CASESTUDY Withlabresults

Davao Doctors College
Davao 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:
Submitted to
TABLE OF CONTENTS
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
V.
THE PATIENT AND HIS/HER CARE
Medical Management
A. IVFs
.
B. Drugs
C. Diet
.
D. Activity and
Exercise
Nursing Management:
A. Nursing Care Plans
B. Actual SOAPIERs
VI.
CLIENTS DAILY PROGRESS IN THE HOSPITAL

A. Clients 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
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
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.Chona Barrun RN,MN 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.
INTRODUCTION
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
immunocompromise,
consciousness,
factors
underlying
smoking,
for
pneumonia
lung
endotracheal
include
disease,
intubation,
advanced
alcoholism,
malnutrition,
age,
altered
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 persons 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

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 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.
NURSING ASSESSMENT
A.
Personal History
a. Demographic Data
Mr. X is a 43-year old naturally born Filipino. He was born on April

16, 1972 and is presently residing at Skyline Village Davao City. He was
admitted last July 6, 2015 at Davao Doctors College in Davao City with a
chief complaint of mass at right submandibular area. His admitting
diagnosis was Community Acquired Pneumonia: r/o TB: parotitis . He had
a final diagnosis of community-acquired Pneumonia.
b. Socio-economic and Cultural Factor
Mr. X was a lawyer, he is a frequent smoker. He started smoking

when he was 16 year old and started taking alcoholic beverages at the
age of 20. He starts smoking early in the morning and consumes
approximately half pack of cigarettes a day.
c. Environmental Factors
Mr. X has 3 children, 2 of which are males and one is female. All of
them are not yet graduated and still studying
B. SCHEMIC DIAGRAM ON FAMILY HEALTH-ILLNESS HISTORY
Physical Examination
July 7, 2015
General appearance: Patient has non-productive cough, he is afebrile
with vital signs taken and recorded as follows:
VS: BP= 120/80 mmHg; PR=80 bpm; RR= 20 bpm;
T=36 C/Axilla
Skin: Uniform in color, good skin turgor, no edema

Skull: Round, symmetrical, 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,
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
Neck: With palpable modules on the left side of the neck, neck
muscles are equal in size, there was a presence of mass on right side
Chest/Lungs: Has symmetrical chest expansion, he has non-productive
caugh
Abdomen: Slightly bloated,
Extremities: Equal in size and length, absence of edema, both lower and
upper extremities move with coordination,
LABOORATORY AND DIAGNOSTIC PROCEDURE
Diagnostic and
Indication
Laboratory
Date Ordered
or
Procedure :
Date Resulted
Purposes
Analysis
Results
Normal
and
Values
Interpretation
Radiology
Date
Chest Radiography
Nodule- haze
Normal lung
The result shows that
Chest (PA)
Ordered :
or x-ray yields
densities are
fields, cardiac
patient are congruent
August 17,
information about the
evident in the right size,
to the diagnosis of
2008
pulmonary, cardiac
lung with traction
pneumonia
and skeletal systems. of the trachea
mediastinal
structures,
rightwards and
thoracic size,
right hemi
ribs and
Date
Evaluate known or
Resulted:
suspected pulmonary diaphragm
August 17,
disorders and
upwards. The
2008
cardiovascular
right apical
disorders.
pleuralis
thickened. Hazy
Monitor resolution,
densities are like
progression or
wise seen in the
diaphragm
maintenance of the
left lungs base.
disease.
Heart is not
enlarged body
thorax is
unremarkable.
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:
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
Diagnostic and
Indication
Laboratory
Date Ordered
or
Procedure :
Date Resulted
Purposes
Analysis
Results
Normal
and
Values
Interpretatio
.40-54
The result show
Coplete Blood
Count
Hematocrit
Date
Measures the
.42
Ordered :
concentration of
the
August 17,
WBC within the blood
within
2008
volume. It is used to
suggesting tha
aid diagnosis
less
abnormal states of
developing
Date
dehydration,
hemmorhage.
Resulted:
polycythemia and
August 18,
anemia
hematocr
the
chance
2008
2am
Hemoglobin
This test evaluates
145
140-180
The result show
blood loss,
the
haemoglob
erythropoietin ability,
within normal
anemia and
IT suggests tha
response to therapy.
is enough num
It is an important
circulating hemo
component of RBC
thus no depriva
that carries oxygen
oxygen supply
and CO2 to and from
different body or
the tissues.
Serve as a buffer to
maintain acid and
base balance in the
extracellular fluid.
The result is with

White blood Cell
Test used to detect
Count
infection or
(WBC)
inflammation to
5.9
5-10x10 9/L
normal range
evaluate
effectiveness of
antibiotic prescribed.
The result is with
Red Blood Cell

(RBC)
Has a principal
4.99
4.5-6.3
normal range
means of delivery of
oxygen to the body
tissues via the blood
The result is with

Platelet Count
Platelet has essential
233
150-400
normal range
function in
coagulation,
homeostasis and
blood thrombus
formation
Confirm low platelet

count which can be
associated with
bleeding
The result ind

Lymphocytes
Lymphocytes play a
0.38
0.10-0.48
with
in
the
major role in bodys
range.
natural defense
system
Monitor the response

on reaction to the
drugs of the patient
This indicates th
Segmenters
A type of neutrophil,
0.62
0.66 -0.70
body
is
its primary function is
capacity
in phagocytosis.
against
has
to
in
microorganisms
RBC
Measures blood
118
118-140
glucose regardless of
when you last eat.
The result is with

normal range
Diagnostic and
Indication
Laboratory
Date Ordered
or
Procedure :
Date Resulted
Purposes
Blood Chemistry
Creatinine
Date
Ordered to patient to
Ordered :
diagnose impaired
August
Analysis
Results
Normal
and
Values
Interpretatio
Traditional
SI
1.7
0.4-1.7
The result is
150.3
35-124
than the normal
17, renal function.
which
2008
ind
decreased func
the kidney.
Date
Resulted:
August
18,
2008
The result is with

