Republic of the Philippines

ARELLANO UNIVERSITY
College of Nursing
Legarda Campus
S.Y. 2011-2012

CASE PRESENTATION

Of

PNEUMONIA

LAS PIAS GENERAL HOSPITAL

Medical Ward
February 2,3,9,10
Thursday Friday (2:00 pm- 10:00 pm)

Submitted to:
Mr. Jon Jon Martinez R.N.,M.A.N
Clinical Instructor

Submitted by:
Lopez, Irish Michelle B
BSN 3-1 / Group 3
I. INTRODUCTION

Pneumonia is an inflammation of the lungs caused by an infection. It is also called

Pneumonitis or Bronchopneumonia. Pneumonia can be a serious threat to our health.
Although pneumonia is a special concern for older adults and those with chronic
illnesses, it can also strike young, healthy people as well. It is a common illness that
affects thousands of people each year in the Philippines, thus, it remains an important
cause of morbidity and mortality in the country.

There are many kinds of pneumonia that range in seriousness from mild to life-
threatening. In infectious pneumonia, bacteria, viruses, fungi or other organisms attack
your lungs, leading to inflammation that makes it hard to breathe. Pneumonia can affect
one or both lungs. In the young and healthy, early treatment with antibiotics can cure
bacterial pneumonia. The drugs used to fight pneumonia are determined by the germ
causing the pneumonia and the judgment of the doctor. Its best to do everything we
can to prevent pneumonia, but if one do get sick, recognizing and treating the disease
early offers the best chance for a full recovery.

A case with a diagnosis of Pneumonia may catch ones attention, though the
disease is just like an ordinary cough and fever, it can lead to death especially when no
intervention or care is done. Since the case is 51 years of age an appropriate care has
to be done to make the patients recovery faster. Treating patients with pneumonia is
necessary to prevent its spread to others and make them as another victim of this
illness.

II. GENERAL OBJECTIVES

. To be able to come up with an understanding of the disease process and formulate

a comprehensive nursing care plan using the specific objectives nursing process.

SPECIFIC OBJECTIVES

1. To review the anatomy and physiology of the disease.

2. To understand the pathophysiology of it.
3. To know the medical treatment such as the medications and laboratory works
involved.
4. To know the importance of laboratory and diagnostic procedures.
5. To know the nursing management for the disease.
6. To practice nursing assessment during data gathering.
7. To prioritize identified health problems of the patient.
 8. To formulate nursing process as a framework in making the nursing care plan.
9. To be able to acquire adequate knowledge on health education needed by the
patient and relatives for the continuous care at home.

Reason:
I am are presenting a case of Pneumonia to review the anatomy and physiology,
the pathophysiology, and to know the medical treatment and nursing management of
the disease.

III. THEORETICAL FRAMEWORK

She stated in her nursing notes that nursing "is an act of utilizing the
environment of the patient to assist him in his recovery" that it involves the
nurse's initiative to configure environmental settings appropriate for the gradual
restoration of the patient's health, and that external factors associated with the
patient's surroundings affect life or biologic and physiologic processes, and his
development.

With regard to a nurses responsibilities of patient care, Nightingale

defined a set of external factors in the patients environment that must be
controlled:

Pure or fresh air

Pure water
Sufficient food supplies
Efficient drainage
Cleanliness
Light (especially direct sunlight

The omission of any of these factors can retard, if not impede, the recovery
process.Any deficiency in one or more of these factors could lead to impaired
functioning of life processes or diminished health status.
In addition to her theory she also emphasized the need for a calm, noise-
free and warm environment for patients. She put forth that nurses should not only
record the times of meals but also assess the effects of the diet on the patient.
IV. NURSING HISTORY

A. General Data

Name : Mr. X
Address : 719 tramo st. Interior Mamuto 1 LPC
Age : 51 y/o
Sex : Male
Date of Birth: March 3, 1961
Nationality: Filipino
Religion: Catholic
Civil Status: Married
Educational Attainment : High School Graduate
Attending Physician: Dr. Diosdado Agao
Source of emergency Wife
Contact Person

Admission data:

Date of Admission: January 30, 2012

Hospital: Las Pias General Hospital

Chief Complaint: 1 day PTA pt. Complaint of right sided chest pain and
dyspnea.

Diagnosis: Pneumonia t/c Effusion

B. History of Present Illness

2 weeks prior to confinement he has low grade fever and productive

cough but he ignored it. He just take solmux for his cough.

