Foundation University

COLLEGE OF NURSING
Dumaguete City

A Case Study on
Community-Acquired Pneumonia
associated with Pleural Effusion and Urinary Tract Infection

In partial fulfillment of the requirements

for
Nursing Care Management (NCM) 106 - Emergency Room Rotation

Submitted to:
Mr. Peter Orlino, BSN-RN

Submitted by:
Francis Adrian Palalon, SN-FUCN

Submitted on:
October 10, 2017
Foundation University
College of Nursing
6200 Dumaguete City

Peter Orlino, BSN-RN

Clinical Instructor
Foundation University
College of Nursing

Dear Sir:
I, Francis Adrian Palalon, Section A1 from the College of Nursing, Foundation University under the Emergency Room Rotation would like to
apply for a case study on my patient Mr. T. L. R. 35 years old, who was admitted at the Negros Oriental Provincial Hospital last September 20, 2017
with a final diagnosis of Community-acquired pneumonia, pleural effusion and urinary tract infection. This case study would also serve as a partial
fulfillment of the course requirement in Nursing Care Management 106. I assure you that all the information gathered in this study are kept
confidential and will be only discussed for academic purposes.

Thank you very much.

Respectfully yours,

Francis Adrian Palalon

TABLE OF CONTENTS

CONTENT PAGE
I. FOUNDATION UNIVERSITY MISSION, VISION & LIFE PURPOSE 1
II. CENTRAL OBJECTIVES AND SPECIFIC OBJECTIVES 2
III. ACKNOWLEDGEMENT 3
IV. INTRODUCTION 4
V. DEMOGRAPHIC PROFILE 5
VI. DEVELOPMENTAL TASKS 6-7
VII. ANATOMY AND PHYSIOLOGY 8-18
VIII. REVIEW OF RELATED LITERATURE 19-21
IX. MEDICAL MANAGEMENT
 LABORATORY EXAMS 22-26
 PATHOPHYSIOLGY 27-30
 TREATMENT MODALITIES 31-32
 DRUG STUDY 33-42
X. NURSING MANAGEMENT
 NURSING HISTORY 43
 GENOGRAM 44
 PHYSICAL ASSESSMENT FINDINGS 46-50
 NURSING THEORIES 52-52
 GORDON’S FUNCTIONAL HEALTH PATTERN 53-57
 SUMMARY OF NURSING DIAGNOSES 58
 NURSING CARE PLAN 59-63
XI. ANNOTATED READINGS 64-68
X. CONCLUSION 69
XI. BIBLIOGRAPHY 70
I. FOUNDATION UNIVERSITY MISSION, VISION & LIFE PURPOSE

Mission
To enhance and promote a climate of excellence relevant to the challenges of the times, where individuals are committed to the pursuit of
new knowledge and life-long learning in service of society.

Vision
To be a dynamic, progressive school that cultivates effective learning, generates creative ideas, responds to societal needs and offers equal
opportunity for all.

Life Purpose
To educate and develop individuals to become productive, creative, useful and responsible citizens of society.

Core Values
• Excellence
• Commitment
• Integrity
• Service

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II. CENTRAL OBJECTIVE

This case study aims to identify and determine the general health problems and needs of the patient with an admitting diagnosis of
Community-Acquired Pneumonia, Pleural Effusion and Urinary Tract Infection. This presentation also intends to help students promote health and
medical understanding of such condition through the application of nursing skills. This paper is also intended to provide a better understanding of
the disease process based on the patient’s health history and as a reference for future nursing students.

Specific Objectives
At the end of the discussion, the learners will be able to:
• obtain the needed information of the client base on its demographic data completely but not surpassing the patient’s privacy;
• identify the physical assessment accurately;
• comprehensively understand the anatomy and physiology of systems involve in the disease condition;
• trace the pathophysiology of the involve disease condition comprehensively;
• identify both medical and nursing intervention satisfactorily;
• identify the different medical interventions and their rationale;
• comprehend the nursing theory applicable to the care of the patient;
• determine the three priority nursing diagnoses comprehensively;
• formulate nursing care plans towards the care of the client critically; and
• evaluate the case presentation by asking relevant questions.

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 ACKNOWLEDGEMENT

The goal of nursing education in Foundation University College of Nursing is to provide quality and competent education, honing its student to
be well rounded in all the aspects of life, namely physically, emotionally, intellectually, socially and spiritually. Our exposure to the clinical setting
would not only entail experiential learning but also are employing our critical learning skills in order to render care effectively yet exercising the use
of resources economically most especially in the institution we are being exposed. For the whole duration of the Medicine rotation I was able to
appreciate the different works and nursing responsibilities.

First and foremost, I would like to give thanks to God, for giving opportunities, for the guidance, for the strength and unconditional love that
keeps them going.

I would like to emphasize the warmest accommodation of the Negros Oriental Provincial Hospital - Emergency Department, the staff and
personnel who have been very supportive and helpful in meeting the needs on certain information regarding the patient’s status.

To Dean Marlene Rosejie Sontillano, RN, RM, MN and Foundation University College of Nursing for the opportunity to integrate knowledge
learned from the four walls of our classrooms to the field we have been assigned.

To the patient and the significant others, for allowing me take up their time to interview, and for being cooperative, responsive and answering
the questions related to the patient’s condition. Without their cooperation I would not be able to collect reliable and precise data.

Lastly, I would like to express my sincere gratitude to Mr. Peter Orlino, BSN-RN for being the adviser of this study, for the patience,
motivation and for his time and expertise and supplemented ideas in addition to our knowledge.

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IV. INTRODUCTION

This is a case of a 35-year-old male patient currently residing at Piapi, Dumaguete City. He was admitted last September 20, 2017 with a chief
complaint of left-sided chest pain in which later diagnosed as community-acquired pneumonia; moderate risk, pleural effusion and UTI. Upon
receiving the patient, 1 L D5W with Eurosol-M was inserted at the right metacarpal vein regulated at 10 gtts/min. He was coherent and able to
respond to queries accurately. He complains of restlessness due to sleepless last night since admission. I have never handled a patient with this
condition so I am fortunate to handle this case and able to render effective care for the patient. Caring throughout our duty was beneficial and a
very good experienced for us in which we’re able to monitor the patient’s current status.

Musher (2014) defined pneumonia as a syndrome in which acute infection of the lungs develops in persons who have not been hospitalized
recently and have not had regular exposure to the health care system. Pneumonia is long recognized as a major cause of death and has been
studied since the late 1800s, the results of which many formative insights in modern microbiology. The most commonly identified pathogens are
Streptococcus pneumoniae, Haemophilus influenza and viruses (Sethi, 2017).

In the case of my patient, he was categorized as ‘moderate risk’ and manifested symptoms such as cough, fever, chills, fatigue and pleuritic
(left-sided) chest pain prior to admission. Although after three days a discharge against medical advice (DAMA) was implemented.

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V. DEMOGRAPHIC PROFILE

Name: T. L. R. Sex: Male Nationality: Filipino

Address: Piapi, Dumaguete City Age: 35 years old Civil Status: Married

Birthdate: September 23, 1961 Date of Admission: 9-20-17 Religion: Roman Catholic

Attending Physician: Dr. Borromeo

Chief Complaint: “Gasakit ning akong dughan sa kilid (points at left side chest) unya laba’g kapoy akong lawas pagka gabii, unya ug ubhon ko
hilantanon ko”, as verbalized by the patient.

HPI: Two weeks PTA, patient experienced hemoptysis and left sided pleuritic chest pain.

A day PTA, patient complains of left-sided chest pain, fatigue and developing fever when coughing.

General Impression:

Received patient sitting in chair with 1L Eurosol-M in D5W injected at right metacarpal vein running at 10 gtts/min. Patient is oriented to
place, day and person but not specifically the time. He is well-groomed but shows restlessness and dark circles in both eyes. Coherent and able to
respond to queries asked.

Final Diagnosis: Community-acquired pneumonia, pleural effusion, UTI

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VI. DEVELOPMENTAL TASKS

Career Development Theory

by Donald Super

Establishment Stage (24-44 years)

Donald E. Super’s (1953) career development theory is perhaps the most widely known life-span view of career development. Developmental
theories recognize the changes that people go through as they mature, and they emphasize a life-span approach to career choice and adaptation.
These theories usually partition working life into stages, and they try to specify the typical vocational behaviors at each stage.
While traditional vocational guidance focused on occupational choice and the prediction of occupational success at some later point in time,
Super (1953) stressed the need to understand and predict a career. He defined a career as a sequence of occupations, jobs, and positions held
during the course of a lifetime, including also prevocational and post-vocational activities. Super asserted that what was actually needed in
vocational guidance was a career model, which takes into account the sequence of positions that an individual occupies during her or his working
life. Interest in understanding careers led Super to look into peoples’ career patterns, which portray one aspect of vocational development—the
sequence of changes in occupational level and field over a period of time. Although initially “set out” by the individual’s parental socioeconomic level,
patterns are also determined by individuals’ abilities, personality traits, and the opportunities to which they are exposed. The analysis of career
patterns supported the view that the life cycle imposes different vocational tasks on people at various times of their lives.

Establishment stage (25-44 years) is the period when the individual, having gained an appropriate position in the chosen field of work,
strives to secure the initial position and pursue chances for further advancement. This stage involves three developmental tasks. The first task is
stabilizing or securing one place in the organization by adapting to the organization’s requirements and performing job duties satisfactorily. The next
task is the consolidation of one’s position by manifesting positive work attitudes and productive habits along with building favorable coworker
relations. The third task is to obtain advancement to new levels of responsibility (Super, 1980).

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Correlation:

The theory by Super (1953) focuses on how careers unfold over the life span. People differ in their abilities, personalities, needs, values,
interests, traits and self-concepts. And each occupation requires a characteristic pattern of abilities and personally traits. The theory partitions
working life into stages, and trying to specify the typical vocational behaviors at each stage.

In the patient’s case, he is able to settle in a career that gives him enough pay to support him and the family. He’s job is a workman doing
manual labors in an establishment. He states he is in an average level employee in their levels of hierarchy in their company. This process of change
may be summed up in a series of life stages characterized as a sequence of growth, exploration, maintenance and decline. The task is partially met
since the patient did not yet proceed in the advancement from his current level of employment. Since the nature of the career pattern is determined
by the individual’s parental socioeconomic level, mental ability, education, skills, personality characteristics, career maturity, and by the opportunities
to which an individual is exposed.

