Republic of The Philippines University of Northern Philippines Tamag, Vigan City College of Nursing

PNEUMONIA
In partial fulfillment of the requirements in Nursing Care Management (RLE)

Presented to: Ms. Joanne Jaramillo Clinical Instructor

Presented by: Chezka Marie Palola BSN III Bromeliads

July 27, 2011

TABLE OF CONTENTS

I.

Introduction a. Disease Process b. History of Past Illness c. History of Present Illness

II.

Objectives a. Student centered b. Patient Centered

III. IV. V.

Patients Profile System by system Assessment Diagnostic a. Ideal b. Actual

VI.

Anatomy of the Organ Involved

VII. Pathophysiology/ Algorithm VIII. Medical Management a. Ideal b. Actual IX. X. XI. Nursing Care Plan Drug Study Discharge Plan

XII. Updates XIII. Consent Form

I. INTRODUCTION
A. Pneumonia is inflammation of the lung that is most often caused by infection with bacteria, viruses, or other organisms. Occasionally, inhaled chemicals that irritate the lungs can cause pneumonia. Healthy people can usually fight off pneumonia infections. However, people who are sick, including those who are recovering from the flu (influenza) or an upper respiratory illness, have a weakened immune system. This makes it easier for bacteria to grow in their lungs. When air is inhaled through the nose or mouth, it travels down the trachea to the bronchus, where it first enters the lung. From the bronchus, air goes through the bronchi, into the even smaller bronchioles and lastly into the alveoli. Disease Process Leading to Pneumonia Pneumonia-causing agents reach the lungs through different routes:

In most cases, a person breathes in the infectious organism, which then travels through the airways to the lungs. Sometimes, the normally harmless bacteria in the mouth, or on items placed in the mouth, can enter the lungs. This usually happens if the body's "gag reflex," an extreme throat contraction that keeps substances out of the lungs, is not working properly.

Infections can spread through the bloodstream from other organs to the lungs.
However, in normal situations, the airways protect the lungs from substances that can cause infection.

The nose filters out large particles. If smaller particles pass through, sensors along the airway prompt a cough or sneeze. This forces many particles back out of the body. Tiny particles that reach the small tubes in the lungs (bronchioles) are trapped in a thick, sticky substance called mucus. The mucus and particles are pushed up and out of the lungs by tiny hair-like cells called cilia, which beat like a drum. This action is called the "mucociliary escalator."

If bacteria or other infectious organisms manage to avoid the airway's defenses, the body's immune system attacks them. Large white blood cells called macrophages destroy the foreign particles.

Signs and Symptoms

Have a high fever Have shaking chills Have a cough with phlegm (a slimy substance), which doesn't improve or worsens Develop shortness of breath with normal daily activities

Have chest pain when you breathe or cough Feel suddenly worse after a cold or the flu

People who have pneumonia may have other symptoms, including nausea (feeling sick to the stomach), vomiting, and diarrhea. Symptoms may vary in certain populations. Newborns and infants may not show any signs of the infection. Or, they may vomit, have a fever and cough, or appear restless, sick, or tired and without energy. Older adults and people who have serious illnesses or weak immune systems may have fewer and milder symptoms. They may even have a lower than normal temperature. If they already have a lung disease, it may get worse. Older adults who have pneumonia sometimes have sudden changes in mental awareness. Complications of Pneumonia

Bacteremia (bak-ter-E-me-ah). This serious complication occurs if the infection moves into your bloodstream. From there, it can quickly spread to other organs, including your brain. Lung abscesses. An abscess occurs if pus forms in a cavity in the lung. An abscess usually is treated with antibiotics. Sometimes surgery or drainage with a needle is needed to remove the pus. Pleural effusion. Pneumonia may cause fluid to build up in the pleural space. This is a very thin space between two layers of tissue that line the lungs and the chest cavity. Pneumonia can cause the fluid to become infecteda condition called empyema (em-pi-E-ma). If this happens, you may need to have the fluid drained through a chest tube or removed with surgery.

