I.

Introduction

Pneumonia is an inflammatory condition of the lung affecting primarily the microscopic air sacs
known as alveoli. Typical signs and symptoms include a varying severity and combination
of productive or dry cough, chest pain, fever, and trouble breathing, depending on the underlying
cause.

Pneumonia is usually caused by infection with viruses or bacteria and less commonly by
other microorganisms, certain medications and conditions such as autoimmune diseases. Risk
factors include other lung diseases such as cystic fibrosis, COPD, and asthma, diabetes, heart
failure, a history of smoking, a poor ability to cough such as following a stroke, or a weak
immune system. Diagnosis is often based on the symptoms and physical examination. Chest X-
ray, blood tests, and culture of the sputum may help confirm the diagnosis. The disease may be
classified by where it was acquired with community, hospital, or health care associated
pneumonia.

Symptoms include malaise, chills, rigor, fever, cough, dyspnea, and chest pain. Cough typically
is productive in older children and adults and dry in infants, young children, and the elderly.
Dyspnea usually is mild and exertional and is rarely present at rest. Chest pain is pleuritic and is
adjacent to the infected area. Pneumonia may manifest as upper abdominal pain when lower lobe
infection irritates the diaphragm. GI symptoms (nausea, vomiting, diarrhea) are also common.
Symptoms become variable at the extremes of age. Infection in infants may manifest as
nonspecific irritability and restlessness; in the elderly, as confusion and obtundation.

Signs include fever, tachypnea, tachycardia, crackles, bronchial breath sounds, egophony (E to A
changesaid to occur when, during auscultation, a patient says the letter E and the examiner
hears the letter A), and dullness to percussion. Signs of pleural effusion may also be present.
Nasal flaring, use of accessory muscles, and cyanosis are common among infants. Fever is
frequently absent in the elderly.

Symptoms and signs were previously thought to differ by type of pathogen. For example, factors
thought to suggest viral pneumonia included gradual onset, preceding URI symptoms, diffuse
findings on auscultation, and absence of a toxic appearance. Atypical pathogens were considered
more likely when onset was less acute and are more likely during known community outbreaks.
However, manifestations in patients with typical and atypical pathogens overlap considerably. In
addition, no single symptom or sign is sensitive or specific enough to predict the organism.
Symptoms and signs are even similar for other noninfective inflammatory lung diseases such as
hypersensitivity pneumonitis and organizing pneumonia.
COPD, or chronic obstructive pulmonary disease, is a progressive disease that makes it hard to
breathe. "Progressive" means the disease gets worse over time. COPD can cause coughing that
produces large amounts of mucus (a slimy substance), wheezing, shortness of breath, chest
tightness, and other symptoms. Cigarette smoking is the leading cause of COPD. Most people
who have COPD smoke or used to smoke. Long-term exposure to other lung irritantssuch as
air pollution, chemical fumes, or dustalso may contribute to COPD. At first, COPD may cause
no symptoms or only mild symptoms. As the disease gets worse, symptoms usually become more
severe. They include a cough that produces a lot of mucus, shortness of breath, especially with
physical activity, wheezing, chest tightness

Gouty arthritis is usually an extremely painful attack with a rapid onset of joint inflammation.
The inflammation is precipitated by the deposition of uric acid crystals in the lining of the joint
(synovial lining) and the fluid within the joint. Intense joint inflammation occurs when white
blood cells engulf the crystals of uric acid and release chemicals that promote inflammation. The
resulting inflammation causes pain, heat, and redness of the joint. Gouty arthritis is a common
cause of a sudden onset of a painful, hot, red, swollen joint, particularly in the foot at the big toe.
Gouty arthritis is reportedly the most common cause of inflammatory arthritis in men over the
age of 40. It is definitively diagnosed by detecting uric acid (monosodium urate) crystals in an
aspirated sample of the joint fluid. These uric acid crystals can accumulate in the joint and tissues
around the joint over years, intermittently triggering repeated bouts of acute inflammation.
Repeated attacks of gouty arthritis, or "flares," can damage the joint and lead to chronic arthritis.
Fortunately, while gout is a progressive disease, there are effective medications to treat gout.
( http://www.doh.gov.ph/node/1482)

COPD is one of the 10 leading causes of death in the Philippines. It has a prevalence rate of 14%
among Filipino adults aged 40 and above.

