Pneumonia Case Study

SULTAN KUDARAT STATE UNVERSTY
College of Nursing
ACCESS Campus, EJC Montilla, Tacurong City
Concepts in NCM 102 DECEMBER, 2019
A CASE STUDY IN PNUEMONIA
NURHASSEM N. AKANG
SAIMA S. AYAO
ROSEMARIE A. DALANON
JESSA N. DELICANA
DONABELLE D. LOBINGCO
SAMINA N. MINANDANG
ROSE SALLIE A. MINGGOD
IRISH D. SAYCON
MARNIE T. SALAMANCA
RUSSEL JOHN P. TALIDONG
MERCH IAN VERGARA
BSN- III
Submitted to:
WILBERT A. CABANBAN, RN, MAN
Clinical Instructor
BSN-III
ACKNOWLEDGMENT
“There's a downside to everything, a dark side to everyone, and those who
willingly walk in the shadows are a hell of a lot more convincing than those who
only acknowledge the sunshine.” ― J.M. Darhower,We’re so grateful for the
opportunity to gathered data rendered to this kind of case study which reflects to
our studies here in Sultan Kudarat State University, specifically in Health and
Sciences Department and making it possible. Our deep thanks for the effort and
cooperation of our individual members of our group that made this kind of task
great and that meets our ability to deal with new people in areas of responsibility
of being a future nurse in the near future. This challenges brought this work
towards a completion.
And of course, we take this opportunity to express our profound gratitude

to Sir Wilbert A. Cabanban, RN, MAN, a clinical Instructor for his monitoring,
exemplary guidance, constant encouragement throughout the course of this case
study and also thanks to the staff nurse at Lambayong District Hospital,
Lambayong, Sultan Kudarat for being kind and humble in assessing our
concerns.
We also thank our family who always there for us and prayed for us
throughout the time of our studies with regards to our financial needs. May the
Almighty God richly bless all of you.
We thank you.
BSN 3RD Year Group 2
Sultan Kudarat State University

A Case Study on Pneumonia
TABLE OF CONTENTS
Contents Page
ACKNOWLEDGMENT i
OBJECTIVES ii
INTRODUCTION iii
DEFINITION OF TERMS 7
GENERAL PATIENT’S PROFILE 11
NURSING HEALTH HISTORY 12
PHYSICAL ASSESSMENT
MEDICAL MANAGEMENT
ANATOMY AND PHYSIOLOGY
LABORATORY RESULT
PATHOPHYSIOLOGY
DRUG STUDY
NURSING CARE PLANS
PROGNOSIS
DISCHARGE PLANNING
REFERENCES
OBJECTIVES OF THE RESEARCH
General objectives:
3|Page Sultan Kudarat State University

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This case study will serve as a guide for nursing students to provide
information about a patient having the disease which is pneumonia.
Specific Objectives:
 To be able to identify and analyze the etiology of the underlying cause of

pneumonia.
 Present Health History of the client.
 To discuss anatomy and physiology of the related disease.
 To deliver the systematic and logical presentation of pneumonia.
 To systematically present the data pertinent to the case being gathered.
 Present and discuss drug study.
 Present an appropriate Nursing Care Plan for the most prioritized problem.
INTRODUCTION

Pneumonia is a common lung infection characterized by collection of pus

and other fluids in the lung air sacs (alveoli). Lung air sacs are structures that
help in the exchange of oxygen and carbon dioxide. Collection of pus in them
makes breathing difficult. Pneumonia can be caused by many kinds of
microorganisms (germs) including bacteria, viruses, fungi or parasites. When an
infected individual coughs or sneezes, these organisms get into the air and
breathing in of this air leads to contraction of the illness. It is thus a contagious
disease. It is of various types occurring in individuals of all ages, affecting
millions of people worldwide.
The condition varies from mild to severe depending on the type of
organism involved, age and the underlying health of the individual. Pneumonia
can be categorized as: community-acquired, hospital-acquired and pneumonia
occuring in Immunocompromised individuals (individuals with weakened immune
system). Pneumonia is usually caused due to an infection with a bacterium, virus,
fungi or parasite. In adults it is mostly caused by bacteria whereas in children and
infants it is commonly due to viruses. Physical or chemical injury to the lungs can
also result in the condition. Individuals who smoke, who are hospitalized and
have long-term illness such as asthma, heart disease, cancer, HIV/AIDS, lung
diseases or diabetes are at a higher risk of developing pneumonia. Hospital-
acquired pneumonia is also common.
The onset of pneumonia can be sudden or slowly progressive. In most
cases the symptoms of pneumonia mimics that of flu or other common lung
infections such as bronchitis. The main signs and symptoms of pneumonia are:
cough that produces phlegm (sputum) which is either yellow, blood-stained or
rust colored, chest pain, difficulty in breathing, chills, fever, headache, excessive
sweating, weight loss, loss of appetite, muscle pain, weakness and tiredness.
Diagnosis is based on a detailed history of the individual which involves the signs
and symptoms, detailed personal and medical history. Certain laboratory
investigations such as chest X-rays to confirm and determine the extent of
infection as well as to rule out other chest infections. Sputum and blood tests are
done to identify the specific organism responsible for the infection. Pulse

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oximetry is carried out to ascertain the flow of oxygen through the blood thus,
determining the functionality of the lungs. Treatment: Treatment for pneumonia
usually depends on the type of pneumonia, bacterial or viral. Viral pneumonia
does not require antibiotics instead antiviral medications are prescribed. The
individual usually takes one to three weeks to recover. Individuals with bacterial
pneumonia are usually treated using antibiotics to cure the infection. Medications
are given to relieve pain, fever and cough along with adequate rest, healthy diet
and plenty of fluids to improve the general health. Hospitalization and oxygen
therapy are advised in severe conditions. Treatment of the underlying medical
problem is necessary if present with periodic follow-up visits.
Pneumonia can be fully cured without complications in most of the cases.

