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Page 1: Casestudy CAP

ANGELES UNIVERSITY FOUNDATION

Angeles City

COLLEGE OF NURSING

S.Y. 2008-2009

A Case Study

COMMUNITY-ACQUIRED PNEUMONIA

In Partial Fulfilment of the Requirements in Related Learning

Experience

Submitted by:

David, Nikki Louise Kina Z.

Gutierrez, Mary Joy R.

Manalo, Ma. Adrianne V.

BSN III-15

Group 57

Submitted to:

Ms. Johana L. Dimla, R.N.

September 19, 2008

TABLE OF CONTENTS

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DEDICATION

ACKNOWLEDGEMENT

I. INTRODUCTION…………………………………………………………………

…….1

II. NURSING ASSESSMENT

A. Demographic Data, Socio Economic, Cultural

And Environmental Factors……………………………

B. Personal

History……………………………………………………….

C. Pertinent Family Health

History……………………………………..

D. History of Past

illness…………………………………………………

E. History of Present

Illness…………………………………………….

F. Physical Examination

(IPPA, Cephalocaudal Approach)

G. Diagnostic and Laboratory

Procedures……………………………

III. ANATOMY AND

PHYSIOLOGY……………………………………………………

IV. THE PATIENTS ILLNESS

A. Synthesis of the disease

1. Definition of the disease…………………………………………

2. Predisposing and Precipitating Factors………………………

3. Signs and Symptoms…………………………………………

4. Health promotion and preventive aspects of the

disease…

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V. THE PATIENT AND HIS/HER CARE

Medical Management

A. IVF’s……………………………………………………………………

.

B. Drugs………………………………………………………………

C. Diet…………………………………………………………………….

D. Activity and Exercise………………………………………………

Nursing Management:

A. Nursing Care Plans………………………………………………

B. Actual SOAPIER’s………………………………………………

VI. CLIENT’S DAILY PROGRESS IN THE HOSPITAL

A. Client’s Daily Progress Chart……………………………………

B. Discharge Planning……………………………………………….

1.General Conditions of the Patient Upon Discharge

2.M.E.T.H.O.D.

VII. CONCLUSION AND

RECOMMENDATIONS…………………………………

VIII. BIBLIOGRAPHY

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DEDICATION

We would like to dedicate this fruit of our toiling to our Heavenly

Father, our Almighty God, for without Him our case would be unfeasible.

To our parents, friends, brothers and sisters in the nursing profession

and to every person who has an affinity to this profession, we dedicate this to

all of you. Moreover, we offer this to those who strive hard to raise the notch

for the development and improvement of the noblest profession on earth –

the nursing profession.

ACKNOWLEDGEMENT

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The aim of this study was attained through the help and guidance of

the following people who have extended their time, support and

encouragements to make this study possible.

The researchers would like to express their appreciation and give

thanks to the Almighty Father, the source of their talent, now more than ever,

and for bestowing upon us patience, strength, wisdom and determination

that helped us to materialize this study.

To their loving families, for providing all the love and care, for always

being there to give guidance and care in times of difficulties and for the

support they have given form the start of this study.

To Ms. Johana L. Dimla, their clinical instructor, for all the patience,

advice and undying support and kindness. Her mere guidance enables us to

produce the best result.

To their patient and the significant others, for their cooperation and

willingness to participate in this study and for providing them essential

information about this study and making their doors open.

Finally, to many unnamed friends, for their support and serving as their

inspiration that helped them believe in their capabilities, we would like to

extend our deepest gratitude.

I. INTRODUCTION

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Pneumonia is an infection of the lower respiratory tract caused by

bacteria, viruses, fungi, protozoa, or parasites. It is the eighth leading cause

of death in the United States. The incidence and mortality of pneumonia are

highest in the elderly. Risk factors for pneumonia include advanced age,

immunocompromise, underlying lung disease, alcoholism, altered

consciousness, smoking, endotracheal intubation, malnutrition, and

immobilization. The causative microorganisms influence the symptoms and

signs with which the patient presents, how the pneumonia should be treated

and the prognosis.

Pneumonias can be classified into several ways. Pathologists originally

classified them according to the anatomic changes that were found in the

lungs during autopsies. As more became known about the microorganisms

causing pneumonia, a microbiologic classification arose, and with the advent

of x-rays, radiological classification. Another important system of

classification is the combined clinical classification, which combines factors

such as age, risk factors for certain microorganism, the presence of

underlying lung disease and underlying systemic disease, and whether the

person has recently been hospitalized.

The combined clinical classification, now the most commonly used

classification scheme, attempt to identify the person’s risk factors when he or

she first comes to medical attention. The advantage of this classification

scheme over previous systems is that it can help guide the selection of

appropriate initial treatments even before the microbiologic cause of

pneumonia is known. There are two broad categories of pneumonia in this

scheme: community-acquired pneumonia and hospital-acquired pneumonia.

A recently introduced type of healthcare-associated pneumonia lies between

this two categories.

Community-acquired pneumonia develops in people with limited or no

contact with medical institutions or settings. CAP tends to be caused by

different microorganisms than those infections acquired in the hospitals. The

characteristics of the individual are important in determining which etiologic

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microorganism is likely. For example, immunocompromised persons tend to

be susceptible to opportunistic infections that are uncommon in normal

adults. In general, nosocomial infections and those affecting

immunocompromised individuals have higher mortality rate community-

acquired pneumonias.

The most common community-acquired pneumonia is caused by

Streptococcus pneumoniae, which has a relatively low mortality rate,

although it is higher in the elderly. Mycoplasma pneumoniae is a common

cause of pneumonia in young people especially those living in group housing

such as dormitories and army barracks. Influenza is the most common viral

community-acquired pneumonia in adults. Legionella species, which also

cause CAP, can contaminate cooling systems and water supplies leading to

outbreaks of disease. Signs and symptoms of CAP are fever, cough, dyspnea,

tachypnea and tachycardia. Diagnosis is based on clinical presentation and

chest x-ray. Treatment is with empirically chosen antibiotics. Prognosis is

excellent for relatively young and healthy patients, but many pneumonias,

especially when caused by Streptococcus pneumoniae and influenza virus,

are fatal in older, sicker patients.

According to the World Health Report by the World Health

Organization, lower respiratory infections, which include community-acquired

pneumonia, ranks ninth among the leading causes of mortality on individuals

aging 15 to 59 worldwide and ranks fourth on individuals aging 60 and over,

and that it is the leading killer of children worldwide.

CAP is one of the most common entities seen in Filipino adults. It is the

most common infectious disease prompting hospitalization and the first and

fifth leading cause of morbidity and mortality in the Philippines, respectively.

Incidence rates mentioned above is primarily the reason of the group

for choosing this case. The prevalence of community-acquired pneumonia in

the local and foreign communities needs attention and through this study,

CAP would be known better and would be helpful for the group to effectively

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play their role as advocates of their patients care and well-being. This will

serve as an important tool for them to render proper nursing care, facilitate

health promotion and perform appropriate interventions to individuals with

such condition.

This study aims to provide the group a clear view of the pertinent facts

surrounding community-acquired pneumonia, which will lead them to become

effective and efficient in the nursing field.

II. NURSING ASSESSMENT

A. Personal History

a. Demographic Data

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Mr. Cap is a 69-year old naturally born Filipino. He was born on

February 17, 1939 and is presently residing at Magalang. He was

admitted last August 17, 2008 at a district hospital somewhere in

Angeles City with a chief complain of difficulty of breathing. His

admitting diagnosis was Bronchopneumonia and Acute Gastroenteritis.

He had a final diagnosis of community-acquired Pneumonia. He was

discharged last August 25, 2008.

b. Socio-economic and Cultural Factor

Brought by their economic status in life, Mr. Cap had only

finished elementary at a public school in Magalang. After graduating in

elementary, he started working as a farmer in their own land. He got

married at an early age of 17 and became the sole provider of his

family by working as a farmer. For many years up to now, he is still the

president of the Association of Farmers in Magalang. His last job was in

the department of agriculture. He retired last 2004 at the age of 66. At

present, his source of income is their land which he tills together with

his grandson. He is earning approximately Php 100,000 a year from

their harvests, which is equivalent to Php 8, 333 per month. Having

this monthly income for the eight members of his family, they are then

considered poor.

Mr. Cap is a religious member of the Iglesia ni Cristo and never

fails to visit their church. He does not believe in hebolarios but uses

medicinal plants available in their yard like guava and oregano

whenever he has a cough.

Mr. Cap is a frequent smoker. He started smoking when he was

16 year old and started taking alcoholic beverages at the age of 27. He

starts smoking early in the morning and consumes approximately half

pack of cigarettes a day.

c. Environmental Factors

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Mr. Cap has 13 children, six of which are males and seven are

females. All of them already have their own family. Twelve of them are

living away from their parents and only one, who is the youngest, lives

with her parents in their ancestral home. Mr. Cap’s family is classified

under an extended type of family with his wife, daughter, son-in-law

and three grandchildren living in the same house. They have a

bungalow type of house made of concrete materials. It has three

bedrooms, a dining room, a living room and a bathroom.

The road in their place is not cemented. Only few part is

cemented before you reach their barangay is cemented. The place

they live is not congested. Their community is quite crowded. The

location of their house is an agricultural land that is why most of the

people there are farmers. No factories or any establishments that can

contribute to air pollution are located in their vicinity. Lung diseases

are not prevalent in their community.

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B. SCHEMIC DIAGRAM ON FAMILY HEALTH-ILLNESS HISTORY

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Mr. Cap ranks fifth in their family. Among his seven siblings, only

four are alive. His eldest brother died of pneumonia at an early age of

age 27. His third eldest sibling died at the age of 31 whose death was

believed to have been caused by nervous breakdown. Both Mr. Cap’s

parents already passed away. His father died because of a liver

disease at the age of 35. His mother, when she was still living,

frequently experienced episodes of allergic reactions from the food she

eats. The last time she had allergies, she experienced pruritus and

difficulty of breathing which lead to her death, as narrated by Mr. Cap.

His grandparents on the maternal side both died because of old

age and they did not have any history of diabetes mellitus,

hypertension, respiratory diseases and cancer. On his paternal side, his

grandfather’s cause of death was unknown while her grandmother died

because of childbirth.

B. History of Past Illness

Mr. Cap rarely consults a physician in the past. He only visits

clinics or hospitals whenever his condition gets worse. He had been

admitted before only once in a district hospital in Angeles City around

1960s with a chief complain of epistaxis. He stayed at the hospital for

a day and a night. Also in 1960’s, he had a check-up at another district

hospital in Angeles City and was ordered to undergo chest x-ray and it

was found out that he had an accumulation of fluid in the lungs or

pleural effusion. According to Mr. Cap, aspiration of the fluid was done

after being diagnosed of such condition. Specific medications taken

cannot be recalled by Mr. Cap but prescribed medications were taken

for three months until the condition was resolved. Succeeding check-

ups at district hospital in Magalang were prompted by unrelieved fever

and cough. On mild fever and coughs, he usually does self-medication

by taking Medicol and Paracetamol. In some cases he uses herbal

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plants like guava and oregano to relieve his cough which are cheaper

and always available. He has no history of diabetes mellitus, cancer or

hypertension and had not undergone any surgical procedures in the

past.

C. History of Present illness

In 1960’s, Mr. Cap had an epistaxis which prompted him to go to

the hospital. Also in 1960’s he had been diagnosed of having pleural

effusion and he had taken medications prescribed for his condition for

three months. The health problems he experienced in the past were

fever, cough and flu which he managed by taking over-the-counter

drugs and herbal plants.

Last August 10, 2008, seven days prior to his admission at a

district hospital in Magalang, Mr. Cap experienced productive cough

and fever. The next day, he still experienced cough and had difficulty

at breathing. A day prior to his admission, he experienced loose watery

stool and few hours before he was admitted, he still had difficulty of

breathing which prompted his family to bring him to the hospital. He

was then referred to a district hospital in Angeles City to better

manage his condition.

He was then admitted last August 17, 2008 with a chief

complain of difficulty of breathing and had an admitting diagnosis of

Bronchopneumonia and Acute Gastroenteritis.

