Community Acquired

Pneumonia –
Moderate Risk
Ward Nursing Training
Program
Group 1
 Patricia G. Tatiana
Ricarte, Jean V.
RN Bautista,
RN

Presente
d by:
Cristine Juvy Anne L. Cindy Ruth
Gretchen E. Gubantes, M. Ypilan,
Chiew, RN RN RN
 Introduction
You would think that in the
light of modern medical treatment
and wide availability of
antibiotics, pneumonia would no
longer kill us, right? Wrong! For
adults, this occur mainly as a
complication of other chronic
diseases like lung cancer, COPD,
tuberculosis, and other
debilitating illnesses that leave
them bedridden most of the time.
 Community-acquired
pneumonia (CAP) is a disease
in which individuals who have
not recently been hospitalized
develop an infection of the
lungs (pneumonia). Pneumonia
is an inflammation of the lower
air passages and air sacs of the
lungs resulting from infection
of the parenchyma of the
lungs. CAP is a common illness
and can affect people of all
 Community-acquired
pneumonia (CAP) remains
a major cause of death
worldwide accounting for
an estimated five (5)
million deaths per year.
In developed countries,
the antimicrobial era has
brought a 66% reduction
 Studying this disease will hopefully
give us nurses, together with the rest
of the health-care team, some more
updated information regarding the
disease and its proper management,
and the different nursing
responsibilities that should be taken
into consideration when faced with
this kind of case. Also, this case study
can contribute greatly to the nursing
research by providing necessary data
that could serve as basis for future
studies. Knowledge accumulated from
the making of this study helps in the
 The study is all about Patient
“Mumai”, 33-year old female
diagnosed with CAP-Moderate Risk.
Information relevant to the disease
treatment and prevention are being
tackled with complete reliable
information during the interview
phase relevant to the building of
concrete data that further
nourished the study. The group
hopes to contribute scholarly
manuscript that depicts the
 “Mumai”
Age: 33 years old Sex : Female
Marital Status: Married
Height: 5’2” Weight: 68 kilos
Address: Dumalag 1, Matina Aplaya Davao
City 8000

Religion: Foursquare
Birthdate: April 26, 1977
Diagnosis: Community
Acquired Pneumonia MR
Admitting Physician: Dr. Carl
Hill N. Florida
 Background of the Study
Patient Mumai is a 33-year old
female who was rushed to the
Emergency Room of Southern
Philippines Medical Center last June
24, 2010 due to onset of cough and
an on & off fever for two (2) weeks.
She also experienced back pain at
the right side. The client was initially
seen by Dr. Florida and was admitted
under his service at Medicine
 Objectives

General
Objective:
This study aims to provide
the nurses, future researchers,
readers and general
audiences to understand,
learn and gain more
knowledge regarding the case
of our patient; that is CAP-MR.
 