Complications usually occur in individuals with other debilitating diseases such
as lung infections, heart ailments, etc. The complications include spread of the
infection to the blood and other organs, empyema or lung abscess (conditions
resulting from collection of pus in and around the lungs), accumulation of fluid in
the lungs, acute respiratory distress (difficulty in breathing due to spreading of
the infection in the lungs).
Pneumonia can be prevented by maintaining hygiene such as washing

hands frequently and thoroughly after blowing nose, going to the bathroom and
before eating, quitting smoking as smoking damages the lungs, staying away
from individuals who are sick, wearing a mask when cleaning dusty areas,
getting vaccinated against pneumonia such as the flu shot.
DEFINITION OF TERMS
AIDS- Acquired immunodeficiency syndrome, a syndrome caused by infection

with the human immunodeficiency virus (HIV), with ensuing compromise
of the body's immune system.

Alveoli- The alveoli are tiny air sacs within the lungs where the exchange of
oxygen and carbon dioxide takes place.
Bacteria- Single-celled microorganisms that can exist either as independent

(free-living) organisms or as parasites (dependent on another organism
for life).
Basophil- A type of white blood cell (leukocyte) with coarse, bluish-black

granules of uniform size within the cytoplasm.
Blood test- a scientific examination of a sample of blood, typically for the

diagnosis of illness or for the detection and measurement of drugs or other
substances.
Bronchitis-is an inflammation of the lining of your bronchial tubes, which carry

air to and from your lungs. People who have bronchitis often cough up thickened
mucus, which can be discolored.
Bronchioles- the tiny branch of air tubes within the lungs that is a continuation of
the bronchus. The bronchioles connect to the alveoli (air sacs).
Cardiomegaly- Enlargement of the heart. Cardiomegaly is a descriptive term

that is used to refer to the physical finding of an enlarged heart and is not a
disease itself. Cardiomegaly can be caused by a number of different conditions
including diseases of the heart muscle or heart valves, high blood pressure,
arrhythmias, and pulmonary hypertension.
Cholesterol- The most common type of steroid in the body. Cholesterol has a
reputation for being associated with an increased risk for heart and blood vessel
disease.
Community-acquired- An infection acquired in the community.
Complete Blood Count- A commonly used abbreviation in medicine that stands

for complete blood count, a set values of the cellular (formed elements) of blood.
Creatinine- A chemical waste molecule that is generated from muscle
metabolism. Creatinine is produced from creatinine, a molecule of major
importance for energy production in muscles.
Debilitating disease- Debilitating diseases come in many shapes and forms –

from those that attack the muscles in our body and affect our physical abilities to
those that affect our brain function and impair our thought processes.
Empyema- Empyema is a condition in which pus and fluid from

infected tissue collects in a body cavity. The name comes from the Greek word
empyrean meaning pus-producing (suppurate).

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Erythrocytes-A cell that contains hemoglobin and can carry oxygen to the body.
Also called a red blood cell (RBC). The reddish color is due to the hemoglobin.
Erythrocytes are biconcave in shape, which increases the cell's surface area and
facilitates the diffusion of oxygen and carbon dioxide. This shape is maintained
by a cytoskeleton composed of several proteins.
Eosinophils- A normal type of white blood cell that has coarse granules within
its cytoplasm. Eosinophils are produced in the bone marrow and migrate to
tissues throughout the body.
Fasting Blood Glucose- A test to determine how much glucose (sugar) is in a

blood sample after an overnight fast. The fasting blood glucose test is commonly
used to detect diabetes mellitus.
Fungi- A single-celled or multicellular organism.
Heart ailments- describes a range of conditions that affect your heart. Diseases
under the heart disease umbrella include blood vessel diseases, such as
coronary artery disease; heart rhythm problems (arrhythmias); and heart defects
you're born with (congenital heart defects), among others.
Hemoglobin- The oxygen-carrying pigment and predominant protein in the red

blood cells. Hemoglobin forms an unstable, reversible bond with oxygen.
Hospital-acquired- An infection caught while hospitalized
Homeostasis-The stoppage of bleeding or hemorrhage. Also, the stoppage of

blood flow through a blood vessel or organ of the body.
Immunocomprised- Having an immune system that has been impaired by

disease or medical treatment.
Leucocytes-White Blood Cells that help the body fight infections and other
diseases. Also called white blood cells (WBCs).
Lung abscess- is a bacterial infection that occurs in the lung tissue. The
infection causes tissue to die, and pus collects in that space. A lung abscess can
be challenging to treat, and it can be life-threatening.
Lung Parenchyma- The key elements of an organ essential to its functioning, as

distinct from the capsule that encompasses it and other supporting structures.
Lymphocytes-A small white blood cell (leukocyte) that plays a large role in
defending the body against disease.

Monocytes- A white blood cell that has a single nucleus and can take in (ingest)
foreign material.
Neutrophils-A type of white blood cell, a granulocyte that is filled with

microscopic granules, little sacs containing enzymes that digest microorganisms.
Also known as polymorph nuclear leukocyte or poly.
Parasite- A plant or an animal organism that lives in or on another and takes its
nourishment from that other organism. Parasitic diseases include infections that
are due to protozoa, helminths, or arthropods.
Phlegm- A thick fluid that is produced by the lining of some organs of the body.
Platelet- An irregular, disc-shaped element in the blood that assists in blood

clotting. During normal blood clotting, the platelets clump together (aggregate).
Pneumonia- Inflammation of one or both lungs, with dense areas of lung

inflammation. Pneumonia is frequently but not always due to infection. The
infection may be bacterial, viral, fungal, or parasitic.
Pulse oximetry-is a test used to measure the oxygen level (oxygen saturation)
of the blood. It is an easy, painless measure of how well oxygen is being sent to
parts of your body furthest from your heart, such as the arms and legs.
Serum Uric Acid- A uric acid blood test, also known as a serum uric
acid measurement, determines how much uric acid is present in your blood.
Sputum-Mucous material from the lungs that is produced (brought up) by

coughing.
Virus- A microorganism that is smaller than a bacterium that cannot grow or
reproduce apart from a living cell. A virus invades living cells and uses their
chemical machinery to keep itself alive and to replicate itself.

