I. INTRODUCTION This is a case of a 74 year old woman who was diagnos e d w i t h Community Acquired Pneumonia.

Pneumonia is an inflammation or infection of the lungs most commonly caused by a bacteria or virus. Pneumonia can also be caused by inhaling vomit or other foreign substances. In all cases, the lungs' air sacs fill with pus , mucous, and other liquids and cannot function properly. This means oxygen cannot reach the blood and the cells of the body.M o s t p n e u m o n i a s a r e c a u s e d b y b a c t e r i a l i n f e c t i o n s . T h e m o s t c o m m o n infectious cause of pneumonia in the United States is the bacteria Streptococcus pneumoniae. Bacterial pneumonia can attack anyone. The most common cause of bacterial pneumonia in adults is a bacteria called Streptococcus pneumoniaeor Pneumococcus. Pneumococcal pneumonia occurs only in the lobar form. An increasing number of viruses are being identified as the cause of respiratory infection. Half of all pneumonias are believed to be of viral origin. Most viral pneumonias are patchy and the body usually fights them off without help from medications or other treatments. Pneumococcus can affect more than the lungs. The bacteria can also cause serious infections of the covering of the brain (meningitis), the bloodstream, and other parts of the body. Community-acquired pneumonia develops in people with limited or no contact with medical institutions or settings. The most commonly identified pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and atypical organisms(ie, Chlamydia pneumoniae,Mycoplasma pneumoniae, Legionella sp). Symptoms a n d s i g n s a r e : fever, cough, pleuritic chest pain, dyspnea, tachypnea, and tachycardia. Diagnosis is based on clinical presentation and chest x-ray. Treatment is with empirically chosen antibiotics. Prognosis is excelle n t f o r relatively young or healthy patients, but many pneumonias, especially when caused by S. pneumoniae or influenza virus, are fatal in older, sicker patients Name: E. CostalesAge: 74 years oldSex: FemaleR e l i g i o n : R o m a n C a t h o l i c Date Admitted: September 17, 2009 at exactly 11:15 AMAdmission diagnosis: COPD not in exacerbationFinal diagnosis: Community Acquired pneumonia (CAP)moderate Ris

III.PATIENTHISTORY Chief Complaint: Difficulty of Breathing General Data: This is a case of a 74 year old female Filipino, presently residing in Adelina 3 Binan, Laguna who was admitted in Perpetual Help Hospital onSeptember 17, 2009. History of Present Illness: 5 days prior to admission, patient had positive signs and symptoms of cough, yellowish pleghm, persistent fever and back pain. Knowing that thesesigns and symptoms were just forms of little discomforts, she self medicatedwith paracetamol. However, she noticed no changes and experienceddifficulty of breathing so she sought medical consultation. IV. PHYSICAL ASSESSMENT Date Assesed: September 17, 2009 Time Assessed:Vital Signs: Blood Pressure: 110/60 Temperature: 35.7 CPulse rate: 78bpmRespiratory rate: 26 breaths/min General appearance: The patient is awake, lying on bed, conscious and coherent withan IVF of PNSS and side drip of D5W with incorporation of aminophylline on the right arm. V. ANATOMIC AND PHYSIOLOGY OVERVIEW The lungs are paired, cone-shaped organs which take up most of the space in our chests, along with the heart. Their role is to take oxygen into the body, which w e n e e d for our cells to live and function properly, and to help us get rid o f carbon dioxide, which is a waste product. We each have two lungs, a left lung a n d a right lung. These are divided up into 'lobes', or big sections of tissue separated by 'fissures' or dividers. The right lung has three lobes but the left lung has only two, because the heart takes up some of the space in the left side of our c h e s t . The lungs can also be divided up into even smaller portions, called 'bronchopulmonary segments'. These are pyramidal-shaped areas which are also separated from each other by membranes. There are about 10 of them in each lung. Each segment receives its own blood supply and air supply. Air enters your lungs through a system of pipes called the bronchi. These pipes start from the bottom of the trachea as the left and right bronchi and branch many times throughout the lungs, until they eventually form little thin-walled air sacs or bubbles, known as the alveoli the alveoli are where the important work of gas exchange takes place between the air and your blood. Covering each alveolus is a w h o l e n e t w o r k o f l i t t l e blood vessel called capillaries, w h i c h a r e v e r y s m a l l

branches of the pulmonary arteries. It is important that the air in the alveoli and the blood in the capillaries are very close together, so that oxygen and carbon dioxide can move (or diffuse) between them. So, when you breathe in, air comes down the trachea and through the bronchi into the alveoli. This fresh air has lots of oxygen in it, and some of this oxygen will travel across the walls of the alveoli into your bloodstream. Travelling in the opposite direction is carbon dioxide, which crosses from the blood in the capillaries into the air in the alveoli and is then breathed out. In this way, you bring in to your body the oxygen that you need to live, and get rid of the waste product carbon dioxide.