Management:
The treatment of pneumonia includes appropriate administration of the appropriate antibiotic. Management of Community Acquired Pneumonia includes blood cultures performed quickly for identification of the casual pathogen and prompt administration of antibiotics. Inpatients should be switched from intravenous to oral therapy when they are hemodynamically stable, are improving clinically, are able to take medications/fluid by mouth and have a normally functioning gastrointestinal tract. Hydration is necessary part of therapy, because fever and tachypnea may result in insensible fluid losses. Antipyretic may be used to treat headache and fever; antitussive medications may be used for the associated cough. Warm, moist inhalations are helpful in relieving bronchial irritation. Antihistamine may provide benefit with reducing sneezing and rhinorrhea. Position patient with head on mid line, with slight flexion to provide patent, unobstructed, airway, maximum lung excursion. Auscultate patients chest to monitor for the presence of abnormal breath sounds. Provide chest and back clapping with vibration because chest physiotherapy facilitates the loosening of secretions. Bed rest is also included for the management of pneumonia.

B. History Of Past Illness:

Patient X has been hospitalized last May 2011, because he underwent surgery due to the replacement of his left pelvis at Gabriela Silang General Hospital. He had been hospitalized also at the same institution last June 1, 2011 and has been diagnosed with Pneumonia. The patient has no history of asthma, diabetes mellitus or hypertension. He has no allergies to any foods or medications. The patient had a fracture on his spinal bone and had worn a brace before to support and correct the injury. He has been a bed ridden patient after his surgery last May 2011. He has also an arthritis and osteoporosis as stated by his wife.

C. History of Present Illness

3 weeks prior to admission, the pt. was hospitalized with the same diagnosis. He had difficulty of breathing, pallor on nail beds, incoherent and has an slurred speech. During inspiration, using of accessory muscle was noted. He was admitted on June 21, 2011. He was examined by Dr. Tobias and ordered to undergo different laboratory examinations related to his conditions. At present, the pt. is bed ridden, has an activity intolerance r/t general body weakness. He has been oxygenated via nasal cannula regulated at 1-2L/min. He is recovering and responding well to nursing care.

II. PATIENTS PROFILE

Name: Patient X Age: 72 years old Date of Birth: July 7, 1938 Gender: Male Address: Padu Grande, Sto. Domingo, Ilocos Sur Civil status: Married Nationality: Filipino Religion: Roman Catholic Date of Admission: June 6, 2011 Time of Admission: 7:00 pm Room: Medical Room Date of Discharge: June 27, 2011 Admitting Physician: Dr. Tobias Attending Physician: Dra. Guerrero Final Diagnosis: Pneumonia Admitting Agency: Magsingal District Hospital

III. OBJECTIVES

Student-centered: To define what is pneumonia To trace the pathophysiology of pneumonia To enumerate the different signs and symptoms of pneumonia To formulate and apply nursing care plans utilizing the nursing process To learn clinical skills and sharpen our current skills required in the management of the patient with pneumonia To develop our unselfish love and empathy in rendering nursing care to our patient

Patient centered: To assist patient with proper nutrition providing information about a healthy lifestyle To provide information about Pneumonia and other underlying illness To improve the family coping process that plays an important role in the patients recovery To impart a health teachings, the prevention and treatment To encourage patient to avoid factors that can aggravate the disease and maintain a healthy habits To provide nursing care about the disease, Pneumonia To impart knowledge related to patients disease To be able for patient to have self-conceptualization To determine the physiological needs necessary for the patient during the disease process