D. Physical Examination

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August 22. 2008

General appearance: Patient appears weak and is conscious to time,

place and person. He is afebrile with vital signs taken and recorded as

follows:

VS: BP= 130/70 mmHg; PR=104 bpm; RR= 20 bpm;

T=36.9 C/Axilla

Skin: Uniform in color, good skin turgor, pale, no edema, with skin

rashes

Skull: Round, symmetrical, normocephalic, absence of nodules and

masses

Face: Symmetrical, absence of nodules and masses

Eyes: Round and symmetrical, equally distributed eyelashes and

eyebrows, no discoloration on eyelids, eyelids close symmetrically,

blinks involuntarily, pale conjunctiva

Ears: Symmetrical with no discharges, auricles aligned with the outer

canthus of the eye

Nose: Symmetrical and straight, both nares are patent, no tenderness

Mouth: Dry and pale lips

Neck: With palpable modules on the left side of the neck,

jugular veins are not distended, neck muscles are equal in size

Chest/Lungs: Has symmetrical chest expansion, presence of rales

on both lung fields upon auscultation

Abdomen: Slightly globular in shape, with 18 bowel sounds per

minute, presence of resonance upon percussion

Extremities: Equal in size and length, absence of edema, both lower

and upper extremities move with coordination, with pale nailbeds

August 23, 2008

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General Appearance: Patient is awake, coherent and conscious to

time, place and person. He is afebrite with vital signs taken and

recorcded as follws:

VS: BP=110/70 mmhg; Pr=95 bpm; rr=21 bpm; T=36.9 C/axilla

Skin: Uniform in color, good skin turgor, pale, no edema, with skin

rashes

Skull: Round, symmetrical, normocephalic, absence of nodules and

masses

Face: Symmetrical, absence of nodules and masses

Eyes: Round and symmetrical, equally distributed eyelashes and

eyebrows, no discoloration on eyelids, eyelids close symmetrically,

blinks involuntarily, pale conjunctiva

Ears: Symmetrical with no discharges, auricles aligned with the outer

canthus of the eye

Nose: Symmetrical and straight, both nares are patent, no tenderness

Mouth: Dry and pale lips

Neck: With palpable modules on the left side of the neck,

jugular veins are not distended, neck muscles are equal in size

Chest/Lungs: Has symmetrical chest expansion, presence of rales

on both lung fields upon auscultation

Abdomen: Slightly globular in shape, with 15 bowel sounds per

minute, presence of resonance upon percussion

Extremities: Equal in size and length, absence of edema, both lower

and upper extremities move with coordinatio

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E. LABOORATORY AND DIAGNOSTIC PROCEDURE

Diagnostic and Laboratory Procedure :

Date OrderedDate Resulted

Indicationor

PurposesResults Normal

Values

Analysis and

Interpretation

RadiologyChest (PA)

Date Ordered :August 17, 2008

Date Resulted:August 17, 2008

Chest Radiography or x-ray yields information about the pulmonary, cardiac and skeletal systems.

Evaluate known or suspected pulmonary disorders and cardiovascular disorders.

Monitor resolution, progression or maintenance of the disease.

Nodule- haze densities are evident in the right lung with traction of the trachea rightwards and right hemi diaphragm upwards. The right apical pleuralis thickened. Hazy densities are like wise seen in the left lungs base. Heart is not enlarged body thorax is unremarkable.

Normal lung fields, cardiac size, mediastinal structures, thoracic size, ribs and diaphragm

The result shows that patient are congruent to the diagnosis of pneumonia

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Nursing Responsibilities

Prior to the Procedure

Inform the patient that the procedure assess cardiopulmonary status

Obtain history of the patient symptoms and complains, including list of

known allergens

Obtain history of results of previously performed laboratory test,

surgical procedures and other diagnostic procedures

Obtain list of the medication the patient is taking

Review the procedure with the patient.

Explain to the patient that no pain will be experience during the test,

but there may be moments of discomforts

There are no food, fluid or medication restrictions unless by medical

direction

During the Procedure:

Ensure the patient has removed jewellery, dentures, all external

metallic objects, wires and the like prior to the procedure

Patient are given a gown, rob and foot coverings to wear and

instructed to void prior to the procedure

Observed standard precautions

Instruct the patient to cooperate fully and to follow directions. Instruct

the patient to remain still throughout the procedure because

movements produces unreliable result

Place the patient in the standing position in front of the x-ray film or

detector

Have the patient place hands on hips, extend neck and position

shoulders forward

Ask the patient to inhale deeply and hold his breath while the x-ray

images are taken and then exhale after the image are taken

After the Procedure:

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A written report of the examination will be completed by a healthcare

provider specializing in this branch of medicine. The report will be sent

to the requesting health care practitioner who will discuss the result to

the patient.

Recognize anxiety related to test result and be supportive of impaired

activity related to respiratory capacity and perceived loss of physical

activity

Reinforce information given by the patient health care practitioner

regarding proper testing, treatment or referral to another health care

provider

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Diagnostic and Laboratory Procedure :

Date OrderedDate Resulted

Indicationor

PurposesResults Normal

Values

Analysisand

Interpretation

Coplete Blood Count

Hematocrit

Hemoglobin

Date Ordered :August 17, 2008

Date Resulted:August 18, 2008

2am

Measures the concentration of WBC within the blood volume. It is used to aid diagnosis abnormal states of dehydration, polycythemia and anemia

This test evaluates blood loss, erythropoietin ability, anemia and response to therapy. It is an important component of RBC that carries oxygen and CO2 to and from the tissues.

.42

145

.40-54

140-180

The result shows that the hematocrit is within the normal suggesting that has less chance of developing hemmorhage.

The result shows that the haemoglobin is within normal range. IT suggests that there is enough number of circulating hemoglobin thus no deprivation of oxygen supply to the different body organs.

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White blood Cell Count(WBC)

Red Blood Cell(RBC)

Platelet Count

Serve as a buffer to maintain acid and base balance in the extracellular fluid.

Test used to detect infection or inflammation to evaluate effectiveness of antibiotic prescribed.

Has a principal means of delivery of oxygen to the body tissues via the blood

Platelet has essential function in coagulation, homeostasis and blood thrombus formation

Confirm low platelet

5.9

4.99

233

5-10x10 9/L

4.5-6.3

150-400

The result is within the normal range

The result is within the normal range

The result is within the normal range

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Lymphocytes

Segmenters

RBC

count which can be associated with bleeding

Lymphocytes play a major role in body’s natural defense system

Monitor the response on reaction to the drugs of the patient

A type of neutrophil, its primary function is in phagocytosis.

Measures blood glucose regardless of when you last eat.

0.38

0.62

118

0.10-0.48

0.66 -0.70

118-140

The result indicates with in the normal range.

This indicates that the body is has low capacity to fight against invading microorganisms.

The result is within the normal range

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Nursing Responsibilities

Prior to the Procedure

Check the doctor’s order

Verify patient’s name

Inform the patient that the test is used to evaluate anemia and

hydration status and to monitor therapy.

Obtain a history of the patient’s complaints, including a list of known

allergens (especially allergies or sensitivities to latex), and inform the

appropriate health care practitioner accordingly.

Obtain a history of the patient’s cardiovascular, gastrointestinal,

hematopoietic, hepatobiliary, immune, musculoskeletal, and

respiratory systems, as well as results of previously performed

laboratory tests, surgical procedures.

Note any recent procedures that can interfere with test results.

Obtain a list of the medications the patient is taking, including herbs,

nutritional supplements so that their effects can be taken into

consideration when reviewing results.

Review the procedure with the patient. Inform the patient that

specimen collection takes approximately 5 to 10 minutes. Address

concerns about pain related to the procedure. Explain to the patient

that there may be some discomfort during venipuncture.

Sensitivity to social and cultural issues, as well as concern for modesty

is important in providing psychological support before, during and after

the procedure.

There are no food, fluid, or medication restrictions, unless by medical

direction.

During the Procedure

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Instruct the patient to cooperate fully and follow directions. Direct the

patient to breathe normally and to avoid unnecessary movement.

Observe standard precautions. Positively identify the patient, and label

the tubes corresponding patient demographics, date and time of

collection. Perform a venipuncture; collect the specimen in a 5 ml

lavender top tube. The specimen should be mixed gently by inverting

the tube 10 times. The specimen should be analyzed within 4 to 6

hours; two blood smears should be made immediately after the

venipuncture and submitted with the blood sample. Smears made from

specimens older than 6 hours will contain an unacceptable number of

misleading artificial abnormalities of red blood cells as well as white

blood cells.

Remove the needle, and apply a pressure dressing over the puncture

site.

Promptly transport the specimen to the laboratory for processing and

analysis.

After the Procedure

Observe venipuncture site for bleeding or hematoma formation. Apply

paper tape or other adhesive to hold pressure bandage in place or

replace with a plastic bandage.

A written report of the examination will be sent to the requesting

health care practitioner, who will discuss the result with the patient.

Reinforce information given by the patient’s health care provider

regarding proper testing, treatment or referral to other health care

practitioner. Answer any questions or address any concerns voiced by

the patient or family.

Depending on the results of this procedure, additional testing may be

performed to evaluate or monitor progression of the disease process

and determine the need for a change in therapy. Evaluate teat results

in relation to the patient’s symptoms and other tests performed.

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Diagnostic and Laboratory Procedure :

Date OrderedDate Resulted

Indicationor

PurposesResults Normal

Values

Analysisand

Interpretation

Blood Chemistry

Creatinine

Cholesterol

Date Ordered :August 17, 2008

Date Resulted:August 18, 2008

5 am

Ordered to patient to diagnose impaired renal function.

To test the total amount of fatty substance in the blood

Helps in building up cells and produce hormones

Traditional

1.7150.3

130.03.4

SI

0.4-1.735-124

150-2503.4-6.48

The result is higher than the normal range which indicates decreased function of the kidney.

The result is within the normal range

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Nursing Responsibilities

Prior to the Procedure

Check the doctor’s order

Verify the patient

Explain the procedure to the patient.

Inform the patient of the sample required and that some discomfort

may be felt from the needle punctures and the pressure of the

tourniquet.

Tell patient to avoid diet high in meat. (No special preparation is

required before having a random blood sugar test.)

Check and/or validate doctor’s order.

During the Procedure

Put on gloves.

After cleaning the venipuncture site with an alcohol swab, clean it

again with a povidone-iodine swab, starting at the site and working

outward in a circular motion. Wait at least 1 minute for the skin to dry,

and then remove the residual iodine with an alcohol swab.

Apply the tourniquet.

Perform a venipuncture and draw 7 ml.

After the Procedure

Send the sample immediately in the laboratory.

The nurse focuses on nursing care of the patient and follows up

activities and observations.

You may develop a small bruise at the puncture site. You can reduce

the risk of bruising by keeping pressure on the site for several minutes

after the needle is withdrawn.

The nurse also reports the results to appropriate health team members.

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Diagnostic and Laboratory Procedure :

Date OrderedDate Resulted

Indicationor

PurposesResults Normal

Values

Analysis and

Interpretation

Urinalysis Date Ordered :August 17, 2008

Date Resulted:August 18, 2008

Is used for basic screening purposes. It is a group of test that evaluate the kidney’s ability to selectively excrete and reabsorb substances while maintaining water balance

Monitor fluid imbalance

Monitor response to the drug therapy and evaluate undesired react was to drug that may impair renal function

Ordered to determine whether the urine contains substances indicate

Color : Yellow

Transparency: Clear

Ph : 6.0

Sp Gravity : 1.015

Sugar : Negative

Albumin : Trace

Microscopic findings:

Pus cells : 0.1 HPF

Light Yellow to deep amber

Clear

4-6.8

1.05-1.030

Negative

Normal/Trace

0-3

Urine color is within normal range

Urine transparency is within the normal range

Urine PH is within the normal range

Sp Gravity is within the normal range

Sugar is within the normal range

Urine albumin is within the normal range

Pus cells is within the normal range

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Sputum AFB

Date Ordered :August 17, 2008

Date Resulted:August 23, 2008August 24, 2008August 25, 2008

of normally absent from urine and detected by urinalysis are proteins, glucose acetone, blood, pus and casts

This test is used to identify pathogenic organisms to determine whether malignant cells are present

RBC 0.1 HPF

Epithelial Cells : Rare

NegativeNegativeNegative

Less than 2

Few

Negative

Urine RBC is within the normal range

Epithelial cells is within the normal range

This indicates that there is absence of pathogenic microorganisms that can cause diseases such as PTB.

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Nursing Responsibilities for Urinalysis

Prior to the Procedure

Inform the patient that the test is used to assist in the diagnosis of

renal diseases and as an indication of inflammatory diseases.

Obtain a history of the patient’s genitourinary, surgical procedures and

other diagnostic procedures.

Obtain a list of medication the patient is taking.

Review the procedure with the patient.

There are no food, fluid or medication restrictions, unless by medical

direction.

During the Procedure

Instruct the patient to thoroughly wash his hands, cleanse the meatus,

void a small amount in the toilet and void directly into the specimen

container.

Promptly transport the specimen to the laboratory for processing and

analysis.

