PAMANTASAN NG LUNGSOD NG MAYNILA (University of the City of Manila) Intramuros Manila

College of Nursing

A Case Study of Pneumonia

In partial fulfillment for the requirement in Medical-Surgical Nursing I

Submitted By: ESTEVES, Christian C. BSN III-1

Submitted To: Professor Enrico P. de Jesus, RN, RM

July 7, 2011

I. CASE INTRODUCTION 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. Below is a presentation of case on Pneumonia.

CASE REPORT This is a case of an 18 year-old, non-hypertensive, non-diabetic single male, Filipino, who is currently residing at Pandacan, Manila, and admitted at Santa Ana Hospital on July 2, 2011 diagnosed with Pneumonia, with chief complaint of Difficulty of Breathing, fever, and chest pain. Upon admission, patient had positive signs and symptoms of cough, yellowish phlegm, persistent fever, chest and back pain. Having a minimal knowledge on diseases, he and his family self-medicated him with Paracetamol. However, he noticed no changes and experienced difficulty of breathing. On examination, the patient exhibits adventitious sounds upon auscultation, more efforts and unequal chess wall expansion when inhaling, dull on percussion, and has presence of wound in the left leg and presence of tattoo in the left deltoid.

II. SCHEMATIC DIAGRAM OF PATHOPHYSIOLOGY Virulent Microorganism Streptococcus Pneumoniae

Microorganism eneters 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

mucus and phlegm production Stimulation in bronchioles Alveolar collapse Narrowing of Air Passage Increase pyrogen in the body DIFFICULTY OF BREATHING FEVER necrosis of bronchial tissues COUGHING

III. DIAGNOSTIC PROCEDURES AND LABORATORY ANALYSIS NURSING HEALTH HISTORY Past Health History Upon interview, the patients mother was asked about the history of illness of her son, she verbalized that her son had cough, dyspepsia, and cold hands. The patients immunization is hardly remembered. The patient has no history of allergies, and no hospitalization records. According to the mother, she gave Biogesic (Paracetamol) and Loiscol (Carbocisteine). Present Health History Prior to admission, the patients mother verbalized that the patient is experiencing cough, and cold since June 24, 2011, and since June 26, 2011, she observed that the patients chest expansion has more effort, and she perceives it as if the patients is experiencing Difficulty of Breathing. Family Health History There is no history of illness in the immediate family. On his fathers side, there is a history of Pneumonia in his grandfather, uncle, auntie. On his mothers side, there is a history of Hypertension. X-RAY Result C/C: Cough, phlegm, fever Exam Requested: Chest AP > There are reticolunodular opacities on both lungfields 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. Figure 1. The radiograph of the patient.

Hemoglobin Erythrocyte Volume Leukocyte count Platelet Count Segmenter Lymphocyte

HEMATOLOGY Normal Value 14-16 gms% 42-50% 5,000-10,000 mm3 150,000-400,000 mm3 36-66% 22-40

Results 11.3 gms% 34 vol% 11,800mm3 200,000 mm3 74% 26

Interpretation Low Low High Normal High Normal

A low hemoglobin level may indicate lower synthesis of erythropoietin, which is needed to stimulate the red bone marrow to produce red blood cell. The erythrocyte volume is lower than the normal value. It may be due to less oxygen that binds with the iron portion to form oxyhemoglobin. Leukocyte count is higher than the normal value since the patients body needs to combat pathogens by phagocytosis and immune response. Other components of the blood are within the normal range.

Color Transparency Specific Gravity Sugar Reaction (pH) Sterility

URINALYSIS Normal Value Pale Yellow Amber Transparent 1.010-1.025 Not Present 4.5-8 pH No microorganism present

Results Light Yellow Cloudy 1.005 Negative 4.1 pH (+) Bacteria

Interpretation Normal Not Normal Low Not Normal Low Not Normal

The patients urine is cloudy, has low specific gravity, and has a presence of bacteria. There may be a presence of white blood cells, bacteria, pus, or contaminants such as prostatic fluid that is causing cloudy urine. Diluted urine has a lower specific gravity thus, causing almost clear or pale yellow color. The patient may have a mild Urinary Tract Infection.