5 am
Cholesterol
normal range
To test the total
amount of fatty
substance in the
blood
130.0
150-250
3.4
3.4-6.48
Helps in building up
cells and produce
hormones
lts to appropriate health team members.
Diagnostic and
Indication
Laboratory
Date Ordered
or
Procedure :
Date Resulted
Purposes
Urinalysis
Date
Is used for basic
Ordered :
screening purposes.
August 17,
It is a group of test
2008
that evaluate the
Analysis
Results
Color : Yellow
Normal
and
Values
Interpretatio
Light Yellow to Urine color is

deep amber
normal range
kidneys ability to
selectively excrete
Date
and reabsorb
Resulted:
substances while
August 18,
maintaining water
2008
balance
Transparency:
Clear
Clear
Urine transpare
within
the
range
Ph : 6.0
4-6.8
Urine PH is with
normal range
Monitor fluid
imbalance
Sp Gravity : 1.015
1.05-1.030
Sp Gravity is
the normal range
Monitor response to
the drug therapy and
Sugar : Negative
Negative
Sugar is withi
normal range
evaluate undesired
react was to drug
Albumin : Trace
Normal/Trace
that may impair renal

function
Urine albumin is
the normal range

Microscopic
findings:
Ordered to determine
whether the urine
Pus cells : 0.1
0-3
HPF
Pus cells is with

normal range
contains substances
indicate of normally
absent from urine
Less than 2
RBC 0.1 HPF
Urine RBC is
the normal range
and detected by
urinalysis are
proteins, glucose
acetone, blood, pus
Few
Epithelial
Epithelial Cells :
within
Rare
range
cell
the
and casts
Sputum AFB
This indicates th
This test is used to
there is absence
identify pathogenic
pathogenic
organisms to
microorganisms
determine whether
can cause disea
Date
malignant cells are
such as PTB.
Ordered :
present
Negative
August 17,
Negative
2008
Negative
Negative
Date
Resulted:
August 23,
2008
August 24,
2008
August 25,
2008
Nursing Responsibilities for Urinalysis
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 patients genitourinary, surgical procedures and

other diagnostic procedures.
Obtain a list of medication the patient is taking.
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 patients symptoms and other test
performed.
Nursing Responsibilities for Sputum AFB
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.
There are no food, fluid or medication restrictions, unless by medical

direction.
Take the test early in the morning
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 patients symptoms and other test
performed.
Diagnostic and
Indication
Laboratory
Date Ordered
or
Procedure :
Date Resulted
Purposes
Analysis
Results
Normal
and
Values
Interpretatio
Fecalysis
Date
Fecalysis aids in this
Ordered :
evaluation
August 17,
digestive
2008
and the integrity of

the
Color : Brown
Brown
of
the
efficiency
stomach
The result show
ha
normal color
and
intestines.
Consistency : Soft
Bulky
The result show

the
Date
consistenc
normal
Resulted:
Used as a screening
Intertinal
August 18,
or
Parasites:
2008
because
7:20 am
stool
diagnostic
identify
its
tool
can
substance
present in, the feces

such
as
parasites
ova
and
so
that
appropriate treatment
can be ordered.
Negative
Negative
The results ind
that there are n
or parasites pres
Check the doctors order
Check the patients name and his identification band
Explain to the patient ad significant others why stool specimen is being

collected
Provide privacy
Decrease discomforts and anxiety allow adequate time
Instruct the patients 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
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 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.
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
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 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
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 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.
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).
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:
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 'reexpansion' was more difficult, inhalation would be very, 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 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 PATIENTS ILLNESS (Book-based and Patients 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 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 4 th 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
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, 2 nd 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.
d. Poor Immune System

CAP could be common in children as well as n adults if they have
poor immune system or didnt 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
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 hospitalfor 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 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.
B. Pathophysiology of Community-Acquired Pneumonia ( Precipitating and predisposing factors )
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

respiratory tract
The body tries to remove
Release of
pathogen that entered the nasal discharges

upper respiratory tract
Damage occurs to mucous membrane
Activation of the inflammatory process, release of chemical mediators
Histamine
Bradykinin
Prostaglandin
Leukotriene
Increase in
Vascular
Stimulates goblet cells

to increase mucus
Stimulate muscle spasm
Chemotaxis
Permeability
that contributes to
production
bronchoconstriction
Migration of WBC to
the site of injury
Accumulation of mucus
Narrowing of airway
secretions in the airway
Leaking of fluids and fluid

shifting resulting to
accumulation of fluid in
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
body temperature
Crackles
Wheezes
Dyspnea/
Nasal flaring
impairs gas exchange

resulting to ventilationperfusion mismatch
Fever
Tachypnea
Chest Pain
Pathophysiology 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
Pallor
Activation of the inflammatory process,

release of chemical mediators
Histamine
Bradykinin
Prostaglandin
Leukotriene
Increase in
Vascular
Stimulates goblet cells

to increase mucus
production
Stimulate muscle spasm
Chemotaxis
that contributes to
bronchoconstriction
Migration of WBC to
the site of injury
Accumulation of mucus
secretions in the airway
Permeability
Narrowing of airway
Leaking of fluids and fluid

shifting resulting to
accumulation of fluid in
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
Crackles
Productive
(Aug.17-2508)
cough
(Aug.17-2508)
Dyspnea
resulting to ventilation-
Nasal flaring
(Aug.17,18,2408)
(Aug.2108)
perfusion mismatch
Fever
(Aug.17-1808)
Tachypnea
Pallor Chest
Pain
(Aug.17,18,
(Aug.22-
2308)(Aug.18&2408)
19,21,22,2308)
Malaise
(Aug.17-2308)
V. THE PATIENT AND HIS CARE

A.MEDICAL MANAGEMENT
a. Intravenous Fluids
Date ordered
Medical
Date performed
Indications or
Clients response to
purpose
treatment
General Description
Management/Treatment
Date changed
IVF: Plain Normal Saline
DO: 8-17-8
PNSS is under isotonic
Used as a
Solution 1L x 31-32
DP: 8-17-8
solution where they
vehicle for
The patient complied
gtts/min
8-18-8
have the same
administration of
with the doctors order.
8-18-8
concentration of
drugs.
8-19-8
solutes (osmolarity as
8-20-8
blood plasma). This
DC: 8-21-8
prevents sudden shift

of fluids & electrolytes
in the body. This
solution contains 154

mEq/L of Na and Cl. It
Source of water,
expands plasma and
electrolytes and
interstitial volume and
calories or as an
does not enter the
alkalinizing
cells.
agent.
5% Dextrose and
5% Dextrose and
DO: 8-21-8
Lactated Ringers
Lactated Ringers
DP: 8-21-8
Solution is a
with the doctors order
Solution 1L x 31-32
8-21-8
hypertonic infusion
and the patient was able
gtts/min
8-22-8
raise serum osmolality
to maintain normal
DC: 8-22-8
by causing a pull of
hydration status.
fluids from the

