I.

INTRODUCTION
This is a case of a 74 year old woman who was diagnosed with
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 oygen cannot reach
the blood and the cells of the body.
!ost pneumonias are caused by bacterial infections.The most common
infectious cause of pneumonia in the "nited #tates is the bacteria #treptococcus
pneumoniae. $acterial pneumonia can attac% anyone. The most common cause
of bacterial pneumonia in adults is a bacteria called #treptococcus pneumoniae
or Pneumococcus. Pneumococcal pneumonia occurs only in the lobar form.
&n increasing number of viruses are being identified as the cause of respiratory
infection. 'alf of all pneumonias are believed to be of viral origin. !ost 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#treptococcus pneumoniae, 'aemophilus influen*ae, and atypical organisms
(ie, +hlamydia pneumoniae,!ycoplasma pneumoniae, ,egionella sp). #ymptoms
and signs are fever, cough, pleuritic chest pain, dyspnea, tachypnea, and
tachycardia. -iagnosis is based on clinical presentation and chest .ray.
Treatment is with empirically chosen antibiotics. Prognosis is ecellent for
relatively young or healthy patients, but many pneumonias, especially when
caused by #. pneumoniae or influen*a virus, are fatal in older, sic%er patients.
II. PATIENT PROFILE
Name: E. Costales
Age: 74 years old
Sex: Female
Religion: Roman Catholic
Date Admitted: Septemer !7" #$$% at exactly !!:!& A'
Admission diagnosis: C()D not in exaceration
Final diagnosis: Comm*nity Ac+*ired pne*monia ,CA)-moderate Ris.
III. PATIENT HISTORY
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 elp ospital on !eptem"er #7, $%%&'
History of Present Illness:
( days prior to admission, patient had positi)e signs and symptoms of cough,
yellowish pleghm, persistent fe)er and "ac* pain' +nowing that these signs and
symptoms were ,ust forms of little discomforts, she self medicated with paracetamol'
owe)er, she noticed no changes and e-perienced difficulty of "reathing so she sought
medical consultation'
IV. PHYSICAL ASSESSMENT
Date Assesed: !eptem"er #7, $%%&
Time Assessed:
Vital Signs:
Blood Pressure. ##%/0%
Temperature. 3('7 1
Pulse rate. 72"pm
3espiratory rate. $0 "reaths/min
General appearance:
The patient is awa*e, lying on "ed, conscious and coherent with an 45F of
P6!! and side drip of D(7 with incorporation of aminophylline on the right arm'
V. ANATOMIC AND PHYSIOLOGY OVERVIEW
The Lungs
The lungs are paired, cone.shaped organs which ta%e up most of the space in
our chests, along with the heart. Their role is to ta%e oygen into the body, which
we need for our cells to live and function properly, and to help us get rid of
carbon dioide, which is a waste product. /e each have two lungs, a left lung
and 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 ta%es up some of the space in the left side of our
chest. 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 01 of them in each lung. 2ach segment receives its
own blood supply and air supply.
&ir 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, %nown as the alveoli. The alveoli are where the important wor% of gas
echange ta%es place between the air and your blood. +overing each alveolus is
a whole networ% of little blood vessel called capillaries, which are very small
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 oygen and carbon
dioide can move (or diffuse) between them. #o, when you breathe in, air comes
down the trachea and through the bronchi into the alveoli. This fresh air has lots
of oygen in it, and some of this oygen will travel across the walls of the alveoli
into your bloodstream. Travelling in the opposite direction is carbon dioide,
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 oygen that you
need to live, and get rid of the waste product carbon dioide.
VI. PATHOPHYSIOLOGY
3irulent !icroorganism
#treptococcus Pneumoniae
!icroorganism eneters the nose( nasal passages)
Passes through the laryn, pharyn, trachea
!icroorganism enters and affects both airway and lung parenchyma
&irway damage ,ung invasion
Infiltration of bronchi flattening of epithelial cells
Infectious organism lodges macrophages and leu%ocytes
#timulation in bronchioles necrosis of bronchial tissues mucus and phlegm production
&lveolar collapse narrowing of air passage COUGHING
Productive/non-productive
Increase pyrogen in the body DIFFICUL! OF "#$AHING
F$%$#
4ecrosis of pulmonary tissue
5verwhelming sepsis

-2&T'
VII. Medical Managemen
VIII. Diagn!"ic E#am
C$e" %&'a( Re")l*
Im+'e""i!n* /here are reticol*nod*lar opacities on oth l*ng0ields 1ith *p1ard
traction o0 le0t hil*s. /here are dilated thic. 1alled ronchi noted on oth lo1er loes.
2eart is not enlarged. Aortic .no is sclerotic other 3is*ali4ed str*ct*res are
*nremar.ale. Findings are s*ggesti3e o0 Extensi3e )/5" 5ilateral 1ith cicatrical
changes" le0t *pper loe.5acteriologic correlation is s*ggested.
Clinical C$emi"'( Re")l*
Sodi*m: !#4.% mmol67 Normal: !8&.$9!4:mmol67
Hema!l!g( Re")l*
2ct: $.#% Normal: $.879$.47
W,C* -../#01 Normal: &.$9!$.$x!$
Segmenters: $.:7
7ymphocytes: $.!8
U'inal("i"*
Color: 7ight ;ello1
/ransparency: Slightly 2a4y
Reaction: ,p2- <.$
)rotein: =!