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PATIENT’S DATA
Name : Patient X
Age : 87 years’ old
Gender : Male
Nationality : Filipino
Civil Status : Married
Date of Birth : October 05, 1932
Address : Purok 5, Bilumin, Lambayong, Sultan Kudarat
Informant : Patient
Religion : Espiritista

Admitting Physician : Dr.Merlita Cerbo

Date of Admission : December 05, 2019 at 2pm
Chief Complaint : Cough,Fever,Body Malaise
Admitting Diagnosis : To consider to PTB Pneumonia
Final Diagnosis : Pneumonia
NURSING HEALTH HISTORY
A. BIOGRAPHIC DATA:
Name : Patient X
Age : 87 years’ old
Gender : Male
Nationality : Filipino
Civil Status : Married
Date of Birth : October 05, 1932
Address : Purok 5, Bilumin, Lambayong, Sultan Kudarat
Informant : Patient
Religion : Espiritista
Admitting Physician : Dr. Merlita Cerbo
Date of Admission : December 05, 2019 at 2pm
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B. CHIEF COMPLAINTS
Cough, Fever, Body Malaise
C.PERSONAL HISTORY
Patient X is an 87 years old male. He lives in Purok 5, Bilumin,
Lambayong, Sultan Kudarat. His nationality is Filipino and born Purok 5, Bilumin,
Lambayong, Hospital on December 5, 2019 at 2:00 in the afternoon with the
principal diagnose of Pneumonia.
D. HISTORY OF PRESENT ILLNESS
Patient X is admitted due to cough on and off of several days’ duration, 3
days prior to admission had fever. Persistent of the above complain hence
developed body malaise, thus admission.
E. PAST HEALTH HISTORY
Based on the interview patient X verbalized that he had no past major medical
conditions and also stated that he has no history of any medical surgeries but
sometimes he had cough, colds and fever.
F. FAMILY HISTORY
Patient X verbalized that his mother had rheuma while his father had
hypertension, diabetes and rheuma.
G. LIFESTYLE
 Personal Habits
Patient X is into gardening sometimes walking every morning.
 Diet
Patient X diet has not a proper diet, he prefers eats meats than
vegetables.
 Sleep rest/ pattern

Patients X sleep at around 9-10 in the evening and wakes up at around 4
in the morning.
 Activities of Daily Living

Patients X wakes up around 4 in the morning. His daily activities include
gardening and going to the farm.

H.SOCIAL DATA
 Family relationship/friendship
Patient X lives with her husband and daughter.
 Ethnic affiliation
Ilocano
 Educational status
Elementary level
 Economic status
Low class family
 Home and neighborhood conditions

The house is made of wood and have a good ventilation. They have
backyard where they plant some vegetables. As verbalized by Patient X
their surrounding is clean.
REVIEW OF SYSTEMS
1. Mental Status
Patient X is conscious, but he doesn’t know what day is now,

where he is but he can still state the name of his wife and
where is his wife.
2. Neuromuscular status
Patient X can still able to walk but with the help of others due
to his rheuma in both lower extremities.
3. Sensory status -
Patient X doesn’t have any sensory disability aside from his

poor hearing due to his aged. He was able to speak, see
things, hear sounds but not too far, and has a good sense of
smelling. He can feel the touch of someone around him.
4. Integumentary Status
Patient X has no skin lesion but his skin is dry and had a
presence of hematoma.
5. Cardiovascular Status
Patient X heart rate of 89 bpm, respiratory rate of 24and

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temperature of 36.2 degree Celsius, and blood pressure of

100/70 mmhg.
6. Nutritional Status
Patient X eats his meal 3 times a day. Commonly he drinks
coffee and eat rice. He preferred meats than vegetables.
7. Gastro-intestinal
Patient X has a good digestion and doesn’t complain
abdominal pain.
PHYSICAL ASSESSMENT
A. Vital Signs
Date: December 06, 2019
Time: 4:00 pm
Temperature - 36.2 Degree Celsius
Pulse Rate - 89bpm
Respiratory Rate - 24cpm
Blood Pressure - 100/70 mmHg
B. General Appearance
Weight - 60kg.
Height - 165cm or 5’5”
Posture - Slightly Forwarded Head,
cannot stand straight, nor stand in long period of
time.
Gait - Patient is unable to walk in his own
due to his condition.
C.Physical Assessment
Head and Hair
 The color is white and straight, no infestation and a proper distribution of hair. No
presence of lesions and lumps.
Scalp

 (-) dandruff and dryness
Skull
 Symmetrical skull
Eyes
 (-) lesion and infestation in the eyebrow with proper distribution of hair and
symmetrically aligned
 (-) involuntary movement/extraocular movement of his eye margin
 Pale conjunctiva
 (-) lesion, swelling and Normal blink reflex
 The color of his eye pupil is black same as to the other side of his eye
pupil
 Patient X able to read.
Face
 Can demonstrate smile, frown, and puff checks, wrinkle forehead raises
eyebrows and close eyes tightly
 (-) edema and hollowness of the eye
Ears
 Patient X has a poor hearing.

 Symmetrical, no discharges, no lesion
Nose
 The color of his nose same as the color of his face

 (-) nasal flaring and any discharges.
 (-) tenderness, mass and dislocation of the bone and cartilage
 Can identify scented objects.
 (-) nodules, obstruction and tenderness in the frontal and maxillary
sinuses
Mouth
 Lips is symmetry, the color of his outer lips is slightly pink and (-) dry yet
slightly moisten
 No presence of lesions or ulcer in the mouth
 (+) bad breath

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 Slightly pale and pinkish color of the tongue and (+) moisten
 Absence of upper and lower teeth
Neck and Throat
 (-) inflammation of lymph nodes in posterior cervical and anterior cervical

area
 (-) stiff neck
 (-) enlargement, deviation, tenderness or nodules of the trachea and
thyroid gland
 No difficulties when head is moving and swallowing
 (-) hoarseness
Chest and lungs
 (-) use of accessory muscle

 The position of the scapula is symmetrical to the other side
 (+) Crackles, decrease breathe sounds
 (-) rashes or lesions, lamps or tenderness over his chest and back
 Chest is symmetrically aligned with (-) tenderness, masses and lesions of
both breast
 During auscultation in his posterior and anterior thorax no abnormal
breath sound detected/ heard.
Abdomen
 Patient X abdomen is in normal contour and shape with (-) presence of

rashes, lesions and wound.
 Normal Bowel sound noted during auscultation
 (-) Tenderness and masses during palpation.
Nails
 Patient X fingernails and toenails are a little bit long and dirty.