I day prior to admission the patient had a right sided chest pain and
difficulty of breathing he brought him to the hospital with his wife and was
admitted immediately.
 C. Past Health History:
No hospitalization / medical history
No opearations / surginal history
No accidents or injuries
No allergies

D. Social History:
The patient does smoke, he smoked 1 pack per day. He lives with his
wife and his only child daughter. He has no job he stayed at home all the time
and watch television.

V. ANATOMY AND PHYSIOLOGY

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.
VI. PATHOPHYSIOLOGY OF PNEUMONIA

PREDISPOSING FACTORS: PRECIPITATING FACTORS:

Age Hygiene
Environmental factor
smoking

Staphylococcus
pneumoniae

Organisms enter the respiratory tract through in

inspiration and aspiration

Activation of defense
mechanisn

Loss of effectiveness of defense

mechanism

Penetrate the sterile lower

respiratory tract (lungs)

Multiplies in alveoli Release damaging toxins

Clinical Manifestations:
Difficulty of breating
Chest pain
Productive cough
Fever
VII. GORDONS FUNCTIONAL PATTERN

Activity of Daily Before During Interpretation and

Living Hospitalization Hospitalization Analysis

1. Nutrition Has a very good asks his wife to The average adult
appetite; eats 2-3 buy him some drinks about 1500
cups of rice per food from outside ml per day with
meal the hospital
moderate activity
Eats 3x/day and drinks
sometimes even approximately and temperature,
eats biscuits for 500cc of but needs 2500 ml.
snacks water/day per day, an
Very fond of additional 1000 ml.
eating (Fundamentals of
vegetables And Nursing, Kozier, pp.
as an alternative,
1067-1068) An
they are fond of
eating canned insufficient fluid
goods specially intake reduces the
sardines if they amount of fluid in
dont have the chime, which
money enters the large
drinks intestine which in
approximately 6
turn results in drier,
cups of water, 2-
3 cups of sodas harder feces. (
Fundamentals of
Nursing, Kozier, pg.
1185)

2. Elimination urinates without urinates more Defecation, normal

difficulty and frequently stool is semisolid in
experiences no consistency. The
pain when
amount and
voiding
urine is light character of the
amber in color, stool is determined
is aromatic, and by the amount and
adequate in kind of food
amount ingested.
voids 5-6x/day (Fundamentals of
defecates once
 every morning Nursing, Phoebe
without pain and Williams and Luz
difficulty Tungpalan, pg. 321
stool is light
brown to brown Urination, Freshly
in color, semi- voided urine is
solid in
generally clear in
consistency, soft
and tubular appearance and
pale to deep yellow.
When formed, urine
is sterile and
aromatic. Urinating
should not be
painful and
difficult.(Essentials
of Human Anatomy
and Physiology,
Elaine Marieb, pg.
487-488)

3. Exercise sits on the chair lying on bed For exercise to be

most of the time most of the time effective, it should
while watching cant perform be regular and
TV ROM exercises sustained.
doesnt have because he Generally,
time to exercise experiences exercising at least
and considered difficulty of thrice a week is
walking around breating advised.
the village as an Unable to (Fundamentals of
exercise perform ADL Nursing, Kozier, pg.
104)

4. Hygiene bathes once never taken a Bathing provides

everyday, full bath since he relaxation and
shampoos hair was hospitalized comfort and it gives
and cleanses daily regimen
moat people a
body with soap includes using
and towel towel with soap sense of well-being.
brushes teeth 2x to wipe clean the Healthy feet are
a day body parts crucial in helping
gets fingernails hair hasnt been people stand and
cleaned and washed since walk. Nails should
trimmed first day of
 changes clothes hospitalization be trimmed as
everyday nails are not cut needed. Proper oral
combs hair but clean hygiene includes
everyday
daily brushing,
flossing, and rinsing
of teeth and care of
dentures. Regular
check-ups ensure
the health of the
teeth and gums.
Normal grooming
patterns includes
daily brushing and
combing of hairs.

5. Substance Use He smoke 1 does not Nicotine causes

pack of smoke cigarettes many harmful
cigarettes per since he was physiologic effects
day hospitalized
and is a precursor
does drink does not drink
alcoholic alcoholic of lung cancer and
beverages beverages coronary artery
sometimes does not use any diseases. Nicotine
does not use any forms of has a stimulating
forms of recreational effect on the body
recreational drugs and smokers often
drugs
have more difficulty
falling asleep than
non smokers.
Smokers are usually
easily aroused and
often describe
themselves as light
sleepers.