Only 2% of the cases are diagnosed by doctors in contrast to the overall prevalence.

(http://www.pinoycopd.com/what-is-copd.html)

II. Statement of the Objectives

General Objectives

This case study aims to identify and determine the general health problems and needs of
the patient with an admitting diagnosis of Pneumonia, COPD, Gauty Athritis. This presentation
also intends to help patient promote health and medical understanding of such condition through
the application of the nursing skills.

Specific Objectives

This study is aimed to promote health of the chosen patient qualitatively by learning
about the patients condition

To raise the level of awareness of patient on health problems that he may

encounter

To facilitate patient in taking necessary actions to solve and prevent the identified
problems on his own.

To help patient in motivating himself to continue the health care provided by the
health workers

To render nursing care and information to patient through the application of the
nursing skills

To know the causes of Pneumonia, COPD, Gauty Arthritis

To identify the different clinical manifestations of the condition

To determine the possible medical and surgical management of this condition

To provide nursing care and information to patient through the application of the
nursing skills

Course in the ward:

11/28/17 The patient was admitted in the ward, the doctor ordered him a DAT diet and
diagnostic exams about CBC with PC, NA, K, MG, Creatinine, UA, FE, CXR, ECG, HDL, LDL,
BUA, Triglycerides, RBS and FBS. The doctor also ordered an IVF of PNSS 1L and medications
namely Cefuroxime, Azithromycin, Atorvastatin, Allupinol, Salbutamol + Ipa, KCL, Ketobest,
Hydrocortisone and Paracetamol. At 9:05 pm, the doctor issued to start ketobest TID, KCL drip
incorporated in PNSS 3 hours in 2 doses and Kalum durule TID.

11/29/17 Tbe doctor ordered to continue meds, V/s q 8 then ordered to increase
Alloprinol to 100mg from 50mg twice a day, continue Kalum Durule tab q 6 and start KCL drip
in PNSS 4 hours
 11/31/17 The doctor ordered to repeat K, BUN, Creatinine stat, discontinue Salbutamol
+ Ipra, start Salbutamol + Plutesem twice a day puff and gargle and transfer the patient to Pulmo
B

III. Patient History

A. Patient Identification

Patient Name : Mr. XYZ

Date of Birth : 12/27/1954
Age : 62 years old
Diagnosis : CAP MR COPD Gouty Arthritis
Date of Hospitalization : 1/28/17
Hospital : Romana Pangan District Hospital

B. Patients Medical History

Patient History:
The patient lived in a place that is surrounded by the
Pampanga River. He is male and married and have 3 daughters and
2 sons. When he was 14 years old he started to work as a fisherman
for his family because he was the eldest among his siblings, when
he reached 24 years old he started to smoke cigarette and he is
consuming at least 1 to 2 packs of cigarettes per day. (30 sticks in a
day, 210 sticks in a week, 840 sticks in a month and 10,080 sticks
x 38 years, 383,040 estimated sticks of cigarettes. He stopped
smoking last November 2016 because he had DOB, coughing with
sputum thats why he was admitted at Diosdado Macapagal
Memorial Hospital for several days which started on Dec 28,2016.
After that one of his children decided to take care of him closely in
their home but after few weeks, the patient experienced same
symptoms thats why they bought him to Romana Pangan District
Hospital last Jan 28, 2017

Present Medical History : (+) cough (+) fever (+) Hypertension

Past Medical History : (+) Arthritis --- (+) Childhood disease --- (+)
Hypertension --- (+) TB

C. Physical Examination
Initial assessment in the ER :
Date of Admmission : 1/28/17
Chief Complaint : Body Malaise
 Vital signs as follows :
BP: 120/80 CR: 84 RR: 21 Temp: 37 c

Physical Assesment

Body Part Technique Used Actual Finding Interpretation

Assessed
Skin Inspection Skin color Dark skin Normal
Palpation Skin is smooth with fair skin turgor Normal

Inspection Normocephalic Normal

Head
Evenly distributed hair, no dandruff, Normal
lesions nor infection
Eyes Palpation Sinuses non-tender Normal