Specific
Objectives: To establish rapport with the
client and her family in order to
develop therapeutic working
relationship and gain trust for
obtaining significant information;
To present the client’s personal
and clinical data;
To trace the client’s health
history (past and present) as well
as the family health history
through the use of a genogram to
relate it to the client’s present
condition;
Specific
Objectives:
To discuss the etiology and
symptomatology of the
disease process;
To present the diagnostic
examinations and their
implications;
To present the drug studies of
all the prescribed medications
with the corresponding
nursing responsibilities;
To develop appropriate
NURSING
HEALTH
HISTORY
 Nursing History
History of Past
Illness
The client had completed her
immunization from 0-5 years of age.
She completed her vaccination from
tetanus toxoid and hepatitis B booster
during her adolescent years. She had
no history of serious illnesses except
for common colds, fever and cough. At
the age of 5-14 years of age, she
acquired common childhood diseases
such as measles, mumps and chicken
History of Present Illness
Fifteen (15) days prior to
admission, the client experienced
a cough and a n on & off-low
grade fever anytime of the day.
She consulted a doctor who
prescribed her Salbutamol. This
somehow gave relief on her,
however, her health condition
didn’t subside. Seven (7) days
prior to admission, then she
experienced a back pain at the
right side and, which is also
 Sociocultural Background of the
Family
Patient Mumai belongs to a
Bisaya group wherein her
biological parents, Kokoy and
Kikay, raised her in the place of
Calinan. She has eight (8)
siblings and she’s the fourth
child. When she decided to get
married, she separated with her
parents and live together with
ANATOMY AND
PHYSIOLOGY
 The next structure after the larynx is the
trachea which leads down to the lower respiratory
system. From the trachea are the bronchi, which
branch down to the pleural cavity, where both lungs
are located. Each lung consists of lobes separated
by deep fissures.
Click to edit Master text stylesThe right lung has three
Second level while the left one has only
● Third level
Fourth level
● two. They are made up of
Fifth level
●
elastic fibers that give the
ability to handle large
changes in air volume. The
diaphragm is the muscle
that makes up the floor of
the thoracic cavity and
plays a major role in the
pressure and volume of air
moving in and out of the
PATHOPHYSIOL
OGY
 narative
Inhalation of the infectious agent causes it to transverse thru the upper
respire airways. Damaging toxins are being released and are multiplied
within the system downwards causing a disease called pneumonia or the
inflammation and edema of the lungs.
At the same time, Normal defense mechanisms occur such as the cough
reflex, mucocilliary transport, pulmonary macrophage, fever,
phagocytosis and increased metabolic demands.
If left untreated, this would result to accumulation of debris, fluids and
exudates which consolidates the lung tissues, ending up in alveolar
collapse, atelectasis, respiratory distress and a possible death.
Recovery usually involves focal organization of the lung by fibrosis,
returning to normal structure and functioning by resolution through early
detection and treatment regimen compliance.
 The pathophysiology
of community
acquired pneumonia
PREDISPOSING AND CAUSATIVE AND
based on the case
PRECIPITATING ETIOLOGIC
provided may be The said causative and
FACTORS: FACTORS:
predisposingly caused etiologic factors
by a high risk causing this infection
environment where are any among
the patient lives in streptococcus
and several familial pneumonia,
histories of haemophilus influenzae
respiratory illnesses. and atypical organisms
However it has most such as chlamydia,
probably been mycoplasma and
precipitated by legionella via
inhalation of any respiratory droplet
among the infectious transmission
agents causing
pneumonia.
 SYMPTOMATOLO CLASSIFICATIO
GY: N:

Upon medical admission,

patients are being classified to
The subjective data
presented on this case be either low risk, moderate
was cough, fever, risk or high risk by the use of
malaise, dyspnea, the pneumonias severity
chest and back pain. index. It is an assessment
However, other based algorithmic method of
symptoms such as categorization. Aside from
chills and palpitations statistical purposes this, aids
may also be included
with the disease’s the health professionals on
symptomatology. how to address the patient
and how to plan nursing care
and treatment regimen for
them.
The 33 year old female
patient in this case was
diagnosed of moderate risk
community acquired with an
PNEUMONIA
SEVERITY
INDEX(PSI)
Score = total
points
accumulated
below
RISK CATEGORY CLASSIFICATION

*Low Risk CAP - outpatient

**Moderate Risk CAP – ward admission
***High Risk CAP – ICU admission
DOCTOR’S ORDER
 NURSING
ASSESSMENT
 Nursing Assesment
Our patient Mumai, 33 year old female, married, a
housewife
I. General and a Filipino Citizen was admitted at the
Survey
Southern Philippines Medical Center due to
complaints of cough and on and off low grade fever
for two week. She was admitted last June 24, 2010 at
exactly 7:29 pm. Upon assessment last June 27,
2010, the patient was alert, responsive and coherent
to time, place where she was and the person around
her. She has an Intravenous Fluid of PNSS 1 liter
regulated at 120cc/hr and infusing well at her right
II. Vital
metacarpal vein. With oxygen inhalation via nasal
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cannula standby at bedside, only used when needed.
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III. The Skin IV. The Nails

Upon inspection, the The nails of our patient

patient’s skin was warm were intact and well-
to touch, slightly moist trimmed. The patient
and smooth. There was has pinkish nail beds
no presence of lesion. and is smooth in texture.
When we test her skin Her capillary refill time
for mobility and turgor, was 2 seconds and has a
skin rapidly resumes its convex curvature of
original shape after fingernail plate. No
pinching. lesions were noted
around her fingernails
and toenails.
V. The Head and Skull VI. The Hair

