Human Behavioral
and necessity for decrease metabolic System)
balancing activities with demands, thus -This theory focuses on the
rest. conserving energy for balance to maintain stability
healing. Activity in the system. It also focuses
restrictions thereafter are on the behavior of the patient
determined by individual threatened with illness.
client response to activity
and resolution of Ida Jean Orlando
respiratory insufficiency. (Nursing Process – ADPIE)
d.) Assist patient to - Nurses can help the patient
assume comfortable d.) Patient may be what they cannot do to their
position for rest / sleep. comfortable with the self.
head of bed elevated, - Exploring the meaning of
sleeping in a chair, or the need and validating the
leaning forward on effectiveness of the action.
overboard table with
pillow support.

e.) Assist with self – care e.) Minimizes exhaustion

activities as necessary. and helps balance
Provide for progressive oxygen supply and
increase in activities demand.
during recovery phase.
 EVALUATION

GOAL PARTIALLY MET

After nursing intervention the patient were able to demonstrate measurable
increase in tolerance to activity, but not totally. Vital signs within client’s
acceptable range
 XII. DISCHARGE PLANNING

M (MEDICATION)
Take the entire course of any prescribed medications. After a patient’s
temperature returns to normal, medication must be continued according to the
doctor’s instructions, otherwise the pneumonia may recur. Relapses can be far
more serious than the first attack.

E (EXERCISE & ACTIVITY)

Get plenty of rest. Adequate rest is important to maintain progress
toward full recovery and to avoid relapse.
Instruct the folks to monitor the client’s position, she must be in moderate
high back rest and change position every two hours.

T (TREATMENT)
Give supportive treatment. Proper diet and oxygen to increase oxygen
in the blood when needed.
Treatment is one of the main factors in restoration of health and curing of the
failure in the body system. Treatments are given to the patient for a specific
time until treatment is not more needed by the patient.
 H (HOME TEACHING IN REACTION TO DISEASE, ETIOLOGY & HYGIENE
MEASURES)
Encourage the folks to wash patient’s hands. The hands come in daily contact
with germs that can cause pneumonia. These germs enter one’s body when he touch
his eyes or rub his nose. Washing hands thoroughly and often can help reduce the risk.
Tell folks to avoid exposing the patient to an environment with too much pollution
(e.g. smoke). Smoking damages one’s lungs’ natural defenses against respiratory
infections.
Protect others from infection. Try to stay away from anyone with a compromised
immune system. When that isn’t possible, a person can help protect others by wearing a
face mask and always coughing into a tissue.

O (OUT PATIENT FOLLOW – UP)

Keep all of follow-up appointments. Even though the patient feels better, his
lungs may still be infected. It’s important to have the doctor monitor his progress.

D (DIET)
Drink lots of fluids, especially water. Liquids will keep patient from becoming
dehydrated and help loosen mucus in the lungs.
Controlled diets are designed to avoid excessive sodium retention.

S (SPIRITUALITY)
Advise the patient to join the church activities. Keeping faith in God and
believing in him can uplift some distress.
 XIV. MY JOURNEY
Being a third year student taking up Nursing is challenging, nerve breaking, head
cracking, interesting, and exhausting. But being a Nurse is somewhat opposite, because
every single intervention you do is remarkable and very accommodating to your patient. I
am a future Nurse and I admit that I’ve been devoted in rendering care to my patient until
such time that she recovers from her illness.

Mrs E.A is an 87 years old woman. She’s from Cogon, Panitan Capiz and has
been admitted in the Immaculate Heart of Mary (IHM) last August 18, 2009 at around 3:20
pm, with the Chief Complaint of Cough & with the Diagnosis of Aspiration Pneumonia. She
has a Nasogastric Tube Feeding (NGT) and Oxygen Saturation of 2 liters.

I always check her IVF (PNSS 1L x 80 cc/hour) every hour to be sure that it is
not delayed or advanced. I follow up her IVF when it was consumed. Her vital signs are
monitored every hour and her Intake & Output is monitored Q shift. I assist her in her OTF
(1,500 kilocalories / day ÷ 6 feedings). I always see to it that her medications are given at
the right time to prevent complications. I assist her in her morning care and oral care every
morning. I also changed her linens and assist her in combing her hair.

It feels so great to know that you did something right and good to your patient. When
you will ask me, “What is good in being a nurse?” I would answer this way, being a Nurse is
AWESOME because I know that I am one of God’s instruments to save people and help
the poor in my own dearest way. I believe that being a Nurse is not merely a job or a
chosen career. It is a Responsibility, Commitment, Destiny and it’s your Calling from up
above. To tell you frankly, those are part of the things that motivates me for doing the best
that I can do as a STUDENT NURSE. 
 XIV.BIBLIOGRAPHY / REFERENCES

•Nursing Care Plan (Guideline for individualizing Client Care across the life
span).
•Nurse’s Pocket Guide
•Nurse’s Manual of Laboratory Tests and Diagnostic Procedures
•Fundamentals of Nursing
•2009 Lippincott’s Drug Guide
•MIMS
•www. Yahoo.com
•www. Google.com
•www. Wekipedia.com