V. SYSTEM BY SYSTEM ASSESSEMENT

1. Psychological Status The patient is Mr. Castro Taasan Alcantara,72 year old, male. Born on July 7,1938 residing in a bungalow house located at Padu Grande, Sto.Domingo, Ilocos Sur. Baptized as a Roman Catholic. He is living in their house together with her wife and 2 children. He had 7 children. Almost all of them are professional now and do have a job. He was a radio commentator for how many years and had been work also as an planner in Provincial Capitol. He was also a farmer, because they own a little farm in their place. He also work as a fisherman. He was a persevering and hardworking father to his family. He loves to travel and work for his family. He always do everything for his family in order for them to have a good life. 2. Mental and Emotional Status The patient is conscious and incoherent. He had a slurred speech. He is oriented that he was in the hospital accompanied by his wife and son. He has a bit of dementia due to old age. He can still comprehend a bit of some conversation. An example of which is that he smiles at his wifes joke or when I give jokes to him. He is sometimes irritable when he wants to urinate. He always play on the sensitive part of his body. Most of the time, he is so silent, thinking so deeply. He is not taking any drugs that can affect his consciousness aside from side effects of drug he is taking like headache. He was been hospitalized 3 weeks PTA with the same diagnosis and due to difficulty of breathing. 3. Environmental Status The patient is 72 year old and is awake. He cannot ambulate because he undergone surgery, replacement of Left pelvic replacement last May 2011.He is fragile and generally appears weak. He is confined at Magsingal District Hospital in Medical Room which is well ventilated and well conducive for recovery. His room is a conducive place for healing process because everything is accessible, his bed is near to the comfort room, he has a urinal basin at the side of his bed every time he wants to void. He has a wall fan that makes the room well ventilated. There is a ready Oxygen Tank and nasal cannula for him to used when he feels difficulty of breathing. His room is near the nurse station so that if they need a help the nurse would immediately guide them. The patient cannot hear clearly and sees well. He has a slurred speech.

4. Sensory Status The patients eyes are equally round and reactive to light and accommodation. Both pupils dilate to its normal size of 3mm. He cannot read without an eyeglasses and cannot see clearly due to aging. He is able to distinguish voice but in a louder sound. He has a poor appetite. He only eat a cup of oatmeal, which means he cannot tolerate nor has a good taste to other foods. He has a dry mucosa and cracking lips and some decayed teeth. He speaks slowly and slurring. He has also an osteoporosis and has a fracture on his spinal bone. 5. Motor Status The patient is a bed ridden because of the replacement of his left pelvis. He cannot ambulate and had a difficulty in moving from side to side. He is weak and unable to get up by him alone. He has poor muscle strength. He cannot flex his legs but he can twist his hands. He had a past injury on his spinal bone. He had used a supportive device that helped treat the fracture on his spinal bone. 6. Nutritional Status The patient is about 52 tall and weighs around 55kgs, appears weak and fragile. He has a poor appetite. Only eats a one cup of oatmeal and drinks at least 3 glasses of water every day. He has no religious food restriction when it comes to intake of foods. He has no allergies to food or medication. He has a dry oral mucosa and cracking lips. The patient is conscious and able to swallow. Has an insufficient intake and output required for his bodys nutrition. Has an IVF of D5lR regulated to 41-42 drops per minute. 7. Elimination Status The patient urinates at least thrice with a small amount for an 8 hour shift. He also has the feeling to urinate but every time her wife give the urinal basin, theres no urine accumulating the basin. His bowel movement is not regular, its not daily as said by his wife. He has a urinal basin on his bedside ready to use when he wants to void. 8. Fluid and Electrolyte The patient has an intake of 200-250 mL of fluids per shift. He only drinks water. His output ranges from 200 per shift. He received D5LR 1000cc regulated to 41-42 drops per minute. He ask water from his wife when he is thirsty. He has a poor hydration status manifested by dry oral mucosa. Capillary refill is 1-2 sec. and skin is warm to touch.