intracellular and
interstitial
To prevent
compartments into the
electrolyte
blood vessels. They
imbalance and
act to greatly expand
serve as a route
the intravascular
for
compartment. Its
administration
shows how red blood
for IV
cells shrink when place
medication;
in a hypertonic
absorbs fluid in
solution.
the interstitial
cell;
D5NM 1L x 31-32
gtts/min
Hypertonic solution
replacement of
DO: 8-22-8
that has osmolarity
fluid, sodium,
DP: 8-22-8
higher than serum
chloride and
with the doctors order.
8-23-8
osmolarity, when a
calories
8-23-8
patient receives a
8-23-8
hypertonic IV solution,
8-24-8
serum osmolarity
8-24-8
initially increasing fluid
8-25-8
to be pulled from the

interstitial and
Date Terminated:
intracellular
8-25-8
compartment into the

blood vessels.
Prior 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 its infusing well.
Monitor patients response and flow of IV.
Record all procedures don
Date ordered
Medical
Clients
Date
General
Indications or
performed
Description
purpose
Management/Tr
response to
eatment
treatment
Date changed
Oxygen occurs
For patients
The patient is
DO: 8-17-8
in atmosphere
experiencing
relieved from
DP: 8-17-8
air in
dyspnea or
dyspnea and
8-18-8
approximately
difficulty of
decreased
8-19-8
20-21%
breathing
patients
8-24-8
concentration.
respiration
It is a
rate.
Oxygen Therapy
at 3-4 lpm via
nasal canula
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
Oxygen Therapy

Inform the patient and patients SO about the procedure.
Explain the importance and use of such treatment.
Tell the patient that there is no pain upon administration of it.
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.

Assess the patient and inspect the equipment regularly.
Fill up the chart and document the procedure.
Date ordered
Medical
Indications or
Date performed
Management/Treatment
General Description
purpose
Date changed
Clie
Bronchodilation
Nebulization: Combivent
DO: 8-17-8
A method of
Neb q 6
DP: 8-17-8
administering
8-18-8
medication through the
8-19-8
use of aerosol mist.
8-20-8
8-21-8
8-22-8
8-23-8
8-24-8
8-25-8
and effective
mucous
expectoration
The
with
and

Assess the respiratory status.
Explain the importance of the treatment.
Be alert for adverse reactions.
Make sure the equipment is clean.

Assist the patient in nebulization.
Advice patient to:
Sit upright so that the air gets deep into his lungs.
Breathe normally through the mouthpiece.
Document, date and time of therapy.
Make sure the nebulizer is dry and clean.
Monitor the patients status especially respiratory rate.
b. DRUGS
Route of
Name of
Date ordered
General action
administration,
drugs,
Date
Clients response to
and
Indications or
dosage and
generic name,
performed
the meds with actual

mechanism of
purpose
frequency of
Brand name
Date changed
S/E
action
administration
Generic name:
DO: 8-17-8
IV, 750mg TID q3 (-)
General action:
Lower
Patient complied woth
Cefuroxime
DP: 8-17 8
ANST
Antiinfective
respiratory tract
the doctors order and
Brand name:
8-23-8
Mechanism of
infections due to
there are no
Zinacef
DC: 8-24-8
action:
s.pneumoniae
undesirable effect
Binds to
experienced by the
bacterial cell
patient.
wall membrane
causing cell
death.

Obtain previous history of medical allergies.
Explain the need for the medication.
Assess for anemia, renal dysfunction.
Observe the 10 rights of giving medications.

Observe for aseptic technique.
Clean the IV port with alcohol.
Administer drug slowly.

Check for the regulation of the IVF.
Document the time of the given medication.
Monitor for adverse reactions.
Date
Route of
ordered
administratio
General
Date
n, dosage
action and
Indication
performe
and
mechanis
s or
frequency of
m of
purpose
Date
administratio
action
changed
Generic
DO: 8-17-
Neb.
General
Treatment
Patient
name:
(inhalation) q6
action:
of COPD in
complied with
Ipratropiu
DP: 8-17
Cholinergic
those who
the doctors
blocking
are on
order and was
bromide
8-18-8
drug and
regular
relieved of
Brand
8-19-8
sympatho
aerosol.
dyspnea.
name:
8-20-8
mimetic
Bronchodil
Combiven
8-21-8
t, Duoneb
8-22-8
Mechanis
therapy
8-23-8
m of
and who
8-24-8
action:
require a
8-25-8
Ipratropium
second
is an
bronchodila
anticholine
tor.
Name of
drugs,
Clients
generic
response to
name,
the meds with
Brand
actual S/E
name
ator
rgic drug
that acts to
inhibit the
effect of
acetylcholi
ne
following

Assess the respiratory status.
Explain the importance of the treatment.
Be alert for adverse reactions.
Make sure the equipment is clean.

Assist the patient in nebulization.
Advice patient to:
Sit upright so that the air gets deep into his lungs.
Breathe normally through the mouthpiece.
Document, date and time of therapy.
Make sure the nebulizer is dry and clean.
Monitor the patients status especially respiratory rate.
Date
Route of
ordered
administratio
Date
n, dosage
performe
and
frequency of
Date
administratio
Name of
General
drugs,
action
generic
Clients
Indication
and
name,
response to
s or
mechanis
Brand
the meds with

purpose
m of
name
actual S/E
action
changed
Generic
DO: 8-17-
PO, 500mg
General
It relieves
Patient complied
name:
tab q4 RTC
action:
pain and
with the doctors
Acetamin
DP: 8-17
Analgesic
reduces
order and the
ophen
and Anti-
fever.
patients
Brand
pyretics
name:
temperature
decreases.
Paraceta
Mechanis
mol
m of
action:
Inhibits the
synthesis
of
prostaglan
din that
may serve
as
mediators
of pain
and fever,
primarily in
the CNS.

Before giving the medication, obtain previous history of medical allergies.
Assess for fever.
Explain the purpose of the drug.