After the Procedure

Instruct the patient to report symptoms such as pain related to tissue

inflammation, pain or irritation during void or alterations in urinary

elimination.

Answer any questions or address any concerns voiced by the patient or

family.

Evaluate test results in relation to the patient’s symptoms and other

test performed.

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Nursing Responsibilities for Sputum AFB

Prior to the Procedure

Inform the patient that the test is used to obtain analysis to identify

pathogenic organisms and to determine whether malignant cells are

present

Obtain a list of medication the patient is taking.

Review the procedure with the patient.

There are no food, fluid or medication restrictions, unless by medical

direction.

Take the test early in the morning

During the Procedure

Instruct the patient to clear the nose and throat and rinse the mouth to

decrease contamination of the sputum.

Instruct the patient to inhale and exhale two times then inhale again

and cough rather than spit, using the diaphragm and expectorates into

a sterile container

Promptly transport the specimen to the laboratory for processing and

analysis.

After the Procedure

Instruct the patient to report symptoms such as pain related to tissue

inflammation, pain or irritation during void or alterations in urinary

elimination.

Answer any questions or address any concerns voiced by the patient or

family.

Evaluate test results in relation to the patient’s symptoms and other test

performed.

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Diagnostic and Laboratory Procedure :

Date OrderedDate Resulted

Indicationor

PurposesResults Normal

Values

Analysisand

Interpretation

Fecalysis Date Ordered :August 17, 2008

Date Resulted:August 18, 2008

7:20 am

Fecalysis aids in this evaluation of digestive efficiency and the integrity of the stomach and intestines.

Used as a screening or diagnostic tool because its can identify substance present in, the feces such as ova and parasites so that appropriate treatment can be ordered.

Color : Brown

Consistency : Soft

Intertinal Parasites:

Negative

Brown

Bulky

Negative

The result shows that the stool have a normal color

The result shows that the consistency is normal

The results indicates that there are no ova or parasites present

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Nursing Responsibilities

Prior to the Procedure

Check the doctor’s order Check the patients name and his identification band Explain to the patient ad significant others why stool specimen is being

collected

During the Procedure

Provide privacy Decrease discomforts and anxiety allow adequate time Instruct the patient’s significant others to put the specimen on the

container Collect stool specimen

After the Procedure

Ensure that the specimen labelled and laboratory acquisition form are

filed out correctly

Send the specimen to the laboratory at once

Document what you have done

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III. ANATOMY AND PHYSIOLOGY

Respiratory System

The respiratory system functions to deliver the oxygen to the blood --

the transport medium of the cardiovascular system -- and to remove oxygen

from the blood. The actual exchange of oxygen and carbon dioxide occurs in

the lungs.

The respiratory centers in the brain stem (pons and medulla) control

respiration's rhythm, rate, and depth. Primary controlling factors include 1)

the concentration of carbon dioxide in the blood (high CO2 concentrations

initiate deeper, more rapid breathing) and 2) air pressure within lung tissue.

Expansion of the lungs stimulates nerve receptors (vagus nerve X) to signal

the brain to "turn off" inspiration. When the lungs collapse, the receptors give

the "turn on" signal, termed the Hering-Breuer inspiratory reflex. Other

regulators are: 3) an increase in blood pressure, which slows down

respiration; 4) a drop in blood acidity, which stimulates respiration; and 5) a

sudden drop in blood pressure, which increases the rate and depth of

respiration. Voluntary controls -- "holding one's breath" -- can also affect

respiration, but not indefinitely. Carbon dioxide build-up soon forces an

automatic start-up.

The respiratory system consists of two tracts: The upper respiratory

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tract includes the nose (nasal cavity, sinuses), mouth, larynx, and trachea

(windpipe). The lower respiratory tract includes the lungs, bronchi, and

alveoli.

The two lungs, one on the right and one on the left, are the body's

major respiratory organs. Each lung is divided into upper and lower lobes,

although the upper lobe of the right lung contains a third subdivision known

as the right middle lobe. The right lung is larger and heavier than the left

lung, which is somewhat smaller in size because of the predominately left-

side position of the heart.

A clear, thin, shiny coating -- the pleura -- envelopes the lungs. The

inner, visceral layer of the pleura attaches to the lungs; the outer, parietal

layer attaches to the chest wall (thorax). Pleural fluid holds both layers in

place, in a manner similar to two microscope slides that are wet and stuck

together. The lungs are separated from each other by the mediastinum, an

area that contains the heart and its large vessels, the trachea (windpipe),

esophagus, thymus, and lymph nodes. The diaphragm, the muscle that

contracts and relaxes in breathing, separates the thoracic cavity from the

abdominal cavity.

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The chart of the respiratory system shows the intricate structures

needed for breathing. Breathing is the process by which oxygen in the air is

brought into the lungs and into close contact with the blood, which absorbs it

and carries it to all parts of the body. At the same time the blood gives up

waste matter (carbon dioxide), which is carried out of the lungs when air is

breathed out.

1. The SINUSES (frontal, maxillary, and sphenoidal) are hollow spaces in the

bones of the head. Small openings connect them to the nose. The functions

they serve include helping to regulate the temperature and humidity of air

breathed in, as well as to lighten the bone structure of the head and to give

resonance to the voice.

2. The NOSE (nasal cavity) is the preferred entrance for outside air into the

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respiratory system. The hairs that line the wall are part of the air-cleaning

system.

3. Air also enter through the MOUTH (oral cavity), especially in people who

have a mouth-breathing habit or whose nasal passages may be temporarily

obstructed, as by a cold or during heavy exercise.

4. The ADENOIDS are lymph tissue at the top of the throat. When they

enlarge and interfere with breathing, they may be removed. The lymph

system, consisting of nodes (knots of cells) and connecting vessels, carries

fluid throughout the body. This system helps to resist body infection by

filtering out foreign matter, including germs, and producing cells

(lymphocytes) to fight them.

5. The TONSILS are lymph nodes in the wall of the throat (pharynx) that often

become infected. They are part of the germ-fighting system of the body.

6. The THROAT (pharynx) collects incoming air from the nose and mouth and

passes it downward to the windpipe (trachea).

7. The EPIGLOTTIS is a flap of tissue that guards the entrance to the windpipe

(trachea), closing when anything is swallowed that should go into the

esophagus and stomach.

8. The VOICE BOX (larynx) contains the vocal chords. It is the place where

moving air being breathed in and out creates voice sounds.

9. The ESOPHAGUS is the passage leading from the mouth and throat to the

stomach.

10. The WINDPIPE (trachea) is the passage leading from the throat (pharynx)

to the lungs.

11. The LYMPH NODES of the lungs are found against the walls of the

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bronchial tubes and windpipe.

12. The RIBS are bones supporting and protecting the chest cavity. They

move to a limited degree, helping the lungs to expand and contract.

13. The windpipe divides into the two main BRONCHIAL TUBES, one for each

lung, which subdivide into each lobe of the lungs. These, in turn, subdivide

further.

14. The right lung is divided into three LOBES, or sections. Each lobe is like a

balloon filled with sponge-like tissue. Air moves in and out through one

opening -- a branch of the bronchial tube.

15. The left lung is divided into two LOBES.

16. The PLEURA are the two membranes, actually one continuous one folded

on itself, that surround each lobe of the lungs and separate the lungs from

the chest wall.

17. The bronchial tubes are lines with CILIA (like very small hairs) that have a

wave-like motion. This motion carried MUCUS (sticky phlegm or liquid)

upward and out into the throat, where it is either coughed up or swallowed.

The mucus catches and holds much of the dust, germs, and other unwanted

matte that has invaded the lungs. You get rid of this matter when you cough,

sneeze, clear your throat or swallow.

18. The DIAPHRAGM is the strong wall of muscle that separates the chest

cavity from the abdominal cavity. By moving downward, it creates suction in

the chest to draw in air and expand the lungs.

19. The smallest subdivisions of the bronchial tubes are called BRONCHIOLES,

at the end of which are the air sacs or alveoli (plural of alveolus).

20. The ALVEOLI are the very small air sacs that are the destination of air

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breathed in. The CAPILLARIES are blood vessels that are imbedded in the

walls of the alveoli. Blood passes through the capillaries, brought to them by

the PULMONARY ARTERY and taken away by the PULMONARY VEIN. While in

the capillaries the blood gives off carbon dioxide through the capillary wall

into the alveoli and takes up oxygen from the air in the alveoli.

Air Distribution

On inspiration, air enters the body through the nose and the mouth.

Nasal hairs and mucosa (mucus) filter out dust particles and bacteria and

warm and moisten the air. Less warming, filtering, and humidification occur

when air is inspired through the mouth.

Air travels down the throat, or pharynx, where two openings exist, one

into the esophagus for passage of food, and the other into the larynx (voice

box) and trachea (windpipe) for continued airflow. When food is swallowed,

the opening of the larynx (the epiglottis) automatically closes, preventing

food from being inhaled. When air is inspired, the walls of the esophagus are

collapsed, preventing air from entering the stomach. The larynx, which also

contain the vocal cords, is lined with mucus that further warms and

humidifies the air.

Air continues continues down the trachea, which branches into the

right and left bronchi. The main-stem bronchi divide into smaller bronchi,

then into even smaller tubes called bronchioles. The bronchial structures

contain hair-like, epithelial projections, called cilia, that beat rythmically to

sweep debris out of the lungs toward the pharynx for expulsion. Once in the

bronchioles, the air is at body temperature, contains 100% humidity, and is

(hopefully) completely filtered.

Bronchioles end in air sacs called alveoli -- small, thin-walled

"balloons," arranged in clusters. When you breathe in, enlarging the chest

cavity, the "balloons" expand as air rushes in to fill the vacuum. When you

breathe out, the "balloons" relax and air moves out of the lungs. It is at the

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alveoli that gas exchange occurs. Tiny blood vessels, capillaries, surround

each of the alveoli. On inspiration, the concentration of dissolved oxygen is

greater in the alveoli than in the capillaries. Oxygen, therefore, diffuses

across the alveolar walls into the blood plasma. In the reverse process,

carbon dioxide concentration is greater in the blood than the alveoli, so it

passes from the blood into the alveoli and is ultimately breathed out.

As oxygen diffuses into the plasma, hemoglobin in the red blood cell

picks up the oxygen, permitting more to flow into the plasma. The oxygen-

carrying capacity of hemoglobin allows the blood to carry over 70 times more

oxygen than if the oxygen were simply dissolved in the plasma alone.

Therefore, the total oxygen uptake depends on: 1) the difference in oxygen

concentration between the blood and alveoli, 2) the healthy functioning of

the alveoli, and 3) the rate of respiration.

Pulmonary Circulation

The pulmonary circulatory circuit describes the process whereby

oxygen and carbon dioxide are delivered to and from the lungs. Oxygen-poor

blood travels to the right atrium via the inferior and superior vena cavae,

then to the right ventricle. The right ventricle subsequently pumps the blood

into the pulmonary artery, which branches to the right and left lungs. The

pulmonary arteries subdivide until reaching the arteriole, then capillary

levels. After gas exchange, the capillaries recombine to form venules and

veins. Ultimately two right and two left pulmonary veins carry oxygen-rich

blood to the heart for distribution, via the aorta/systemic circuit, to the rest of

the body.

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Lung Volumes/ Capacities

The air that the lungs can hold can be divided into smaller

designations called "volumes."

The amount of air a person breathes in and out at rest is called the

Tidal Volume (Vt about 500ml). During such breathing, a person could

actually take in more air or blow more out. The additional amount a person

could inhale, such as during maximum physical activity, is called the

Inspiratory Reserve Volume (IRV 3,000 ml). The additional amount a person

could exhale is called the Expiratory Reserve Volume (ERV 1,000 ml). The

Residual Volume (RV) is the amount of air that stays in the lung even after

maximum expiration.

Breathing is an active process - requiring the contraction of skeletal

muscles. The primary muscles of respiration include the external intercostal

muscles (located between the ribs) and the diaphragm (a sheet of muscle

located between the thoracic & abdominal cavities).

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The external intercostals plus the diaphragm contract to bring about

inspiration:

Contraction of external intercostal muscles > elevation of ribs &

sternum > increased front- to-back dimension of thoracic cavity >

lowers air pressure in lungs > air moves into lungs

Contraction of diaphragm > diaphragm moves downward > increases

vertical dimension of thoracic cavity > lowers air pressure in lungs > air

moves into lungs:

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To exhale:

relaxation of external intercostal muscles & diaphragm > return of

diaphragm, ribs, & sternum to resting position > restores thoracic cavity

to preinspiratory volume > increases pressure in lungs > air is exhaled

Intra-alveolar pressure during inspiration & expiration

As the external intercostals & diaphragm contract, the lungs expand.