6. Sleep and Rest usually sleeps at the patient cant The sleep wake
around 8 or 9 sleep easily due cycle is very
pm and wakes to difficulty of important to adults.
up at 7 to 7:30 breathing The usually have an
am wakes up for active lifestyle, and
describes sleep vital signs are thought to
as complete and describes sleep require 7 to 8 hours
stated feeling as incomplete of sleep each night
 relaxed after and feels tired by may do well on
waking up even after less.
sleeps soundly waking up This is a normal
and describes Sleeps lightly sleep pattern in the
sleep as deep and is easily hospital ward,
wakes up in the awaken by however, this
middle of the disturbances in resulted due to
night to urinate the environment acute pain due to
but can easily go UTI.
back to sleep
again
does not nap
during the
afternoons or
any time of the
day besides
night time
7. Sexual Activity inactive sex life inactive sex life At any time in life,
primary form of primary form of physical,
affection is kiss affection is kiss psychological and
on the forehead on the forehead
social problems
may a profound
effect on a persons
expression of
sexuality. This
should be taken into
account when it
involves a persons
health or the
delivery of care.
People who do not
have active sex life
still express
sexuality in their
clothes, grooming,
activities and roles.
VIII. PHYSICAL ASSESSMENT

Vital Signs:
Tempereature: 36.7c
Pulse Rate 89 bpm
Respiratory Rate: 25 cpm
Blood Pressure: 120/80 mmHg

General Norms Actual Findings Interpretation and

Appearance Analysis

1. Posture / Gait Erect posture,

coordinated, smooth
and steady gait

2. Skin Color Varies from light to Light brown and Normal

deep brown; from even with freckles
ruddy pink to light
pink; from yellow
overtones to olive
The client is well Deviation from
3. Personal A healthy adult groomed and normal, he has
Hygiene / should be well doesnt looks dirty. uncut nails
Grooming groomed. The hair is There is no because of
combed while the presence of dirt at hospitalization and
nails are trimmed. the tip of her nails, he cant perform
uncombed hair. normal activities of
daily living.
4. Verbal
Behavior He speaks clearly
Speech should be and able to Normal
clear, well paced and express her
coherent. Language thought.
should seem
appropriate for
5. Non-Verbal educational level.
Behavior
Facial expression His facial Normal
and body movement expression is
should be appropriate to the
appropriate with the situation.
mood and the
answers to the
questions
 Body Parts Norms Actual Findings Interpretation and
Analysis

Scalp

>> Color, >> Lighter than the >> Lighter than the Normal
appearance color of the face; color of the face;
negative to masses, >>presence of Deviation from
lumps, lice and dandruff normal due to
dandruff, nits and hospitalization
other depressions

>> Areas of >> Negative for area >> no tenderness normal

tenderness of tenderness

*Hair

>> Color >> Black >> white and gray Normal for his age
hair
>>Evenness of >>Evenly distribution Deviation from
growth over the of hair >>Hair is not evenly normal due to aging
scalp distributed
Normal due to
>>Thickness or >>Thick hair aging
thinness >>Thin hair

>>Texture and >>Silky, resilient hair

oiliness >> Silky, resilient Normal
>>No infection or hair
>>Presence of infestation Normal
infections or >>No infection or
infestations infestation
*Nails

>>Curvature and >>Convex curvature; >>round nails, Normal

angle of the angle of nail plate about 160 degree
fingernail plate about 160 degrees nail base
Normal
>>Fingernail and >>Smooth texture >>thick, hard and
toenail texture smooth nails
Normal
>>Fingernail and >>Highly vascular
toenail bed color and pink in light- >> pink nail bed
skinned clients; dark-
skinned clients may
have brown or black
pigmentation in Normal
>>Tissues longitudinal streaks
surrounding the
nails >>Intact epidermis >>Intact; no Normal
hangnails
>>Blanch test
>>Prompt return of
pink or usual color >>Nail beds return
(generally less than to pink after 3
four seconds) seconds.