Assist patient while taking the drug; offer water.
Monitor for decrease in temperature.
Document.
Date
Route of
ordered
administratio
Date
n, dosage
performe
and
frequency of
Date
administratio
Name of
General
drugs,
action
generic
Clients
Indication
and
name,
response to
s or
mechanis
Brand
the meds with

purpose
m of
name
actual S/E
action
changed
Generic
DO: 8-17-
PO, 1 tab for
General
Symptomat
Patient complied
name:
loose stool
action:
ic relief of
with the doctors
Loperami
8-25-8
Anti-
acute non-
order and was
de
DP: 8-22
diarrheal
specific
relieved from
Hydrochlo
diarrhea
diarrhea.
ride
Mechanis
associated
Brand
m of
with
name:
action:
inflammator
Imodium
Slows
y bowel
intestinal
disease.
motility by
acting on
the nerve
endings
and/or
intraneural
ganglia
embedded
in the
intestinal
wall. The


Witness the intake of medication.
Monitor he patients reaction to the drug.
Document date, and time the medication was given.
Date
Route of
ordered
administratio
General
Date
n, dosage
action and
Indication
performe
and
mechanis
s or
frequency of
m of
purpose
Date
administratio
action
changed
Generic
DO: 8-17-
PO, 1 tab TID
name:
Name of
drugs,
Clients
generic
response to
name,
the meds with
Brand
actual S/E
name
General
For acute
Patient
action:
cough of
complied with
Butamirat
DP: 8-17-
Cough
any
the doctors
e citrate
Suppresan
etiology/
order and was
Brand
8-18-8
ts
Cough
relieved from
name:
8-19-8
associated
cough.
Sinecod
Date
Mechanis
with
forte
discontinu
m of
thickened
ed:
action:
mucus and
8-20-8
Butamirate
impaired
citrate
mucus
belongs to
transport.
the anti
cough
medicines
of central
action.
Sinecod
exerts
expectoran
t, moderate


Monitor for adverse reactions like nausea, diarrhea and dizziness.
Date
Route of
ordered
administratio
Date
n, dosage
performe
and
frequency of
Date
administratio
Name of
General
drugs,
action
generic
Clients
Indication
and
name,
response to
s or
mechanis
Brand
the meds with

purpose
m of
name
actual S/E
action
changed
Generic
DO: 8-20-
PO,
General
Acute and
Patient complied
name:
500mg/cap
action:
chronic
with the doctors
Carbocist
DP: 8-20-
TID
Mucolytics
disorders of
order and his
eine
respiratory
secretions
Brand
8-21-8
Mechanis
tract
partially loosen.
name:
8-22-8
m of
associated
Abluent
8-23-8
action:
with
8-24-8
Its major
excessive
8-25-8
action is
mucous.
on the
metabolis
m of
mucus
producing
cells. It
reduces or
prevents
bronchial
inflammati
on and
bronchosp


Date
Route of
ordered
administratio
Date
n, dosage
performe
and
frequency of
Date
administratio
Name of
General
drugs,
action
generic
Clients
Indication
and
name,
response to
s or
mechanis
Brand
the meds with

purpose
m of
name
actual S/E
action
changed
Generic
DO: 8-21-
IV, 20mg now,
General
For acute
Patient complied
name:
then q12 with
action:
pulmonary
with the doctors
Furosemi
DP: 8-21-
bp precaution
Loop
edema.
order.
de
Brand
8-22-8
name:
8-23-8
Mechanis
drug,
Lasix
8-24-8
m of
undesirable
action:
effects were not
Inhibits the
experienced.
diuretic
Upon taking the
readsorpti
on of
sadium
and
chloride
from the
loop Henle
and distal
renal
tubule.Incr
eases
renal



Date
Route of
ordered
administratio
Date
n, dosage
performe
and
frequency of
Date
administratio
Name of
General
drugs,
action
generic
Clients
Indication
and
name,
response to
s or
mechanis
Brand
the meds with

purpose
m of
name
actual S/E
action
changed
Generic
DO: 8-21-
PO, 500mg
General
For
Patient complied
name:
tab, 1 tab OD
action:
pneumonia,
with the doctors
Azithromy
DP: 8-21-
x 3 days
Antibiotic,
and lower
order.
cin
macrolide
respiratory
Brand
8-22-8
name:
8-23-8
Zithromax
Mechanis
tract
Upon taking the
infections.
drug,
m of
undesirable
action:
effects were not
experienced
macrolide
such as
derived
hypersensitivity
from
reactions and GI
erythromy
disturbances.
cin. Acts
by binding
to the p
site of the
50 s
ribosomal
subunit
and may


Route of
Name of
Date ordered
General action
administration,
drugs,
Date
Clients response to
and
Indications or
dosage and
generic name,
performed
the meds with actual

mechanism of
purpose
frequency of
Brand name
Date changed
S/E
action
administration
Generic name:
DO: 8-24-8
Ceftriaxone Na
DP: 8-24-8
Brand name:
IV, 1 gm q12
General action:
For lower
Patient complied with
Antibiotic,
respiratory tract
the doctors order and
cephalosporins
infections and
the occurrence of
pneumonia.
severe infection is
Chevron
Mechanism of
reduced. And also he
action:
experienced slight
They kill the
discomfort when
bacteria to form
infusing of the
cell walls. The
medication is done.
bacteria
therefore break
up and die.



Date
Route of
ordered
administratio
General
Date
n, dosage
action and
Indication
performe
and
mechanis
s or
frequency of
m of
purpose
Name of
drugs,
Clients
generic
response to
name,
the meds with
Brand
actual S/E
Date
administratio
action
changed
Generic
DO: 8-24-
PO, 1 capsule
General
name:
TID
action:
and
with the doctors
Albuterol
DP: 8-24-
Sympatho
treatment
order and
Brand
mimetic
of
demonstrated
name:
8-25-8
bronchospa
improvement in
Mechanis
sm due to
breathing
m of
reversible
pattern.
action:
obstructive
Stimulates
airway
beta-2
disease.
name
Ventolin
receptors
of the
bronchi,
leading to
bronchodil
ation.
Prophylaxis Patient complied