9. Circulatory Status The patient was diagnosed with Pneumonia and has a chest x-ray findings of cardiomegaly and atheromatous aorta. He has a pulse rate of 94 bpm. He has a respiration rate of 26 cpm. His blood pressure is 130/80 mmHg, stable until end of the shift. 10. Temperature status The patient wears a sando and boxer shorts. His temperature is 36 degree Celsius. His skin is warm to touch. His room is well ventilated. 11. Respiratory Status The patient was admitted due to difficulty of breathing. During inspiration, using of accessory muscle was noted. The pt.s nail beds are pallor and have a slurred speech. He has been oxygenated via nasal cannula regulated at 1-2L/min. Due to activity intolerance because the pt. was bed ridden; he had further complications of a cardiomegaly and atheromatous aorta. The blood circulation has not been working well to his body. 12. Integumentary Status The patient skin is fair in color and already has wrinkles due to aging. He has a muscle wasting due to old age. He has a good skin turgor and is warm to touch. There are scars present on the different site in his body. He has a bald hair. Clubbing of fingers noted at times. He has a poor hydration manifested by dry oral mucosa and cracking lips. He has a dry skin at his back due to prolonged bed ridden. 13. Comfort and Rest Status The patient sleeps often times and sleeps about 8-10 hours. No medications altering his comfort. No pain noted during the shift. A discomfort is felt by the patient every time he urinates. He appears weak and emaciated.

V. DIAGNOSTICS
A. Ideal Chest X-ray How the Test is Performed: The test is performed in a hospital radiology department or in the health care provider's office by an x-ray technician. Two views are usually taken: one in which the x-rays pass through the chest from the back (posterior-anterior view), and one in which the x-rays pass through the chest from one side to the other (lateralview). You stand in front of the machine and must hold your breath when the x-ray is taken. How to Prepare for the Test: Inform the health care provider if you are pregnant.. You must wear a hospital gown and remove all jewelry. Why the Test is Performed: if you have any of the following symptoms:

A persistent cough Chest injury Chest pain Coughing up blood Difficulty breathing

What Abnormal Results Mean; Abnormal results may be due to may things, including the following. In the lungs:

Collapsed lung Collection of fluid around the lung Lung cancer Lung tumor Malformation of the blood vessels Pneumonia Scarring of lung tissue Tuberculosis

In the heart:

Problems with the size or shape of the heart determined Problems with the position and shape of the large arteries

In the bones:

Fractures of ribs and spine Osteoporosis

 Blood Culture How is it used?: Blood cultures are used to detect the presence of bacteria or yeasts in the blood, to identify the microorganism(s) present, and to guide treatment. Two or more blood cultures are typically ordered and collected as consecutive samples. Often, acomplete blood count (CBC) is ordered along with or prior to the blood culture to determine whether the person has an increased number of white blood cells, indicating a potential infection. A doctor may order blood cultures when a person is having symptoms of sepsis. A person with sepsis may have: Chills, fever Rapid breathing, rapid heartbeat Decreased urine output Nausea Confusion

What does the test result mean?: If blood cultures are positive, it most likely means that the tested person has a bacterial or yeast bloodstream infection that needs to be treated immediately, usually in a hospital. Sepsis can be lifethreatening, especially in immunocompromised patients. Complete Blood Count A complete blood count (CBC) is a series of tests used to evaluate the composition and concentration of the cellular components of blood. It measures the following:

The number of red blood cells (RBCs) The number of white blood cells (WBCs) The total amount of hemoglobin in the blood The fraction of the blood composed of red blood cells (hematocrit)

The platelet count is also usually included in the CBC. Purpose:

as a preoperative test to ensure both adequate oxygen carrying capacity and hemostasis to identify persons who may have an infection to diagnose anemia to identify acute and chronic illness, bleeding tendencies, and white blood cell disorders such as leukemia to monitor treatment for anemia and other blood diseases to determine the effects of chemotherapy and radiation therapy on blood cell production