The expansion of the lungs causes the pressure in the lungs (and alveoli) to

become slightly negative relative to atmospheric pressure. As a result, air

moves from an area of higher pressure (the air) to an area of lower pressure

(our lungs & alveoli). During expiration, the respiration muscles relax & lung

volume descreases. This causes pressure in the lungs (and alveoli) to become

slight positive relative to atmospheric pressure. As a result, air leaves the

lungs.

The walls of alveoli are coated with a thin film of water & this creates a

potential problem. Water molecules, including those on the alveolar walls, are

more attracted to each other than to air, and this attraction creates a force

called surface tension. This surface tension increases as water molecules

come closer together, which is what happens when we exhale & our alveoli

become smaller (like air leaving a balloon). Potentially, surface tension could

cause alveoli to collapse and, in addition, would make it more difficult to 're-

expand' the alveoli (when you inhaled). Both of these would represent serious

problems: if alveoli collapsed they'd contain no air & no oxygen to diffuse into

the blood &, if 're-expansion' was more difficult, inhalation would be very,

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very difficult if not impossible. Fortunately, our alveoli do not collapse &

inhalation is relatively easy because the lungs produce a substance called

surfactant that reduces surface tension.

Role of Pulmonary Surfactant

Surfactant decreases surface tension which increases pulmonary

compliance (reducing the effort needed to expand the lungs) and reduces

tendency for alveoli to collapse.

Partial Pressure

Partial pressure is the individual pressure exerted independently by a

particular gas within a mixture of gasses. The air we breath is a mixture of

gasses: primarily nitrogen, oxygen, & carbon dioxide. So, the air you blow

into a balloon creates pressure that causes the balloon to expand (& this

pressure is generated as all the molecules of nitrogen, oxygen, & carbon

dioxide move about & collide with the walls of the balloon). However, the

total pressure generated by the air is due in part to nitrogen, in part to

oxygen, & in part to carbon dioxide. That part of the total pressure generated

by oxygen is the 'partial pressure' of oxygen, while that generated by carbon

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dioxide is the 'partial pressure' of carbon dioxide. A gas's partial pressure,

therefore, is a measure of how much of that gas is present (e.g., in the blood

or alveoli).

The partial pressure exerted by each gas in a mixture equals the total

pressure times the fractional composition of the gas in the mixture. So, given

that total atmospheric pressure (at sea level) is about 760 mm Hg and,

further, that air is about 21% oxygen, then the partial pressure of oxygen in

the air is 0.21 times 760 mm Hg or 160 mm Hg.

IV THE PATIENT’S ILLNESS (Book-based and Patient’s Centered)

Synthesis of the Disease

1. Definition of the Disease

Community- Acquired Pneumonia (CAP) is a condition caused by

Streptococcus pneumoniae (also known as the pneumococcus) which

has a relatively low overall mortality rate, although it is higher in the

elderly. Influenza is the most common viral community-acquired

pneumonia in adults. Community-Acquired Pneumonia occurs either in

the community setting or within the first 48 hours after hospitalization or

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institutionalization. The need of hospitalization for CAP depends on the

severity of pneumonia. (Adrews, Nadjm, Gant, et.al. 2003)

The causative agent for CAP that requires hospitalization are most

frequently S. Pneumoniae, H. Influenzae, Legionella, Pseudomonas

aeruginosa and other gram-negative rods. CAP is a common illness and

can affect people of al ages. It often causes problems like breathing,

fever. Chest pain and cough. CAP occurs because the areas of the lung

which absorbed oxygen from the atmosphere become filled with fluid

and cannot work efficiently.

CAP occurs throughout the world and is the leading cause of illness

and death. CAP ranks as the fourth most common death in the United

Kingdom and sixth as the leading infectious cause of death when

combined with influenza in the United States. Overall, CAP mortality rate

range from less than 1% to 9% for those managed as out-patient, but

increase to 50% for those requiring ICU management ( Retrieved at

www. Medscape.com/viewarticle/475218 accessed on August 29, 2008

10:20 pm) The Global burden of the disease study publish by the World

Health Organization ranks pneumonia as the third leading cause of

mortality. Ass of 2002there were 3.8 million or 6.8% deaths out of the

6.1 billion total estimated population (Brunner, 2008)

In the Philippines, pneumonia ranks as the 4th leading cause of

morbidity and 3rd leading cause of mortality based on the latest health

statistics report of the Department of Health. The morbidity and

mortality tred for pneumonia has fallen from 96.7 deaths per 100,000

populations to 49 deaths per 100,000 populations. (Philippine Health

Statistics, 2006)

2. Predisposing and Precipitating Factors

Predisposing / Non- modifiable factors

a. Age

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Most common in people younger than 60 years of age without

comorbidity and in those 60 years and older among at risk

factors for the development of CAP

b. Race

African- American has higher rates of Community Acquired

pneumonia than among whites.

c. Gender

CAP is most common among men than in women due to their

lifestyle such as smoking and drinking.

d. Seasonality

It is most prevalent during winter and spring, where Upper

Respiratory Tract infections are frequent.

e. Medical History and Treatments

Those people who have illness such as diabetes, HIV infection,

Bronchielectasis, Neutropenia, COPD and other factors involving

microorganisms.

Precipitating / Modifiable Factors

a. Lifestyle

CAP can occur with people who are smoking, 2nd hand smokers

and alcohol abuse

b. Occupation

People who are expose in microorganisms especially in the

community. Laboratories, Veterinarians clinics and other

institution involving microorganisms.

c. Hygiene

Those that have a poor hygiene, improper hand washing,

perineal care, and preparing foods.

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d. Poor Immune System

CAP could be common in children as well as n adults if they have

poor immune system or didn’t acquire vaccination. malnutrition

can also contribute to poor immune.

3. Signs and Symptoms

a. Pleuritic Chest pain that is aggravated by deep breathing and

coughing

Indicates of having pleural inflammation arising from parietal

pleura, which is richly supplied by sensory nerve endings

b. Rapid Rising Fever (38.5 to 40.5 °c)

Cause by release of endogenous pyrogens that reset the

hypothalamus thermostat

c. Sudden onset of chills

Due to invasion of microorganisms causing inflammatory

process

d. Tachypnea, rapid pulse and bounding

It usually increase about 10 bpm for every degee acts as

compensatory echanism for hyperthermia

e. Crackles

Due to lung congestion or consolidation

f. Wheezes

Due to accumulation of secretions the airway becomes narrowed

g. Dyspnea, cyanosis

Due to the interference in oxygen and carbon dioxide exchange

that caused hypoxemia

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h. Bacteremia

The invasion of microorganisms in the body

i. Cough

Brings up a greenish and yellowish mucous due to the bacterial

invasion

4. Health Promotion and Prevention aspects of disease

Several ways to prevent infectious Community- Acquired

Pneumonia like smoking, it is important since it will not only helps to

limit lung damage but also because cigarette smoking interferes with

many of the bodies natural defenses against pneumonia.

Vaccination is also important in preventing pneumonia in

children and adults. Vaccination against Haemophilus Influenzae and

Streptococcus pneumoniae in the first year of life have greatly reduced

their role in pneumonia in children. These would also decreased

incidence of these against infections in adults because adults may

acquire infections from children. Flu vaccine prevents pneumonia and

other problems cause by the influenza virus. Furthermore, health care

workers, nursing home residents and pregnant women should receive

the vaccine. A repeat vaccination may also be required after five to ten

years, the vaccines that confers immunity against pneumococus. It is

also given to people who most at risk like those the age of 65 with

chronic heart, lung and liver disease.

Aside from vaccines, deep-breathing exercise may also help in

preventing pneumonia especially if you are in the hospital—for

example, while recovering from surgery. Drinking plenty of fluids does

not suppress, because retained secretions interfere with gas exchange

and may slow recovery. Hydration of 2-3 L/day because adequate

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hydration thins and loosens pulmonary secretions. Humidification may

be used to loosen secretions and improve ventilation.

Lastly the best solution to prevent infections is proper hand

washing and sanitation. Always wash your hands frequently can

prevent the spread of viral respiratory illness, taking vitamins

especially vitamin C will also be helpful in reducing the risk for having

CAP. Avoiding stress, avoid over exertion and possible exacerbation of

symptoms.

The solution to the problem is preventing the infections rather

than curing them. As the saying goes “PREVENTION IS BETTER THAN

CURE”, these preventive measures includes avoid uncooked or

unwashed fruits and vegetables in areas when sanitation is poor, good

personal hygiene, wee protective clothing and use insect repellent are

some of the ways to prevent pneumonia.

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B. Pathophysiology of Community-Acquired Pneumonia (Book-Based)

Inhalation of microorganisms

Invasion of foreign bodies in the URT

Activation of the upper airway defense mechanism, cough reflex, mucociliary clearance and nasopharyngeal defense

Pathogens begin to colonize

Pathogens enter the lower The body tries to remove Release of respiratory tract pathogen that entered the nasal

discharges upper respiratory tractDamage occurs to mucous membrane

Activation of the inflammatory process, release of chemical mediators

Histamine Bradykinin Prostaglandin Leukotriene Increase inVascular

Stimulates goblet cells Stimulate muscle spasm Chemotaxis Permeability to increase mucus that contributes to production bronchoconstriction Migration of WBC to Leaking of fluids and fluid

the site of injury shifting resulting to Accumulation of mucus Narrowing of airway accumulation of fluid insecretions in the airway Release of pyrogens the alveolar sacs contributing to the narrowing of airway Stimulates the thermoregulatory This accumulation of fluids

center of the body to reset impairs gas exchange body temperature resulting to ventilation-

Crackles Wheezes Dyspnea/ perfusion mismatch

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Nasal flaring Fever Tachypnea Pallor

Chest PainPathophysiology of Community-Acquired Pneumonia (Client-Based)

Inhalation of microorganisms

Invasion of foreign bodies in the URT

Activation of the upper airway defense mechanism, cough reflex,mucociliary clearance and nasopharyngeal defense

Pathogens begin to colonize

Pathogens enter the lower

Damage occurs to mucous membrane

Activation of the inflammatory process,release of chemical mediators

Histamine Bradykinin Prostaglandin Leukotriene Increase inVascular

Stimulates goblet cells Stimulate muscle spasm Chemotaxis Permeability to increase mucus that contributes to production bronchoconstriction Migration of WBC to Leaking of fluids and fluid

the site of injury shifting resulting to Accumulation of mucus Narrowing of airway accumulation of fluid insecretions in the airway Release of pyrogens the alveolar sacs contributing to the

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narrowing of airway Stimulates the thermoregulatory This accumulation of fluids

center of the body to reset impairs gas exchange

body temperature resulting to ventilation- Crackles Productive Dyspnea Nasal flaring perfusion mismatch (Aug.17-25’08) cough (Aug.17,18,24’08) (Aug.21’08) Fever

(Aug.17-25’08) (Aug.17-18’08) Tachypnea Pallor Chest

Pain (Aug.17,18, (Aug.22-23’08)

(Aug.18&24’08)19,21,22,23’08)

Malaise

(Aug.17-23’08)

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V. THE PATIENT AND HIS CAREA.MEDICAL MANAGEMENT

a. Intravenous FluidsMedical

Management/Treatment

Date orderedDate performedDate changed

General Description

Indications or purpose

Client’s response to treatment

IVF: Plain Normal Saline Solution 1L x 31-

32 gtts/min

5% Dextrose and Lactated Ringer’s

DO: 8-17-8DP: 8-17-8

8-18-88-18-88-19-88-20-8

DC: 8-21-8

DO: 8-21-8DP: 8-21-8

PNSS is under isotonic solution where they have

the same concentration of

solutes (osmolarity as blood plasma).

This prevents sudden shift of

fluids & electrolytes in the body. This solution contains 154 mEq/L of Na

and Cl. It expands plasma and

interstitial volume and does not enter

the cells.

Used as a vehicle for

administration of drugs.

Source of water,

electrolytes and calories or

as an alkalinizing

agent.

The patient complied with the doctors

order.

The patient complied

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Solution 1L x 31-32 gtts/min

D5NM 1L x 31-32 gtts/min

8-21-88-22-8

DC: 8-22-8

DO: 8-22-8DP: 8-22-8

8-23-88-23-88-23-88-24-88-24-88-25-8

Date Terminated:8-25-8

5% Dextrose and Lactated Ringer’s

Solution is a hypertonic infusion

raise serum osmolality by

causing a pull of fluids from the

intracellular and interstitial

compartments into the blood vessels. They act to greatly

expand the intravascular

compartment. Its shows how red

blood cells shrink when place in a

hypertonic solution.