IV. MEDICAL-SURGICAL MANAGEMENT

Organism-specific antibiotic therapy. Administration of initial drug therapy such as broad spectrum antibiotics. Oxygen should be administered. Administration of bronchodilator medications, postural drainage, chest physiotherapy, and nasotracheal suctioning for maintain airway patency Light diet that will not excite the cough in swallowing or increase dyspnea by distention of the stomach, or augment the en-feeblement of the heart action by overtaxing digestion. Starch-rich, and saccharine-rich foods must be withheld.

V. NURSING MANAGEMENT Administer prescribed medications. Promote infection-control measures, especially droplet precautions as indicated. Keep the client in an upright position during feedings and for 30 minutes afterward. Check for residual gastric contents Encourage increased fluid intake to promote internal rehydration. Teach and supervise in coughing, turning and deep breathing techniques. Position the client in side-lying positions, to prevent aspiration. Provide psychological support and restful environment to reduce anxiety and promote rest. Perform respiratory assessment every 4 hours, including determination of rate and characteristics of respirations auscultate the chest, and document findings. Monitor Arterial Blood Gas.

NURSING CARE PLAN PATIENT: Patient X ASSESSMENT Subjective Cues: Dinala naming sya dito sa ospital kasi nilalagnat, nahihirapan huminga tska inuubo na may kasamang dugo, as verbalized by the patients mother Objective Cues: HR: 110 bpm RR: 31 cpm Temp: 38.3 C (+) fever (+) chills (+) dyspnea (+) cough (+) hemoptysis (+) sputum production (+) fatigue (+) crackles (+) tachypnea NURSING DIAGNOSIS Ineffective airway clearance due to inflammation and secretions AGE: 18 years old INFERENCE Invasion of affecting organism (Streptococcus Pneumoniae) Inhalation of organism in the alveolus Multiplication of S. Pneumoniae in the alveolus Invasion in the alveolus epithelium Inflammation of airways Inflammatory exudates fills the alveolar spaces PLANNING Goal: Maintain adequate, and patent airway SPECIFIC OBJECTIVES: Within 8 hours of nursing intervention, the patient will report increased airway patency as manifested by: - Respiratory rate decreased or within the normal range - Maintain Normal Body Temperature - Decreased cough - Decreased sputum production (-) dyspnea (-) crackles GENDER: Male INTERVENTION >Establish rapport with the patients significant other >Monitor vital signs q4 >Monitor respirations and breath sounds, noting rate and sounds >Encourage increased fluid intake >Teach and supervise effective coughing, turning and deep breathing techniques Diagnosis: Pneumonia RATIONALE >To gain cooperation and trust >To obtain baseline data >To indicate respiratory distress or accumulation of secretions >To promote internal rehydration >To help the patient develop a sense of normality without creating undue respiratory distress EVALUATION GOAL MET. Within 8 hours of nursing intervention, the patient reported an increased airway patency, as manifested by: - RR: 23cpm - Temp: 37.5C - Decreased cough - Decreased sputum production (-) dyspnea (-) crackles (-) tachypnea

Lung consolidation Ineffective gas exchange Alveolar exudates consolidates S/Sx Fever, Dyspnea, Sputum Production, Cough, Hemoptysis

>Position the client in side-lying position >Evaluate patients cough/ gag reflex and swallowing ability >Keep environment allergen-free >Administer bronchodilators as ordered >Provide a positive and quiet environment

>To prevent aspiration >To determine the patients ability to protect the airway >To avoid the allergencausing microorganisms >To relax bronchial muscles >To lessen the stress felt by the patient

PATIENT: Patient X ASSESSMENT Subjective Cues: Nananakit yung dibdib tska nahihirapan akong huminga, as verbalized by the patient. Objective Cues: HR: 110 bpm RR: 31 cpm Temp: 38.3 C (+) chest pain (+) dyspnea (+) tachypnea; bradypnea (+) pursed-lip breathing (+) nasal flaring (+) cyanosis NURSING DIAGNOSIS Ineffective Breathing Patterns due to Pneumonia, as manifested by: (+) chest pain (+) dyspnea (+) tachypnea; bradypnea (+) pursed-lip breathing (+) nasal flaring