Hemoglobin Hematocrit WBC Platelet Count RBC

140 170 g/L 0.40 0.54 4.1 10.9 x103/uL 150,000 450,000/cmm F: 4.2 5.4 miilion/ uL 6.4 mil/uL M:4.6

b. Actual Complete Blood Count: June 26, 2011 Blood Components Hemoglobin Hematocrit 120 0.40 Normal Values 140 -170g/L 0.40 0.54 Interpretation NORMAL NORMAL

Complete Blood Count: June 22, 2011 Blood Components Hemoglobin: 76 Normal Values 140 170 g/L Interpretation Low level of hgb indicates anemia Hematocrit: WBC: Neutrophils: 0.24 10.1 0.82 0.40 0. 54 4.1 10.9 x103/uL 0.45 0.73 Decreased in hgb level NORMAL Slightly elevated: due to acute infection in LRT c/b streptococcus pneumoniae and bone marrow suppression d/t elevated hgb level Lymphocytes: 0.18 0.20 0.40 Decreased due to Increased neutrophils

Chest X-ray

Impression: Cardiomegaly Atheromatous Aorta Osteoporosis

VI. ANATOMY OF THE SYSTEM INVOLVED

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

Complications of Pneumonia

Bacteremia (bak-ter-E-me-ah). This serious complication occurs if the infection moves into your bloodstream. From there, it can quickly spread to other organs, including your brain.

Lung abscesses. An abscess occurs if pus forms in a cavity in the lung. An abscess usually is treated with antibiotics. Sometimes surgery or drainage with a needle is needed to remove the pus.

Pleural effusion. Pneumonia may cause fluid to build up in the pleural space. This is a very thin space between two layers of tissue that line the lungs and the chest cavity. Pneumonia can cause the fluid to become infecteda condition called empyema (em-pi-E-ma). If this happens, you may need to have the fluid drained through a chest tube or removed with surgery.

VII. Pathophysiology/ Algorithm

Causes/Risk Factor (Bacteria) Hematogenous or lymphatic dissemination

Inhalation of droplets

Bone marrow suppression

Aspirate secretions from upper airways

Increased hemoglobin level

Decreased hematocrit Neutrophils migrate Reach to the alveoli level

Filled normally air filled space Increased neutrophils

Inflammatory reaction

Fatigue/ Generalize Body Malaise

Produces Exudates Activity Intolerance Interferes diffusion of 02 & CO2

Decreased leukocytes

Tachypnea Mucosal Edema Difficulty of Breathing Partial Occlusion of bronchi or alveoli

Hypoventilation

Venous blood passes to underventilated area

Ineffective airway clearance Travels to Left ventricle

Decreased Alveolar Oxygen tension

Increased heart workload

Atheromatous aorta

Increased Oxygen demand

Increased blood supply

Enlargement of the heart/ Cardiomegaly

VIII. Management
A. Ideal The treatment of pneumonia includes appropriate administration of the appropriate antibiotic. Management of Community Acquired Pneumonia includes blood cultures performed quickly for identification of the casual pathogen and prompt administration of antibiotics. Inpatients should be switched from intravenous to oral therapy when they are hemodynamically stable, are improving clinically, are able to take medications/fluid by mouth and have a normally functioning gastrointestinal tract. Hydration is necessary part of therapy, because fever and tachypnea may result in insensible fluid losses. Antipyretic may be used to treat headache and fever; antitussive medications may be used for the associated cough. Warm, moist inhalations are helpful in relieving bronchial irritation. Antihistamine may provide benefit with reducing sneezing and rhinorrhea. Position patient with head on mid line, with slight flexion to provide patent, unobstructed, airway, maximum lung excursion. Auscultate patients chest to monitor for the presence of abnormal breath sounds. Provide chest and back clapping with vibration because chest physiotherapy facilitates the loosening of secretions. Bed rest is also included for the management of pneumonia.

B.