Hypertonic solution that has osmolarity higher than serum osmolarity, when a patient receives a

hypertonic IV solution, serum

osmolarity initially increasing fluid to

To prevent electrolyte

imbalance and serve as a route for

administration for IV

medication;absorbs fluid

in the interstitial cell;replacement

of fluid, sodium,

chloride and calories

with the doctors order and the patient was able to maintain

normal hydration status.

The patient complied with the doctors

order.

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be pulled from the interstitial and

intracellular compartment into the blood vessels.

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Nursing ResponsibilitiesPrior to the procedure:

Ask the patients name, verify the physicians order. Explain the procedure to the patient. Explain the importance and purpose of the procedure. Assess the status of the vein to determine venipuncture site. Prepare the IV bottle and necessary materials for insertion.

During the procedure: Maintain aseptic technique. Select venipuncture site. Put on gloves and clean the insertion site. Insert catheter and initiate infusion. Hang the solution on the IV pole. Check for the patency. Regulate as ordered.

After the procedure: Label the bottle; write the name of the patient, the date, time, no. of bottle,

and the rate. Check for the patency and if it’s infusing well. Monitor patient’s response and flow of IV. Record all procedures don

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Medical Management/Treat

ment

Date orderedDate performedDate changed

General Description

Indications or purpose

Client’s response to treatment

Oxygen Therapy at 3-4 lpm via nasal canula

DO: 8-17-8DP: 8-17-8

8-18-88-19-88-24-8

Oxygen occurs in atmosphere air in approximately 20-

21% concentration. It is

a colorless, tasteless gas

which is essential for maintaining life. It must be

continually supplied to body cells, since it is stored in any

parts of the body. All body cells

require oxygen in order to function and supply the

body with oxygen is fundamental to

life.

For patients experiencing dyspnea or difficulty of breathing

The patient is relieved from dyspnea and decreased patients

respiration rate.

Oxygen Therapy

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Nursing ResponsibilitiesPrior to the procedure:

Ask the patient’s name, verify the physicians order. Inform the patient and patient’s SO about the procedure. Explain the importance and use of such treatment. Tell the patient that there is no pain upon administration of it.

During the procedure: Set the flow rate as prescribed. Check if there is air coming out from the tube. Place the nasal cannula in the patient. Make sure that the air delivered is humidified.

After the procedure: Assess the patient and inspect the equipment regularly. Fill up the chart and document the procedure.

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Medical Management/Treatm

ent

Date orderedDate

performedDate changed

General Description

Indications or purpose

Client’s response to treatment

Nebulization: Combivent

Neb q 6

DO: 8-17-8DP: 8-17-8

8-18-88-19-88-20-88-21-88-22-88-23-88-24-88-25-8

A method of administering

medication through the use of aerosol

mist.

Bronchodilation and effective

mucous expectoration

The patient complied with the doctor’s

order and was relieved from

dyspnea.

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Nursing ResponsibilitiesPrior to the procedure:

Ask the patients name, verify the physicians order. Assess the respiratory status. Explain the importance of the treatment. Be alert for adverse reactions. Make sure the equipment is clean.

During the procedure: Assist the patient in nebulization. Advice patient to:

Sit upright so that the air gets deep into his lungs. Breathe normally through the mouthpiece.

After the procedure: Document, date and time of therapy. Make sure the nebulizer is dry and clean. Monitor the patient’s status especially respiratory rate.

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b. DRUGS

Name of drugs, generic

name, Brand name

Date ordered

Date performed

Date changed

Route of administration,

dosage and frequency of

administration

General action and mechanism

of action

Indications or purpose

Client’s response to the meds with

actual S/E

Generic name:

CefuroximeBrand name:

Zinacef

DO: 8-17-8DP: 8-17 8

8-23-8DC: 8-24-8

IV, 750mg TID q3 (-) ANST

General action:

AntiinfectiveMechanism of

action:Binds to

bacterial cell wall

membrane causing cell

death.

Lower respiratory

tract infections due to

s.pneumoniae

Patient complied woth the doctors

order and there are no undesirable effect experienced by the

patient.

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Nursing ResponsibilitiesPrior to the procedure:

Ask the patients name, verify the physicians order. Obtain previous history of medical allergies. Explain the need for the medication. Assess for anemia, renal dysfunction. Observe the 10 rights of giving medications.

During the procedure: Check for the patency. Observe for aseptic technique. Clean the IV port with alcohol. Administer drug slowly.

After the procedure: Check for the regulation of the IVF. Document the time of the given medication. Monitor for adverse reactions.

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Name of drugs, generic name,

Brand name

Date ordered

Date performed

Date changed

Route of administration,

dosage and frequency of

administration

General action and

mechanism of action

Indications or purpose

Client’s response to the meds with

actual S/E

Generic name:

Ipratropium bromide

Brand name:Combivent,

Duoneb

DO: 8-17-8DP: 8-17 8

8-18-88-19-88-20-88-21-88-22-88-23-88-24-88-25-8

Neb. (inhalation) q6

General action:Cholinergic

blocking drug and

sympathomimetic

Mechanism of action:

Ipratropium is an

anticholinergic drug that acts to inhibit the effect of acetylcholine following vagal

nerve stimulation. This

results in bronchodilation

which is primarily a local,

site specific

Treatment of COPD in those

who are on regular aerosol.

Bronchodilator therapy and

who require a second

bronchodilator.

Patient complied with the doctors order and

was relieved of dyspnea.

Page 65: Casestudy CAP

effect. Albuterol is a beta 2 adrenergic

agonist that also causes

bronchodilation.

Page 66: Casestudy CAP

Nursing ResponsibilitiesPrior to the procedure:

Ask the patients name, verify the physicians order. Assess the respiratory status. Explain the importance of the treatment. Be alert for adverse reactions. Make sure the equipment is clean.

During the procedure: Assist the patient in nebulization. Advice patient to:

Sit upright so that the air gets deep into his lungs. Breathe normally through the mouthpiece.

After the procedure: Document, date and time of therapy. Make sure the nebulizer is dry and clean. Monitor the patient’s status especially respiratory rate.

Page 67: Casestudy CAP

Name of drugs, generic

name, Brand name

Date ordered

Date performed

Date changed

Route of administration,

dosage and frequency of

administration

General action and mechanism

of action

Indications or purpose

Client’s response to the meds with

actual S/E

Generic name: Acetaminophe

n Brand name:Paracetamol

DO: 8-17-8DP: 8-17 8

PO, 500mg tab q4 RTC

General action:

Analgesic and Anti-pyretics

Mechanism of action:

Inhibits the synthesis of

prostaglandin that may serve as

mediators of pain and

fever, primarily in

the CNS. Have no significant

anti-inflammatory properties or GI toxicity.

It relieves pain and reduces

fever.

Patient complied with the doctor’s order and the patient’s

temperature decreases.

Page 68: Casestudy CAP

Nursing ResponsibilitiesPrior to the procedure:

Ask the patients name, verify the physicians order. Before giving the medication, obtain previous history of medical allergies. Assess for fever. Explain the purpose of the drug. Observe the 10 rights of giving medications.

During the procedure: Assist patient while taking the drug; offer water.

After the procedure: Monitor for decrease in temperature.

Document.

Page 69: Casestudy CAP

Name of drugs, generic

name, Brand name

Date ordered

Date performed

Date changed

Route of administration,

dosage and frequency of

administration

General action and mechanism

of action

Indications or purpose

Client’s response to the meds with

actual S/E

Generic name:

Loperamide HydrochlorideBrand name:

Imodium

DO: 8-17-8 – 8-25-8

DP: 8-22 8

PO, 1 tab for loose stool

General action:

Anti-diarrheal

Mechanism of action:Slows

intestinal motility by

acting on the nerve endings

and/or intraneural

ganglia embedded in the intestinal

wall. The prolonged

retention of the feces in the intestine

results in reducing the

Symptomatic relief of acute non-specific

diarrhea associated with inflammatory

bowel disease.

Patient complied with the doctor’s order

and was relieved from diarrhea.

Page 70: Casestudy CAP

volume of the stools,

increasing viscosity and decreasing fluid and

electrolyte loss.

Page 71: Casestudy CAP

Nursing ResponsibilitiesPrior to the procedure:

Ask the patients name, verify the physicians order. Before giving the medication, obtain previous history of medical allergies. Explain the purpose of the drug. Observe the 10 rights of giving medications.

During the procedure: Witness the intake of medication.

After the procedure: Monitor he patients reaction to the drug.

Document date, and time the medication was given.

Page 72: Casestudy CAP

Name of drugs, generic

name, Brand name

Date ordered

Date performed

Date changed

Route of administration,

dosage and frequency of

administration

General action and mechanism

of action

Indications or purpose

Client’s response to the meds with

actual S/E

Generic name:

Butamirate citrate

Brand name:Sinecod forte

DO: 8-17-8DP: 8-17-8

8-18-88-19-8Date

discontinued:8-20-8

PO, 1 tab TID General action:Cough

Suppresants

Mechanism of action:

Butamirate citrate belongs

to the anti cough

medicines of central action. Sinecod exerts expectorant,

moderate bronchodilation

, and inflammatory action. It also increases the spirometery indexes and

blood

For acute cough of any

etiology/Cough

associated with thickened mucus and impaired mucus

transport.

Patient complied with the doctor’s order and was relieved

from cough.

Page 73: Casestudy CAP

oxygenation.

Page 74: Casestudy CAP

Nursing ResponsibilitiesPrior to the procedure:

Ask the patients name, verify the physicians order. Before giving the medication, obtain previous history of medical allergies. Explain the purpose of the drug. Observe the 10 rights of giving medications.

During the procedure: Witness the intake of medication.

After the procedure: Monitor for adverse reactions like nausea, diarrhea and dizziness.

Document date, and time the medication was given.

Page 75: Casestudy CAP

Name of drugs, generic

name, Brand name

Date ordered

Date performed

Date changed

Route of administration,

dosage and frequency of

administration

General action and mechanism

of action

Indications or purpose

Client’s response to the meds with

actual S/E

Generic name:

CarbocisteineBrand name:

Abluent

DO: 8-20-8DP: 8-20-8

8-21-88-22-88-23-88-24-88-25-8

PO, 500mg/cap TID General action:

Mucolytics

Mechanism of action:

Its major action is on

the metabolism of

mucus producing

cells. It reduces or prevents bronchial

inflammation and

bronchospasm.

Acute and chronic

disorders of respiratory

tract associated with excessive

mucous.

Patient complied with the doctor’s order and his secretions partially loosen.

Page 76: Casestudy CAP

Nursing ResponsibilitiesPrior to the procedure:

Ask the patients name, verify the physicians order. Before giving the medication, obtain previous history of medical allergies. Explain the purpose of the drug. Observe the 10 rights of giving medications.

During the procedure: Witness the intake of medication.

After the procedure: Monitor he patient’s reaction to the drug.

Document date, and time the medication was given.

Page 77: Casestudy CAP

Name of drugs, generic

name, Brand name

Date ordered

Date performed

Date changed

Route of administration,

dosage and frequency of

administration

General action and mechanism

of action

Indications or purpose

Client’s response to the meds with

actual S/E

Generic name:

FurosemideBrand name:

Lasix

DO: 8-21-8DP: 8-21-8

8-22-88-23-88-24-8

IV, 20mg now, then q12 with bp precaution

General action:Loop diuretic

Mechanism of action:

Inhibits the readsorption of

sadium and chloride from the loop Henle

and distal renal

tubule.Increases renal

excretion of water, sodium,

chloride, magnesium,

hydrogen and calcium.

Effectiveness persists in

For acute pulmonary

edema.

Patient complied with the doctor’s order.

Upon taking the drug, undesirable effects

were not experienced.

Page 78: Casestudy CAP

impaired renal function.

Page 79: Casestudy CAP

Nursing ResponsibilitiesPrior to the procedure:

Ask the patients name, verify the physicians order. Obtain previous history of medical allergies. Explain the need for the medication. Observe the 10 rights of giving medications.

During the procedure: Check for the patency. Observe for aseptic technique. Clean the IV port with alcohol. Administer drug slowly.

After the procedure: Check for the regulation of the IVF. Document the time of the given medication. Monitor for adverse reactions.

Page 80: Casestudy CAP

Name of drugs, generic

name, Brand name

Date ordered

Date performed

Date changed

Route of administration,

dosage and frequency of

administration

General action and mechanism

of action

Indications or purpose

Client’s response to the meds with

actual S/E

Generic name:

AzithromycinBrand name:

Zithromax

DO: 8-21-8DP: 8-21-8

8-22-88-23-8

PO, 500mg tab, 1 tab OD x 3 days

General action:

Antibiotic, macrolide

Mechanism of action:

A macrolide derived from erythromycin.