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VII. ANATOMY AND PHYSIOLOGY

Respiratory System

Nose and Nasal Cavity

The nose and nasal cavity form the main external opening for the respiratory system and are the first section of the body’s airway—the
respiratory tract through which air moves. The nose is a structure of the face made of cartilage, bone, muscle, and skin that supports and protects
the anterior portion of the nasal cavity. The nasal cavity is a hollow space within the nose and skull that is lined with hairs and mucus membrane.
The function of the nasal cavity is to warm, moisturize, and filter air entering the body before it reaches the lungs. Hairs and mucus lining the nasal
cavity help to trap dust, mold, pollen and other environmental contaminants before they can reach the inner portions of the body. Air exiting the
body through the nose returns moisture and heat to the nasal cavity before being exhaled into the environment (Taylor, 2017).

Mouth

The mouth, also known as the oral cavity, is the secondary external opening for the
respiratory tract. Most normal breathing takes place through the nasal cavity, but the oral cavity
can be used to supplement or replace the nasal cavity’s functions when needed. Because the
pathway of air entering the body from the mouth is shorter than the pathway for air entering
from the nose, the mouth does not warm and moisturize the air entering the lungs as well as the
nose performs this function. The mouth also lacks the hairs and sticky mucus that filter air
passing through the nasal cavity. The one advantage of breathing through the mouth is that its
shorter distance and larger diameter allows more air to quickly enter the body (Taylor, 2017).

Pharynx

The pharynx is divided into 3 regions: the nasopharynx, oropharynx, and laryngopharynx.
The nasopharynx is the superior region of the pharynx found in the posterior of the nasal cavity.
Inhaled air from the nasal cavity passes into the nasopharynx and descends through the
oropharynx, located in the posterior of the oral cavity. Air inhaled through the oral cavity enters
the pharynx at the oropharynx. The inhaled air then descends into the laryngopharynx, where it is
diverted into the opening of the larynx by the epiglottis. The epiglottis is a flap of elastic cartilage
that acts as a switch between the trachea and the esophagus. Because the pharynx is also used Figure 1.0: Anatomy of the Respiratory
to swallow food, the epiglottis ensures that air passes into the trachea by covering the opening to System

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the esophagus. During the process of swallowing, the epiglottis moves to cover the trachea to ensure that food enters the esophagus and to prevent
choking (Taylor, 2017).

Larynx

The larynx, also known as the voice box, is a short section of the airway that connects the laryngopharynx and the trachea. The epiglottis is
one of the cartilage pieces of the larynx and serves as the cover of the larynx during swallowing. Inferior to the epiglottis is the thyroid cartilage,
which is often referred to as the Adam’s apple as it is most commonly enlarged and visible in adult males. The thyroid holds open the anterior end of
the larynx and protects the vocal folds. Inferior to the thyroid cartilage is the ring-shaped cricoid cartilage which holds the larynx open and supports
its posterior end. In addition to cartilage, the larynx contains special structures known as vocal folds, which allow the body to produce the sounds of
speech and singing. The vocal folds are folds of mucous membrane that vibrate to produce vocal sounds. The tension and vibration speed of the
vocal folds can be changed to change the pitch that they produce (Lynch, 2014).

Trachea

The trachea (Figure 1.1), or windpipe, is a 5-inch long tube made of C-shaped
hyaline cartilage rings lined with pseudostratified ciliated columnar epithelium. The
main function of the trachea is to provide a clear airway for air to enter and exit the
lungs. In addition, the epithelium lining the trachea produces mucus that traps dust
and other contaminants and prevents it from reaching the lungs. Cilia on the surface
of the epithelial cells move the mucus superiorly toward the pharynx where it can be
swallowed and digested in the gastrointestinal tract (Taylor, 2017).

Bronchi and Bronchioles

The main function of the bronchi and bronchioles is to carry air from the trachea into
the lungs. Smooth muscle tissue in their walls helps to regulate airflow into the lungs.
When greater volumes of air are required by the body, such as during exercise, the
smooth muscle relaxes to dilate the bronchi and bronchioles. The dilated airway
provides less resistance to airflow and allows more air to pass into and out of the
lungs. The smooth muscle fibers are able to contract during rest to prevent
hyperventilation. The bronchi and bronchioles also use the mucus and cilia of their
epithelial lining to trap and move dust and other contaminants away from the lungs.
Figure 1.1: Anatomy of the Lungs

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Lungs

The lungs (Figure 1.1) are a pair of large, spongy organs found in the thorax lateral to the heart and superior to the diaphragm. Each lung is
surrounded by a pleural membrane that provides the lung with space to expand as well as a negative pressure space relative to the body’s exterior.
The negative pressure allows the lungs to passively fill with air as they relax. The left and right lungs are slightly different in size and shape due to
the heart pointing to the left side of the body. The left lung is therefore slightly smaller than the right lung and is made up of 2 lobes while the right
lung has 3 lobes.

The interior of the lungs is made up of spongy tissues containing many capillaries and around 30 million tiny sacs known as alveoli. The
alveoli are cup-shaped structures found at the end of the terminal bronchioles and surrounded by capillaries. The alveoli are lined with thin simple
squamous epithelium that allows air entering the alveoli to exchange its gases with the blood passing through the capillaries (Taylor, 2017).

Muscles of Respiration

Surrounding the lungs are sets of muscles that are able to cause air to be inhaled or exhaled from the lungs. The principal muscle of
respiration in the human body is the diaphragm, a thin sheet of skeletal muscle that forms the floor of the thorax. When the diaphragm contracts, it
moves inferiorly a few inches into the abdominal cavity, expanding the space within the thoracic cavity and pulling air into the lungs. Relaxation of
the diaphragm allows air to flow back out the lungs during exhalation. Between the ribs are many small intercostal muscles that assist the diaphragm
with expanding and compressing the lungs. These muscles are divided into 2 groups: the internal intercostal muscles and the external intercostal
muscles. The internal intercostal muscles are the deeper set of muscles and depress the ribs to compress the thoracic cavity and force air to be
exhaled from the lungs. The external intercostals are found superficial to the internal intercostals and function to elevate the ribs, expanding the
volume of the thoracic cavity and causing air to be inhaled into the lungs (Lynch, 2014).

Pulmonary Ventilation

Pulmonary ventilation is the process of moving air into and out of the lungs to facilitate gas exchange. The respiratory system uses both a
negative pressure system and the contraction of muscles to achieve pulmonary ventilation. The negative pressure system of the respiratory system
involves the establishment of a negative pressure gradient between the alveoli and the external atmosphere. The pleural membrane seals the lungs
and maintains the lungs at a pressure slightly below that of the atmosphere when the lungs are at rest. This results in air following the pressure
gradient and passively filling the lungs at rest. As the lungs fill with air, the pressure within the lungs rises until it matches the atmospheric pressure.
At this point, more air can be inhaled by the contraction of the diaphragm and the external intercostal muscles, increasing the volume of the thorax
and reducing the pressure of the lungs below that of the atmosphere again (Lynch, 2014).

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External Respiration

External respiration is the exchange of gases between the air filling the alveoli and the blood in the capillaries surrounding the walls of the
alveoli. Air entering the lungs from the atmosphere has a higher partial pressure of oxygen and a lower partial pressure of carbon dioxide than does
the blood in the capillaries. The difference in partial pressures causes the gases to diffuse passively along their pressure gradients from high to low
pressure through the simple squamous epithelium lining of the alveoli. The net result of external respiration is the movement of oxygen from the air
into the blood and the movement of carbon dioxide from the blood into the air. The oxygen can then be transported to the body’s tissues while
carbon dioxide is released into the atmosphere during exhalation.

Internal Respiration

Internal respiration is the exchange of gases between the blood in capillaries and the tissues of the body. Capillary blood has a higher partial
pressure of oxygen and a lower partial pressure of carbon dioxide than the tissues through which it passes. The difference in partial pressures leads
to the diffusion of gases along their pressure gradients from high to low pressure through the endothelium lining of the capillaries. The net result of
internal respiration is the diffusion of oxygen into the tissues and the diffusion of carbon dioxide into the blood.

Transportation of Gases

The 2 major respiratory gases, oxygen and carbon dioxide, are transported through the body in the blood. Blood plasma has the ability to
transport some dissolved oxygen and carbon dioxide, but most of the gases transported in the blood are bonded to transport molecules. Hemoglobin
is an important transport molecule found in red blood cells that carries almost 99% of the oxygen in the blood. Hemoglobin can also carry a small
amount of carbon dioxide from the tissues back to the lungs. However, the vast majority of carbon dioxide is carried in the plasma as bicarbonate
ion. When the partial pressure of carbon dioxide is high in the tissues, the enzyme carbonic anhydrase catalyzes a reaction between carbon dioxide
and water to form carbonic acid. Carbonic acid then dissociates into hydrogen ion and bicarbonate ion. When the partial pressure of carbon dioxide
is low in the lungs, the reactions reverse and carbon dioxide is liberated into the lungs to be exhaled.

Homeostatic Control of Respiration

Under normal resting conditions, the body maintains a quiet breathing rate and depth called eupnea. Eupnea is maintained until the body’s
demand for oxygen and production of carbon dioxide rises due to greater exertion. Autonomic chemoreceptors in the body monitor the partial
pressures of oxygen and carbon dioxide in the blood and send signals to the respiratory center of the brain stem. The respiratory center then adjusts
the rate and depth of breathing to return the blood to its normal levels of gas partial pressures (Taylor, 2017).

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 Urinary System

The urinary system, also known as the renal system, produces, stores and eliminates urine, the fluid waste excreted by the kidneys. The
kidneys make urine by filtering wastes and extra water from blood. Urine travels from the kidneys through two thin tubes called ureters and fills the
bladder. When the bladder is full, a person urinates through the urethra to eliminate the waste. The urinary system works with the lungs, skin and
intestines to maintain the balance of chemicals and water in the body. Adults eliminate about 27 to 68 fluid ounces (800 to 2,000 milliliters) per day
based on typical daily fluid intake of 68 ounces (2 liters), National Institutes of Health (NIH).

Kidneys

The kidneys (Figure 2.0) are two bean-shaped organs, each about the size of a fist. They are located just below the
rib cage, one on each side of the spine. Every day, the kidneys filter about 120 to 150 quarts of blood to produce about 1
to 2 quarts of urine. The kidneys work around the clock; a person does not control what they do (Lynch, 2014).