Skin
 Brown skin with wrinkles

 Dry skin
 (-) lesions
Genitourinary
 (-) painful urination when voiding with urine color of yellowish (-) foul odor
 No presence of pus, blood, pain, swelling and incontinence in urinating.
Upper and lower extremities
 (-) tremors
 Both Upper and lower extremities are symmetrical
 (-) rashes, ulcer wound, lesion, varicosities and edema seen
 With good skin turgor and tonicity
 (-) deformities, tenderness and edema during palpation
 Presence of hematoma in both feet
 Nail: < 2 secs. In his capillary refill test.
Musculoskeletal
 Muscles are symmetrical in size with no involuntary movements

 (-) presence of tenderness, swelling or masses and wounds
 Skin temperature is in normal with a result of 36.2 degree celcius.
 Patient X can do abduction, extension, supination and pronation and other
range of motion.

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MEDICAL MANAGEMENT
DOCTOR’S ORDER RATIONALE

12 – 05 –  Please admit To be able to provide
2019 the patient with the
2:00pm specific care.
Progress  DAT with aspiration precaution To prevent choking

Notes to the patient.
T - 38ºc
BP –  TPR every shift To have baseline data
120/70 and to assess the
RR - 28 stability of the clients
health status.
 Stat IVF with PNSS 1L @20gtts/min For supply of water,

calories and
electrolytes to the
body and port of
intravenous
medication.
 Labs; CBC, Creatinine determination, urinalysis. To note any

abnormalities in the
results thus proper
management and
treatment will be
given.
 Chest X-ray posterior and anterior view. For proper

visualization of the
lungs.
Meds
o Cefuroxime 750mg every 8hours, To treat bacterial

ANST infections.
o
o Paracetamol 500mg, 1 tab now To relieve pain and
then every 4 hours for fever. fever reducer.
o
o Lagundi 300mg, 1 tab TID To relieve cough.

o Multivitamins, 1 cap OD To treat vitamin

deficiency and to
increase the actions
of the other drugs.
o Nebulize with salbutamol, 1 To treat COPD.

nebule every 8 hours.
o
o Refer immediately accdg. to Dr. For further
Cerbo. monitoring and direct
reference to other
physician.
12 – 6-  For repeat CBC and Platelet count To assess the blood

2019 count and the
9am concentration of the
hemoglobin. Also, to
Progress assist in the diagnosis
Notes of any bleeding
T – 36.6ºc disorders.
BP –
120/80  Follow up chest X-ray result
(+) cough 
(+)  IVF to follow PNSS 1L @ 25gtts For supply of water,
creatinine calories and
electrolytes to the
body and port of
intravenous
medication.
 Continue meds To receive

medication
appropriate to clinical
needs.
 Refer to Internal Medication For further

monitoring and direct
reference to other
physician.
12 – 07 –  Continue IVF @ 30gtts/min For supply of water,

2019 calories and
11am electrolytes to the
body and port of
intravenous
medication.
 Ferrous Sulfate and Folic acid 4 cap BID To treat low

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hemoglobin count
 Increase OFI 2L/day

 Vitamin C 2 tab OD For faster absorption
of ferrous sulfate and
folic acid.
 Repeat hematocrit and platelet count today
 Watch out for any bleeding To avoid severe
bleeding and
thrombocytopenia
 VS every 4 hours. To have baseline data
and to assess the
stability of the clients
health status.
- Dr. Cerbo
12 – 08 –  Start Fluimucil 600mg TID To reduce the

2019 thickness of the
11am sputum.
 Continue meds. To receive

medication
needs.
 IVF to follow PNSS 1L at same rate (30gtts) For supply of water,

calories and
electrolytes to the
body and port of
intravenous
medication.
 Please refer For further

reference to other
physician.
Pm  For AP lordotic view For proper

lungs especially
between apices.
12 – 09 –  Continue meds To receive

2019 medication
Am appropriate to clinical
needs.

 Follow up results
 Refer for unusualities To recognize and
treat it as early as
possible.
1:20pm  For repeat X-ray, AP lordotic view For proper

lungs especially
between apices.
3:45pm To assess the blood

 Repeat CBC and Platelet count count and the
concentration of the
hemoglobin. Also, to
assist in the diagnosis
of any bleeding
disorders.
12 – 10 -  For FBS To give vital clues

2019 about how the
8:20am patient’s body is
managing blood
sugar.
 Uric acid To monitor uric acid
levels.
 Lipid profile To know if there is

abnormalities in
lipids such as
cholesterol.
 Suggest ECG 12 leads/ 2D echo To have a baseline

data about the
condition of the
patient cardiac
activity.
 For serum Na and K determination To help maintain

blood volume in the
body.
 IVF to KVO To prevent central

line occlusions and
any associated delays
in care.
 Continue all meds To receive

medication

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needs.
 Monitor VS every 6 hours To have baseline data

and to assess the
stability of the clients
health status.
 Refer For further

reference to other
physician.
12 – 11 –  Follow up ECG and AP lordotic view result For evaluation.

2019
6:20am  IVF strictly KVO To prevent central
line occlusions and
in care.
 Lanoxin 0.25mg OD To help make the

heart beat stronger
and with a more
regular rhythm.
 d/c IV cefuroxime It may interfere the

action of the lanoxin.
 cefixime 400mg 1tab TID To stop the growth of

the bacteria
 Continue Hemarate tablet To prevent and treat
iron defieciency
anemia.
 Keep analogue 600mg 1tab TID
 NaHCO3 1tab TID To relieve acid

indigestion.
12 – 12 –  Repeat hematocrit and platelet today To evelaute changes.