Acts by binding to the p site of the

50 s ribosomal subunit and may inhibit

RNA dependent

protein synthesis by stimulating

the

For pneumonia, and lower respiratory

tract infections.

Patient complied with the doctor’s order.

Upon taking the drug, undesirable effects

were not experienced such as

hypersensitivity reactions and GI

disturbances.

Page 81: Casestudy CAP

dissociation of peptidyl t-RNA

from ribosomes.

Page 82: Casestudy CAP

Nursing ResponsibilitiesPrior to the procedure:

Ask the patients name, verify the physicians order. Before giving the medication, obtain previous history of medical allergies. Explain the purpose of the drug. Observe the 10 rights of giving medications.

During the procedure: Witness the intake of medication.

After the procedure: Monitor he patient’s reaction to the drug.

Document date, and time the medication was given.

Page 83: Casestudy CAP

Name of drugs, generic

name, Brand name

Date ordered

Date performed

Date changed

Route of administration,

dosage and frequency of

administration

General action and mechanism

of action

Indications or purpose

Client’s response to the meds with

actual S/E

Generic name:

Ceftriaxone Na

Brand name:Chevron

DO: 8-24-8DP: 8-24-8

IV, 1 gm q12 General action:

Antibiotic, cephalosporins

Mechanism of action:

They kill the bacteria to

form cell walls. The bacteria

therefore break up and

die.

For lower respiratory

tract infections and

pneumonia.

Patient complied with the doctor’s order

and the occurrence of severe infection is

reduced. And also he experienced slight discomfort when infusing of the

medication is done.

Page 84: Casestudy CAP

Nursing ResponsibilitiesPrior to the procedure:

Ask the patients name, verify the physicians order. Obtain previous history of medical allergies. Explain the need for the medication. Observe the 10 rights of giving medications.

During the procedure: Check for the patency. Observe for aseptic technique. Clean the IV port with alcohol. Administer drug slowly.

After the procedure: Check for the regulation of the IVF. Document the time of the given medication. Monitor for adverse reactions.

Page 85: Casestudy CAP

Name of drugs, generic name,

Brand name

Date ordered

Date performed

Date changed

Route of administration,

dosage and frequency of

administration

General action and

mechanism of action

Indications or purpose

Client’s response to the meds with

actual S/E

Generic name:

AlbuterolBrand name:

Ventolin

DO: 8-24-8DP: 8-24-8

8-25-8

PO, 1 capsule TID General action:Sympathomimeti

c

Mechanism of action:

Stimulates beta-2 receptors of the bronchi, leading to

bronchodilation.

Prophylaxis and treatment

of bronchospasm

due to reversible

obstructive airway disease.

Patient complied with the doctor’s order and demonstrated

improvement in breathing pattern.

Page 86: Casestudy CAP

Nursing ResponsibilitiesPrior to the procedure:

Ask the patients name, verify the physicians order. Explain the purpose of the drug. Obtain history, assess EKG and CNS status. Assess symptom characteristics, onset, duration, frequency, and any

precipitating factors. Observe the 10 rights of giving medications.

During the procedure: Witness the intake of medication.

After the procedure: Monitor he patient’s reaction to the drug.

Document date, and time the medication was given.

Page 87: Casestudy CAP

c.DIET

TypeOf

Diet

Date ordered

Date performed

Date changed

General Description

Indications or purpose

Specific foods taken

Client’s response and/or reaction to

the diet

Soft Diet DO: 8-17-8DP: 8-17-8

8-18-88-19-88-20-88-21-88-22-88-23-88-24-88-25-8

The texture of food is soft. It can be

nutritionally adequate, but prophylactic

supplementation of diets with vitamins

and minerals is recommended if for

long term use.

To rest the GI tract of the

patient.

Water, grapes, gruel

Patient complied with the doctor’s order.

Page 88: Casestudy CAP

Nursing responsibilities:

Prior to the procedure:

Check the doctor’s order about the diet.

Identify the patient & instruct SO about the diet.

During:

Give foods in small frequent meals to check for tolerance.

Assist patient when eating & provide comfort measures.

Observe for aspiration precaution.

Avoid interruption while eating.

After:

Encourage the patient to follow the diet regimen.

Assess patient’s condition on how to respond to the diet.

Page 89: Casestudy CAP

TypeOf

Activity

Date ordered

Date performed

Date changed

General Description

Indications or purpose

Specific foods taken

Client’s response and/or reaction to

the diet

Complete Bed Rest

Deep Breathing Exercise

BOOK-bASEd

Patient is prohibited to

strenuous activities/ exercises.

Respiratory functioning can be facilitated by deep breathing exercises

to remove secretions from the

airways. A commonly employed

breathing exercise is abdominal

(diaphragmatic) and pursed-lip

To avoid discomfort,

restore energy, and to

decrease oxygen

consumption thus

decreasing the work load of the heart.

To enhance lung

expansion and mobilize

secretions, thereby

preventing atelectasis

and pneumonia.

Water, gruel

Water, gruel

He was able to take a rest and whenever he

wants to eat or change position he

asked for assistance.

Page 90: Casestudy CAP

breathing. Abdominal

breathing permits deep full breaths with little effort.

Pursed-lip breathing helps the

client develop control over

breathing. The pursed-lip create a resistance to the air flowing out of

the lungs, thereby prolonging

exhalation and preventing airway

collapse by maintaining

positive airway pressure. The client purses the lips as if

about to whistle and breaths out

slowly and gently, tightening the

abdominal muscle to exhale more

effectively.

Page 91: Casestudy CAP

Nursing ResponsibilitiesPrior to the procedure:

Assess for vital signs.

Check the doctors order and verify the client.

Assess hearing ability to ensure the elder client hears the information.

Explain to the client what is the importance of the activity.

During the procedure: Assist the patient in the activity.

Demonstrate deep breathing exercises.

Instruct the patient to hold his breath, then exhale slowly through the mouth.

After the procedure: Document all the teachings given and the assessment.

Page 92: Casestudy CAP

NURSING MANAGEMENT

Problem No. 1 Ineffective Airway Clearance

Assessme

nt

Nursing

Diagnosis

Scientific

Explanation

Planning Nursing

Intervention

Rationale Evaluation

S= patient

may

verbalize

“magkasaki

t ku

papalwal

ing plema

pag

manguku

ku.”

O=Patient

Manifeste

d the

following :

Ineffective

Airway

Clearance

related to

retained

secretions in

the bronchi

( increased

thick

mucous

secretions)

and lung

inflammatio

n leading to

accumulatio

n of mucous

in the

Community-

Acquired

Pneumonia is the

inflammation of

the lung

parenchyma

when the

offending

organism

reaches the

alveoli via

droplets or saliva

in whi8ch goblet

cells produces an

outpouring fluid

into the alveoli.

The organisms

Short Term

:

After 5

hours of

Nursing

Intervention

s, the

patient will

expectorate

mucous as

evidenced

by

productive

cough,

effective

coughing

> Assess

respiratory

status: breath

sounds,

respiratory rate,

oxygen

saturation, note

abnormalities

such as dyspnea,

presence of

cyanosis, use of

accessory

muscles, flaring

of nostrils

> Assess anxiety

and reassure

> Abnormal

breathing patterns

may signal

worsening of

condition: flaring of

nostrils indicate a

significant decline in

respiratory status:

assessment

establishes baseline

and monitor

response to

interventions

> Being unstable to

breath causes

Short

Term :

The patient

shall be

able to

expectorate

mucous as

evidenced

by

productive

cough

effective

coughing

and

breathing

exercise

Page 93: Casestudy CAP

>appears

weak

>pale

palpebral

conjunctiva

>ć rales on

both lung

lobes upon

chest

auscultatio

n

>ć difficulty

of

breathing

> shortness

of breath

> ć non-

alveoli multiply in the

serous fluid and

the infection is

spread. The

organisms

damage the host

by their

overwhelming

growth and

interference with

lung function

leading to

massive

accumulation of

mucus.

Disruption of the

mechanical

defenses of

cough and ciliary

motility leads to

the colonization

of the lungs and

and

breathing

exercise

Long

Term :

After 2 days

of Nursing

Intervention

s, the

patient will

maintain

airway

patency as

evidenced

by clear

breath

sounds,

absence of

dyspnea,

patient ć

presence

> Place patient

in high fowler’s

position and

support ć

overbed table as

needed.

> Encourage

expectoration of

secretions and

assess the

viscosity amount

and color of

secretions

anxiety and fear:

the patient needs a

calming presence:

anxiety increases

the demand for

oxygen

> Maximize chest

excursion and

subsequent

movement of air

> Thickened

secretions of Cap re

more likely to

occlude the airway:

making this

observation would

allow for

implementation if

Long Term

:

The patient will maintain airway patency as evidenced by clear breath sounds, absence of dyspnea, etc.

Page 94: Casestudy CAP

productive

cough

Patient

may

manifest

the

following :

>decreased oxygen saturation

> Cyanosis>Tachypnea

>Abnormal blood gases(decreased O2, Increased CO2)

> Restlessness

> ć

accumulation of

secretions in the

alveoli and

bronchi leading

to ineffective

airway clearance

as evidence by

non-productive

cough etc.

alveolar

exudates tend to

consolidate,

increasingly

difficult to

expectorate.

etc.

> Assist the

patient ć

coughing and

deep breathing

> Increase fluid

intake

> Provide for

periods of rest

and activity,

assisting ć

devices as

needed

> Elevate head

of bed/ change of

measures to thin

and loosen the

secretions

> Mobilizes

secretions and

prevent atelectasis

> Assists with

liquefying secretions

and enhancing

ability to clear

airways

> Decrease demand

for oxygen

Page 95: Casestudy CAP

Orthopnea

> Flaring of nostrils

position every 2

hours

> Assist

respiratory

therapist ć the

administration of

nebulizer

> Establish

intravenous

access as

ordered

> Assess arterial

blood gases

(ABG)

> To maintain an

open airway and to

take advantage of

gravity decreasing

pressure on the

diaphragm and

enhancing drainage

of secretions.

>This causes

bronchiodilation to

ease breathing

> Ensures a route

for rapid- acting

medications

>ABG provide data

for treatment

regarding the lungs’

Page 96: Casestudy CAP

> Provide

humidified

oxygen as

ordered to

maintain O2

saturation >90%

ability to oxygenate

tissues

> Loosen

secretions, making

them easier to

expectorate ć

coughing: improves

oxygenation

Problem No. 2 Impaired Gas Exchange

Assessment Nursing Scientific Planning Nursing Rationale Evaluatio

Page 97: Casestudy CAP

Diagnosis Explanation Intervention n

S= patient

may

verbalize

“magkasakit

ku

mangisnawa

ampo agad

ku papagal

gang

maglakad

kumu.”

O=Patient

Manifested

the

following :

>difficulty of

breathing

Impaired

Gas

Exchange

related to

inflamed

lung tissue

and

consolidati

on of

mucous /

ffluid in

specific

lung lobes

preventing

transfer of

gases

across the

alveolar

capillary

cellular

Community-

Acquired

Pneumonia is

defined as a

lower respiratory

tract infection of

the lungs

parenchyma with

onset in the

community or

during thre first

2days of

hospitalization.

Pneumonia

occurs when the

offending

organism

stimulate

inflammatory

response the

Short Term

:

After 8hours

of Nursing

Intervention

s, the

patient will

be relieved

from

dyspnea by

participating

in breathing

exercises,

effective

coughing

and use of

oxygen as

evidenced

by absent of

> Perform a

complete

respiratory

assessment ;

respiratory rate,

rhythm, chest

expansion, ease

of breathing, use

of accessory

muscles, pursed

lip breathing,

breath sounds,

mucous

expectoration,

perioral cyanosis,

tachypnea,

dyspnea, pulse

oximetry and

monitor

laboratory and

> Because airway

inflammation and

mucous

accumulation,

pneumonia can

cause fluid in the

lungs and increase

the work of

breathing, resulting

in impaired gas

exchange. These

assessment provide

data use for planning

Interventions and

assessing progress.

Sputum cultures

identify the causative

organisms, arterial

blood gases

demonstrate

Short

Term :

The

patient

shall be

relieved

from

dyspnea

by

participati

ng in

breathing

exercise,

effective

coughing

and use of

oxygen as

evidenced

by

absence of

Page 98: Casestudy CAP

>nasal

flaring

>shortness

of breath/

exertional

discomfort

>with

presence of

crackles on

both lung

lobes upon

auscultation

> with non

productive

cough

> easy

fatlgability

membrane defense

mechanism of

the lung lo9se

effectiveness

and allow

organisms to

penetrate the

sterile, lower

respiratory tract,

where

inflammation

develops.