*Skull and Face >>Rounded >>Rounded shape, Normal

>>Skull: size, (normocephalic and symmetrical
shape, and symmetrical, with
symmetry frontal, parietal, and
occipital
prominences);
smooth skull contour >>Absence of Normal
>>Skull: nodules nodules or masses
or masses and >>Smooth uniform
depressions consistency; absence
of nodules or masses >> asymmetrical Deviation from
>>Facial features facial features normal due to aging
>>Symmetric or
slightly asymmetric
facial features;
palpebral fissures
equal in size;
>>Eyes: edema symmetric nasolabial >> head in central Normal
and hollowness folds position
>>Symmetry of >>Deviation:
facial movements periorbital edema; >>Eyes are hollow, Normal
(facial nerve) sunken eyes no edema

>>Symmetric facial
movements

*Eye structures
and visual acuity

>>Eyebrows >>Hair evenly >>Evenly Normal

distributed; skin intact distributed,
>>Eyebrows symmetrical
symmetrically aligned; movement and
equal movement alignment
Normal
>>Eyelashes >>Equally distributed;
curled slightly >>Distributed
outward evenly; shot lashes, Normal
>>Eyelids curled outward
>>Skin intact; no
discharge; no >>Symmetrically
discoloration closed, no
>>Lids close discharge and
symmetrically discoloration

Normal
>> Blinking >>Approximately 15
to 20 involuntary
blinks per minute; >> both eyes blink
bilateral blinking at the same time Normal
>>Bulbar >>When lids open, no
conjunctiva visible sclera above
corneas, and upper
and lower borders of >> Transparent
cornea are slightly
covered Deviation from
>>Palpebral normal due to poor
conjunctiva >> Bilateral blinking, peripheral
involuntary, at circulation and lack
approximately 15 >> Pale conjunctiva of sleep
blinks/min
>>Lacrimal gland Normal
 >>Transparent; >> No edema or Normal
>>Lacrimal sac capillaries sometimes tenderness
and nasolacrimal evident
duct >> No edema Normal
>>Shiny, smooth, and
>>Cornea pink or red
>> Iris are visible,
transparent shiny Normal
>>No edema or
>>Pupil: color, tenderness over
shape, symmetry lacrimal gland >> Black in color,
of size, direct and equal in size
consensual >>No edema or >> The pupil
reaction to light tearing constricted when
and illuminated
accommodation
>>Transparent, shiny, >> Pupil constricted
and smooth; details of when looking at
the iris are visible near objects and
pupils dilate when
>>Black in color; looking at far object
equal in size;
normally 3-7 mm in
diameter; round,
smooth border, iris
flat and round
>>Illuminated pupil
constricts (direct
response)
>>Nonilluminated
pupil constricts
(consensual response
>>Pupil constrict
when looking at near Deviation from
vision; pupils dilate normal due to
when looking at far deterioration of the
>>Extraocular object; pupils >> unable to read optic nerves as a
Muscles converge when near newsprint result of aging
(Oculomotor, object is moved
Abducens, toward the nose
Trochlear Nerves)
>>Eyes are
coordinated, move in
unison, with parallel
alignment
>>Visual acuity >>>Able to read
>>>Near vision newsprint

*Mouth and >>Uniform pink color >>Symmetrical, dry, Normal

Oropharynx (darker, e.g. bluish no swelling or
>>Lips: hue, in Mediterranean lesions
symmetry of groups and dark-
contour, color, skinned clients)
and texture >>Soft, moist, smooth
texture
>>Symmetry of
contour Deviation from
>>Inner lips and Ability to purse lips >> Dry oral mucosa Normal due to poor
buccal mucosa peripheral
>>Uniform, pink color circulation
(freckled brown
pigmentation in dark-
skinned clients)
>>Moist, smooth, soft,
glistening, and elastic
>>Teeth and texture (drier oral >> pink gums Deviation from
gums mucosa in elderly due normal due to aging
to decreased
salivation)

>>32 adult teeth

>>Smooth, white,
shiny tooth enamel
>>Pink gums (bluish
or dark patches in
dark-skinned clients)
>>Moist, firm texture >> pink color on Normal
>>Surface of the to gums tongue borders
tongue >>No retraction of >>No lesions
gums (pulling away >> Raised Papillae
from the teeth)

>>Pink color (some

brown pigmentation
 on tongue borders in
dark-skinned clients); >> Moves freely Normal
>>Tongue moist; slightly rough;
movement thin whitish coating
(hypoglossal >>Smooth, lateral
nerve) margins; no lesions >> Smooth tongue Normal
>>Raised papillae base
(taste buds)
>>Base of the
tongue, floor of >>Moves freely; no
the mouth, and tenderness
frenulum