2019
 Increase oral fluids To enhance
absorption of the
drugs and to avoid
feeling faint or light
headed sick while
taking Furosemide.
 Furosemide 40mg 1tab 0D, x3 days Treatment of fluid

build-up due to heart

failure or kidney
disease. It can also be
treatment of high
blood pressure.
 Defer if BP is lower than 90/60 Adverse effect of the

Furosemide.
 Trimetazidine 35mg 1tab OD Improves myocardial

glucose utilization.
 Decrease Sodium Bicarbonate to OD

 PLR 1L @ KVO For supply of water,
calories and
electrolytes to the
body and port of
intravenous
medication.
 Refer to IM for further evaluation For further

reference to other
physician.
12 – 13-  For repeat CBC, Platelet and Hematocrit To evaluate changes

2019 determination. and recovery.
 Follow up other result

 IVF to KVO To prevent central
line occlusions and
in care.
 Please refer to IM, Nephro. For assment in the

condition of his
internal organs
especially his kidney.
 Continue meds. To prevent central

line occlusions and
in care
12 – 14 -  Continue meds To receive

2019 medication
needs.

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 IVF PNSS 1L @ same rate (30 gtts) For supply of water,

calories and
electrolytes to the
body and port of
intravenous
medication.
 Refer For further

reference to other
physician.
ANATOMY AND PHYSIOLOGY

LABORATORY TEST RESULTS
Dec. 05, 2019

LAB TEST RESULT REFERENCE REMARKS INDICATION
RANGE
Clinical
chemistry
Creatinine 238.9 44.4-150.28 High Possible
mmol/L malfunction or
kidney failure
HEMATOLOGY
Lab test result Reference range remarks Indication
Hemoglobin 90.8 M (140-170/L) Low Possible signs
mass count of anemia
Leukocyte 6.0 x 10 9/L 5-10x10 9/L Normal Possible signs
of infection
Neutrophils 0.63 0.55-0.65 Normal Normal
Lymphocytes 0.35 0.25-0.35 Normal Normal
Eosinophils 0.02 0.02-0.04 Normal Normal
Platelet count 124,000/cc.mm 150,000- Low Possible signs
350,000/cc.mm of dengue
fever or
infection
ROENTGENOLOGIC
LAB TEST RESULT REFERENCE REMARKS INDICATION
RANGE
Chest PA Questionable ill-defined  Cardiomegaly

densities are seen in the  Minimal pulmonary
left upper lung field. The tuberculosis not
rest of the lungs are clear.
ruled out.
The heart is enlarged.
Bony thorax is intact. The Apicolordotic view
rest of the included suggested.
structures are remarkable

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DEC 6 2019
CBC
Hemoglobin 85 M:135-180g/L Low Possible sign
F:120-140g/L of anemia
Hematocrit 25% M:42-52 vol.% Low Insufficient
F: 37-47 vol%. supply of RBC,
WBC elevation
due to
infection.
Leukocytes 5.6 4.5-6 x 10^12/L Normal Normal
Segmented 0.53 0.50-0.70 Normal Normal
neutrophils
Monocytes 0.11 0.03-0.09 High Presence of
infection
Platelet count 110 150-450 x 10/L Low Possible signs
of dengue
DEC 7 2019
CBC
F:37-47 vol%. supply of
RBC,WBC
elevation due
to infection.
of dengue
DEC 9 2019
Roentgenologic Reading/observation Impression/remarks
Chest PA Chest apicolordotic view  Left upper lobe
shows hazy infiltrates in Pneumonia.TB
the left upper lobe etiology not ruled
DEC 10 2019
CBC
Hemoglobin 85 M:135-180g/L Low Possible sign
F:120-140g/L of anemia
Leukocytes 5.6 4.5-610x Normal Possible sings
10^12/L of infection
Neutrophils 0.64 0.55-0.65 Normal Normal

Eosinophiles 0.03 0.02-0.04 Normal Normal

of dengue
DEC 12 2019
Hematology
F:37-47 vol%. supply of
RBC,WBC
elevation due
to infection.
of dengue
DEC 13 2019

BSN-III

PATHOPHYSIOLOGY
PNEUMONIA
Predisposing Factor
Precipitating Factor
Age
Environment
Infectious agent enters to respiratory

system via oral and nasal and inhalation
Exceedingly virulent Body defense mechanism cannot Impaired host

Large inoculum eliminate the infectious agent defense
Invasion to the lung

parenchyma

BSN-III
Inflammatory Response
Infectious agent
attacks the alveoli
Body will try to
maintain the
homeostasis
Produces
Impaired gas
exchange greenish
Shortness of discharge
Breath
Fever
Sweating
Chills
Body will try to

compensate from
impaired gas
exchange causing
rapid and shallow
breathing

DRUG STUDY
Name of Drug Action Indication Contraindication Adverse Effects Nursing Responsibilities

Brand Name: Inhibits sodium Chronic Intermittent Anorexia. Before
Lanoxin potassium activated cardiac failure complete heart Gastrointestinal -Observe for 10 Rights
adenosine with atrial black or 2nd disturbance. Central
triphosphates, fibrillation, degree nervous system effects. in drug administration
Generic thereby allowing ventricular atrioventricular Atrial Tachycardia - Assess for any
Name: influx of calcium into dilatation block specially allergy
Digoxin the intracellular supraventricula with history of -Assess for other
space (cytoplasm) r arrhythmias strokes-Adams
more available attacks: contraindication Obtain
Route: oral calcium promotes patients history of
increased force of underlying condition
Dosage:0.25 myocardial before therapy
mg half tab contraction (positive
inotropic effect) -
resulting to During
Classification increased cardiac  -Asses vital sign
s: output. Assess Cardio-
respiratory function:
Frequency: B/P, Heart rate and
OD
rhythm and breath
sound
-
After
-Asses vital sign
-Asses patients
family’s knowledge
BSN-III
about the drug therapy
Drug Name Action Indication contraindication Adverse effects Nursing Responsibilities