Ureters

The ureters (Figure 2.1) are a pair of tubes that carry urine from the kidneys to the urinary bladder. The ureters are
about 10 to 12 inches long and run on the left and right sides of the body parallel to the vertebral column. Gravity and
peristalsis of smooth muscle tissue in the walls of the ureters move urine toward the urinary bladder. The ends of the
ureters extend slightly into the urinary bladder and are sealed at the point of entry to the bladder by
the ureterovesical valves. These valves prevent urine from flowing back towards the kidneys
(Taylor, 2017).
Figure 2.0: Anatomy of
Bladder Urinary System - Kidneys

The bladder, located in the pelvis between the pelvic bones, is a hollow, muscular, balloon-shaped organ that expands
as it fills with urine. Although a person does not control kidney function, a person does control when the bladder empties.
Bladder emptying is known as urination. The bladder stores urine until the person finds an appropriate time and place to
urinate. A normal bladder acts like a reservoir and can hold 1.5 to 2 cups of urine. How often a person needs to urinate
depends on how quickly the kidneys produce the urine that fills the bladder. The muscles of the bladder wall remain relaxed
while the bladder fills with urine. As the bladder fills to capacity, signals sent to the brain tell a person to find a toilet soon.
During urination, the bladder empties through the urethra, located at the bottom of the bladder (Lynch, 2014).

Figure 2.1: Anatomy of

Urinary System - Ureter
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 Urethra

The urethra is the tube through which urine passes from the bladder to the exterior of the body. The female urethra is around 2 inches long
and ends inferior to the clitorisand superior to the vaginal opening. In males, the urethra is around 8 to 10 inches long and ends at the tip of
the penis. The urethra is also an organ of the male reproductive system as it carries sperm out of the body through the penis. The flow of urine
through the urethra is controlled by the internal and external urethral sphincter muscles. The internal urethral sphincter is made of smooth muscle
and opens involuntarily when the bladder reaches a certain set level of distention. The opening of the internal sphincter results in the sensation of
needing to urinate. The external urethral sphincter is made of skeletal muscle and may be opened to allow urine to pass through the urethra or may
be held closed to delay urination (Lynch, 2014).

Maintenance of Homeostasis
The kidneys maintain the homeostasis of several important internal conditions by controlling the excretion of substances out of the body.

 Ions. The kidney can control the excretion of potassium, sodium, calcium, magnesium, phosphate, and chloride ions into urine. In cases where these
ions reach a higher than normal concentration, the kidneys can increase their excretion out of the body to return them to a normal level. Conversely,
the kidneys can conserve these ions when they are present in lower than normal levels by allowing the ions to be reabsorbed into the blood during
filtration.

 pH. The kidneys monitor and regulate the levels of hydrogen ions (H+) and bicarbonate ions in the blood to control blood pH. H+ ions are produced
as a natural byproduct of the metabolism of dietary proteins and accumulate in the blood over time. The kidneys excrete excess H+ ions into urine
for elimination from the body. The kidneys also conserve bicarbonate ions, which act as important pH buffers in the blood.

 Osmolarity. The cells of the body need to grow in an isotonic environment in order to maintain their fluid and electrolyte balance. The kidneys
maintain the body’s osmotic balance by controlling the amount of water that is filtered out of the blood and excreted into urine. When a person
consumes a large amount of water, the kidneys reduce their reabsorption of water to allow the excess water to be excreted in urine. This results in
the production of dilute, watery urine. In the case of the body being dehydrated, the kidneys reabsorb as much water as possible back into the blood
to produce highly concentrated urine full of excreted ions and wastes. The changes in excretion of water are controlled by antidiuretic hormone
(ADH). ADH is produced in the hypothalamus and released by the posterior pituitary gland to help the body retain water.

 Blood Pressure. The kidneys monitor the body’s blood pressure to help maintain homeostasis. When blood pressure is elevated, the kidneys can help
to reduce blood pressure by reducing the volume of blood in the body. The kidneys are able to reduce blood volume by reducing the reabsorption of

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 water into the blood and producing watery, dilute urine. When blood pressure becomes too low, the kidneys can produce the enzyme renin to
constrict blood vessels and produce concentrated urine, which allows more water to remain in the blood (Lynch, 2014).

Filtration
Inside each kidney are around a million tiny structures called nephrons. The nephron is the functional unit of the kidney that filters blood to
produce urine. Arterioles in the kidneys deliver blood to a bundle of capillaries surrounded by a capsule called a glomerulus. As blood flows through
the glomerulus, much of the blood’s plasma is pushed out of the capillaries and into the capsule, leaving the blood cells and a small amount of
plasma to continue flowing through the capillaries. The liquid filtrate in the capsule flows through a series of tubules lined with filtering cells and
surrounded by capillaries. The cells surrounding the tubules selectively absorb water and substances from the filtrate in the tubule and return it to
the blood in the capillaries. At the same time, waste products present in the blood are secreted into the filtrate. By the end of this process, the
filtrate in the tubule has become urine containing only water, waste products, and excess ions. The blood exiting the capillaries has reabsorbed all of
the nutrients along with most of the water and ions that the body needs to function (Taylor, 2017).

Storage and Excretion of Wastes

After urine has been produced by the kidneys, it is transported through the ureters to the urinary bladder. The urinary bladder fills with urine
and stores it until the body is ready for its excretion. When the volume of the urinary bladder reaches anywhere from 150 to 400 milliliters, its walls
begin to stretch and stretch receptors in its walls send signals to the brain and spinal cord. These signals result in the relaxation of the involuntary
internal urethral sphincter and the sensation of needing to urinate. Urination may be delayed as long as the bladder does not exceed its maximum
volume, but increasing nerve signals lead to greater discomfort and desire to urinate.
Urination is the process of releasing urine from the urinary bladder through the urethra and out of the body. The process of urination begins when
the muscles of the urethral sphincters relax, allowing urine to pass through the urethra. At the same time that the sphincters relax, the smooth
muscle in the walls of the urinary bladder contract to expel urine from the bladder (Taylor, 2017).

Production of Hormones
The kidneys produce and interact with several hormones that are involved in the control of systems outside of the urinary system.

 Calcitriol. Calcitriol is the active form of vitamin D in the human body. It is produced by the kidneys from precursor molecules produced by UV
radiation striking the skin. Calcitriol works together with parathyroid hormone (PTH) to raise the level of calcium ions in the bloodstream. When the
level of calcium ions in the blood drops below a threshold level, the parathyroid glands release PTH, which in turn stimulates the kidneys to release
calcitriol. Calcitriol promotes the small intestineto absorb calcium from food and deposit it into the bloodstream. It also stimulates the osteoclasts of
the skeletal system to break down bone matrix to release calcium ions into the blood.

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 Erythropoietin. Erythropoietin, also known as EPO, is a hormone that is produced by the kidneys to stimulate the production of red blood cells. The
kidneys monitor the condition of the blood that passes through their capillaries, including the oxygen-carrying capacity of the blood. When the blood
becomes hypoxic, meaning that it is carrying deficient levels of oxygen, cells lining the capillaries begin producing EPO and release it into the
bloodstream. EPO travels through the blood to the red bone marrow, where it stimulates hematopoietic cells to increase their rate of red blood cell
production. Red blood cells contain hemoglobin, which greatly increases the blood’s oxygen-carrying capacity and effectively ends the hypoxic
conditions.
 Renin. Renin is not a hormone itself, but an enzyme that the kidneys produce to start the renin-angiotensin system (RAS). The RAS increases blood
volume and blood pressure in response to low blood pressure, blood loss, or dehydration. Renin is released into the blood where it catalyzes
angiotensinogen from the liver into angiotensin I. Angiotensin I is further catalyzed by another enzyme into Angiotensin II.

Angiotensin II stimulates several processes, including stimulating the adrenal cortex to produce the hormone aldosterone. Aldosterone then
changes the function of the kidneys to increase the reabsorption of water and sodium ions into the blood, increasing blood volume and raising blood
pressure. Negative feedback from increased blood pressure finally turns off the RAS to maintain healthy blood pressure levels (Taylor, 2017).

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 Hematologic System

The hematologic system consists of the blood and the sites where blood is produced, including the bone marrow and the reticuloendothelial
system (RES). Blood is a specialized organ that differs from other organs in that it exists in a fluid state. Blood is composed of plasma and various
types of cells. Plasma is the fluid portion of blood; it contains various proteins, such as albumin, globulin, fibrinogen, and other factors necessary for
clotting, as well as electrolytes, waste products, and nutrients. About 55% of blood volume is plasma. (Iazzetti, 2002)

Blood
The cellular component of blood (Figure 3.1) consists of three primary cell types : RBCs (red
blood cells or erythrocytes), WBCs (white blood cells or leukocytes), and platelets (thrombocytes).
These cellular components of blood normally make up 40% to 45% of the blood volume. Because
most blood cells have a short life span, the need for the body to replenish its supply of cells is
continuous; this process is termed hematopoiesis. The primary site for hematopoiesis is the bone
marrow. During embryonic development and in other conditions, the liver and spleen may also be
involved. Under normal conditions, the adult bone marrow produces about 175 billion RBCs, 70 billion
neutrophils (mature form of a WBC), and 175 billion platelets each day. When the body needs more
blood cells, as in infection (when WBCs are needed to fight the invading pathogen) or in bleeding
(when more RBCs are required), the marrow increases its production of the cells required. Thus,
under normal conditions, the marrow responds to increased demand and releases adequate numbers
of cells into the circulation. (Stephens, 2007)
Figure 3.0: Hematologic System - Blood vessel

The volume of blood in humans is approximately 7% to 10% of the normal body weight and amounts to 5 to 6 L. Circulating through the
vascular system and serving as a link between body organs, the blood carries oxygen absorbed from the lungs and nutrients absorbed from the
gastrointestinal tract to the body cells for cellular metabolism. Blood also carries waste products produced by cellular metabolism to the lungs, skin,
liver, and kidneys, where they are transformed and eliminated from the body. Blood also carries hormones, antibodies, and other substances to their
sites of action or use.
Blood is made up of plasma (fluid component) and formed elements (cellular component). Plasma consists of about 90% water and 10% solutes
(electrolytes, albumin, globulins, and clotting factors). The formed elements include erythrocytes (red blood cells [RBCs]), leukocytes (white blood
cells [WBCs]), and platelets (PLTs).