Inspection Symmetrical eyelids Normal

Pinkish conjuctiva Normal
Anicteric sclera Normal

Body Part Technique Used Actual Finding Interpretation

Assessed
Ears Inspection Normoset Normal

Palpation No discharge Normal

Non tender Normal
Nose Inspection No presence of mass or nodules Normal
Symmetrical nasal folds Normal
Nasal septum at midline Normal
Mucosa is moist, pinkish, intact and Normal
no discharge
Airways patent on both nares Normal
 Palpation Non tender sinuses Normal

Mouth Inspection Lips pinkish and dry Normal

Tongue at midline Normal
Gums and mucosa pink Normal

Pharynx Inspection Uvula at midline Normal

Tonsils not inflamed Normal

Neck Inspection Neck symmetrical with full ROM Normal

Pulmonary Inspection Symmetric Normal

Auscultation Crackles breath sounds Abnormal

Body Part Technique Used Actual Finding Interpretation

Assessed
Cardiovascula Auscultation Normal heartbeats Normal
r
Inspection Flat and symmetrical Normal
Abdomen No lesions Normal
Palpation No tenderness Normal

Extremities Inspection Skin smooth Normal

Skin intact Normal
Nails convex curved Normal
Pink nail beds Normal
 Palpation Skin normal temperature Normal

Motor Inspection 100% intact Normal

Sensory 12 cranial nerves responsive Normal

IV. Anatomy and Physiology

V. Gordons 11 Level of Functioning:

Areas of Functional Before Hospitalization During Hospitalization Analysis

Pattern
Health Perception Patient XYZ was a Patient XYZ is now The onset of all pneumonias is Pa
Health Management fisherman near the being hospitalized marked by any or all of the following fun
Pampanga River. As because he is manifestations; fever, chills, sweats, res
experiencing a health
part of his daily routine fatigue, cough, sputum production and pn
problem, he was
he vends his harvested diagnosed with dyspnea. (Medical-Surgical Nursing by
fishes to the fish market Community Acquired Vol. 2 8th Edition by Joyce Black an
in the community. He Pneumonia Mod Risk, p.1599)
rarely visits the COPD, Gauty Arthritis
barangay health center and have undergone
for check-ups because confinement. He
manifested body
he thinks that going to
malaise prior to her
their health center is a confinement. He is
burden and time expecting to recover
consuming for him. from his present
condition with the help
and support of his family
and the health providers
attending to his needs.

Patient XYZ is on DAT

Nutritional - Metabolic Patient XYZ is living a diet thats being served An individual health status greatly Nu
healthy lifestyle his in the hospital. affects eating habits and nutritional me
appetite is well. Hes status (Fundamentals of Nursing by pa
fond of eating different Kozier p.1178) no
types of dishes
consisting of
vegetables, fishes and
meat and drinks plenty
of water also.
 Bowel
Elimination Bowel Patient XYZ only Elimination is important because Bo
defecated 1 time on the urinary and bowel movement affects
Patient XYZ defecates days he was observed. your entire physiology. It makes the Th
5-6 times a week and Stool is brownish in fre
body pH in balance and it eliminates
he was observed color, normal in amount elim
but with discomfort. body toxins with it.
without experiencing
discomfort. Stool is
color brown and well- Bladder
formed. Patient XYZ urinates 5-7 Urinalysis is an array of test
times daily without performed on urine and one of the
having discomfort. Urine most common methods of medical
is light-yellow in color diagnosis.
Bladder without any discomfort.
(Fundamentals of Nursing by Taylor,
Patient XYZ usually Lillis)
voids 3-4 times a day.
Urine is light-yellow in
color and without any
discomfort.

Patient XYZs activities

Activity-Exercise In the morning patient in the hospital are Individuals who have inactive Du
XYZ walks around their limited only within his lifestyles all who are faced with con
community as an room. Patient XYZ is inactivity because of illness or injury lim
activity-intolerance due
exercise. At his work, are at risk for many problems that can of
to his condition. He
He sails to the river to often lies in bed and affect major body systems dis
catch fishes. After her only shifts to a chair with (Fundamentals of Nursing by Kozier an
work patient XYZ the help of his relatives page 1068.)
mingles with his co- whenever he wants to
fishermen then sells the sit. He talks with his
fishes they have relatives whenever He
feels bored and
harvested to the fish
frequently reads the
market. Patient XYZ newspaper.
likes watching
television shows,
listening to radio and
make conversation with
his friends.