>l*cose: negati3e
Speci0ic >ra3ity: !.$!$
)*s cells: 89462)F
R5C: #986hp0
Crystals: A ?rates: 'any
'*c*s threads: 0e1
Cast: Fine >ran*lar cast : !9#62)F
I%. D')g S)d(
Generic Name: ydrocortisone !odium succinate
Brand Name: !olu81ortef
Classification: 1orticosteroid, short acting
Dosage: #%%mg 45, 9 0 hours
Pharmacoinetics:
:eta"olism. epatic; half life 2%8#$%min'
Distri"ution. 1rosses Placenta; enters "reast mil*
<-cretion. =rine
Indicai!n"*
3eplacement therapy in adrenal cortical insufficiency
ypercalcemia; associated with cancer
!hort term inflammatory disorders
Contraindications:
4nfections, especially tu"erculosis, fungal infections, amoe"iasis, hepatitis B, li)er
disease, li)er cirrhosis, acti)e or latent peptic ulcer'
Ad2e'"e Reaci!n*
5ertigo, headache, hypotension, shoc*, thin, fragile s*in, petechiae, amenorrhea,
muscle wea*ness'
N)'"ing C!n"ide'ai!n"*
#' >i)e daily "efore &A: to mimic normal pea* diurnal corticosteroid le)els and
minimi?e PA suppression'
$' !pace multiple dose e)enly throughout the day'
3' =se minimal dose for minimal duration to minimi?e ad)erse effects'
4' =se alternate day maintenance therapy with short acting corticosteroids
whene)er possi"le'
Generic Name: Acetylcysteine
Brand Name: Fluimucil
Classification: :ucolytic Agent
Dosage:
Pharmacoinetics:
:eta"olism. epatic; half life 0'$( hr
<-cretion. =rine @3%AB
Indicai!n"*
:ucolytic Ad,u)ant therapy for a"normal, )iscid, or inspissated mucus secretion
in acute and chronic "ronchopulmonary disease @pneumonia,asthma,TBB'
Contraindications:
1ontraindicated with hypersensiti)ity to acetylcysteine; use caution and
discontinue if "ronchospasm occurs'
Ad2e'"e Reaci!n*
6ausea, rhinorrhea, "ronchospasm especially in asthmatics, stomatitis,and
urticaria'
N)'"ing C!n"ide'ai!n"*
#' dilute with normal saline solution or sterile water for in,ection'
$' Administer the ff drugs separately "ecause they are incompati"le with
acetylcysteine. tetracyclines, hydrogen pero-ide, trypsin'
3' =se water to remo)e residual drug solution on the patientCs face after
administration "y face mas*'
4' 4nform patient that ne"uli?ation may produce an initial disagreea"le odor, "ut
will soon disappear'
!" N#$SING CA$% P&AN
Pro'lem: Diffic(lty of 'reathing
Diagnosis: Ineffecti)e Air*ay Clearance related to increased m(c(s prod(ction"
ASS%SS+%
NT
DIAGN,SIS SCI%NTI-IC
$%AS,N
,B.%CTIV%
S
INT%$V%NTI
,N
$ATI,NA&% %VA&#ATI,
N
&u'(ective6
7nagrere%lamo
nga yang si
nanay na
nahihirapan
siya huminga,
dami din %asi
plema eh8 as
verbali*ed by
relative.
O'(ective6
9::. ;<
9-yspnea
Ineffective
airway
clearance
related to
increase
mucus
production
Increased
mucus
production is
often caused
by an
underlying
illness. If
mucus is the
most prevalent
symptom, it is
usually caused
by something
simple li%e
allergies or the
common cold.
5ther illnesses
that result in
ecessive
&)ort term
*oa+,
&fter =.4 hours
of intervention,
patient will
epectorate
secretions
effectively and
:: will
decrease from
;< to normal
range of 0<.
;1>min.
Lon* term
Independent,
0.&ssessed
rate>depth of
respiration and
chest movement.
;.2levated head
of bed and
changed position
frequently.
0.Tachypnea,
shallow
respiration are
usually
present.
;.,owers
diaphragm,
promoting
chest
epansion,
mobili*ation
and
epectoration
of secretion.
Goal half
met"
&fter 4 hours of
nursing
intervention,
patient
epectorated
secretion and
:: decreased
from ;<>min to
;;>min.
9(?)non.
productive
cough
9"se of
accessory
muscle
mucus
production
include
pneumonia, flu
and bronchitis
*oa+,
&fter = days of
intervention,
patient will
maintain
patent airway
as evidenced
by normal ::.
=.&ssisted
patient with
frequent deep
breathing
eercises.
4. 2ncouraged
increase in fluid
inta%e.
Co++a'orative6
@.&dministered
mucolytics as
indicated.
=.-eep
breathing
facilitates
maimum
epansion of
the lungs and
smaller
airways.
4.Aluids aid in
mobili*ation
and
epectorations
of secretions
@.&ids in
mobili*ation of
secretion.
(Aluimucil)
<.Provided
supplemental
fluids.
(I3A6 P4##)
7.!onitored
chest Bray, &$C
and pulse
oimetry results.
<.Aluids are
required to
replace
insensible loss
and aids in
mobili*ation of
secretions.
7.Aollows
progress and
effects of
disease
process.