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 To function, blood must remain in its normally fluid state. Because blood is fluid, the danger always
exists that trauma can lead to loss of blood from the vascular system. To prevent this, an intricate clotting
mechanism is activated when necessary to seal any leak in the blood vessels. Excessive clotting is equally
dangerous, because it can obstruct blood flow to vital tissues. To prevent this, the body has a fibrinolytic
mechanism that eventually dissolves clots (thrombi) formed within blood vessels. The balance between
these two systems, clot (thrombus) formation and clot (thrombus) dissolution or fibrinolysis, is called
hemostasis. (Stephens, 2007)

Bone Marrow

The bone marrow is the site of hematopoiesis, or blood cell formation. In a child all skeletal bones
are involved, but as the child ages marrow activity decreases. By adulthood, marrow activity is usually
limited to the pelvis, ribs, vertebrae, and sternum. Marrow is one of the largest organs of the body, making
up 4% to 5% of total body weight. It consists of islands of cellular components (red marrow) separated by
fat (yellow marrow). As the adult ages, the proportion of active marrow is gradually replaced by fat;
however, in the healthy person, the fat can again be replaced by Figure 3.1: Components of the Blood
active marrow when more blood cell production is required. In
adults with disease that causes marrow destruction, fibrosis, or scarring, the liver and spleen can also
resume production of blood cells by a process known as extramedullary hematopoiesis. The marrow is highly
vascular. Within it are primitive cells called stem cells. The stem cells have the ability to self-replicate,
thereby ensuring a continuous supply of stem cells throughout the life cycle. When stimulated to do so, stem
cells can begin a process of differentiation into either myeloid or lymphoid stem cells. These stem cells are
committed to produce specific types of blood cells. Lymphoid stem cells produce either T or B lymphocytes.
Myeloid stem cells differentiate into three broad cell types: RBCs, WBCs, and platelets. Thus, with the
exception of lymphocytes, all blood cells are derived from the myeloid stem cell. A defect in the myeloid
stem cell can cause problems not only with WBC production but also with RBC and platelet production. The
entire process of hematopoiesis is highly complex. (Stephens, 2007)
Figure 3.2: Platelet

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Platelets

Platelets (Figure 3.2), or thrombocytes, are not actually cells. Rather, they are granular fragments of giant cells in the bone marrow called
megakaryocytes. Platelet production in the marrow is regulated in part by the hormone thrombopoietin, which stimulates the production and
differentiation of megakaryocytes from the myeloid stem cell. Platelets play an essential role in the control of bleeding. They circulate freely in the
blood in an inactive state, where they nurture the endothelium of the blood vessels, maintaining the integrity of the vessel. When vascular injury
does occur, platelets collect at the site and are activated. They adhere to the site of injury and to each other, forming a platelet plug that temporarily
stops bleeding. Substances released from platelet granules activate coagulation factors in the blood plasma and initiate the formation of a stable clot
composed of fibrin, a filamentous protein. Platelets have a normal life span of 7 to 10 days. (Stephens, 2007)

Plasma and Plasma Proteins

After cellular elements are removed from blood, the remaining liquid portion is called plasma (Figure 3.3). More than 90% of plasma is water.
The remainder consists primarily of plasma proteins, clotting factors (particularly fibrinogen), and small amounts of other substances such as
nutrients, enzymes, waste products, and gases. If plasma is allowed to clot, the remaining fluid is called serum. Serum has essentially the same
composition as plasma, except that fibrinogen and several clotting factors have been removed
in the clotting process. Plasma proteins consist primarily of albumin and globulins. The
globulins can be separated into three main fractions—alpha, beta, and gamma—each of
which consists of distinct proteins that have different functions. Important proteins in the
alpha and beta fractions are the transport globulins and the clotting factors that are made in
the liver.
The transport globulins carry various substances in bound form around the circulation.
For example, thyroid-binding globulin carries thyroxin, and transferrin carries iron. The
clotting factors, including fibrinogen, remain in an inactive form in the blood plasma until
activated by the clotting cascade. The gamma globulin fraction refers to the immunoglobulins,
or antibodies. These proteins are produced by the well-differentiated lymphocytes and plasma
cells. The actual fractionation of the globulins can be seen on a specific laboratory test
(serum protein electrophoresis). Albumin is particularly important for the maintenance of fluid
balance within the vascular system. Capillary walls are impermeable to albumin, so its
presence in the plasma creates an osmotic force that keeps fluid within the vascular space.
Figure 3.3: Components of Plasma Albumin, which is produced by the liver, has the capacity to bind to several substances that
are transported in plasma (Stephens, 2007).

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VIII. REVIEW OF RELATED LITERATURE

Pneumonia is an infection of the lung parenchyma. Community-acquired pneumonia refers to pneumonia acquired outside of hospitals or
extended-care facilities. Nursing home–acquired pneumonia refers to infection acquired in an extended-care facility. Nosocomial pneumonia and
hospital-acquired pneumonia describe infections acquired in the hospital setting. The signs and symptoms of acute pneumonia develop over hours to
days, whereas the clinical presentation of chronic pneumonia often evolves over weeks to months (Shmidt 2010). Pneumonia still remains one of the
leading cause of mortality (10%) in a 2013 statistics (DOH, 2013).

Community-acquired pneumonia (CAP) is one of the most common infectious diseases and is an important cause of mortality and morbidity
worldwide. Typical bacterial pathogens that cause CAP include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis (see
images below). However, with the advent of novel diagnostic technologies, viral respiratory tract infections are being identified as common etiologies
of CAP. The most common viral pathogens recovered from hospitalized patients admitted with CAP include human rhinovirus and influenza (Jain, et.
al, 2015).

Common clinical symptoms of CAP include cough, fever, chills, fatigue, dyspnea, rigors, and pleuritic chest pain. Depending on the pathogen,
a patient’s cough may be persistent and dry, or it may produce sputum. Other presentations may include headache and myalgia. Certain etiologies,
such as legionella, also may produce gastrointestinal symptoms (Craig & Kamer, 2016).

A pleural effusion is a buildup of fluid between the layers of tissue that line the lungs and chest cavity. The body produces pleural fluid in
small amounts to lubricate the surfaces of the pleura. This is the thin tissue that lines the chest cavity and surrounds the lungs. Pleural effusion is an
abnormal, excessive collection of this fluid and one of the common causes is infection, in this case, pneumonia. Symptoms can include chest pain,
usually a sharp pain that is worse with cough or deep breaths, cough, fever and chills, hiccups, rapid breathing and shortness of breath. Chest CT
scan or a chest x-ray may be enough for your provider to decide on treatment. The goal of treatment is to remove the fluid, prevent fluid from
building up again, and determine and treat the cause of the fluid buildup (A.D.A.M., 2016).

The following are nursing interventions for a patient with a pneumonia:

Improving airway patency

The nurse encourages hydration (2 to 3 L/day) because adequate hydration thins and loosens pulmonary secretions. Humidification may be
used to loosen secretions and improve ventilation.

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  A high humidity facemask (using either compressed air or oxygen) delivers warm, humidified air to the tracheobronchial tree, helps to liquify
secretions, and relieves tracheo-bronchial irritation.

 Coughing can be initiated either voluntarily or by reflex.

 Lung expansion maneuvers, such as deep breathing with an incentive spirometer,may induce a cough.

 The nurse encourages the patient to perform an effective, directed cough, which includes correct positioning.

 Chest physiotherapy (percussion and postural drainage) is important in loosening and mobilizing secretions.

 The patient is placed in the proper position to drain the involved lung segments, and then the chest is percussed and vibrated either manually
or with a mechanical percussor.

Promote Rest
 The nurse encourages the debilitated patient to rest and avoid overexertion and possible exacerbation of symptoms.

 The patient should assume a comfortable position to promote rest and breathing (eg, semi-Fowler’s) and should change positions frequently
to enhance secretion clearance and ventilation/perfusion in the lungs.

 It is important to instruct outpatients not to overexert themselves and to engage in only moderate activity during the initial phases of
treatment.

Promoting Fluid Intake

 The respiratory rate of a patient with pneumonia increases because of the increased workload imposed by labored breathing and fever.

 An increased respiratory rate leads to an increase in insensible fluid loss during exhalation and can lead to dehydration. Therefore, it is
important to encourage increased fluid intake (at least 2 L/day), unless contraindicated.

Maintaining Nutrition
 Patients with shortness of breath and fatigue often have a decreased appetite and will take only fluids. Fluids with electrolytes may help
provide fluid, calories, and electrolytes. Other nutritionally enriched drinks or shakes may be helpful.

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  In addition, fluids and nutrients may be administered intravenously if necessary.

Promoting The Patients Knowledge

 The patient and family are instructed about the cause of pneumonia,management of symptoms of pneumonia, and the need for follow-up.

 If hospitalized for treatment, the patient is instructed about the purpose and importance of management strategies that have been
implemented

 Explanations need to be given simply and in language that the patient can understand. If possible, written instructions and information should
be provided.

 Because of the severity of symptoms, the patient may require that instructions and explanations be repeated several times.

On a different case, our patient as also diagnosed with a urinary tract infection (UTI) which is an infection involving the kidneys, ureters,
bladder, or urethra. These are the structures that urine passes through before being eliminated from the body. These infections are much more
common in girls and women than in boys and men younger than 50 years of age. The reason for this is not well understood, but anatomic
differences between the genders (a shorter urethra in women) might be partially responsible. About 40% of women and 12% of men have a urinary
tract infection at some time in their life (Watson & Preedy, 2015).

The culprit in at least 90% of uncomplicated infections is a type of bacteria called Escherichia coli, better known as E. coli. These bacteria
normally live in the bowel (colon) and around the anus. These bacteria can move from the area around the anus to the opening of the urethra. The
two most common causes of this are improper wiping and sexual intercourse. The usual treatment for both simple and complicated urinary tract
infections is antibiotics. The type of antibiotic and duration of treatment depend on the circumstances. In our patient’s case, several antibiotics were
administered such as clarithromycin, ceftriaxone, levofloxacin and penicillins (Balentine, 2017).

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IX. MEDICAL MANAGEMENT

A. Laboratory Exams

HEMATOLOGY

Complete Blood Count

The Complete Blood Count is a screening test, used to diagnose and manage numerous diseases. A CBC determines if there are any increases
or decreases in your cell counts. Normal values vary depending on your age and your gender. Your lab report will tell you the normal value range for
your age and gender.

Laboratory Exams Result Normal Values Correlation/Implication

WBC 25.1 (H) 4.0-11.0 T/cumm Since the patient is diagnosed with
pneumonia, there is already an entry
of pathogens in the system specifically
in the lung fields and urinary tract
resulting immunologic response
thereby acting on the site of infection.

RBC 4.05 (H) 4.50-6.50 Normally, there should be increased

RBC count. But the decreased levels
may indicate a long period of
compensation of low O2 until it no
longer compensate since the the
patient is experiencing shortness of
breath.

There is low hemoglobin due to

Hemoglobin 11.3 (L) 13.0-18.0 gm% patient having problems in
oxygenation exchange or function.

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Hematocrit 33.9 (L) 40-50 % A low in hematocrit also is due to
problems in oxygenation exchange or
function since the patient has
pneumonia manifesting cough and
shortness of breath.