Obtain history, assess EKG and CNS status.
Assess symptom characteristics, onset, duration, frequency, and any
precipitating factors.
c.DIET
Date ordered
Type
Clients response
Date
General
Indications or
Specific foods
Of
and/or reaction to the

performed
Description
purpose
taken
Diet
diet
Date changed
Soft Diet
DO: 8-17-8
The texture of food is
To rest the GI
Water, grapes,
Patient complied with
DP: 8-17-8
soft. It can be
tract of the
gruel
the doctors order.
8-18-8
nutritionally
patient.
8-19-8
adequate, but
8-20-8
prophylactic
8-21-8
supplementation of
8-22-8
diets with vitamins
8-23-8
and minerals is
8-24-8
recommended if for
8-25-8
long term use.
Nursing responsibilities:
Check the doctors 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 patients condition on how to respond to the diet.
Date
ordered
Type
Date
Of
perform
Activity
ed
Clients
Indicatio
Specific
response
ns or
foods
and/or
purpose
taken
reaction to
General
Description
Date
the diet
changed
Complete
Patient is
To avoid
Water,
He was able to
Bed Rest
prohibited to
discomfor
gruel
take a rest and
strenuous
t, restore
whenever he
activities/
energy,
wants to eat or
exercises.
and to
change
decrease
position he
oxygen
asked for
-b
consumpt
assistance.
ion thus
decreasin
g the
work load
Deep
Respiratory
of the
Water,
Breathin
functioning
heart.
gruel
can be
Exercise
facilitated by
deep
To
breathing
enhance
exercises to
lung
remove
expansio
secretions
n and
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.
Assist the patient in the activity.
Demonstrate deep breathing exercises.
Instruct the patient to hold his breath, then exhale slowly through the
mouth.
Document all the teachings given and the assessment.
NURSING MANAGEMENT
Problem No. 1 Ineffective Airway Clearance
Assessme
Nursing
Scientific
nt
Diagnosis
Explanation
S=
patient Ineffective
Planning
Rationale
Evaluation
Intervention
Community-
Short
> Assess
> Abnormal breathing Short
Term :
respiratory status:
patterns may signal
breath sounds,
worsening of
may
Airway
Acquired
verbalize
Clearance
Pneumonia is the
magkasakit
related to
inflammation
ku papalwal retained
the
ing
parenchyma
plema secretions in
Nursing
of After 5 hours respiratory rate,

lung of
condition: flaring of
The patient
nostrils indicate a
shall be
significant decline in
able to
respiratory status:
expectorate
such as dyspnea,
assessment
mucous as
presence of
establishes baseline
evidenced
and monitor
by
response to
productive
Nursing oxygen
Interventions
pag
the bronchi (
when
manguku
increased
offending
ku.
thick
organism reaches expectorate
mucous
the
secretions)
droplets or saliva evidenced
saturation, note
the , the patient abnormalities
alveoli
will
via mucous
Term :
as cyanosis, use of
accessory
O=Patient
and lung
in whi8ch goblet by
muscles, flaring of interventions
cough
Manifested
inflammation
cells produces an productive
nostrils
effective
the
leading to
outpouring
following :
accumulatio
into the alveoli. effective
> Assess anxiety
> Being unstable to
and
n of mucous
The
and reassure
breath causes
breathing
in the alveoli
multiply
patient
anxiety and fear: the
exercise
presence
patient needs a
>appears
weak
fluid cough,
organisms coughing
in
the and
serous fluid and breathing

the
infection
coughing
is exercise
>pale
spread.
palpebral
organisms
conjunctiva
damage the host Long Term :
calming presence:
The
by
anxiety increases the

demand for oxygen
their
> Place patient in
> rales on
overwhelming
After 2 days high fowlers
both lung
growth
and of
lobes upon
interference
with Interventions
chest
lung
Nursing position and

support overbed
function , the patient table as needed.
> Maximize chest

excursion and
Long
subsequent
Term :
movement of air
The patient
auscultation
leading
to will maintain
massive
airway
> Encourage
> difficulty
accumulation
of patency
of breathing
mucus. Disruption evidenced

of the mechanical by
> shortness
defenses
of breath
cough and ciliary sounds,
will maintain
as expectoration of
> Thickened
patency as
secretions of Cap re
evidenced
more likely to
by clear
viscosity amount
occlude the airway:
breath
and color of
making this
sounds,
observation would
absence of
secretions and
clear assess the
of breath
motility leads to absence
airway
of secretions
> non-
the colonization of dyspnea,
allow for
dyspnea,
productive
the
implementation if
etc.
cough
accumulation
lungs
and etc.
of
measures to thin and
secretions in the
loosen the secretions
Patient
alveoli
and
may
bronchi leading to
patient
> Mobilizes
manifest
ineffective airway
coughing and
secretions and
the
clearance
deep breathing
prevent atelectasis
as
> Assist the
following :
evidence by nonproductive cough
> Increase fluid
>decreased
etc.
intake
oxygen
exudates tend to
liquefying secretions
saturation
consolidate,
and enhancing ability
increasingly
to clear airways
alveolar
> Cyanosis
difficult
>Tachypnea
expectorate.
> Assists with
to
> Provide for
> Decrease demand
periods of rest
for oxygen
>Abnormal
and activity,
blood gases
assisting
(decreased
devices as
O2,
needed
Increased
CO2)
> Elevate head of
> To maintain an
bed/ change of
open airway and to
>
position every 2
take advantage of
Restlessnes
hours
gravity decreasing
pressure on the
diaphragm and
>
enhancing drainage
Orthopnea
of secretions.
> Flaring of
> Assist
>This causes
nostrils
respiratory
bronchiodilation to
therapist the
ease breathing
administration of
nebulizer
> Ensures a route for
> Establish
rapid- acting
intravenous
medications
access as
ordered
>ABG provide data
> Assess arterial
for treatment
blood gases
regarding the lungs
(ABG)
ability to oxygenate
tissues
> Loosen secretions,

> Provide
making them easier
humidified oxygen to expectorate

as ordered to
coughing: improves
maintain O2
oxygenation
saturation >90%
Problem No. 2 Impaired Gas Exchange

Assessment
S=
Nursing
Scientific
Diagnosis
Explanation
patient Impaired
Planning
Nursing
Rationale
Evaluation
Intervention
Community-
Short
> Perform a
> Because airway
Short
Term :
complete
inflammation and
Term :
respiratory
mucous
The patient
may verbalize
Gas
Acquired
magkasakit
Exchange
Pneumonia
is
ku
related to
defined
mangisnawa
inflamed
lower respiratory of
ampo
ku
agad lung tissue

papagal and
as
a After 8hours assessment ;