AGE: 18 years old INFERENCE Invasion of affecting organism (Streptococcus Pneumoniae) Inhalation of organism in the alveolus Multiplication of S. Pneumoniae in the alveolus Invasion in the alveolus epithelium Inflammation of airways Inflammatory exudates fills the alveolar spaces Lung consolidation

GENDER: Male OBJECTIVES INTERVENTION >Establish rapport with the patients significant other > Monitor vital signs q4 > Auscultate chest

Diagnosis: Pneumonia RATIONALE > To gain cooperation and trust > To obtain baseline data >To evaluate presence/ character of breath sounds or secretions > To indicate if there is a possibility of obstruction > Anxiety may be causing acute or chronic hyper ventilation > To diagnose presence/seve rity of lungs disease. EVALUATION GOAL MET. Within 8 hours of nursing intervention, the patient verbalized an improvement in his breathing pattern as manifested by: > decreased chest pain > normal breathing patterns > RR: 23cpm > (-) nasal flaring > (-) cyanosis

Goal: The patient will experience effective respiratory pattern SPECIFIC OBJECTIVES: Within 8 hours of nursing intervention, the patient will verbalize an improvement in his breathing pattern as manifested by: > decreased chest pain > normal breathing patterns > RR within normal range > (-) nasal flaring > (-) cyanosis

> Evaluate cough or presence of secretion > Note emotional responses

> Assist with/ review results of necessary testing

Ineffective gas exchange Alveolar exudates consolidates S/Sx Tachypnea; Bradypnea Nasal flaring Chest pain Cyanosis

>Administer oxygen at lowest concentration as ordered

>For management of underlying pulmonary conditions, respiratory diseases >To limit the level of anxiety >To promote deeper respiration and cough >To limit fatigue

>Maintain calm attitude while dealing with client >Administer Analgesics as ordered >Encourage adequate rest periods between activities >Teach the client on how to splint the chest wall with a pillow

>To provide comfort during coughing

NAME: PATIENT X ASSESSMENT Subjective data: Nakakaramdam ako ng pagod at hirap sa paghinga, as verbalized by the patient Objective data: HR: 110 bpm RR: 31 cpm Temp: 38.3 C (+) restlessness (+) pallor (+) cyanosis (+) fatigue (+) tachypnea

AGE: 18 years old

GENDER: Male INTERVENTION >Establish rapport with the patients significant other > Maintain airway patency

Diagnosis: Pneumonia RATIONALE > To gain cooperation and trust > To ensure opyimal oxygenation and ventilation >To enhance sense of wellbeing > To sustain motivation EVALUATION GOAL MET. Within 8 hours of nursing intervention, the patient participated willingly in necessary/ desired activities, as manifested by: (-)restlessness (-)pallor (-)cyanosis (-)fatigue RR=23cpm

NURSING INFERENCE OBJECTIVES DIAGNOSIS Activity Invasion of Goal: The Intolerance affecting patient will due to fatigue, organism demonstrate a febrile illness, (Streptococcus decrease in hypoxemia, Pneumoniae) physiological and increased signs of work of Inhalation of intolerance breathing, as organism in manifested by: the alveolus SPECIFIC Respiratory OBJECTIVES: Rate Multiplication Within 8 hours decreased or of S. of nursing within the Pneumoniae in intervention, normal range. the alveolus the patient will (+)restlessness participate (+) pallor Invasion in the willingly in (+) cyanosis alveolus necessary/ (+) fatigue epithelium desired (+) tachypnea activities, as Inflammation manifested by: of airways (-)restlessness (-)pallor Inflammatory (-)cyanosis exudates fills (-)fatigue the alveolar RR within spaces normal range Lung consolidation Ineffective gas

>Encourage client to maintain positive attitude > Give client information that provides evidence of daily/weekly progress >Provide referral to other disciplines, such as exercise physiologist, psychological counseling/therapy, etc. > Provide positive atmosphere, while acknowledging difficulty of the situation of the client

> To develop individually appropriate therapeutic regimens.