The Skull was Our patient has a long

normocephalic and had black hair, slightly dry,
symmetrical facial and evenly distributed.
features. There were no No presence of infection
deformities noted such or any infestations noted
as masses, bulges and upon inspection at the
tenderness upon back of the ears and
palpation. There was along the hairline in the
symmetrical facial neck. Hair on the body
expression when the was fine and evenly
group asked the patient distributed.
to raise her eyebrow,
puff her cheeks, smile
and frown, close her
eyes tightly and showing
VII. The Eyes
Both eyes were symmetrical upon
inspection; it can follow the direction
of our finger when we test her visual
acuity. The patient’s eyebrows were
evenly distributed. It was
symmetrically aligned and has equal
movement. Eyelashes curled slightly
outward. The eyelid on the other
hand has no discharges and
discoloration. The sclera on both
eyes was yellow and clear, irises are
black and round. Pupils are equally
round, reactive to light and constrict
simultaneously with 2mm in size
when passed by a light. The
Conjunctivas are pinkish in color.
There was no tenderness noted upon
palpation of the lacrimal duct. The
patient was able to see objects in
periphery when we test her ocular
eye movement.
VIII. The Ears
Symmetrical auricles on both
ears were noted. Pinnas were
in line with the outer canthus
of her eyes. There was no
tenderness noted upon
palpation. Auricle had the
same color with the facial
skin. Thus, it is firm and non
tender. The external canal of
her ear has no discharges,
inflammation nor impacted
cerumen noted upon
inspection. Ears were elastic
and coils back to its original
shape after being folded.
Patient was able to hear and
respond to a normal tone of
 IX. The Nose
No discharges noted upon
inspection. Nasal flaring was
noted upon early monitoring of
the vital signs. Both nostrils are
present, and no tenderness and
masses or nodules noted upon
palpation. The mucosa is
pinkish with hair. Thus, no
tenderness on sinuses noted
upon palpation. There was
good patency on both nasal
cavities as the group instructed
the patient to occlude of her
nares and breathe.
X. The Mouth
Lips were pinkish in
color, moist in texture,
with no cracks noted on
the upper and lower lips;
gums are pinkish in
color; tongue is located
in the midline. No
missing teeth noted. No
dentures present. Uvula
and tonsils are not
inflamed and gag reflex
is present.
 XII. The Thorax and
XI. The Neck Lungs

The patient’s neck has The thorax is symmetrical from

no evident masses, posterior and lateral views.
unusual swelling, or any There was no presence of
pulsations. Upon letting masses or tenderness upon
palpation. At the early vital sign
her neck move such as
monitoring, the respiratory rate
flexing, extending, right
of the patient was 30 cycles
and left rotation, and
per minute, use of accessory
hyperextension, she was muscles were noted. Increase
able to move it easily tactile fremitus on the right
without pain or side of the lung was noted
discomfort. The thyroid upon percussion. There was
was not visible upon presence of crackles upon
inspection and is auscultation. Rapid shallow
smooth, without breathing pattern was also
nodules, masses or noted.
 XIII. The Heart XIV. Breast and Axilla

The heart sounds are Breasts are round in shape and

asymmetrical. Areola is round
distinct and regular with and dark brown color. Nipples
the rate of 90 beats per are round and inverted, and
minute. The point of brown in color. No discharges
maximal impulse is best or lesions noted. No masses or
tenderness noted upon
heard at the left mid palpation on both breast and
clavicular line, 5th axilla. Upon inspecting the
intercostal space axilla, there were no rashes or
any signs of infection such as
redness or swelling observed.
The axilla is smooth, light
brown with moderate amount
of hair. The lymph nodes were
also not palpable.
XV. The Abdomen XVI. Genitourinary

Upon inspection, there no Voiding pattern of the

scars or lesions noted. client is usually done
There are no evident early in the morning,
signs of infection of the between the day and
umbilicus such as before going to sleep.
redness, pus formation,
discoloration or swelling. Voiding usually ranges
No abdominal distention from 3 to 4 times a day.
noted. Urine is light yellow in
color; amount of urine
usually ranges from
570cc to 800cc.
 XVII. Extremities
Upper Limb
The patient has equal
strength on both upper
extremities. Full range of
motion was observed when
asked to move her arms in
a circular motion. There
was no presence of swelling
or deformity.
Lower Limb
There were no
deformities noted on
both legs. Her legs and
knees can do all the
range of motion such as
extending and flexing
without feeling of
discomfort.
 XVIII. Neurological Assessment

Language. The patient had no difficulty

communicating to us. She was able to answer our
questions well which made our interaction brief
and concise.