Differential Count

Neutrophil Seg 79 (H) 40-75 %

There is a high white blood cell
count which indicates presence of
Lymphocyte 11 (L) 20-45 %
an infection since the patient has
pneumonia and urinary tract
Monocyte 9 0-10 % infection which are both caused by
foreign pathogens thereby
Eosinophil 1 0-1 % stimulating the immunologic
mechanism of the body as
evidenced by increase in white
Basophil 0 0-1 % blood cell components.

Platelet Count 677 (H) 150-450 T/cumm Increased levels of platelet is due to
presence of infection and causes
induction of inflammation and tissue
repair in addition to their
participation in hemostasis.

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 RADIOLOGY REPORT

Chest X-ray is an imaging test that uses X-rays to look at the structures and organs in the chest. It can help to see how well the lungs and
heart are working. Certain heart problems can cause changes in the lungs. Certain diseases can cause changes in the structure of the heart or lungs.
Chest X-rays can show the health care provider the size, shape, and location of the heart, lungs, bronchi, aorta, pulmonary arteries, mid-chest area
(mediastinum), and bones of the chest.

Chest PAL:

Haziness on right base due to pneumonia with moderate pleural effusion left.
Suggest left lateral decubitus view or ultrasound of left lung to confirm that.

Chest left lateral decubitus view shows fluid layering on most dependent portion however cannot rule out underlying mass. May
suggest ultrasound of the left lung for further evaluation if clinically indicated.

Correlation:
These findings confirm a diagnosis of pneumonia due to haziness visualized in the lung fields. There is already pleural effusion due to excess
of fluids in the lungs probably caused by alveolar leakage therefore increasing likelihood of extravasation and mucus production.

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 URINALYSIS

Urinalysis is a test that evaluates a sample of your urine. Urinalysis is used to detect and assess a wide range of disorders, such as urinary
tract infection, kidney disease and diabetes. Urinalysis is commonly done upon admission to identify any abnormalities in the urine specification.

Physical & Chemical Exam Microscopic Examination

Color Dark yellow Protein trace Epith. Cells Few

Transparency Nitrite (-) RBC 0-2/hpf

Urobilinogen Normal pH (Urine) 6.0 Pus Cells 2-3/hpf

Glucose trace Blood Trace Mucous Threads Moderate

Ketone (-) Specific Gravity 1.020 Bacteria Few

Bilirubin (-) Leukocytes (-) Amorp. Urates Few

Correlation:

An indicator of urinary tract infection is either the presence of nitrites or leukocyte esterase (product of white blood cells) and bacteria. in the
case of the patient, the urinalysis result shows presence of bacteria thus indicating an infection in the urinary tract.

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 BLOOD CHEMISTRY (Electrolytes)

Analysis of blood chemistry can provide important information about the function of the kidneys and other organs. This common panel of
blood tests measures levels of important electrolytes and other chemicals. This provides general information about how your body is functioning.
This can also help in screening for a wide range of problems, including kidney, liver, heart, adrenal, gastrointestinal, endocrine, and neuromuscular
disorders. And it can also monitor patient who have hypertension (high blood pressure) or hypokalemia (low levels of potassium) and measure
chemical substances in the blood.

Chemistry
Sodium 136.8 mmol/L 135-148

Potassium 2.76 mmol/L 3.50-5.3

Uric Acid 2.9 mg/dl 3.6-7.7

SGPT/ALT 19 U/L 0-45

Correlation:

Elevated potassium is found among people with Pneumonia, especially for people who are male, 60+ old in a study conducted by eHealthMe.
it is also found that medications such as antibiotics, including penicillin, have been found to increase the levels of potassium.

Although for the low uric acid levels, it is difficult to correlate it with the patient’s current condition since there are no statements or studies
that support this statement. Perhaps there is another underlying cause to this result.

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 CONCEPT MAP PREDISPOSING FACTOR PRECIPITATING FACTOR
- Gender (Male) - Polluted environment
- Age (35 y/o) - Cigarette smoking

adherence to alveolar macrophages entrance of bacteria in airway

exposure of cell wall component material propelled (Streptococcus pneumonia, Haemophilus
(bacterial invasion to lungs) into alveolar system influenza and Staphylococcus species)

phagocytosing bacteria

WBC - 25.1 (H)

macrophages suppress
immune response

secreting chemokines & promotes neutrophil loss of effectiveness of penetrate the sterile lower
local inflammation defense mechanism
cytokines accumulation respiratory tract (lungs)

trigger disseminated colonization multiplication affects alveoli

leakage from capillaries
Butamirate 1 tab
release of damaging
exotoxins Irritation of airways
inducing uncontrolled
fluid extravasation - cough
- crackles
infection
Clarythromycin ↑ goblet cells ↑ mucus production - dyspnea
Levofloxacin
tissue edema Ceftriaxone
Hydrocortisone inflammation Hgb - 11.3 (H) occludes airway Mgt:
Hct - 33.9 (L) occludes the airway
 Removal of secretions.
 Adequate hydration of 2 to
↑ interstitial Plt - 677 (H) 3 liters per day.
pressure to  Humidification
Pagemay
| 27loosen
organ impairing 02 and CO2
secetions and improve
Acute pain related to inflammation Decrease O2 intake exchange
venilation.
of lung parenchyma
protein leaks into
pulmonary alveoli
S/S:
- Left-sided chest
pain
- chills
- SOB

fluid leakage to pleural space

decreasing lung alveolar overinflates & burst Trimetazidine 35mg

Chest x-ray Pleural effusion expansion

air leaks to chest cavity

Ineffective breathing pattern
Ineffective airway clearance related to decreased lung volume
related to pleuritic pain secondary capacity secondary to pleural Mgt:
lung collapse
to pneumonia effusion  Encourage avoidance of
overexertion.
 Semi-Fowler’s position to
promote rest and breathing.
 Maintenance of proper fluid
low blood oxygen levels in volume.
the body  Maintenance of adequate
nutrition.
 Administer analgesics as
prescribed.
multiple organs deprived

DEATH

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 URINARY TRACT INFECTION

PREDISPOSING FACTORS PRECIPITATING FACTORS

- none - Avoidance of the urge to void

- Inadequate fluid intake

Bacterial invasion (i.e. E.coli)

Multiplication of the bacteria

Interruption in the normal homeostatic

environment of the urinary tract

Meds:
Clarythromycin Immune response by the body (defense Increased WBC subsequent
Levofloxacin mechanism of the body to foreign bodies) to pus formation
Ceftriaxone
Hydrocortisone
Cytokine and prostaglandin release Urinalysis

Body induces the action of the

cytokines and prostaglandins changes in urine color
(dark yellow)

A
The body responds by producing
Inflammation of the lining Irritation of the lining of Page | 29
fever physiologic changes aimed at
of the urinary tract the urinary tract
elevating body temperature
Mgt: Narrowed urine passage

 Monitor input and output characteristics Spasm of the

of the urine. bladder
 Determine the patient's voiding patterns Poor emptying of the bladder dysuria
 Encourage increased fluid intake
 Observations of changes in mental
status: behavior or level of urinary incontinence
consciousness
 Monitor laboratory tests: electrolytes,
creatinine

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C. Treatment Modalities
DOCTOR’S ORDER
9/20  Admit to the Dept. of Medicine Ward
 Secure consent
 TPR q 4h
 Labs: CBC with urinalysis
Serum Na+, K+, SGPT
RBS; FBS, lipid profile
ECG 12 leads in the AM
Chest x-ray PAI; AFB sputum x3
CKMB stat
 D5NM 1L at 10gtts/min
RATIONALE
- For proper monitoring, management and evaluation.
- To have ethical considerations and also to protect
patient’s freedom to make healthcare decisions.
- To have baseline data and to assess the stability of
the client’s health status.
- To evaluate blood components and clotting factor of
the patient.
- To detect abnormal concentrations of sodium and
potassium.
- Blood glucose test measures the amount of glucose,
or sugar, in your bloodstream.
- To screen patients for cardiac ischemia since the
patient complains of chest pain.
- To visualize the prognosis behind the patient’s left-
sided chest pain and cough.
- Used as a follow-up test to an elevated creatine
kinase (CK) in order to determine whether the
increase is due to heart damage
- A hypertonic solution that is nonpyrogenic and is a
Page | 31
 nutrient replenisher.
 Meds:
1. Omeprazole 40mg IVTT OD ac lunch - To suppress acids in gastric
2. Levofloxacin 500mg IVTT now - For bacterial infection since the patient is diagnosed
as pneumonia
3. Butamirate 1 tab TID - For suppressing cough of the patient
9/20 4. Ceftriaxone 1gm IVTT ANST then q 4h - For pneumococcal infection
8:50pm
 Spironolactone 100mg 1 tab OD at 6 am with BP prec - To facilitate diuresis
 ↓ IVF rate to 10cc/min - To prevent over dosage of fluids
9/21  IVFF D5NM 500cc at 10cc/min
11:25am
 Continue IVF - To replenish fluid and electrolyte losses
9/23  Reuse Hydrocortisone 200mg IVTT q 8h with BP prec! - For inflammation of the lung parenchyma
2:35pm
 Continue IVF - To replenish fluid and electrolyte losses
 Piperacillin + Tazobactam 4.5g IVTT to q 8h ANST - For pneumococcal infection
 Discharge against medical advice - Requests for discharge before physician implements
 Discontinue IVT trreatment

D. Drug Study

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 Drug Order
Clarythromycin 500mg 1 tab BID
Drug Study
Generic name: Clarythromycin
Brand name: Biaxin, Biaxin XL, Clamycin, Claryl, Klarimac, Onexid
Classification: Macrolide antibiotic
Mechanism of Action: Clarithromycin inhibits protein synthesis in
susceptible organisms by penetrating the cell wall and binding to 50S
ribosomal subunits . It has activity against a variety of aerobic and
anaerobic gm+ve and gm-ve bacteria.
Side effects: stomach pain, indigestion, gas, vomiting, mild diarrhea,
unusual or unpleasant taste in your mouth, headache, sleep problems
(insomnia), mild itching or rash, vaginal itching or discharge
Nursing Responsibilities:
 Monitor CBC w/ differential, BUN and creatinine.
 Culture infection before therapy.
 Do not cut or crush, and ensure that patient does not chew ER tablets.
 Monitor patient for anticipated response.
 Administer without regard to meals; administer with food if GI effects
occur.
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Levofloxacin 500mg IVTT Generic name: Levofloxacin
Brand name: Levaquin
Classification: Quinolones, Antibiotic
Mechanism of Action: Levofloxacin exerts antibacterial action by
inhibiting bacterial topoisomerase IV and DNA gyrase, the enzymes required
for DNA replication, transcription repair and recombination. It has in vitro
activity against a wide range of gm-ve and gm+ve microorganisms.
Side effects: diarrhea, insomnia, tendinitis, tendon rupture
Nursing Responsibilities:
 Do C&S test prior to beginning therapy and periodically.
 Oral Levaquin tablets can be administered without regard to food. Take
oral Levaquin solution one hour before or two hours after food.
 Take at least two hours before or two hours after antacids or
preparations containing iron or zinc.
 Ensure you keep hydrated while taking Levaquin to prevent crystal
formation in your urine.
 Discontinue Levaquin immediately if you experience tendon pain,
swelling, inflammation or rupture and contact your healthcare provider.
 Avoid excessive sun or UV light exposure, and wear sunblock when
outdoors. Report any apparent sunburn to your doctor immediately.