> To help minimize frustration and rechannel energy.

exchange Alveolar exudates consolidates S/Sx Tachypnea Restlessness Cyanosis Fatigue

>Plan care to carefully balance rest periods

>To reduce fatigue

Generic Name

Brand Name

Classifica tion Antiinfective

Action Interferes with or inhibits protein synthesis in bacteria by binding to 50S ribosomal subunit

Dosa ge 300g IV thru 50 cc solus et every 6 hr

Indication Treatment of rickettsial infection

Chloromphe Chloromy nical cetin

Adverse Reaction s Doserelated bone marrow depressio n& aplastic anemia, GI disturbanc es

Nursing Consideration > Assess lung sounds, respiratory pattern, pulse and blood pressure before administration and during peak of medication > Monitor pulmonary function tests before initiating therapy and periodically throughout course to determine effectiveness of medication > Observe patient for drug tolerance and rebound bronchospasm. If condition occurs, withhold medication and notify physician immediately > Administer medicine at the time specified or as close to that time as possibleif there is a delay, document it.

Paracetamo l

Omol Syrup

Antipyretic Analgesic

reducing the activity of the cyclooxygenase (COX) enzyme; this enzyme participates in the production of prostaglandins

125/v ol 5ml every 6 hrs

Relief of pain & for rapid lowering of fever in bronchitis

Allergic reactions, GI disturbanc es

Flexotide

Flixotide Accuhale

Antiinflammati on

which in turn are involved in the pain and fever processes controls the signs and symptoms of asthma that are responsive to orally inhaled corticosteroids

neb.

Treatment of acute exacerbations of asthma

sneezing attacks immediate ly after use; irritation and burning in the nose

Salbutamol

Ventolin Syrup

2 adrenocep tor agonist

Acetylcystei ne

Fluimucil

Mucolytic Agent

acts on the 2 adrenoceptors of bronchial muscle, with little or no action on the -1 adrenoceptors of the heart. Decreases viscosity of secretions, promoting secretion removal through coughing, postural

1 tbsp 3x a day

Bronchospasm & excessive secretions of tenacious mucus (e.g. bronchial asthma, chronic asthma, chronic bronchitis)

Hypokale mia, tachycardi a, tremor, muscle cramps

> Administer only the drug that you prepare > If patient refuses medication, ask a relative to assist in administering the medications. > Evaluate client's condition and medication compatibility > Administer medicine at the time specified or as close to that time as possibleif there is a delay, document it. > Evaluate client's condition and medication compatibility >dilute with normal saline solution or sterile water for injection. >Administer the ff drugs separately because they are incompatible with acetylcysteine:

6 to 10 ml of 10% soluti on or 3 to 5 ml of

in adjunctive treatment of acute and chronic bronchopulmonary disease

Nausea, rhinorrhea , bronchosp asm especially in asthmatic

drainage, and mechanical means. In acetaminophen overdose, maintains and restores hepatic glutathione, needed to inactivate toxic metabolites.

20% soluti on three or four times daily.

s, stomatitis, and urticaria.

tetracyclines, hydrogen peroxide, trypsin. >Use water to remove residual drug solution on the patients face after administration by face mask. >Inform patient that nebulization may produce an initial disagreeable odor, but will soon disappear. >Give daily before 9AM to mimic normal peak diurnal corticosteroid levels and minimize HPA suppression. >Space multiple dose evenly throughout the day. >Use minimal dose for minimal duration to minimize adverse effects. >Use alternate day maintenance therapy with short acting corticosteroids whenever possible.

Hydrocortis one Sodium succinate

SoluCortef

Shortacting Corticoste roid

Suppresses inflammatory and immune responses, mainly by inhibiting migration of leukocytes and phagocytes and decreasing inflammatory mediators

100m g IV, q6 hours

Replacement therapy in adrenal cortical insufficiency Hypercalcemia; associated with cancer Short term inflammatory disorders

Vertigo, headache, hypotensi on, shock, thin, fragile skin, petechiae, amenorrh ea, muscle weakness