Cognitive-Perceptual Patient XYZ is a
elementary school
graduate. He can read
and speak well and
listens attentively.
Sleep- Rest Patient XYZ usually
sleeps around 11 pm.
He watches television;
this helps him to fall
asleep. He wakes up
early in the morning
around 5 am as his
daily routine and body
clock.
Self-Perception Patient XYZ is a his self sick. He now
friendly and happy
Self-Concept person. And he use to
socialize with her
friends in their
neighborhood and to
his clients in his fishing
work. He is a well-
determined person and
He wants to be happy
and free from anxieties.
His family and relatives
are always there for
him to give assistance
and support. He wants
to have good health
and live her life to the
Patient XYZs present
condition affects her When a patient is admitted to a Th
cognitive-perceptual health agency he or she is confronted co
pattern. His sensory with stimuli that are different in quality pa
perception is limited to
and quantity than that to which he or stim
his hospital room, and
within the hospital area. she is accustomed. (Fundamentals the
of Nursing, 5th ed. By Taylor, Lillis, is
p.906) are
Patient XYZs sleeping
pattern is disturbed due Illness that causes pain or distress Pa
to random attack of pain can result in sleep problems. People res
and also the cold breeze who are ill require more sleep than cha
of air through the
normal and normal rhythm and ad
windows of the patients
room also adds as a wakefulness is often disturbed. Du
factor to her difficulty in oth
sleeping. (Fundamentals of Nursing by fac
Kozier.7th ed.)
Patients XYZ considers
Events or situations may change the Du
thinks that he cant level of self-concept overtime illness con
function well as before. and trauma can also effect the self- cha
concept (Fundamentals of Nursing pa
by Kozier page 959 and 962.) an
his
life
his
lim
 fullest.

He can express
hiimself very well.
Patient is married and
lives with his eldest
Pa
daughter . He is also
his
very active and When an illness occurs, roles sup
socializes with her changes for both patient and family. an
Role-Relationship friends and neighbors. Patient XYZs family are (Fundamentals of Nursing by Taylor
with him during his he
page 63). pre
confinement, they are
supportive in giving the
necessary needs. The
patients visited by his
friends and relatives
during his stay in the
hospital.

Sexuality- Patient XYZ verbalizes Patients XYZ sees Sexual response involves peoples Th
Reproductive that he is not that himself healthy even- emotional psychological physical and pa
sexually active due to though hes not sexually spiritual makeup, which plays a rep
his age. active anymore. significant role in sexual
satisfaction.(Fundamentals of
Nursing by Kozier page 980.

Coping Stress- When he is anxious, During his According to Folkman and Lazarus, Th
Tolerance patient XYZ wants to hospitalization, patients coping is the cognitive and behavioral let
be alone and have XYZ copes by with effort to manage specific external and ou
some rest. When he family and friends with internal demands that are appraised the
has problems he wants their support. as taxing exceeding the resources of du
to communicate and the person. (Fundamentals of an
share her problems to Nursing by Kozier page 1020.) pa
his family and friends. con
She makes herself str
busy like watching
 television or listening to
radio.

Patient XYZ is a
Roman Catholic, and A persons values influences belief
he goes to mass every about human needs, health, and
Patient XYZ still believe illness, the practice of health Pa
Sunday with her family.
that God will always behaviors and human responses to tha
Value-Belief The patients have a
help them. According to illness. (Fundamentals of Nursing, 5th pu
great value of faith
his family, they still Ed. By Taylor, Lillis, LeMone, p. 91) pa
when it comes to
attend mass even situ
religion.
without him, praying for an
the patients faster his
recovery. ac
an
as
up
illn

VI. Laboratory Results and Diagnostic Test

 Date Examined : January 28 , 29 2017

Procedure Date Client- Actual Normal Analysis &

Ordered Centered Results Findings Interpretation
& Indication Of the Results
Date of
results