Nursing respiratory rate,
tract infection of Interventions

the
rhythm, chest
lungs , the patient expansion, ease
shall be
pneumonia can cause
relieved
fluid in the lungs and
from
increase the work of
dyspnea by
breathing, resulting in
participatin
impaired gas
g in
exchange. These
breathing
assessment provide
exercise,
data use for planning
effective
gang
consolidati
parenchyma with will
maglakad
on of
onset
kumu.
mucous /
community
ffluid in
during thre first participating
specific
2days
O=Patient
lung lobes
hospitalization.
exercises,
mucous
Interventions and
coughing
Manifested
preventing
Pneumonia
effective
expectoration,
assessing progress.
and use of
the following
transfer of
occurs when the coughing
perioral cyanosis,
Sputum cultures
oxygen as
gases
offending
and use of tachypnea,
identify the causative
evidenced
across the
organism
oxygen
organisms, arterial
by absence
>difficulty of
alveolar
stimulate
evidenced
blood gases
of nasal
breathing
capillary
inflammatory
by absent of monitor laboratory demonstrate
in
be of breathing, use
accumulation,
the relieved from of accessory

or dyspnea by muscles, pursed
lip breathing,
of in breathing breath sounds,
as dyspnea, pulse
oximetry and
flaring,
decreased oxygen
shortness
concentration, chest
of breath,
mechanism of the breath, easy as sputum
x-ray will confirm the
easy
>shortness of
lung
cultures,
presence of fluid in
fatigability.
breath/
effectiveness and etc.
complete blood
the lungs or areas of
Etc.
exertional
allow
count, arterial
consolidation
discomfort
to penetrate the
>nasal flaring
cellular
response
membrane
defense
the nasal flaring, and diagnostic

shortness of procedures such
lo9se fatigability,
organisms
blood gases, etc.
sterile,
lower Long Term :
>with
respiratory
tract,
presence of
where
After 1 to 3 subjective data
> knowledge of the
Long Term
crackles on
inflammation
days
patient respiratory
both lung
develops.
Nursing
or significant
status contributes to
lobes upon
Inflammation
Interventions
other, including
information that can
The patient
auscultation
occurs
to , the patient history of chronic
assist in
shall have
of will have an respiratory
determination other
an
factors that may have
improved
due
colonization
> with non
offending
> Obtain
improved
of from the patient
disease and
productive
organization
cough
wherein there is and

the
release
ventilation
history of smoking contributed to
of adequate
> Assist patient to
> easy
chemical
oxygenation
fatlgability
mediators,
of
attraction
of tissue
> Patient
neutrophils,
hooked to O2
accumulation
therapy 2-3
fibrinous
LPM
exudates,
as
evidenced
of by
normal >Take
red gases,
every 4 hours
will
Patient may
macrophages.
manifest the
These would in breath
> Provide comfort
following :
turn
measures change
>abnormal
swelling,
and
influence its treatment
adequate
oxygenatio
> Sitting upright
n of lung
allows the diaphragm
tissue as
to descend, resulting
evidenced
in easier breathing
by normal
arterial blood temperature
blood cells and patient
erythema
pneumonia or
semi fowlers
lung position
have a clear
trigger sounds,
absence
edema purulent
of linen or clothing
ventilation
arterial
> Infectious
blood
processes can cause
gases,
an increase body
clear
temperature
Breathing
sounds,
>Following
absence of
temperature spikes,
purulent
blood gases /
and stimulation of discharge
linen and clothing
discharges,
arterial ptt
nerve
may become
etc.
( hypoxia,
leading to pain.
increase CO2
Goblet cells will
> Encourage
increase
mucus
adequate fluid
in
intake to 2000
> Helps thin and
cc/day
liquefy secretions
fibers,
production
>Diaphoresis
attempt to dilute
saturated with
perspiration
amd wash away

>Tachycardia
offending
> Assess mucous
organisms out of
amount, color
> abnormal
the
consistency.
rate rhythm,
tract.
depth of
fluid-filler alveolar
pneumonia, amount
breathing
sacs
should be decreasing
respiratory
Inflamed
cannot
>Helps to detect
improving status of
exchange O2 and
and viscosity should
CO2
be thinning following
effectively
> abnormal
leading to hypoxia
interventions; green,
skin color
of the lung tissue
brown or purulent
(pale, dusty)
and a significant
mucus indicate
ventilation-
continued presence of
> abnormal
perfusion
>Encourage
capillary refill
mismatch
coughing and
pneumonia
deep breathing
>Coughing and deep
>Restlessnes
with mucous
breathing cause
expectoration
alveoli to open and

loosen mucous to
>Confusion
help clear the airways

> Provide chest
>O2
physiotherapy
saturation of
postural drainage,
>Loosen mucous
less than
chest percussion
plugs thus increasing
90%
and vibration
are available for gas
exchange
>fever
> Elevate head of

bed
O2
> Encourage
> To maintain airway
frequent position
patency
changes
>Promotes optimal
> Encourage
chest expansion and
adequate rest and drainage of secretion
limit activities to
with in patient
> Helps limit oxygen
tolerance.
needs/ consumption
Promote calm
and restful
environment
> Administer
oxygen as
ordered
>Pneumonia
increased mucous
production and fluid
retention in lungs
which decreases
adequate gas
exchange;
supplemental oxygen
provides additional
>Administer
oxygen for tissue
antibiotic as
oxygenation
ordered and
monitor for side
>Helps to stop the
effects.
proliferation of
microorganisms
Ado
Problem No. 3 Ineffective Breathing Pattern

Assessment
Nursing
Scientific
Diagnosis
Explanation
Planning
Nursing
Intervention
Rationale
Evaluation
S=
patient Ineffective
Community-
may verbalize
breathing
Acquired
Magkasakit
pattern
disease
ku
related to
involving
mangisnawa. thick
is
Short
a Term :
process
> Assess
> Any of this
Short
respiratory
abnormalities would
Term :
system by noting
indicate the studies
After 4 hours respiratory rate,
The patient
system and
shall have a
progression of
normal
disease; also
respiratory
inflammation
of of
tenacious
lung
It Interventions
secretions
typically
O=Patient
in the
when
shall have a blood gases, etc.
establishes a
rate,
Manifested
bronchi
microorganisams
normal
baseline comparison
rhythm,
the following
due to
enter the normally respiratory
inflammati
sterile lungs from rate, rhythm, > Assist Patient
>maximizes thoracic
breathing
on of lung
the nasopharynx depth
cavity space,
and relief
tissue
and
decreases pressure
from
from diaphragm and
shortness of
abdominal organs
breath as
>difficulty of
breathing
tissue.
expansion, breath
results , the patient sounds, arterial
produces reports
inflammation
the
Nursing depth chest
of the respiratory
depth of
and in assuming a
a high- fowlers
of shortness of position or
lung breath
as position of choice
>shortness of
parenchyma.
breath on
Because of the decrease
exertion,
inflammation
paleness
the
alveoli
evidence by such as leaning