Orientation. Patient was oriented, she knows that

she was admitted on June 24, 2010 at Southern
Philippines Medical Center. She was also of the
time during our assessment.

Memory. Patient has no problem in recalling

memory. She remembers her birthday and the day
she was admitted.
 EVALUATION:
The patient’s overall attitude towards the
assessment was good since she was able to
cooperate and answer the questions when asked.
She is very participative and willing to submit
oneself for the welfare of everyone involve in the
assessment that includes her. The only
abnormalities noted were observed during the vital
signs monitoring early at 8:00 am. Moreover, such
abnormalities noted were respiratory rate of 30
cycles per minute, temperature of 38.2 degree
Celsius, patient’s skin was warm to touch, presence
of nasal flaring, crackles upon auscultation of
patient’s lungs, presence of rapid shallow breathing,
DIAGNOSTIC
LABORATORY
STUDIES
CBC + PLATELET
Date: June 25,2010
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BLOOD CHEMISTRY
Date: June 25,2010
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 URINALYSIS
Date: June 25,2010
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 SPUTUM AFB
Date: June 27, 2010
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CHEST X-RAY
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NURSING
THEORIES
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Prob Scientific G Interven Ratio Evalua
lem Basis o tion nale tion
al

NURSING CARE
PLAN
Nursing Diagnosis: Ineffective Airway
Clearance related to Retained Mucus
Secretions
 Nursing Diagnosis: Altered
Thermoregulation related to disease
process
Nursing Diagnosis: Fatigue related to
Sleep Deprivation
 Nursing Diagnosis: Altered Tissue
Perfusion related to Impaired
Transport of Oxygen across Alveolar
Membrane
DRUG STUDY
 AMPICILLIN SULBACTAM (UNASYN)

Classification: Anti-infective
Drugs/Penicillin
Dosage: 750 mg 2 vials every 8 hours
ANST
Indication: It is a combination penicillin antibiotic.
Ampicillin kills bacteria that cause infection, or stops
the growth of bacteria. Sulbactam helps the
ampicillin to work better. They fight bacteria in the
body. It is used to treat many different types of
infections caused by bacteria.
Mechanism of action: Ampicillin exerts
bactericidal action on both gram-positive and
gram-negative organisms. Its spectrum includes
gram-positive organisms e.g. S pneumoniae and
other Streptococci, L monocytogenes and gram-
negative bacteria e.g. M catarrhalis, N
gonorrhoea, N meningitidis, E coli, P mirabilis,
Salmonella, Shigella, and H influenzae.
Ampicillin exerts its action by inhibiting the
synthesis of bacterial cell wall. Sulbactam
inhibits β-lactamases and extends the spectrum
of ampicillin to include β-lactamase producing
 Contraindications: Allergy to penicillins; infectious
mononucleosis

Adverse Reactions: Pain at Injection site,

thrombophlebitis, diarrhoea, itching, nausea,
vomiting, flatulence, candidiasis, fatigue, malaise,
headache, chest pain, glossitis, abdominal
distention, dysuria, urinary retention, oedema,
erythema, epistaxis, mucosal bleeding.
Potentially Fatal: Fatal anaphylaxis
Nursing Responsibility:
•Check drug three times and with another nurse. Follow the 10 Drug Rights.

•Check patient for hypersensitivity

•Obtain specimen for culture and sensitivity tests before giving first dose

•Watch for bleeding tendency and hemorrhage.