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Hydrocortisone 200mg IVTT then 100mg IVTT q 6h x2days Generic name: Hydrocortisone
Brand name: Anusol-HC, Proctocream-HC, Proctosol HC, Locoid
Classification: Corticosteroid
Mechanism of Action: Hydrocortisone is a corticosteroid used for its anti-
inflammatory and immunosuppressive effects. Its anti-inflammatory action
is due to the suppression of migration of polymorphonuclear leukocytes and
reversal of increased capillary permeability. It may also be used as
replacement therapy in adrenocortical insufficiency.
Side effects: skin redness/burning/itching/peeling, thinning of your skin,
blistering skin, stretch marks, nausea, heartburn, headache, dizziness,
menstrual period changes, trouble sleeping (insomnia), increased sweating.
Nursing Responsibilities:
 Establish baseline and continuing data on BP, weight, fluid and
electrolyte balance, and blood glucose.
 Lab tests: Periodic serum electrolytes blood glucose, Hct and Hgb,
platelet count, and WBC with differential.
 Monitor for adverse effects. Older adults and patients with low serum
albumin are especially susceptible to adverse effects.
 Be alert to signs of hypocalcemia.
 Monitor for persistent backache or chest pain; compression and
spontaneous fractures of long bones and vertebrae present hazards.

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Bilastine 20mg 1 tab OD q HS
 Monitor for and report changes in mood and behavior, emotional
instability, or psychomotor activity, especially with long-term therapy.
 Be alert to possibility of masked infection and delayed healing
(antiinflammatory and immunosuppressive actions).
Generic name: Bilastine
Brand name: Bilaxten
Classification: Antihistamine
Mechanism of Action: Bilastine inhibits immune system reactions
mediated by the interaction of histamine on its H1-receptor.
Side effects: Sleepiness, headache, Dizziness, Feeling weak or tired, Dry
mouth, Dryness or discomfort in the nose, Shortness of breath, Increased
appetite, Weight gain, Anxiety, Difficulty sleeping (insomnia
Nursing Responsibilities:
 Take the tablet 'on an empty stomach'.
 Take 1 hr before or 2 hr after intake of food or fruit juice.
 If you forget to take a dose at your usual time, take it when you
remember (making sure you take it when your stomach is empty). If you
do not remember until the following day then leave out the forgotten
dose from the previous day and take the dose that is due that day.
 Do not take two doses at the same time to make up for a missed dose.
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Butamirate 1 tab TID Generic name: Butamirate citrate
Brand name: Sinecod Forte
Classification: non-opioid cough suppressant
Mechanism of Action: Butamirate is reported to have a central action
that is used as a cough suppressant in non-productive cough. It is a non-
narcotic antitussive which presents nonspecific anticholinergic and
antispasmodic effect, facilitating respiration.
Side effects: Drowsiness, nausea, vomiting, diarrhea, loss of balance,
hypotension
Nursing Responsibilities:
 Assess cough type and frequency
 Assess patient’s VS and sleep pattern.
 If cough persist 10 days + fever or chest pain – check with Doctor.
 Drink fluids but not immediately after dose.
 Since the drug may cause dizziness or drowsiness, caution patient to
avoid driving or other activities requiring alertness until response to
medication is known.
 Advise patient to minimize cough by avoiding irritants (cigarette smoke,
fumes, Dust)
 Instruct patient to cough effectively, sit upright and take several deep
breaths before attempting.

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Omeprazole to 40mg 1 tab OD q hs Generic name: Omeprazole
Brand name: PriLOSEC, Zegerid
Classification: Proton-pump inhibitor
Mechanism of Action: It suppresses stomach acid secretion by specific
inhibition of the H+/K+-ATPase system found at the secretory surface of
gastric parietal cells.
Side effects: constipation, diarrhea, gas, or stomach pain, fever,
headache, stuffy or runny nose, and sneezing
Nursing Responsibilities:
- Tell patient to take drug before eating (before breakfast) and to swallow
capsules whole. Tell the patient to drink a glass of cool water.
- Encourage patient to avoid alcohol, aspirin products, ibuprofen, and foods
that may increase gastric secretions during therapy.
- Advise patient to notify doctor immediately if they have abdominal pain or
diarrhea.
- Because drug can interfere with absorption of vitamin B12, monitor for
anemia.

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Trimetazidine 35mg 1 tab TID q 12h Generic name: Trimetazidine
Brand name: Angimax, Vastarel, Cardivon, Trimedin, Trimezar, Vastarel,
Xanginart
Classification: Anti-anginal, Anti-ischemic metabolic agent
Mechanism of Action: Trimetazidine inhibits β-oxidation of fatty acids
through inhibition of long-chain 3-ketoacyl-CoA thiolase, which enhances
glucose oxidation. It ensures proper functioning of ionic pumps and
transmembrane Na-K flow by preventing decrease in intracellular ATP
levels.
Side effects: dizziness, headache, abdominal pain, dyspepsia, diarrhea,
nausea, vomiting, pruritus, rash, urticaria, asthenia
Nursing Responsibilities:
 Assess for hypersensitivity to trimetazidine, with heart failure and
pregnancy
 Monitor blood pressure and pulse rate before and after giving the meds.
 Administer drug after patient has eaten with a full glass of water
 Encourage patient to continue efforts at smoking cessation
 Provide safety measures if lethargy occurs

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Ceftriaxone 1gm IVTT ANST then q 8h Generic name: Ceftriaxone
Brand name: Rocephin, Acrexon, Ceftrox, Cryaxon, Ceftrone, Bactrias,
Ceftibet
Classification: Third Generation Cephalosporin
Mechanism of Action: Ceftriaxone binds to 1 or more of the penicillin-
binding proteins (PBPs) which inhibit the final transpeptidation step of
peptidoglycan synthesis in bacterial cell wall, thus inhibiting biosynthesis
and arresting cell wall assembly resulting in bacterial cell death.
Side effects: Diarrhea, nausea, vomiting; neutropenia, eosinophilia,
anemia, rash, pruritus, fever, chills, local reactions (e.g. pain, induration,
ecchymosis, tenderness at inj site)
Nursing Responsibilities:
 Assess patient’s previous sensitivity reaction to penicillin or other
cephalosporins.
 Assess patient for signs and symptoms of infection before and during
the treatment
 Obtain C&S before beginning drug therapy to identify if correct
treatment has been initiated.
 Report signs such as petechiae, ecchymotic areas, epistaxis or other
forms of unexplained bleeding.
 Assess for possible upper infection: itching fever, malaise, redness

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Spironolactone 100mg 1 tab OD q 6am c BP prec! Generic name: Spironolactone
Brand name: Aldactone
Classification: Potassium-sparing diuretic
Mechanism of Action: Spironolactone acts on the distal renal tubules as a
competitive antagonist of aldosterone. It increases the excretion of NaCl
and water while conserving K and hydrogen ions.
Side effects: drowsiness, dizziness, headache, lethargy, leg cramps, GI
disturbances (e.g. diarrhea, cramps), ataxia, mental confusion, rashes,
pruritus, alopecia, hyponatremia, electrolyte disturbances, gynecomastia,
hirsutism, menstrual irregularities, breast pain, deepening of the voice
Nursing Responsibilities:
 Check blood pressure before initiation of therapy and at regular intervals
throughout therapy.
 Lab tests: Monitor serum electrolytes (sodium and potassium) especially
during early therapy; monitor digoxin level when used concurrently.
 Assess for signs of fluid and electrolyte imbalance, and signs of digoxin
toxicity.
 Monitor daily I&O and check for edema. Report lack of diuretic response
or development of edema; both may indicate tolerance to drug.
 Weigh patient under standard conditions before therapy begins and daily
throughout therapy. Weight is a useful index of need for dosage

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 adjustment. For patients with ascites, physician may want
measurements of abdominal girth.
 Observe for and report immediately the onset of mental changes,
lethargy, or stupor in patients with liver disease.
 Adverse reactions are generally reversible with discontinuation of drug.

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X. NURSING MANAGEMENT

A. NURSING HISTORY

1. Chief Complaints:

“Gasakit ning akong dughan sa kilid (points at left side chest) unya laba’g kapoy akong lawas pagka gabii, unya ug ubhon ko hilantanon ko”,
as verbalized by the patient.

2. History of Present Illness:

Two weeks PTA, patient experienced hemoptysis and left sided pleuritic chest pain.

A day PTA, patient complains of left-sided chest pain, chills, fatigue and developing fever when coughing.

3. Past Health History:

Seven years PTA, patient hospitalized with ulcer, stayed for about a month

Two weeks PTA, patient experienced hemoptysis and left sided pleuritic chest pain.

A day PTA, patient complains of left-sided chest pain, chills, fatigue and developing fever when coughing.

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 5. Family History with Genogram

HPN HPN

68 y.o 74 y.o

Patient
40 y.o
30 y.o Ulcer 45 y.o 50 y.o
pneumonia

LEGEND:

- Female

- Male

- Deceased

- Patient

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6. Psychosocial History:

Patient emphasizes that he does usually interact with the neighborhood since he works every day as a kargador during the day. Though he’s
married he does not have any children yet but maintains a good intimate relationship with his wife and also with his relatives who lives with them.
He also admits he drinks with his colleagues but only occasionally. And in reference with his psychosocial development in his stage, he is able to
explore relationships leading toward a longer-term commitment with someone other than a member of the family. Since avoiding intimacy, fearing
commitment and relationships can lead to isolation, loneliness, and sometimes depression. Since success in this development will lead to the virtue
of love (McLeod 2013).

7. Environmental History:

Patient currently resides Piapi, Dumaguete City living in a wooden two-story house located just along a highway road. Source of drinking
supply is via faucet from the public water source. Quality of air is acceptable and do not complain of the moderate air pollution. A high school is
located a few meters from their house and no factory or smoke-emitting industries near their home.