Inflammation

occurs due to

colonization of

offending

organization

wherein there is

the release of

chemical

mediators,

attraction of

nasal

flaring,

shortness of

breath, easy

fatigability,

etc.

Long

Term :

After 1 to 3

days of

Nursing

Intervention

s, the

patient will

have an

improved

ventilation

and

adequate

diagnostic

procedures such

as sputum

cultures,

complete blood

count, arterial

blood gases, etc.

> Obtain

subjective data

from the patient

or significant

other, including

history of chronic

respiratory

disease and

history of

smoking

> Assist patient

to semi fowler’s

position

decreased oxygen

concentration, chest

x-ray will confirm the

presence of fluid in

the lungs or areas of

consolidation

> knowledge of the

patient respiratory

status contributes to

information that can

assist in

determination other

factors that may

have contributed to

pneumonia or

influence its

treatment

> Sitting upright

nasal

flaring,

shortness

of breath,

easy

fatigability

. Etc.

Long

Term :

The patient shall have an improved ventilation and adequate oxygenation of lung tissue as evidenced

Page 99: Casestudy CAP

> Patient hooked to O2 therapy 2-3 LPM

Patient may

manifest

the

following :

>abnormal blood gases / arterial ptt ( hypoxia, increase CO2 )

>Diaphoresis

>Tachycardia

> abnormal rate rhythm, depth of breathing

> abnormal

neutrophils,

accumulation of

fibrinous

exudates, red

blood cells and

macrophages.

These would in

turn trigger

erythema

swelling, edema

and stimulation

of nerve fibers,

leading to pain.

Goblet cells will

increase mucus

production in

attempt to dilute

amd wash away

offending

organisms out of

the respiratory

tract. Inflamed

oxygenation

of lung

tissue as

evidenced

by normal

arterial

blood gases,

patient will

have a clear

breath

sounds,

absence of

purulent

discharge

>Take

temperature

every 4 hours

> Provide

comfort

measures

change linen or

clothing

> Encourage

adequate fluid

intake to 2000

cc/day

> Assess mucous

allows the diaphragm

to descend, resulting

in easier breathing

> Infectious

processes can cause

an increase body

temperature

>Following

temperature spikes,

linen and clothing

may become

saturated with

perspiration

> Helps thin and

liquefy secretions

>Helps to detect

by normal arterial blood gases, clear Breathing sounds, absence of purulent discharges, etc.

Page 100: Casestudy CAP

skin color (pale, dusty)

> abnormal capillary refill

>Restlessness

>Confusion

>O2 saturation of less than 90%

>fever

O2

fluid-filler

alveolar sacs

cannot exchange

O2 and CO2

effectively

leading to

hypoxia of the

lung tissue and a

significant

ventilation-

perfusion

mismatch

amount, color

consistency.

>Encourage

coughing and

deep breathing

with mucous

expectoration

> Provide chest

physiotherapy

postural

drainage, chest

improving status of

pneumonia, amount

should be decreasing

and viscosity should

be thinning following

interventions; green,

brown or purulent

mucus indicate

continued presence

of pneumonia

>Coughing and deep

breathing cause

alveoli to open and

loosen mucous to

help clear the

airways

>Loosen mucous

plugs thus increasing

are available for gas

Page 101: Casestudy CAP

percussion and

vibration

> Elevate head

of bed

> Encourage

frequent position

changes

> Encourage

adequate rest

and limit

activities to with

in patient

tolerance.

Promote calm

and restful

environment

> Administer

oxygen as

exchange

> To maintain

airway patency

>Promotes optimal

chest expansion and

drainage of secretion

> Helps limit oxygen

needs/ consumption

>Pneumonia

increased mucous

Page 102: Casestudy CAP

ordered

>Administer

antibiotic as

ordered and

monitor for side

effects.

Ado

production and fluid

retention in lungs

which decreases

adequate gas

exchange;

supplemental oxygen

provides additional

oxygen for tissue

oxygenation

>Helps to stop the

proliferation of

microorganisms

Problem No. 3 Ineffective Breathing PatternAssessment Nursing

Diagnosis

Scientific

Explanation

Planning Nursing

Intervention

Rationale Evaluation

Page 103: Casestudy CAP

S= patient

may

verbalize

“Magkasakit

ku

mangisnawa.

O=Patient

Manifested

the

following :

>difficulty of

breathing

>shortness

of breath on

exertion,

paleness

Ineffective

breathing

pattern

related to

thick

tenacious

secretions

in the

bronchi

due to

inflammati

on of lung

tissue

Community-

Acquired is a

disease process

involving

inflammation of

lung tissue. It

typically results

when

microorganisams

enter the

normally sterile

lungs from the

nasopharynx and

produces

inflammation of

the lung

parenchyma.

Because of the

inflammation of

the alveoli are

filed with fluid

Short Term

:

After 4

hours of

Nursing

Intervention

s, the

patient shall

have a

normal

respiratory

rate,

rhythm,

depth and

reports a

shortness of

breath as

evidence by

decrease RR

from 38

> Assess

respiratory

system by noting

respiratory rate,

depth chest

expansion,

breath sounds,

arterial blood

gases, etc.

> Assist Patient

in assuming a

high- fowler’s

position or

position of choice

such as leaning

forward or over

bed table

> Increase oral

> Any of this

abnormalities would

indicate the studies

of the respiratory

system and

progression of

disease; also

establishes a

baseline comparison

>maximizes

thoracic cavity

space, decreases

pressure from

diaphragm and

abdominal organs

and facilitates use of

accessory muscles

>help to improve

hydration status and

Short

Term :

The patient

shall have a

normal

respiratory

rate,

rhythm,

depth of

breathing

and relief

from

shortness

of breath as

evidence

by

decrease

RR from 38

cpm to 16-

20 cpm

Page 104: Casestudy CAP

>RR of 38

cpm with

shallow,

rapid

breathing

>use of

supraclavicul

ar muscles

for

respiration as

well as

shoulder

muscles

> ć non-

productive

cough

> with

presence of

and mucus and

oxygen and

carbon dioxide

exchange cannot

take place at a

alveolar capillary

cellular

membrane level

due to blood flow

decreases

(deceased

perfusion of

blood in the

lungs)and

leukocytes and

fibrin consolidate

in the affected

part of the lung

due to a

decreased blood

flow there is a

decreased supply

cpm to 16-

20 cpm

Long

Term :

After 2 days

of Nursing

Intervention

s, the

patient shall

be free from

any signs

and

symptoms

of hypoxia

as

evidenced

by normal

ABG, etc.

fluids to 2000-

3000 ml/day as

tolerated

> Provide chest

physiotherapy,

bronchial

tapping,

vibration, etc.

>Assist with

activities of daily

living as required

> Teach patient

how to decrease

shorthness of

breath by

decrease secretions.

> mobilizes thick

secretions, and

facilitates clearing

of lung fields.

>patient with

pneumonia may lack

sufficient oxygen

reserves to perform

activites; even

eating may cause

severe dyspnea

> Knowing how to

control shortness of

breath will help

cope and have

optimal functioning

Long Term

:

The patient shall be free from any signs and symptoms of hypoxia as evidenced by normal ABG, etc.

Page 105: Casestudy CAP

rales on both

lung lobe

upon chest

auscultation

easily

fatigability

Patient may

manifest

the

following :

>severe dyspnea

> sitting up leaning forward, hands on knees

>Abnormal blood gases

of oxygen to

other tissues

leading to

ineffective

breathing

pattern

restructuring

activities

>Teach

pulmonary

hygiene;

prevention of

spread of

infection

>Provide

humidified low

flow of oxygen as

ordered

>Administer

bronchodilators

and expectorants

> Preventing spread

of infection and

subsequent

hospitalization

>Provide some

supplemental

oxygen to improve

oxygenation and to

make secretions

less viscous

>Enhances

expectoration of

secretions of

previously

ineffective cough

Page 106: Casestudy CAP

> abnormal inspiratory or/and expiratory ration

> pursed lip breathing

> altered chest excursion

>hypoxia (Confusion, restlessness, decreased vital capacity)

> Administer

antibiotics as

ordered

>Helps to prevent

or eradicate

infections to reduce

secretions and to

end to inflammation

Problem No. 4 Hyperthermia

Assessment Nursing Scientific Planning Nursing Rationale Evaluation

Page 107: Casestudy CAP

Diagnosis Explanation Intervention

S= patient

may

verbalize

“Mapali ku

panandman .

O=Patient

Manifested

the

following :

>flushed skin

>skin is

warm to

touch

> increased

Hyperther

mia

CAP is the

inflammation of

the lung

parenchyma due

to offending

organisms,

inflammatory

lung response

will be

stimulated

leading to the

release of

chemical

mediators that

would increase

blood flow to the

lung tissues

leading to

erythema,

swelling, pain,

Short Term

:

After 4

hours of

Nursing

Intervention

s, the

patient’s

body

temperature

will

decrease

from 38oC to

37oC.

Long

> Monitor body

core temperature

>Note presence

or absence of

sweating as body

attempts to

increase heat

loss by

evaporation,

conduction,

diffusion

> promote

surface cooling

by means of

loose clothing;

cool

>To have a baseline

data

>Evaporation is

decreased by

environmental

factors of high

humidity and high

ambient

temperature as well

as the body factors

producing loss of

ability to sweat

>Promote heat loss

by radiation,

conduction and

evaporation

Short

Term :

The

patient’s

body

temperatur

e shall have

decreased

from 38oC

to 37oC.

Long Term

:

Page 108: Casestudy CAP

RR

>

Diaphoresis

Patient may

manifest

the

following :

>Convulsions

> Hypotension

>Fluid and electrolyte imbalance

and increased

body

temperature that

would reset the

hypothalamus

which is the

major center for

regulation of

body

temperature

Term :

After 24

hours of

Nursing

Intervention

s, the

patient will

maintain a

normal body

temperature

during

hospitalizati

ons and be

free from

any

complicatio

ns of

pneumonia.

environment/fan;

cool/tepid

sponge bath

local icepack

especially in the

axilla and groin

> Review signs

and symptoms of

hyperthermia

>Encourage the

patient to take

vitamin C in the

diet such as

citrus fruits, etc.

>Discuss

importance of

adequate fluid

intake

>indicates need for

prompt

interventions

> to increase

resistance

> To prevent

dehydration

>To reduce

The patient shall have maintained a normal body temperature during hospitalizations and be free from any complications of pneumonia.

Page 109: Casestudy CAP

>Maintain bed

rest

>Provide high-

calorie diet

>Provide

supplemental

oxygen

>administer anti-

pyretics as

ordered

metabolic demands/

oxygen

consumption

> to meet increased

metabolic demands

>To offset increased

oxygen demand and

consumption

>To control

shivering and

seizure

Problem No. 5 Activity Intolerance

Assessmen

t

Nursing

Diagnosis

Scientific

Explanation

Planning Nursing

Intervention

Rationale Evaluation

Page 110: Casestudy CAP

S= patient

may

verbalize

“magkasakit

ku

mangisnawa

ampo

mimingal ku

gan

maglakad

kumu.”

O=Patient

Manifested

the

following :

> appears

weak

> poor skin

Activity

Intolerance

related to

increased

oxygen

demand

with

activity and

hypoxia

(lack of

oxygen

supply with

oxygen

demand)

The onset of

pneumonia is

generally marked

by fever,

dyspnea, and

shortness of

breath and easy

fatigability that

may lead to

inability to

perform

activities of daily

living.

Due to the

accumulation of

thick tenacious

mucous in the

alveoli altering

gas exchange

( oxygen and

Short Term

:

After 4

hours of

Nursing

Intervention

s, the

patient is

able to

perform

activities of

daily living

without

shortness of

breath such

as doing

personal

hygiene,

etc.

> Obtain

subjective data

from patient

regarding normal

activities prior to

onset of

pneumonia;

monitor for

labored

breathing,

fatigue and

exhaustion.

> Reduce level

of activity as

required in

response to

shortness of

breath.

>Helps to determine

the effects of

pneumonia on the

patient’s ability to

be active.

>If increased

physical activity

causes shortness of

breath, activity

should be reduced

until oxygenation is

adequate.

> Conserves energy

and reduces oxygen

demand patients

with pneumonia lack

enough oxygen

Short

Term :

The patient

shall be

able to

perform

activities of

daily living

without

shortness

of breath

such as

doing

personal

hygiene,

etc.