•Check patient’s temperature and watch for other signs and symptoms of

superinfection, especially oral and rectal candidiasis

•Instruct pt. to immediately report signs and symptoms of hypersensitivity

reaction,
such as rash, fever, or chills.
•Monitor liver function test results during therapy, especially in patients with

impaired liver function

 PARACETAMOL (TYLENOL)

Classification: Non-narcotic
analgesic

Dosage: Paracetamol 500mg every 4 hours PRN

or ↑37.7
Indication: To reduce fever in bacterial or viral
infections. It also control pain due to headache,
earache, arthralgia, myalgia, musculoskeletal pain,
arthritis, teething

Mechanism of action: Decreases fever by a

hypothalamic effect leading through sweating
and vasodilation. Also inhibits the effect of
pyrogens on the hypothalamic heat-regulating
centers. May cause analgesia by inhibiting CNS
prostaglandin synthesis; however, due to
minimal effects on peripheral prostaglandin
synthesis, acetaminophen has no anti-
inflammatory or uricosuric effects. Does not
cause any anticoagulant effect or ulceration of
the GI tract. Antipyretic and analgesic effects
are comparable to those of aspirin.
Contraindications: Renal insufficiency, anemia.
Clients with cardiac or pulmonary disease are
more susceptible to acetaminophen toxicity.

Adverse Reactions:
•Hematologic: methemoglobinemia, hemolytic anemia,

•Allergic: urticarial, erythematous, skin reaction

•Miscellaneous: CNS stimulation, hypoglycemic coma, jaundice,

drowsiness

Nursing Responsibility:
•make sure that the drug is given at the right time as ordered

•make sure that is drug is not expired

•Observe for adverse reaction of the drug

•Encouraged patient to drink plenty of water

•Document on patients medication sheet

•Check urine for occult blood and albumin to assess for nephritis

•Report pallor, weakness, and palpitations; S&S of hemolytic anemia, dyspnea,

rapid, weak pulse; cold extremities; unexplained bleeding, bruising, sore throat,
malaise, feeling clammy or sweaty; or subnormal temperatures may also be
symptoms of chronic poisoning;
•Document presence of fever. Rate pain, noting type, onset, location, duration, &

intensity.
•Recheck temperature after 15 minutes
 BUTAMIRATE CITRATE (Sinecod Forte)

Classification: Antitussive

Dosage: Butamirate Citrate 1 tablet TID

Indication: For dry cough of any

aetiology(including in pertussis) and cough caused
by bronchoscopy.

Mechanism of action: Butamirate citrate

belongs to the anti cough medicines of
central action. Sinecod exerts
antitussive(antitussic),  expectorant,
moderate bronchodilatory action with anti-
inflammatory effects. Sinecod lowers the
resistance of airways and improves blood
oxygenation and spirometery indexes.
Contraindications: Hypersensitivity, Pregnancy
and Breastfeeding
Adverse Reactions: Rash, nausea,
diarrhoea and vertigo have been
observed in a few rare cases (a total of
approximately 1% of treated cases in
clinical trials), resolving after dose
reduction or treatment withdrawal.

Nursing Responsibility:
•Assess cough type and frequency
•Assess patient’s Vital Signs

•Assess sleep pattern.

•Instruct patient to take drug exactly as

prescribed
•Monitor for adverse reactions

•Advise patient to take each dose with one glass

of water
•Encourage patient to increase fluid intake

•Encourage deep-breathing exercises

 Indication: For dry
cough of any
aetiology(including in
pertussis) and cough
caused by bronchoscopy.
Dosage:
AZITHROMYCIN (ZITHROMAX) Azithromycin 500mg 1 tablet
Classification: Agent for OD
atypical mycobacterium, anti-
infectives
Mechanism of action: Butamirate citrate
belongs to the anti cough medicines of
central action. Sinecod exerts
antitussive(antitussic),  expectorant,
moderate bronchodilatory action with anti-
inflammatory effects. Sinecod lowers the
resistance of airways and improves blood
oxygenation and spirometery indexes.
Contraindications: Contraindicated with
hypersensitivity to azithromycin, erythromycin, or
any macrolide antibiotic
 Adverse Reactions:
•CNS: Dizziness, headache, vertigo, somnolence,

fatigue
•CV: Palpitations, chest pain

•GI: Diarrhea, abdominal pain, nausea, vomiting,

diarrhea, dyspepsia, flatulence, vomiting, melena,

pseudomembranous colitis
•Hepatic: Cholestatic jaundice

•Skin: rash, photosensitivity

•Other:Superinfec tions, angioedema, rash,

photosensitivity, vaginitis
Nursing Responsibility:
•Asses patient for infection (vital signs; appearance of wound, sputum,

urine and
•stool; WBC)

•Obtain specimens for culture and sensitivity before initiating therapy

•Observe signs and symptoms of anaphylaxis

•Administer 1 hr before or 2 hr after meals. Food affects the absorption of

this drug
•Instruct client not to take azithromycin with food or antacids. May cause

stomach cramping, discomfort, diarrhea and etc.