8. Spiritual History:

Patient believes in God but does not completely consider himself as religious or spiritual. He also deems on God as giving him life meaning
and purpose. He is not part of any religious or spiritual community. Patient states emphasizes that his family’s presence and support provides value
at a time like this. By having faith and his own personal beliefs and family support, he trusts that this will help him cope with his current medical
situation. In light of his diagnosis, he verbalizes that God has his own way doing things and he accepts his current condition.

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B. PHYSICAL ASSESSMENT

System Normal Findings PA Findings

Respiratory System

 Anterior Chest INSPECTION: - chest symmetrical in appearance with symmetrical

- Ribs slope obliquely
- Chest symmetrical in appearance with
symmetrical rise and fall when breathing
- Skin intact
- Abdominal respiratory movements for men
- Skin color and hair distribution consistency
rise and fall when breathing
- skin intact
- normal abdominal respiratory movement
- skin color lighter than exposed area with normal
fine hair distribution

 Lateral Chest INSPECTION: - chest symmetrical in appearance with symmetrical

- Intact skin rise and fall when breathing
- Chest expansion equal - skin intact
- chest expansion equal

 Posterior Chest INSPECTION:

- Intact skin - skin intact, chest expansion equal
- Chest expansion equal - spine straight without lateral curves or deformities

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 - Spine straight without lateral curves or
deformities

 Tracheal Position PALPATION:

- Trachea should be midline - trachea midline upon palpation

 Chest Tenderness & Crepitus PALPATION:

- Nontender - tenderness felt at left chest area
- No deformities or crepitus - no deformities noted

 Chest Excursion
PALPATION:
- Symmetrical without lag - symmetrical without lag
- presence of tenderness upon excursion

PALPATION:
 Tactile Fremitus
- Equally bilateral and diminished midthorax - equal bilaterally and diminished midthorax

 Anterior Thorax PERCUSSION:

- Resonance to 2nd intercostal space on left - resonant upon percussion
- Slight dullness over 3rd through 5th intercostal
space over heart

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 Lateral Thorax PERCUSSION:
- Resonance to eight intercostal space - resonant upon percussion

 Breath Sounds AUSCULTATION:

- Bronchial breath sounds loud, high-pitched , - presence of bubbling sound in left-side area
and hollow
- Bronchovesicular breath sounds moderate
sounding and medium-pitched
- Vesicular breath sounds soft and low-pitched

Abdomen
INSPECTION:
- Skin color should be consistent with patient’s - skin lighter in abdomen than exposed areas
ethnicity - consistent with the ethnicity
- Skin color same throughout the abdomen

 Umbilicus - Umbilicus inverted and midline - inverted and midline

 Symmetry - Abdomen symmetrical bilaterally from costal - abdomen symmetrical

margin to iliac crest, with umbilicus in center

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 Contour and Distension - No abdominal distension - no distension
- Contour should be either flat, round, or - contour is flat
scaphoid

 Bowel Sounds AUSCULTATION:

- Bowel sounds present at rate of 5-30
clicks/min in each quadrant - bowel sounds between 15-26 clicks/min per
quadrant
PERCUSSION:
- Tympany to dullness (depending on abdominal - tympanic upon percussion
contents)

AUSCULTATION:
- Abdomen soft and nontender - soft and nontender noted
- No organomegaly or masses

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 Peripheral-Vascular System
 Upper/Lower Extremities
INSPECTION:
- Skin color uniform - skin color uniform in both upper & lower
- Fingernails of equal thickness extremities
- Positive brisk capillary refill less than 2-3 - capillary refill for less than 1.5 seconds
seconds - no edema on extremities
- No edema, erythema, red steaks or skin lesions - leg hair evenly distributed
- Leg hair distributed evenly - few varicosities noted on both leg
- No varicosities
- No swelling or edema
- No lesions or ulcers

 Pulses& Lymph nodes PALPATION:

- Temporal and carotid arteries are regular and
smooth
- Brachial, radial, ulnar pulses easily palpated
and equal in strength
- Ulnar artery difficult to palpate
- Infraclavicular, axillary, and epitrochlear nodes
are either nonpalpable or small, soft &
nontender
- temporal and carotid arteries are regular
- brachial, radial pulses are palpable but unequal in
strength
- epitrochlear nodes nonpalpable and nontender
- femoral, popliteal and dorsalispedis pulse are
palpable

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C. NURSING THEORIES

The Dynamic Nurse-Patient Relationship

by Ida Jean Orlando

Orlando’s nursing process discipline is rooted in the interaction between a nurse and a patient at a specific time and place. A sequence of
interchanges involving patient behavior and nurse reaction takes place until the patient’s need for help, as he perceives it, is clarified. The nurse then
decides on an appropriate action to resolve the need in cooperation with the patient. This action is evaluated after it is carried out. If the patient
behavior improves, the action was successful and the process is completed. If there is no change or the behavior gets worse, the process recycles
with new efforts to clarify the patient’s behavior or the appropriate nursing action (Gonzalo, 2011).

Ida Jean Orlando's Deliberative Nursing Process is set in motion by the behavior of the patient. According to the theory, all patient behavior
can be a cry for help, both verbal and non-verbal, and it is up to the nurse to interpret the behavior and determine the needs of the patient. The
Deliberative Nursing Process has five stages: assessment, diagnosis, planning, implementation, and evaluation (Evelyn, 2002).

The goal of this model is for a nurse to act deliberately rather than automatically. This way, a nurse will have a meaning behind the action
which means the patient gets care geared specifically toward his or her needs at that time. This nursing process is also one that can easily be
adapted to different patients with different problems, and can be stopped at any time, depending on the patient's progress or health. This makes
Orlando's theory universal for the nursing field (Gonzalo, 2011).

Nursing care has to be flexible. Not only does a nursing care plan depend on the needs of the patient at the time of admittance, but it also
needs to be able to change when and if any complications come up during the treatment and recovery process (Gonzalo, 2011).

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Correlation:

Regardless of how well thought out a nursing care plan is for a patient, obstacles on the patient's recovery may come up at any time. This
may cause problems for the original nursing care plan, and it's the nurse's job to know how to deal with these obstacles so the patient can continue
to recover and stay on the path to health. Ida Jean Orlando's nursing theory allows nurses to create an effective nursing care plan that can also be
easily adapted when and if any complications arise with the patient.

Throughout the care of my patient, I was able to obtain sufficient and necessary data which helped me identify three priority nursing
diagnosis. Selecting a precise nursing diagnosis requires a good sense of dexterity by making use of all the gathered data in identifying the priority
problems.

Similarly, choosing the correct interventions is also difficult since you ought to make it applicable with the patient’s condition and the
environment his situated in. I did not only use the actions and interventions upon the time of admission of my patient as my basis but also perceived
on the possible changes and complications that may occur throughout the recovery process. Orlando’s theory guided me in rendering nursing
interventions to my patient, and taught me ways not only on nursing care plans but by focusing on my patient’s state if and when it changes.

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D. GORDON’S FUNCTIONAL HEALTH PATTERN

USUAL INITIAL (9-21-17)

I. HEALTH-PERCEPTION – HEALTH-MANAGEMENT PATTERN

- patient’s usual health is good before hospitalization - patient complains moderate pain in left side chest area
- eats nutritious foods and water to improve health - patient unable to sleep last night upon admission
- complete immunizations - vital signs:
- does not anticipate problems caring for himself T- 37.5C PR- 72 bpm RR- 22 cpm BP-110/70 mmHg
- hospitalized last 2010 due to ulcer - Meds:
Clarythromycin 500mg 1 tab BID
Omeprazole 40mg IVTT OD ac lunch
Levofloxacin 500mg IVTT now
Hydrocortisone 200mg IVTT now then 100mg IVTT q 6h x2 days
Bilastine 20mg 1 tab OD q hs
Butaminate 1 tab TID
Trimetazidine 35mg 1 tab q 12h
Ceftriaxone 1gm IVTTANSTthen q 8h
Spironolactone 100mg 1 tab OD q 6am c BP prec!
II. NUTRITIONAL-METABOLIC PATTERN
- patient usually eats vegetables, fish, meat, etc in breakfast, lunch, or - patient is ate biscuit this morning
dinner - Diet: Full diet, NPO if dyspneic or drowsy

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- patient eats a lot of rice about 1 ½ - 2 cups
- seldom drinks alcohol
- did not experience indigestion, nausea or vomiting
- no food restrictions or allergies
- patient’s not taking any food supplements
- no problems in ability to eat

III. ELIMINATION PATTERN

Bladder Bladder
- no problems or complaints with the usual pattern of urinating - able to urinate this morning; yellowish in color
- usually urinates 3 times a day - no complaints upon urinating
- no assistive devices used
Bowel Bowel
- usually moves bowel once a day - patient not yet defecated
- no assistive devices used
Skin Skin
- patient’s skin condition: - patient’s skin condition:
> dark-brown > dark-brown
> warm to touch > warm
> normal skin turgor > normal skin turgor
> absence of any edemas or lesions > presence of tattoos

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IV. ACTIVITY-EXERCISE PATTERN
- patient is a workman doing manual labor - patient verbalizes moderate alleviation of pain
- no limitations in ability to ambulate, dress, toileting, or bathing self - able to move extremities and ambulate

V. SLEEP-REST PATTERN
- patient usually sleeps around 11PM to 5AM - patient was unable to sleep last night due to pain and environment
- 6-7 hours of sleep at night - no sleeping aids used
- no sleeping aids used or any medications or foods

VI. COGNITIVE-PERCEPTION PATTERN

- no deficits in sensory perception (hearing, sight, or touch) - no deficits in sensory perception (hearing, sight, or touch)
- does not wear eyeglasses or any hearing aids - able to see, hear and sense touch
- no complaints of vertigo or insensitivity to superficial pain or cold/heat - able to read and write
- patient able to read and write
- patient finished high school

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VII. SELF-PERCEPTION PATTERN
- patient’s is concerned of his family health and well-being - patient able to coherently express thoughts thoroughly
- describes himself as a hardworking person - patient is concerned of his own health
- patient works as a workman doing manual labor

VIII. ROLE-RELATIONSHIP PATTERN

Communication Communication
- patient speaks Cebuano and English - patient speaks coherently and very responsive
- speech is clear and relevant - able to express verbally
- able to express self verbally
Relationships Relationships
- patient’s parents speaks Cebuano and English and also clear and - patient is with his wife
relevant - able to speak Cebuano and English
- patient lives with his wife and 3 children
- turns to relatives or siblings in times of need
- no difficulties with relatives and in-laws
- no signs of any type of abuse (physical, verbal, substance)

IX. SEXUALITY-SEXUAL PATTERN

- patient is married; no children - patient is still married and no children yet
- does not anticipate changes in sexual relations - patient is accompanied by his wife during hospitalization