Brand Name: Stimulates beta-2 Relief of Hypersensitivity Fine skeletal muscle
Salbutamol, receptors of bronchospasm to salbutamol tremors, leg cramps,
Proventil, bronchioles by in bronchial also to atropine palpitations, tachycardia,
Ventolin, increasing levels of asthma, and its hypertension, headache,
Accuneb, camp which relaxes chronic derivatives. nausea and vomiting,
aired, novo- smooth muscles to bronchitis, Threatened dizziness hyperactivity,
Salbutamol produce emphysema abortion during insomnia, hypotension,
bronchodilation. Also and other 1st trimester or peripheral vasodilatation,
cause CNS reversible, 2nd trimester. flushing, feeling of
Generic stimulation, cardiac obstructive Cardiac tension, or nervousness
Name: stimulation, pulmonary arrhythmia and other emotional
Albuterol increased dieresis, diseases. Also associated with upsets.
skeletal muscle useful for tachycardia
tremors, and treating caused by
Route: increased gastric bronchospasm digitals
acid secretion. in patients with intoxications.
Longer acting than coexisting
Dosage: isoproterenol heart disease
of
hypertension.
Classification:
Frequency:
Drug Name Action Indication Contraindication Adverse effect Nursing Responsibilities

Brand Name: It acts on the  Diagnosis  Anuria, CNS:Headache,  Monitor electrolyte

Aldactone, distal renal and hyperkalemia drowsiness, lethargy, levels, fluid intake and
Novospiroton tubules as a maintenan , acute or confusion, ataxia output, weight, and Bp
competitive ce of progressive closely
antagonist of primary renal GI:Diarrhea, gastric  Monitor elderly patients
Generic Name: aldosterone. It bleeding, ulceration,
hyperaldo insufficiency. closely who are more
spironolactone increases the cramping, gastritis,
excretion of steronism Addison’s vomiting susceptible to
chloride and water  Adjunctive disease excessive dieresis
Route:oral while conserving therapy in GU:Renal failure,  Inform Laboratory that
potassium and edema inability to maintain patient is taking Spiro
hydrogen ions. associate erection, menstrual lactone because drug
Dosage:25mg 1 d with disturbances, post- may interfere with test
tab CHF, menopausal bleeding that measure the
nephritic digoxin level.
Classifications: syndrome,
hepatic
cirrhosis
Frequency: OD
when
other
therapies
are
inadequat
e or
inappropri
ate
Drug Name Action Indication Contraindication Adverse effects Nursing Responsibilities

Brand Name: Inhibits bacterial cell Used to treat Cefixime is Seizures, chlolethiasis,  Asses for infection at
Suprax wall and binds with infections contraindicated in urticaria, beginning of and
BSN-III
high affinity to caused by patients with agranulocytosis, throughout therapy.

Generic penicillin-binding bacteria such known allergy to eosinophilia, hemolytic  Obtain specimens for
Name: proteins in the as pneumonia: the cephalosporin anemia. culture and sensitivity
Cefixime bacterial cell wall, bronchitis group of before initiating
thus interfering with Gonorrhea and antibiotics: therapy.
Route:oral peptidoglycan can ear, lung, contraindicated in
 Observe patient for
synthesis. Hence throat, and conditions like
Dosage:400m causing bacterial cell urinary tract hypersensitivity. sign and symptoms of
g death. infections. anaphylaxis (rash,
Antibiotics will pruritus, laryngeal
not work for edema, wheezing)
Classification colds, flu, or
s: other viral
infections
Frequency:
BID

Brand Acts by directly Long treatment Monoamine Rare cases of GI Before
Name:Vaster counter acting all the of coronary oxidase disorders  Observe for the 10
al MR major metabolic insufficiency, inhibitors rights in drug
disorders occurring angina administration
within the ischemic pectoris.  Assess for the
Generic cell. The action of other
Name: trimetazidine include
contraindication
Trimetazidine limitation of
intracellular acidosis,
correction of During

Route:oral disturbances of
transmembrane ion  Asses Vital sign
Dosage: exchanges and  Use cautiously in
35mg/1 tab prevention of
patients with heart
excessive production
Classification of free radicals. failure or
s: hypertension and in
elderly patients
Frequency:O After
D  Educate the
patients for the side
effects
 Instruct the patient
to take drug as
prescribed
 Instruct patient not
to use alcohol,
sleep remedies or
sedatives serious
sedation could
occur

Brand Inhibits sodium Treatment of Hypersensitivity Orthostatic hypotension, Before
Name:Lasix, and chloride and edema to sulfonylureas thrombophlebitis, chronic  Observe for the 10
reabsorption at associated anuria. otitis, vertigo, headache, rights of
Generic the proximal with dizziness, paresthesia,
administering
Name:Furosemi tubules, distal congestive restlessness, fever,
tubules and heart failure photosensitivity, medication
de
ascending loop of (CHF) hepatic urticarial, pruritus,  Asses patients
Henley leading to cirrhosis and necrotizing angitis. underlying before
excretion of water renal disease starting therapy.
Route:IVTT together with hypertension During
BSN-III
sodium, chloride  Monitor weight,

Dosage: and potassium, peripheral edema,
diuretic breath sounds,
Classifications: antihypertensive blood pressure,
Diuretics fluid intake and
output, electrolyte:
Frequency:OD potassium, sodium,
for 3 days calcium,
magnesium,
glucose uric acid
and Bun.
 Monitor for renal,
Cardiac, neurologic
GI, Pulmonary
manifestation of
hypokalemia.
After
 Educate the
patients for the side
effects
 Instruct the patient
to take drug as
prescribed
to use alcohol,
sleep remedies or
sedatives serious
sedation could
occur.
 Do proper
documentation