WBC Count 14.1 x 5.0-10 x 10^?/L There is a

10^?/L prese
M: 140180 g/L
Hemoglobin 120 g/L F: 120160 g/L

M:0.40 - 0.52
Hematocrit 0.36 F: 0.37-0.47

CBC with PC 01-28-2017 Within the

6am Segmenter 0.69 0.50-0.70 normal limits

Within the
Lymphocyte 0.31 0.20-0.40 normal limits

A: 150450 x Within the

Platelet 293 x 10^9/L normal limits
10^9/L NB: 84-450 x
10^9/L
Within the
FBS 70.84 mg/dl 60-110 mg/dl normal limits

RBS 142 mg/dl 70 164 mg/dl Within the

normal limits

Creatinine 2.05 mg/dl 0.8 1.70 mg/dl

Blood 01-28-2017
Chemistry I 6pm 140-250 mg/dl Within the
Cholesterol 143.1 g/L normal limits

M:40-160 mg/dl Within the

Tryglycerides 75.69 F: 35-135 mg/dl normal limits

Within the
HDL 42.65 30-85 mg/dl normal limits
 LDL 85.31 66-178 mg/dl Within the
normal limits
BUA 11.2 M: 3.5-8.5 mg/dl
F: 2.5-7.5 mg/dl

FBS
60-110 mg/dl
100.71 Within the
mg/dl normal limits

Blood 01-29-2017 140-250 mg/dl Within the

Chemistry I Cholesterol 221.8 g/L normal limits

M:40-160 mg/dl Within the

Tryglycerides 82.1 g/L F: 35-135 mg/dl normal limits

Within the
HDL 45.2 g/L 30-85 mg/dl normal limits

Within the
LDL 160.18 g/L 66-178 mg/dl normal limits

M: 3.5-8.5 mg/dl
BUA 13.0 g/L F: 2.5-7.5 mg/dl

Procedure Date Client- Actual Normal Analysis &

Ordered Centered Results Findings Interpretation
& Indication Of the Results
Date of
results

Sodium 133.1 135-145 mmol/L

Blood 01-28-2017 mmol/L
Chemistry II 6am

3.5 5.5 mmol/L

Potassium 2.72
 mmol/L
96-110 mmol/L
Chloride 100.9
mmol/L
Total Calcium 2.44
mmol/L 2.10 2.60 mmol/L
Ionized 1.17
Calcium mmol/L 1.05 1.30 mmol/L

Ionized 1.17 1.05 1.30 mmol/L

Calcium mmol/L

Procedure Date Client- Actual Analysis &

Ordered Centered Results Interpretation
& Indication Of the Results
Date of
results

Color Yellow

Transparency Turbid

Reaction
6.5
Specific
Urinalysis 01-29-2017 Gravity 1.015

Sugar Negative
Albumin Negative

Pus cells 7-10

Epithelial Few
Cells
A. Urates / Few
Phosphates
Procedure Date Client- Actual Analysis &
Ordered Centered Results Interpretation
& Indication Of the Results
Date of
results
Within normal
Color Yellow limits

Within normal
01-29-2017 Transparency Turbid limits

Reaction 6.5 Within normal

Urinalysis limits
Pus cells 7-10

Procedure Date Client- Actual Analysis &

Ordered Centered Results Interpretation
& Indication Of the Results
Date of
results
Within normal
Color Brown limits
Within normal
Transparency Formed limits

Fecalysis 01-29-2017 Parasites Within normal

Negative limits
 Procedure Date Client- Actual Analysis &
Ordered Centered Results Interpretation
& Indication Of the Results
Date of
results

The lungs are clear.

The hila and
pulmonary vessels
are normal in pattern

The heart is normal

in size and
configuration.
CXR 01-28-2017 Chest PA: Mediastinum and Normal Chest
diaphragm are
unremarkable

The visualized
osseous structures
are intact. Soft tissue
do not appear
unusual

X. References
Fundamentals of Nursing, 5th Ed. By Taylor

Fundamentals of Nursing by Kozier

Medical-Surgical Nursing Vol. 2 8th Edition by Joyce Black

Fundamentals of Nursing by Kozier.7th edition

Medical-Surgical Brunner and Shiddarts Vol 2