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X. COPING-STRESS MANAGEMENT PATTERN
- patient together with wife makes decisions in the household - both patient and wife makes decisions during hospitalization
- no loss in life for the past year - patient wishes to change his habits of drinking and smoking
- patient likes about himself as hardworking
- smokes and/or drinks when under stress
- does not have anything to change in his life

XI. VALUE-BELIEF PATTERN

- patient is Roman Catholic
- patient finds source of strength and meaning from God
- verbalizes that God is very important to their family
- seldom goes to church in Sunday - patient’s values or moral beliefs
were not challenged
- no religious practices or rituals followed
- patient is Roman Catholic
- patient finds source of strength and meaning from God
- states not really a religious person
- patient’s values or moral beliefs were not challenged
- no religious practices or rituals were observed

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E. SUMMARY OF NURSING DIAGNOSES

THREE PRIORITY NURSING DIAGNOSES

Ineffective airway clearance related to pleuritic pain secondary to pneumonia

Ineffective breathing pattern related to decreased lung volume capacity secondary to pleural effusion

Acute pain related to inflammation of lung parenchyma

OTHER APPLICABLE NURSING DIAGNOSES

Deficient knowledge

Risk for infection

Disturbed sleep pattern

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 CUES NURSING OBJECTIVE INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective: Ineffective airway At the end of Assess the rate and depth Shallow respirations, and
“Gasakit ning kilids clearance related to rendering nursing of respirations and chest asymmetric chest
dughan nako, maka- pleuritic pain interventions, the movement. movement are frequently
apekto sa akong secondary to patient will: present because of
ginhawa usahay”, as pneumonia discomfort of moving
verbalized by the - demonstrate chest wall or fluid in
patient. behaviors to achieve lung.
airway clearance;
Auscultate lung fields, Decreased airflow occurs
- display patent noting areas of decreased in areas with
Objective: airway with breath or absent airflow and consolidated fluid.
- reports left side sounds clearing; adventitious breath Crackles and wheezes
chest pain sounds: crackles, wheezes. are heard on inspiration
- crackles upon - alleviate chest pain or expiration in response
auscultation and report absence of to fluid accumulation,
- restlessness restlessness and thick secretions, and
- fatigue fatigue. airway spasms and
obstruction.

Elevate head of bed, Doing so would lower the

change position frequently.
diaphragm and promote
chest expansion, aeration
of lung segments,
mobilization and
expectoration of
secretions.

Teach and assist patient Deep breathing exercises

with proper deep-breathing facilitates maximum
exercises. Demonstrate expansion of the lungs

Page | 59
proper splinting of chest and smaller airways.
and effective coughing
while in upright position.

Force fluids to at least Fluids, especially warm

3000 mL/day (unless liquids, aid in
contraindicated). Offer mobilization and
warm, rather than cold, expectoration of
fluids. secretions.

Collaborative:
Administer meds as
indicated:

Clarithromycin 500mg 1
tab BID

Ceftriaxone 1gm IVTT To fight of

ANST then q 8h infection in system

Levofloxacin 500mg IVTT

now

Butamirate 1 tab OD q HS To suppress cough

Page | 60
 CUES NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective: Ineffective breathing At the end of Monitor and record vital To obtain baseline data
“Duha na ni ka pattern related to rendering nursing signs.
simana na mag wala- decreased lung interventions, the
wala akong ubo, volume capacity patient will: Assess breath sounds, To note for respiratory
unya hilantanon ko”, secondary to pleural respiratory rate, depth and abnormalities that may
as verbalized by the effusion - demonstrate rhythm indicate early respiratory
patient. appropriate coping compromise and hypoxia.
behaviors and
methods to improve Elevate head of the patient To promote lung
breathing pattern; expansion
Objective:
- pleuritic chest pain - reports absence of Encourage patient to To promote lung
- crackles upon crackles, perform deep breathing expansion.
auscultation restlessness and exercises
- restlessness fatigue;
- fatigue Assist client in the use of To provide relief of
- verbalizes relaxation technique causative factors
alleviation of chest
pain. Maximize respiratory effort To promote wellness
with good posture and
effective use if accessory
muscles.

Encourage adequate rest To limit fatigue

periods between activities

Collaborative:
Administer supplemental To maximize oxygen
oxygen as ordered available for cellular
uptake

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 CUES NURSING OBJECTIVE INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective: Acute pain related At the end of Monitor vital signs. Changes in heart rate or
“Nagsakit ning kilid to inflammation of rendering nursing BP may indicate that
nako (points at left lung parenchyma interventions, the patient is experiencing
side chest), duha na patient will: pain.
ni ka simana wala-
wala”, as verbalized - verbalize relief and Provide comfort measures: Non-analgesic measures
by the patient. control of pain rated back rubs, position administered with a
1-2 out of 10 scale; changes, massage. gentle touch can lessen
Encourage use of relaxation discomfort and augment
- demonstrate and/or breathing exercises. therapeutic effects of
relaxed manner, analgesics.
Objective: resting. sleeping and
- reports pleuritic engaging in activity Offer frequent oral hygiene. Mouth breathing and
chest pain (5/10) appropriately; oxygen therapy can
- restlessness irritate and dry out
- guarding of affected - reports total mucous membranes,
area absence of potentiating general
restlessness and discomfort.
guarding position.
Instruct and assist patient Aids in control of chest
in chest splinting discomfort while
techniques during coughing enhancing effectiveness
episodes. of cough effort.

Collaborative:
Administer medications as
indicated:

Page | 62
Hydrocortisone 200mg IVTT - For presence of
now inflammation

Trimetazidine 35mg 1 tab q - For chest angina

12h

Clarithromycin 500mg 1 tab

BID

Ceftriaxone 1gm IVTT ANST To fight of

then q 8h infection in system

Levofloxacin 500mg IVTT

now

Page | 63
XI. ANNOTATED READINGS

Page | 64
Reaction:

By being updated with the latest trends and studies in nursing field, it could increase likelihood of proper patient monitoring and
management. In this study, the common practices in emergency department such as measuring respiratory rates, assessing GCS, and preprocedural
fasting have undergone descriptive-comparative studies based on the usual routines and new ones. Most studies were concluded that simple, newly
adapted ways of incorporating such practices increase the accuracy and responsiveness of data from the patient.

So just to say, new updates and studies related to medical practices do not only supplement us with knowledge and information but greatly
change how the healthcare system works in everyday future. This is to say that we learn new thing each day and this gives us the opportunities to
validate them using evidence-based practices.

Page | 65
Page | 66
Page | 67
Reaction:

This is not an article about scientific studies on certain researches of medical practices but rather a good and sentimental commentary of a
dad who has Parkinson disease. The person narrating tells of a story of how every day they cope up and adapt to physical and emotional changes
with their father experiencing Parkinson disease. They have already come to a resolution on a ‘Do Not Resuscitate’ order, sticking onto their
refrigerator and reminding them of the soon awaited day that they would have to endure the pain and remorse of coming in to such decision.

As a person, we might learn something from this narrative which is to remind us that everyday a single hair might fall from our heads and
then a new one grows, and until such time that all of those turns silver and completely dissipate. And as future health care professionals, this also
reminds on considering the emotional consciousness in each of the patients and/or family members under the supervision of our care. By treating
them as whole human being, and not just a person asking for medicine, we are able to render a productive care to the patient.

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X. CONCLUSION

I have made numerous of case studies before and with each of them I gradually learn more and more of my assigned diseases. While making
this case study, I have gained a great deal of knowledge on the condition – Pneumonia, specifically community-acquired. This is a first for me to
make a case study of this condition, despite the disease being common.

This disease process – community-acquired pneumonia – made me aware of the need to be self-cautious about my own health and the
people around me, that if I experience any abnormalities, I ought to immediately seek for the doctor’s attention. And how you yourself should not
recklessly forget about your health and welfare and think about the advantages & disadvantages on engaging certain activities.

I would like to extend my gratitude to the Negros Oriental Provincial Hospital - Emergency Department nurses & staffs that gladly helped us in
times of great need and guidance during our clinical exposure in the area. They are a great example of how we should act as being a true health
care professional.

Also, I highly appreciate the efforts and time put in by our clinical instructor, Mr. Peter Orlino who meticulously cared for our future as soon-
to-be professional nurses. He advised us accordingly and assisted us throughout the entire rotation. He was also considerate enough and patient
with us, despite our often inattentiveness in the area. I thank God for his good heart and efforts towards shaping us into better nurses. May God
bless him abundantly because if it were not for him, I couldn’t have made onto conclusion in writing this conclusion.

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XI. BIBLIOGRAPHY

Books:

Black, J.M. & Hawks, J.H.(2004). Medical-Surgical Nursing. 7th Edition. Philippines: Elsevier (Singapore) PTE LYD.
Craig, R. G. & Kamer, A. R. (2016).A Clinician’s Guide to Systematic Effects of Periodontal Disease. Berlin: Springer-Verlag.
Harrison, T.R., et. al. Principles of Internal Medicine. 5th Edition. The Blackiston Division; McGraw Hill Book Company.
Kozier, B., et. al.,(2004). Fundamentals of Nursing, Concepts, Process and Practice, 7th Edition. New Jersey: Pearson Education Inc.
Potter, P.A. & Perry, A.G.(2004) Fundamentals of Nursing. Philippines: Elsevier (Singapore) PTE LYD.
Porth, C.M.(2002). Pathophysiology: Concepts of Altered Health States. 6th Edition. Philadelphia: Lippincott Williams & Wilkins.
Torney, A. M., et. al.(2002). Nursing Theorists and their Work. 5th Edition. Mosby, Inc.

Internet:

Accessed on 9/25/17, 5:28pm. http://emedicine.medscape.com/article/234240-overview

Accessed on 9/25/17, 5:31pm. http://www.msdmanuals.com/professional/pulmonary-disorders/pneumonia/community-acquired-pneumonia
Accessed on 9/26/17, 9:45am. http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/infectious-disease/community-acquired-
pneumonia/
Accessed on 9/26/17, 10:28pm. http://www.aafp.org/afp/2016/1101/p698.html
Accessed on 9/26/17, 10:42pm. http://www.doh.gov.ph/mortality
Accessed on 9/27/17, 12:28pm. https://data.unicef.org/topic/child-health/pneumonia/
Accessed on 9/27/17, 12:32pm. http://www.nejm.org/doi/full/10.1056/NEJMra1312885

Dictionary:

Merriam-Webster’s collegiate dictionary (10th ed.). (1999). Springfield, MA: Merriam-Webster Incorporated.

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