Brand Name: Lagundi is the only For the relief of . There are no Dizziness, headache, Before:
extensively studied mild to known nausea, nervousness, or  Observe for the 10
cough remedy herbal moderate contraindications trouble sleeping may rights of
Generic preparation in the cough due to . occur. If any of
administering
Name: Philippines today. common colds these effects persist or
lagundi The National and flu. For the worsen, contact your medication
Integrated Research relief of mild to doctor or pharmacist
Program on moderate promptly.
Medicinal Plants reversible During:
Route:oral (NIRPROMP) has bronchospasm
 Assess for Vital
validated in adults and
Dosage:1 scientifically the children.
sign

BSN-III
tablet ancient popular

knowledge and After:
Classification practices of our
s: traditional healers.  Educate the
They have patients for the side
established in both effects
Frequency: animal and human
TID studies, the wide  Instruct the patient
margin of safety and to take drug as
efficacy of Lagundi prescribed
as a Cough Remedy.
to use alcohol,
sleep remedies or
sedatives serious
sedation could
occur.
 Do proper
documentation
Drug Name Action Indication Contraindication Adverse effect Nursing

Responsibilities
Brand Mucolytic Activity: Mucolytic adjuvant Mucolytic Mucolytic use: Before
Name:Fluim splits links in the therapy for abnormal Use hypersensitivity GI: nausea stomatitis  Observe for
ucil muco-protiens viscid or inspissated to acetyl cysteine the 10 rights of
contained in the mucus secretions in use caution and Hypersensitivity: Drug
respiratory mucus acute and chronic discontinue Urticarial medications
Generic secretions disease immediately if  Assess for the
Name:Acety decreasing the bronchospasm Respiratory
allergy

l cysteine viscously of the To prevent hepatic occur bronchospasm

mucos injury that may occur During
after ingestion of Other rhinorrhea  Asses for vital
Antidote to potentially sign
Route:oral acetaminophen hepatotoxic dose of Antidotal use:  Assess for the
hepatoxicity to acetaminophen dermatologic rash color of the
protects live cells sputum
by maintaining GI: nausea vomiting
 Instruct patient
Dosage:1 cells function and other GI symptoms
tablet detoxifying to increase
acetaminoiphen oral fluid
metabolies intake
After
Classificatio  instruct patient
n: or significant
Mucolytic— others to
report difficulty
breathing or
nausea
Frequency:  Educate the
BID
patients for the
side effects
 Instruct the
patient to take
drug as
prescribed
 Instruct patient
not to use
alcohol, sleep

BSN-III
remedies or
sedatives
serious
sedation could
occur.
 Do proper
documentation
Drug Name Action Indication Contraindication Adverse effects Nursing

Responsibilities
Brand Name: Folic acid Ferrous sulfate and folic  .
helps your acid is used to Hypersensitivi Before
body treat iron deficiency ty  sore throat,  Observe the
Generic produce and anemia (a lack of red trouble 10 right for
Name:fe SO6 maintain blood cells caused by Severe swallowing; administerin
And Folic new cells, having too little iron in hypotension g medication
 severe stomach
Acid and also the body). ... Do not  Advise
pain; or
helps give ferrous sulfate to a
 blood in your patient to
prevent child without the advice
changes to of a doctor. Take ferrous stools. take
Route:oral DNA that sulfate and folic acid on medicine as
Less serious side
may lead to an empty stomach, at effects may include: prescribed
cancer. least 1 hour before or 2
Dosage:1 hours after a meal. During
 diarrhea;
cap Ferrous  Monitor vital
sulfate and  constipation;

folic acid is  nausea, sign

used to treat vomiting,  Instruct the
iron heartburn; patient to
deficiency  leg pain; or avoid
Classification anemia (a concurrent
:Myoglobin lack of red  darkened skin or
urine color. use of otc
blood cells
caused by drugs or
having too alcohol
little iron in without
Frequency: the body). consulting
BID physician
After
 Advise
patient to
consult
physician if
irregular
heartbeat
dyspnea
swelling of
hands and
feet and
hypotension
occur

BSN-III
NURSING CARE PLANS
NAME: Patient X DATE & TIME SHIFT: DEC. 07, 2019 3PM
DIAGNOSIS: REMARKS: 8PM
ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
Subjective:
“Mabilis lang ako Activity intolerance After 8 hours of *Establish rapport *To gain trust and After 8 hours of
mapagod” as related to nursing cooperation of the nursing interventions
verbalized by the generalized interventions, the patient. the patients
patient weakness and patient will be able *Monitor vital signs. *To obtain baseline maintains activity
debilitation to maintain activity data. level within
Objective: secondary to acute level within *Determine capabilities, as
Vital Signs: and chronic illness capabilities. patient’s perception *May be temporary or evidenced by normal
BP: 100/70 and disease. of causes of fatigue permanent, or heart rate and blood
Temp: 37.2 or activity psychological. pressure during
PR: 89 bpm intolerance. activity; as well as
RR: 24 bpm absence of

*Assess patient’s shortness of breath,

level of mobility. weakness, and
*Aids in defining what fatigue.
*Assess nutritional patient is capable of.
status.
*Adequate energy
*Monitor patient’s reserves are required
sleep pattern and for activity.
amount of sleep *Difficulties sleeping
achieved over fast need to be addressed
few days. before activity
progression.
*Encourage
adequate rest
periods. *To reduce cardiac
workload.
*Teach energy
conservation
techniques. *They reduce oxygen
consumption, allowing
more prolonged activity.

BSN-III
NURSING CARE PLANS
Name: Patient X Date & time Shift: Dec. 05, 2019 3pm-11pm
Diagnosis:Pneumonia Remarks: 4pm
NURSING PLANNING NURSING RATIONALE EVALUATION
ASSESSMENT DIAGNOSIS INTERVENTION
Subjective: Ineffective After 8 hours

“Ginaubo po ako Breathing of nursing *To gain trust and After 8 hours of
ngayon mam” as pattern related interventions, cooperation of the nursing
verbalized by the to decreased the patient patient. intervention the
patient. lung expansion will be able to *To obtain baseline patient’s
(fluid and air expectorate data. breathing
Objective: accumulation) effectively. pattern is
Productive cough *To maintain maintained as
noted (+). Crackles hydration status evidenced by:
noted. and monitor the eupnea, normal
Green sputum IVF level. skin color, and
secretion noted. *Hydration can regular
improve secretion respiratory
Vital signs clearance. rate/pattern.