forward or over
and facilitates use of
evidence by
accessory muscles
decrease
of RR from 38 bed table

are cpm to 16-
RR from 38
>help to improve
cpm to 1620 cpm
filed with fluid and 20 cpm
> Increase oral
hydration status and
>RR of 38
mucus
and
fluids to 2000-
decrease secretions.
cpm with
oxygen
and
3000 ml/day as
shallow, rapid
carbon
breathing
exchange cannot
> mobilizes thick
take place at a After 2 days > Provide chest
secretions, and
>use of
alveolar capillary of
facilitates clearing of
supraclavicul
cellular
ar muscles
membrane
for respiration
due to blood flow shall be free
as well as
decreases
from
any >Assist with
>patient with
The patient
shoulder
(deceased
signs
and activities of daily
pneumonia may lack
shall be free
dioxide Long Term :
tolerated
Nursing physiotherapy,
Interventions
bronchial tapping,
lung fields.
level , the patient vibration, etc.
Long
Term :
muscles
perfusion of blood symptoms of living as required
sufficient oxygen
from any
in the lungs)and hypoxia
reserves to perform
signs and
activites; even eating
symptoms
may cause severe
of hypoxia
dyspnea
as
> non-
leukocytes
productive
fibrin consolidate by
cough
in
the
as
and evidenced
normal
affected ABG, etc.
part of the lung

> with
due
presence of
> Teach patient
> Knowing how to
by normal
decreased blood
how to decrease
control shortness of
ABG, etc.
rales on both
flow there is a
shorthness of
breath will help cope
lung lobe
decreased supply
breath by
and have optimal
upon chest
of oxygen to other
restructuring
functioning
auscultation
tissues leading to
activities
easily
ineffective
fatigability
breathing pattern
Patient may
to
evidenced
>Teach
> Preventing spread
pulmonary
of infection and
hygiene;
subsequent
manifest the
prevention of
following :
spread of
hospitalization
infection
>severe
dyspnea
> sitting up
>Provide
>Provide some
humidified low
supplemental oxygen
flow of oxygen as
to improve
ordered
oxygenation and to
leaning
make secretions less
forward,
viscous
hands on
knees
>Administer
>Enhances
bronchodilators
expectoration of
and expectorants
secretions of
>Abnormal
previously ineffective
blood gases
cough
> abnormal
> Administer
>Helps to prevent or
inspiratory
antibiotics as
eradicate infections
or/and
ordered
to reduce secretions
expiratory
and to end to
ration
inflammation
> pursed lip

breathing
> altered
chest
excursion
>hypoxia
(Confusion,
restlessness,
decreased
vital capacity)
Problem No. 4 Hyperthermia

Assessment
S=
Nursing
Scientific
Diagnosis
Explanation
patient Hyperther
may verbalize
Mapali
ku
panandman .
mia
CAP
is
inflammation
the
Planning
Nursing
Rationale
Evaluation
Intervention
the Short
of Term :
> Monitor body
>To have a baseline
Short
core temperature
data
Term :
lung
The
parenchyma due After 4 hours >Note presence
>Evaporation is
patients
to
decreased by
body
offending of
organisms,
Nursing or absence of
Interventions
sweating as body
the attempts to
environmental factors temperature
O=Patient
inflammatory lung ,
of high humidity and
shall
have
Manifested
response will be patients
increase heat loss high ambient
decreased
the following
stimulated leading body
by evaporation,
temperature as well
from 38oC to
to the release of temperature
conduction,
as the body factors
37oC.
chemical
>flushed skin
will decrease diffusion

that from 38oC to
mediators
>skin is warm
blood flow to the
to touch
lung
>Promote heat loss
tissues
leading
> promote
to
> increased
erythema,
RR
swelling,
> Diaphoresis
ability to sweat
increase 37oC.
would
and
producing loss of
by radiation,
surface cooling by conduction and

means of loose
pain, Long Term :
increased
evaporation
clothing; cool
environment/fan;
body temperature After
24 cool/tepid sponge
that would reset hours
of bath local icepack
Long
Term :
Patient may
the hypothalamus Nursing
especially in the
The patient
manifest the
which is the major Interventions
axilla and groin
shall have
following :
center
>Convulsions
for , the patient
maintained
regulation of body will maintain > Review signs
>indicates need for
a normal
temperature
prompt interventions
body
normal and symptoms of
body
hyperthermia
>
temperature
Hypotension
during
temperature
during
>Encourage the
hospitalizatio patient to take
> to increase
hospitalizati
resistance
ons and be
>Fluid and
ns and be vitamin C in the
free from
electrolyte
free
any
imbalance
any
from diet such as citrus

fruits, etc.
complicatio
complication
s
ns of
of >Discuss
pneumonia.
importance of
> To prevent
dehydration
adequate fluid
intake
>Maintain bed
>To reduce
rest
metabolic demands/
oxygen consumption
pneumonia.
>Provide high-
> to meet increased
calorie diet
metabolic demands
>Provide
>To offset increased
supplemental
oxygen demand and
oxygen
consumption
>administer anti-
>To control shivering
pyretics as
and seizure
ordered
Problem No. 5 Activity Intolerance