Page 111: Casestudy CAP

turgor

>pale nail

beds

> easy

fatigability

> non-

productive

cough

>shortness

of breath

during

activities

> RR of 38

cpm, with

shallow,

carbon dioxide)

between the

alveoli And

Long

Term :

After 24

hours of

Nursing

Intervention

s, the

patient

states that

he is

comfortable

with activity

performanc

e and

shortness of

breath is

improved

following

> Assist with

activities as

needed.

>Pace activities

and encourage

periods of rest

and activity

during the day.

> Monitor VS and

oxygen

saturation before

and after

activity.

> Gradually

increase activity

reserves to perform

activities

independently.

>It conserves

energy.

> Use the result to

indicate when the

activity may be

increased or

decreased.

> Activities should

be increased

gradually, as

tolerated, to avoid

over taxing the

patient.

Long Term

:

The patient shall states that he is comfortable with activity performance and shortness of breath is improved following cessation of activity, and the patient’s RR returns to baseline within 5 minutes.

Page 112: Casestudy CAP

rapid

breathing

Patient

may

manifest

the

following :

>Inability to perform physical activities

> level I functional level classification ( walk, regular phase, on level indefinitely; one flight or more but more

cessation of

activity, and

the patient’s

RR returns

to baseline

within 5

minutes.

as tolerated and

share guidelines

for progression

with patient.

> Discuss with

the patients

activities that

would be

appropriate once

at home that

would be within

the patient’s

activity

tolerance.

> Inform the

patient to stop

any activity that

> Physical activity

increases endurance

and stamina;

following

pneumonia, return

to normal activity

may take time.

> This indicate

intolerance to

activity and the

level of activity

should be

evaluated.

> Iron has a role in

oxygen transport

and increases

energy level.

Page 113: Casestudy CAP

shortness of breath than normal)

>labored breathing

>physical exhaustion

>oxygen saturation less than 90%

phy

produces

shortness of

breath.

> Encourage

intake of foods

high in iron and

good source of

energy such as

lean meat,

legumes which

are rich in

protein.

> Assist patient

to learn and

demonstrate

appropriate

safety measures.

> Have the

patient use

>To prevent

injuries.

>Improves

oxygenation and

provides oxygen

reserves to be used

with increased

demand.

Page 114: Casestudy CAP

oxygen

immediately

prior to activity

in the acute

setting, as

ordered.

Page 115: Casestudy CAP

2. Actual SOAPIERs

August 22, 2008

S= Ø

O= Received patient supine on bed, conscious & coherent; with an IVF

no. 10 of D5NM 1l at 550 cc level, regulated at 31-32 qtts/min, infusing

well on the left dorsal metacarpal vein

Vs taken and recorded are as follows: BP= 130/70 mmHg;

PR=104 bpm; RR=20bpm; T=36.9C/axilla

Patient appears weak

With pale conjunctiva and nailbeds

With dry lips and buccal mucosa

With symmetrical chest expansion

With non-productive cough

With rales upon auscultation on both lungs

Capillary refill of <3sec

A= Ineffective airway clearance r/t retained secretions secondary to

COPD AEB rales upon auscultation and non-produce cough

D= After 1 hr of NI, the patient will demonstrate behaviors to

improve/maintain clear airway

I= • Establish Rapport

Monitored and recorded VS

Identifies presence of dyspnea, cyanosis, and hemoptysis

Auscultated wealth sounds

Observe for signs of respiratory distress

Measured capillary refill

Encouraged patient to perform breathing/coughing exercises

and pursed-lip breathing

Encouraged patient to change positions every two hours

Instructed patient to increase fluid intake with SAP

Encouraged and provided adequate rest periods

Instructed to limit activities to level of respiratory tolerance

Encouraged patient to permanently quit smoking

Encouraged patient to eat nutritious foods

Page 116: Casestudy CAP

E= Goal met AEB patient’s demonstration of coughing exercise and

pursed-lip breathing and position changes.

August 23, 2008

S= “Agad kung susunga.” as verbalized by the patient

O= Received patient supine on bed, conscious and coherent; with an

IVF no. 12 of D5NM 1L at 150 cc level regulated at 31-32 qtts/min

infusing well on the left dorsal metacarpal vein

VS taken and recorded are as follows: Bp=110/70 mmhg; PR-95

bpm; RR=21 bpm; T=36.9 C/axilla

Patient appears weak

With pail conjunctiva and nailbeds

With productive coughs, yellowish in color

With rales on both lungs upon auscultation

Capillary refill of <3sec

Patient reports fatigue and weakness

A= Activity intolerance r/t imbalanced between oxygen supply and

demand AEB pallor, fatigue and Weakness

P= After 1hr of NI, the patient will participate willingly in necessary

activities within the level of own ability

I= • Established Rapport

Monitored and recorded VS

Noted presence of factors contributing to fatigue

Evaluated current limitations/degree of deficit in light of usual

status.

Noted client reports of weakness, fatigue, pain, difficulty

accomplishing tasks or insomia

Assessed emotional/psychological factors affecting the current

situation

Adjusted activities to prevent overexertion

Taught method to conserve energy.

Encouraged rest periods during /between activities to reduce

fatigue

Assisted with activities

Page 117: Casestudy CAP

Promoted comfort measures

Instructed patient on appropriate safety measures to prevent

injuries

Provided information about the effect of lifestyle and overall

health factors on activity tolerance

E= Goal Met AEP patient’s participation in activities within the level of

his own ability.

Page 118: Casestudy CAP

IV. CLIENT’S DAILY PROGRESS IN THE HOSPITAL

Admission

17 18 19 20 21 22 23 24

Discharged

25

NURSING PROBLEMS

Ineffective Airway

Clearance

Impaired Gas Exchange

Ineffective breathing

Pattern

Hyperthermia

Activity Intolerance

VITAL SIGNS

Temperature

Pulse Rate

Respiratory Rate

Blood Pressure

LABORATORY /

DIAGNOSIS

Φ

Φ

Φ

38.7

90

38

120/80

Φ

Φ

Φ

37.6

80

24

120/70

Φ

36.2

79

24

120/70

Φ

36.4

76

20

110/80

Φ

Φ

36.3

90

26

120/70

Φ

Φ

36.9

90

24

10/70

Φ

36.8

95

21

110/80

Φ

36.6

80

20

110/70

Φ

36.4

82

20

130/10

0

Φ

Page 119: Casestudy CAP

Chest X-ray

Sputum AFB

Blood Chemistry

Complete BLood

Count(CBC)

Urinalysis

Fecalysis

MEDICAL MANAGEMENT

PNSS 1L x 8 hours

D5LRS 1L x 8 hours

D5NM 1L x 8 hours

Nebulization

O2 Therapy

DRUGS

Cefuroxime 750 mg TID

Combivent neb q 6 hours

Paracetamol 500mg Tab

q 4 RTC

Loperamide 1 Tab for

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Page 120: Casestudy CAP

loose stool

Carbocesteine 500mg 1

cap TID

Furosemide 20 mg IV

now then q 12 ć BP

precaution

Azithromycin 500 mg

Tab 1 tab OD x 3 days

Ceftriaxone 1gm IV q 12

ANST (-)

Sinecod 1 Tab TID

Ventoline Expectorant

Capsule 1 cap TID

DIET

Soft

Φ

Φ

Φ

Φ

Φ

Φ Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Φ

Page 121: Casestudy CAP

2 DISCHARGE PLANNINGa. General Condition of Client Upon Discharge

Patient was not assessed upon discharge but was noted to have recovered.

b.S= O= Received patient on bed on supine position, conscious and coherent

VS taken and recorded as follows: T: 36.4C PR: 82bpm RR: 20bpm BP: 130/100mmHg.

Patient appears good and afebrile.

A= For home maintenance and management.P= After 2 hrs of nursing interventions patient will be able to verbalize understanding given prior to discharge. I= M> Ciprofloxacin 500mg/cap BID x 7 days. > Salbutamol tab 2mg BID > Ansimar neb/1 tab ½ BID. E> Deep Breathing Exercises

> Coughing Exercises> Limit activities and have rest periods.

T> IV fluids and medications. H> Encourage d to keep environment allergen free.

> Encouraged warm versus cold liquids as appropriate.> Provided information about the necessity of raising and expectorating secretions versus swallowing them.> Encouraged to have rest periods and limit activities to level of respiratory tolerance.> Encouraged to have a monthly check-up.> Encouraged to stop smoking.> Demonstrated pursed lip or diaphragmatic breathing techniques.> discussed rationale for and encourage continuation of successful interventions.

O> Advised patient to have a Follow-up check-up after one week.

D> Increased oral fluid intake. > High calorie, high protein diet of soft foods.

E= Goal Met AEB patient verbalized understanding of the health teachings give

Page 122: Casestudy CAP

CONCLUSION

Community- Acquired Pneumonia is one of the most common

infectious diseases addressed by clinician’s cause of morbidity and mortality

worldwide

In the case of Mr. CAP, the disease was caused primarily by personal

and environmental factors such as cigarette smoking, lack of vaccinations

during childhood years, job exposure to pathogens, and other factors. This

lead to the development of the disease and lack of action on the part of the

caretakers. Mr. CAP manifested difficulty of breathing, productive cough,

crackles on both lung fields, wheezing and angina pectoris

Through these manifestations different laboratory and diagnostic

procedures that would confirm and support the admitting diagnosis were

performed. Different results have been taken out such as to consider illness

such as PTB, AGE and Atelectasis which have been ruled out and the hospital

final diagnosis was Community- Acquired Pneumonia.

The result played an essential part on the part of the patient. Since the

family has no information about the signs and symptoms of the disease they

will now be aware on those things in order to prevent this illness.

Years have passed and still these diseases are present especially with

developing countries. The solution is simple but needs great discipline to

make it concrete. A clean surrounding will definitely boost our chances of

invading such disease condition.

The group strongly recommends that further studies are to be done to

clear out other vague information and misconceptions regarding this disease.

RECOMMENDATIONS

Page 123: Casestudy CAP

Information dissemination is the most important factor in this study.

In the ongoing battle against the pneumonia and its different types, the

turning point is the ability of the people to recognize the signs and

symptoms of the disease as well as the ability of the existing health sector

to respond immediately about the incidence. With these, the group

formulated the following recommendations in order to maternalize this

vision of emancipation from Community-Acquired Pneumonia.

Since pneumonia is one of the leading cause of mortality and

morbidity in the Philippines, the Department of Health as the major arm of

the Government when it comes to health together with the other sectors

of the society, allied medical professionals both in the government or

private sectors, must work and in hand arresting the incidence and

prevalence of pneumonia in the country. The programs of these sectors

should not only focus on the treatment but more importantly on the

preventive aspect. Department of health must also conduct studies on the

incidence, prevalence of the disease so as to mitigate its occurrence.

Community Health Workers must make an effort to update their

data about the incidence, prevalence of the disease by doing studies,

research and surveys. This should be done periodically. They should do

medical mission and target the vulnerable sectors of the society. Members

of the Health care team must gear themselves by continual education

about the disease so as to properly diagnose and manage of pneumonia in

the community level.

Since family members are the one who are always in contact with

the other members of the family, they are the better position of

monitoring the health of everyone. They should promote then health of

each member so as o prevent any progression of the disease like

Community- Acquired Disease. Acting in a swift manner regarding signs

and symptoms of the disease, is very important. This may empower

Page 124: Casestudy CAP

everyone and fulfil the goal of the Department of Health which is “Health

in the hands of the people by 2020.”

Page 125: Casestudy CAP

VIII. BIBLIOGRAPHY

BOOK SOURCES:

Smeltzer, et. al. Medical-Surgical Nursing: 11th Edition. Lippincott Williams

and Wilkins. 2008

DeglinHopfer, Valierant, Nazorel. Davis’ Drug Guide for Nurses: 10th Edition.

F.A. Davis Company, Philadelphia. 2007

Doenges, et. al. Nurses Pocket Guide: Diagnosis, Prioritized Interactions and

Rationales: 10th Edition. F.A. Davis Company, Philadelphia

McCance, et. al. Pathophysiology: The Biologic Basis for Disease Adul and

Children: 4th Edition. 2002

Schilling, et. al. Nursing Process Approach To Excellent Care: 4the Edition.

Lippincott Williams and Wilkins. 2006

ONLINE SOURCES:

http://www.medscape.com/viewarticle/475218

http://www.emedicine.com/MEDtopic3162.htm

http://www.utmedicalcenter.org/encyclopedia/1/000145.htm

http://www.mims.com/

http://www.doh.gov.ph/data_stat/html/mortality.htm

http://www.wrongdiagnosis.com/p/pneumonia/prevalenve.htmtypes

http://www.lungusa.org/site/c.dvLUK900E/b.22576/K.7FFF/

Human_Respiratory_System.htm

Page 126: Casestudy CAP

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