•Report any adverse effects felt by the patient.

•Advise patient to take drug as prescribed, even after he feels better

•Advise patient to avoid excessive sunlight and to wear protective clothing

and use sunscreen when outside

INTRAVENOUS FLUID – PNSS (30-31 gtts/min)

Isotonic
Solution
Indication: Replacement &
maintenance of fluid &
electrolytes
Nursing Responsibilities:
 
2

Before hooking to patient, check for any

discoloration and expiration date.
1. Make sure when priming the line there is
no bubbles
2. Monitor pt. frequently for:
a. Signs of infiltration / sluggish flow
b. Signs of phlebitis / infection
c. Dwell time of catheter and need to
be replaced
d. Condition of catheter dressing
3. Check the level of the IVF.
4. Correct solution, medication and
volume.
5. Check and regulate the drop rate.
6. Change the IVF solution if needed
PROGNOSIS
 General Prognosis

Our patient’s overall prognosis is fair

because despite her stay in the hospital
she wasn’t able to comply with most of her
medications which were essential to her
ultimate recovery. In all of our interactions
with her, she was very open about lifestyle
and concerns which allowed us to render
nursing care and health teachings. It made
our time with her worthwhile.
MEDICA EXER TREAT HEALT O DI SPIRIT
TIONS CISE MENTS H T. P E UAL
D T

DISCHARGE PLAN
 M EDICATIONS
Explain to the patient an the significant others
the importance of the following:
the medications name, its action and its potential
side effects
the right time and route of administering the drug
how to manage common side effects of the drugs
Instruct the patient to take the entire course of
the prescribed medications to prevent recurrence
of the illness.
Encourage patient to watch out and report any
unusualities during taking the prescribed drugs.
 E XERCISE
Encourage patient to take plenty of rest.
Adequate rest is important to maintain
progress towards full recovery.
Encourage patient to lessen doing
strenuous activity to avoid fatigue.
Encourage patient to do deep breathing
exercises.
 T REATMENT

Explain to patient to follow the prescribed

medications to promote wellness.
Instruct patient to report any signs of side
effects of the treatment done.
Explain the significance of having a follow-up
appointment to the doctor.
 H EALTH
TEACHING
Encourage to have a clean and safe
environment conducive for wellness.
Encourage to have good personal
hygiene and to always wash hands.
Instruct patient and family to avoid
exposing to an environment with too
much pollution like smoking.
Explain to the patient the importance of
protecting others form the infection.
 O UTPATIENT
DEPARTMENT

Encourage patient to comply with the

therapeutic regimen such as the
medications.
Instruct patient to have a follow-up
check up to the doctor.
D IET

Encourage patient to eat healthy and

nutritious foods. Eat foods rich in
calorie and Vitamin C.
Encourage patient to drink lots of
fluids, especially water.
 s PIRITUAL
Encourage family to provide emotional
support to the patient.
Encourage patient and family to have
time praying together to enhance self
concept and hope that could aid in the
wellness of the patient.
Encourage patient and family to always
have an open communication.
 INSIGHTS
As nursing graduates, we have encountered many patients
with different diseases. We learned and experienced many things
throughout our endeavors. In our study about Community Acquired
Pneumonia (CAP) Moderate Risk, we learned that for the past
years it remained a formidable foe and that it should never be
underestimated. It ranked fourth in the Top Ten Leading causes of
morbidity in the 2007 survey of the Department of Health and
third in the Top Ten Leading cause of Mortality. Prompt treatment
is needed to avoid life-threatening complications. People must
remember that simple acts of hand washing, covering your mouth
and nose when coughing/sneezing and taking your vitamins
everyday are vital to disease prevention. These simple acts can
make a big difference in our lives. They must be constantly
reminded of these steps for disease prevention and early
consultation. A lot of patients stop taking their medications the
moment they feel better. Since pneumonia patients usually get
prescribed antibiotics, it is essential for them to be reminded about
medication compliance in terms of schedule and duration to
prevent microbial resistance and disease reoccurrence.