>>Smooth tongue
base with prominent
base
>>Smooth with no
palpable nodules
>>Swallowing ability,
tongue movement,
taste (posterior
tongue
(Barbara Kozier, et
al., Fundamentals of
Nursing Seventh
Edition, page 614)
>> Able to identify
taste
(Weber Handbook of
Health Assessment,
p. 101)

*Musculoskeletal
system
>>Muscles for >>Equal on both >>equal on both Normal
size sides of the body sides

No fasciculation or Normal
>>Muscles for tremors >> no tremors
fasciculation or
tremors
Deviation due to
>>Muscle tonicity >>Normally firm >> not firm aging

>>Muscle >>Equal strength on >> equal strength Normal

strength each body side

>>No deformities >> equal in Normal

>>Skeleton for strength,
normal structure >>No tenderness or
and deformities swelling
Normal
>>Joints >>Varies to some
degree in accordance
with persons genetic
makeup and degree
of physical activity
>>Full range of >> no tenderness or
motion >>No tenderness or swelling
swelling
IX. LABORATORY DIAGNOSIS

URINALYSIS
Macroscopic
Color Dark yellow
Transparency Turbid
Reaction 6.0
Specific gravity 1.030
Protein 3+
Microscopic
Sugar Negative
Pus cells 50-100/HPF
Rbc 2-5/HPF
Bacteria Many
Fine granular cast 0-2/LPF

Clinical Chemistry
Examination Result Reference Analysis
FBS 5.49 3.3-6.1 mmol/L Normal
Uric acid 596 149-458 mmol/L Increased uric acid levels
may indicate gout or
impaired kidney function.
Uric nitrogen 22.06 2.5-7.5 mmol/L Elevated BUN levels occurs
in renal disease, reduced
renal blood flow (due to
dehydration), urinary tract
obstruction,
Createnine 204.4 M 71 115 Elevated levels generally
mmol/L indicate renal disease that
F 53 106 has seriously damaged
mmol/L 50% or more of the
nephrons.
Elevated levels may also
indicate gigantism and
acromegaly.

Total cholesterol 4.63 Up to 5.2 mmol/L Normal

Triglyceride 1.75 Up to 1.74 mmol/L Normal
Electrolytes
Potassium 4.12 3.5 5.5 mmol/L Normal
Sodium 144.4 135 145 mmol/L normal
 Hematology
Examination Result Reference Analysis
Hemoglobin 15.9 g/dl M-13.5 17.0 Normal
F-12.0 16.0
Hematocrit 0.48 M-0.40 0.54 Normal
F-0.36 0.47
Platelet 318 150 450 Normal
RBC 5.26 M-4.7 6.1 Normal
F-4.2-5.4
WBC 30.10 5-10 High numbers of
WBCs
(leukocytosis) may
indicate:
Infectious
diseases
Inflammatory
disease (such as
rheumatoid
arthritis or
allergy)
Leukemia
Severe
emotional or
physical stress

Neutrophil 90 55-70 Neutrophils

increase in
response to
bacteria infection or
inflammatory
disease
Lymphocytes 7 25-40
Monocytes 3 3-8 Normal
XII. DISCHARGE PLANNING

Take the entire course of any prescribed medications.

After a patients temperature returns to normal, medication must be continued
according to the doctors instructions, otherwise the pneumonia may recur.
Relapses can be far more serious than the first attack.

Get plenty of rest.

Adequate rest is important to maintain progress toward full recovery and to
avoid relapse.

Drink lots of fluids, especially water.

Liquids will keep patient from becoming dehydrated and help loosen mucus in
the lungs.

Keep all of follow-up appointments.

Even though the patient feels better, his lungs may still be infected. Its
important to have the doctor monitor his progress.

Encourage patient to wash his hands.

The hands come in daily contact with germs that can cause pneumonia. These
germs enter ones body when he touch his eyes or rub his nose. Washing
hands thoroughly and often can help reduce the risk.

Tell wife to avoid exposing the patient to an environment with too much
pollution (e.g. smoke).
Smoking damages ones lungs natural defenses against respiratory infections.

Give supportive treatment.

Proper diet and oxygen to increase oxygen in the blood when needed.

Protect others from infection.

Try to stay away from anyone with a compromised immune system. When that
isnt possible, a person can help protect others by wearing a face mask and
always coughing into a tissue.