VI. PATHOPHYSIOLOGY Virulent Microorganism Streptococcus Pneumoniae

Microorganism enters the nose( nasal passages)

Passes through the larynx, pharynx, trachea

Microorganism enters and affects both airway and lung parenchyma

Airway Damage

Lung Invasion

Infiltration of Bronchi

flattening of epithelial cells

Infectious organism lodges

macrophages and leukocytes

Stimulation in bronchiole

necrosis of bronchial tissue

Mucus and phlegm production

Narrowing of air passage Alveolar collapse Increase pyrogen in the body Necrosis of pulmonary tissue Fever Overwhelming sepsis Productive/ non productive Difficulty of breathing Coughing

Death

VII. Medical Management VIII. Diagnostic Exam Chest X-ray Result: Impression: There are reticolunodular opacities on both lung fields with upward traction of left hilus. There are dilated thick walled bronchi noted on both lower lobes. Heart is not enlarged. Aortic knob is sclerotic other visualized structures are unremarkable. Findings are suggestive of Extensive PTB, Bilateral with cicatrical changes, left upper lobe. Bacteriologic correlation is suggested. Clinical Chemistry Result: Sodium: 124.9 mmol/L Normal: 135.0-148mmol/L Hematology Result: Hct: 0.29 Normal: 0.37-0.47 WBC: 23.5x10 Normal: 5.0-10.0x10 Segmenters: 0.87 Lymphocytes: 0.13 Urinalysis: Color: Light Yellow Transparency: Slightly Hazy Reaction:(pH) 6.0 Protein: +1 Glucose: negative Specific Gravity: 1.010 Pus cells: 3-4/HPF RBC: 2-3/hpf Crystals: A Urates: Many Mucus threads: few Cast: Fine Granular cast : 1-2/HPF

IX. Drug Study Generic Name: Hydrocortisone Sodium succinate Brand Name: Solu-Cortef Classification: Corticosteroid, short acting Dosage: 100mg IV, q 6 hours Pharmacokinetics: Metabolism: Hepatic; half life 80-120min.Distribution: Crosses Placenta; enters breast milk Excretion: Urine Indications: Replacement therapy in adrenal cortical insufficiency Hypercalcemia; associated with cancer Short term inflammatory disorders Contraindications: Infections, especially tuberculosis, fungal infections, amoebiasis, hepatitis B, liver disease, liver cirrhosis, active or latent peptic ulcer. Adverse Reaction: Vertigo, headache, hypotension, shock, thin, fragile skin, petechiae, amenorrhea, muscle weakness. Nursing Considerations: 1. Give daily before 9AM to mimic normal peak diurnal corticosteroidlevels and minimize HPA suppression.2.Space multiple dose evenly throughout the day.3.Use minimal dose for minimal duration to minimize adverse effects.4.Use alternate day maintenance therapy with short acting corticosteroids whenever possible.

Generic Name: Acetylcysteine Brand Name: Fluimucil Classification: Mucolytic Agent Dosage:Pharmacokinetics: Metabolism: Hepatic; half life 6.25 hrExcretion: Urine (30%) Indications: Mucolytic Adjuvant therapy for abnormal, viscid, or inspissated mucussecretion in acute and chronic bronchopulmonary disease(pneumonia,asthma,TB). Contraindications: Contraindicated with hypersensitivity to acetylcysteine; use cautionand discontinue if bronchospasm occurs. Adverse Reaction: Nausea, rhinorrhea, bronchospasm especially in asthmatics,stomatitis,and urticaria. Nursing Considerations: 1.dilute with normal saline solution or sterile water for injection. 2.Administer the ff drugs separately because they are incompatiblewith acetylcysteine: tetracyclines, hydrogen peroxide, trypsin.3.Use water to remove residual drug solution on the patients face after administration by face mask.4.Inform patient that nebulization may produce an initial disagree able odor, but will soon disappear.

X. NURSING CARE PLAN Problem: Difficulty of breathing Diagnosis: Ineffective Airway Clearance related to increased mucus production. ASSESS MENT Subjective :nagrereklamonga yang si nanay na nahihirapan siya huminga, dami din kasi plema eh as verbalized by relative DIAGNOSIS SCIENTIFIC REASON Increased Mucus Production Is often Caused by an underlying illness. If mucus is the most prevalent symptom, it is usually caused by something simple like allergies or the common cold. Other illnesses that result in excessive mucus production include pneumonia, flu and bronchitis OBJECTI VES Short term goal: After 3-4 hours of intervenetion, patient will expectrate secretions effectively and RR will decrease from 26 to normal range of 16-20/min Long term goal: After 3 days of intervention, patient will maintain patent airway as evidenced by normal RR INTERVENTION Independent: 1.Assessed rate/depth of respiration and chest movement. 2.Elevated Head of bed and changed position frequently. 3.Assisted Patient with frequent deep breathing exercises. 4. Encouraged increase in fluid intake. Collaborative :5.Administered Mucolytics asIndicated. (Fluimucil) 6.Provided Supplementalfluids. (IVF: PNSS) 7.Monitored chest Xray, ABG and pulseoximetry results RATIONALE EVALUA TION Goal half met. After 4 hours of nursing Intervenetion, patient expectorate secretion and RR decreased from 26/min to22/min

Ineffective Airway Clearance related to increase mucus production

Objective :*RR- 26 *Dyspnea *(+)nonproductive cough *Use of Acessorymuscle

1.Tachypnea, Shallow respiration are usually present. 2.Lowers Diaphragm, promoting chest expansion, mobilezation and expectoration of secretion 3.Deep Breathing Facilitates Maximum expansion of the lungs & smaller airways 4.Fluids aid inmobilizatio n& ExpectoRations of secretions 5.Aids inmobilization of secretion 6.Fluids Are required to replace insensible loss & aids in mobiliza-tion of secretions. 7.Followsprog ress & effects of disease process