Actual The patient was admitted to Magsingal District Hospital, in room of choice for 1 week. He underwent different laboratory examinations such as Complete Blood Count and Chest X-ray to assess the underlying disease of the patient and monitor his status. He is a complete bed rest and needs had been attended. He received an oxygenation via nasal cannula regulated at 2-3 L/min. The patient received medications as a medical treatment: Salbutamol + GR, Ceftriaxone, Ranitidine, Amino Acid, Chlorphenamine and Salbutamol neb.

XI. Discharge Plan Medications

Salbutamol + GF I cap thrice a day for 5 days Cefaclor 500mg thrice a day for 1 month Multivitamins + Amino Acid once a day Omeprazole 20 mg once a day for 2 weeks Promote adequate rest Turn pt. from side to side every 2 hours to prevent bedsores. Promote adequate sleep without disturbances Assist pt. in passive ROM like flexing or extending knees and hands Drink plenty of fluids Do not suppress a cough. Take expectorants Take analgesics if pain occurs like aspirin Practice chest therapy Instruct pt. to increased OFI as tolerated Instruct pt. to elevate head of bed id difficulty of breathing occurs. Encourage pt. to eat foods rich in Iron to compensate low level of hemoglobin Instruct pt. to take medications as prescribed by the doctor Encourage pt. to have Deep Breathing Exercise & Coughing reflex to promote expectoration of secretions Encourage pt. to have an adequate rest and sleep Instruct pt.s SO to turn him from side to side to prevent bed sores.

Exercise

Treatment

Health Teachings

OPD(Out patient) Diet

The pt. was advised to have a follow up check up on July 27, 2011 as ordered by his attending physician, Dra. Guerrero. Stay hydrated by increasing OFI at least 1L/ day as tolerated Eat foods rich in Iron Eat leafy vegetables Add Vitamin C rich foods in diet for better Immune System

XII. Updates
Updated Quality Data - Pneumonia Pneumonia is an infection in one or both lungs caused by bacteria. Every year there are approximately 3 million cases of pneumonia in the USA, and over 500,000 of these cases are admitted to hospitals. Every year 5% will die, causing pneumonia to be the 6th leading cause of death in the USA. The goal of treating pneumonia is to ensure patients with the diagnosis are receiving the most appropriate antibiotics, at the earliest possible stage. Another goal is prevention; by making sure individuals over 65years of age receive the pneumonia vaccine. PNEUMONIA VACCINATION GIVEN This is a measure that shows how well the hospital has documented that pneumonia patients over the age of 65years have been screened for or asked if they wish vaccination. Scientific literature has shown that people over the age of 65 years of age are more at risk for pneumonia. SMOKING CESSATION ADVICE/COUNSELING This measure shows how well a hospital documents the education given to heart attack patients regarding smoking cessation. Smoking is known to cause damage to the heart, the lungs and the circulatory system. Smoking makes heart disease worse. INITIAL ANTIBIOTIC WITHIN 6 HOURS This is the measure that shows the percentage of pneumonia patients who were given an appropriate antibiotic within 6 hour of arriving at the hospital. Patients who receive appropriate antibiotics within 6 hours of their arrival at the hospital has been shown to be very effective in treating community acquired pneumonia. ANTIBIOTIC SELECTION FOR PATIENTS IN THE INTENSIVE CARE UNIT This is the measure that shows the percentage of community acquired pneumonia patients admitted to the intensive care unit who were given appropriate antibiotics within 24 hours of their hospital admission. Patients who receive appropriate antibiotics within 24 hours of their hospital admission has been shown to be very effective in treating community acquired pneumonia. ANTIBIOTIC SELECTION FOR NON INTENSIVE CARE UNIT PATIENTS This is the measure that shows the percentage of community acquired pneumonia patients admitted to the hospital who were given appropriate antibiotics within 24 hours of their admission.Patients who receive appropriate antibiotics within 24 hours of their hospital admission has been shown to be very effective in treating community acquired pneumonia.