BP: 100/70 mmHg

Temp: 37.7 *It is the most
PR: 89 bpm common
RR: 24 bpm convenient way to
remove most
secretions.
*To promote
oxygenation
*It enhances
drainage or
ventilation to
different lung
segments.
*It helps to break

up the mucus much
easier.
*to identify further

needs of care of
the patient.
*Treatment for
coughs

NURSING PROGNOSIS
Criteria Favorable/Unfavorable Rationale

a. Onset of illness Favorable The patient is 87 years old and
has a history of cough on and
off, Fever and body malaise.
b. Age and sex unfavorable
c. Lifestyle Unfavorable The patient is at risk due to
chemical exposure.
d. attitudes and willingness favorable The patient is cooperative in
towards medications and undergoing treatment or
treatments medication for his condition.
e. Bodily responses towards unfavorable His body responded poorly to
therapy the treatment and medication
due to his condition.
Interpretation:
Favorable -2
Unfavorable -3
_________________________
5/
The patient’s prognosis is ----------------as evidenced by the interpretation.
DISCHARGE PLANNING
MEDICINE:
Before the patient is discharged, the family must be encouraged to follow the prescribed
medications for their father with the right dose and right time. This could be also enhanced by
explaining to the family the reason why the drug is given and the possible effects that may occur.
It would also minimize the chances of stopping the medications once the family understand it.
Also teach the family that even if their father’s symptoms have been relieved, medications must
still be continued according the doctor’s instruction, otherwise pneumonia may recur and it will
be worse than the previous attack.
ENVIRONMENT:
Ask the family not to expose their father in places with too much pollutions. Have clean
and good environment.
TREATMENT:
Encouraged the patient to take medications as prescribed.
HEALTHTEACHING:
Inform the family that their father needs to have adequate rest because it is important to
maintain progress toward full recovery.
OUT PATIENT’S FOLLOW UP:

Remind the family to have follow-up cheek-ups with the doctor. Inform for any
appointment they may have and request the family to bring their father to a health care facility as
soon as any problems will occur. Even though the patient may feel and look better, his lungs may
still be infected and it is important that the physician monitors it.
DIET:
Tell about the importance of eating a well-balanced diet. Remind requirements and
advice foods that are rich in natural vitamins such as fruits.
SUPPORT SYSTEM:
Advised the family members to promote wellness and to maintain patient’s hygiene.

BSN-III
REFERENCES
Sample Format:
Name of author. ( Year) . Title of book . Edition. location of Publication. Name of
Publisher.
Example:
Cuevas J. et al. (2007) . Public Health Nursing in the Philippines. Manila. Philippine
League of Government Nurses.



Pneumonia Case Study

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SULTAN KUDARAT STATE UNVERSTY

ACCESS Campus, EJC Montilla, Tacurong City

Concepts in NCM 102 DECEMBER, 2019

A CASE STUDY IN PNUEMONIA

“There's a downside to everything, a dark side to everyone, and those who

only acknowledge the sunshine.” ― J.M. Darhower,We’re so grateful for the

And of course, we take this opportunity to express our profound gratitude

BSN 3RD Year Group 2

Sultan Kudarat State University

GENERAL PATIENT’S PROFILE 11

NURSING HEALTH HISTORY 12

ANATOMY AND PHYSIOLOGY

NURSING CARE PLANS

OBJECTIVES OF THE RESEARCH

3|Page Sultan Kudarat State University

 To be able to identify and analyze the etiology of the underlying cause of

Sultan Kudarat State University

Pneumonia is a common lung infection characterized by collection of pus

5|Page Sultan Kudarat State University

Pneumonia can be fully cured without complications in most of the cases.

Pneumonia can be prevented by maintaining hygiene such as washing

AIDS- Acquired immunodeficiency syndrome, a syndrome caused by infection

Sultan Kudarat State University

Bacteria- Single-celled microorganisms that can exist either as independent

Basophil- A type of white blood cell (leukocyte) with coarse, bluish-black

Blood test- a scientific examination of a sample of blood, typically for the

Bronchitis-is an inflammation of the lining of your bronchial tubes, which carry

Cardiomegaly- Enlargement of the heart. Cardiomegaly is a descriptive term

Community-acquired- An infection acquired in the community.

Complete Blood Count- A commonly used abbreviation in medicine that stands

Debilitating disease- Debilitating diseases come in many shapes and forms –

Empyema- Empyema is a condition in which pus and fluid from

7|Page Sultan Kudarat State University

Fasting Blood Glucose- A test to determine how much glucose (sugar) is in a

Fungi- A single-celled or multicellular organism.

Hemoglobin- The oxygen-carrying pigment and predominant protein in the red

Hospital-acquired- An infection caught while hospitalized

Homeostasis-The stoppage of bleeding or hemorrhage. Also, the stoppage of

Immunocomprised- Having an immune system that has been impaired by

Lung Parenchyma- The key elements of an organ essential to its functioning, as

Sultan Kudarat State University

Neutrophils-A type of white blood cell, a granulocyte that is filled with

Platelet- An irregular, disc-shaped element in the blood that assists in blood

Pneumonia- Inflammation of one or both lungs, with dense areas of lung

Sputum-Mucous material from the lungs that is produced (brought up) by

9|Page Sultan Kudarat State University

Sultan Kudarat State University

Admitting Physician : Dr.Merlita Cerbo

NURSING HEALTH HISTORY

11 | P a g e Sultan Kudarat State University

 Sleep rest/ pattern

 Activities of Daily Living

Sultan Kudarat State University

 Home and neighborhood conditions

Patient X is conscious, but he doesn’t know what day is now,

Patient X doesn’t have any sensory disability aside from his

13 | P a g e Sultan Kudarat State University

temperature of 36.2 degree Celsius, and blood pressure of

Sultan Kudarat State University

 (-) dandruff and dryness

 Patient X has a poor hearing.

 The color of his nose same as the color of his face