Assessment
S=
Nursing
Scientific
Diagnosis
Explanation
patient Activity
The
onset
Planning
Nursing
of Short
> Obtain
>Helps to determine
Short
is Term :
subjective data
the effects of
Term :
from patient
pneumonia on the
Intolerance
pneumonia
verbalize
related to
generally marked
magkasakit
increased
by
ku
oxygen
dyspnea,
mangisnawa
demand
shortness
ampo
with activity
breath and easy , the patient pneumonia;
fever, After 4 hours regarding normal
lead
Evaluation
Intervention
may
mimingal ku and hypoxia fatigability
Rationale
and of
Nursing activities prior to
of Interventions
that is
able
gan
(lack of
may
to perform
maglakad
oxygen
inability
kumu.
supply with
perform activities daily
patients ability to be
The patient
active.
shall
be
able
to
onset of
to monitor for
perform
>If increased
labored breathing, physical activity
to activities
of fatigue and
living exhaustion.
activities of
daily
living
causes shortness of
without
breath, activity
shortness of
oxygen
O=Patient
of daily living.
demand)
Manifested
Due
to
the
accumulation
following :
thick
should be reduced
breath such
shortness of > Reduce level of
until oxygenation is
as
adequate.
personal
the breath such activity as

of as
doing required in
tenacious personal
mucous
in
> appears
alveoli
altering
weak
gas
(
without
> poor skin
carbon
turgor
between
etc.
shortness of
> Conserves energy
breath.
and reduces oxygen
exchange
oxygen
hygiene,
response to
the hygiene, etc.
doing
demand patients with
and
pneumonia lack
dioxide)
the Long Term :
alveoli And
>pale nail
After
24
beds
hours
of
> Assist with
enough oxygen
activities as
reserves to perform
Long
needed.
activities
Term :
independently.
The patient
Nursing
>Pace activities
Interventions
and encourage
>It conserves energy. shall states

that he is
> easy
, the patient periods of rest
comfortable
fatigability
states
with activity
that and activity during > Use the result to
he
is the day.
indicate when the
performanc
comfortable
activity may be
e and
> non-
with activity
increased or
shortness of
productive
performance
decreased.
breath is
cough
and
> Monitor VS and
improved
shortness of oxygen saturation
> Activities should be
following
>shortness
breath
increased gradually,
cessation of
of breath
improved
as tolerated, to avoid
activity, and
during
following
over taxing the
the patients
activities
cessation of
patient.
RR returns
is before and after

activity.
activity, and > Gradually
to baseline
> RR of 38
the patients increase activity
within 5
cpm, with
RR
shallow,
to
returns as tolerated and

baseline share guidelines
> Physical activity

increases endurance
minutes.
rapid
within
breathing
minutes.
5 for progression
with patient.
and stamina;
following pneumonia,
return to normal
activity may take
Patient may
> Discuss with
manifest
the patients
the
activities that
following :
would be
> This indicate
appropriate once
intolerance to activity
>Inability to
at home that
and the level of
perform
would be within
activity should be
physical
the patients
evaluated.
activities
activity tolerance.
> level I
time.
> Iron has a role in
functional
> Inform the
oxygen transport and
level
patient to stop
increases energy
classification
any activity that
level.
( walk,
produces
regular
shortness of
phase, on
breath.
level
>To prevent injuries.
>Improves
indefinitely;
> Encourage
oxygenation and
one flight or
intake of foods
provides oxygen
more but
high in iron and
reserves to be used
more
good source of
with increased
shortness of
energy such as
demand.
breath than
lean meat,
normal)
legumes which
are rich in protein.
>labored
breathing
> Assist patient to
>physical
learn and
exhaustion
demonstrate
appropriate safety
>oxygen
measures.
saturation
> Have the
less than
patient use
90%
oxygen
immediately prior
to activity in the
phy
acute setting, as
ordered.
2. Actual SOAPIERs
August 22, 2008
S=
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
E= Goal met AEB patients 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
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 patients participation in activities within the level of his
own ability.
IV. CLIENTS DAILY PROGRESS IN THE HOSPITAL
Admissi
on
Dischar
18
19
20
21
22
23
24
17
ged
25
NURSING PROBLEMS
Ineffective
Airway
Clearance
Impaired Gas Exchange
Ineffective
38.7
37.6
36.2
36.4
36.3
36.9
36.8
36.6
36.4
90
80
79
76
90
90
95
80
82
breathing
Pattern
Hyperthermia
Activity Intolerance
VITAL SIGNS
Temperature
Pulse Rate
38
24
24
20
26
24
21
20
20
120/80
120/70
120/70
110/80
120/70
10/70
110/80
110/70
130/10
Respiratory Rate
Blood Pressure
LABORATORY
DIAGNOSIS
Chest X-ray
Sputum AFB
Blood Chemistry
Complete
BLood
Count(CBC)
Urinalysis
Fecalysis
MEDICAL MANAGEMENT
PNSS 1L x 8 hours
Nebulization
O2 Therapy
D5LRS 1L x 8 hours
D5NM 1L x 8 hours
DRUGS
Cefuroxime 750 mg TID
Combivent neb q 6 hours

Paracetamol 500mg Tab q
4 RTC
Loperamide 1 Tab for loose
stool
Carbocesteine
cap TID
500mg
Furosemide 20 mg IV now
then q 12 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
2 DISCHARGE PLANNING
a. 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 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
CONCLUSION
Community- Acquired Pneumonia is one of the most common infectious

diseases addressed by clinicians 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
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 everyone and fulfil the goal of the Department
of Health which is Health in the hands of the people by 2020.
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: 10 th 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
Patients Profile
Name:Mr. X
Age: 43y/o
Sex: Male
Address: 13 Sto. Nino St, Skyline Village Phase 1 Davao City
Birthday: 4/16/1972
Birthplace: Butuan City
Civil Status: Married
Religion: Catholic
Present Medical History

On the day of admission signs and symptoms are presented.
Past Medical History

4 days Prior to Admission, patient had onset of cardiovascular fever
associated with a mass located at left submandibular area with temporary relief.
1 day Prior to Admission, patient noted enlargement of mass on right
submandibular area.
Family Medical History

Paternal side: (+) CVA, (+) CVD, (+) CA, (+) HPN,
Maternal side: (+) DM
Nutritional History
(+) smoking stopped 8 years ago
(+) alcohol 2x a week
Laboratory results
Examination
Result
Unit
Range
High
/Low Remarks
Hemoglobin
137.00
g/L
140-179
Hematocrit
0.43
Red Blood Cell
4.64
^10812/L
4.5-6.0
White Blood Cell
6.00
^1089/L
5.0 10.0
Platelet Count
253.00
^1089/L
140 - 440
Nuetrophils
0.75
0.65 0.65
Lymphocyte
0.46
0.35 0.45
Monocyte
0.08
0.06 0.12
Eosinophil
0.01
0.02 0.04
Basophil
0.00
0 - 0.02
0.40-0.60
Absolute Neutrophil
^1058/L
1.8 7.8
Absolute lymphocyte
1.28
^1059/L
1.0 4.8
Absolute Monocyte
Absolute Eosinophill
0.64
0.08
Absolute Basophil
MCV
^1059/L
^1059/L
0.0 0.80
0.0 0.45
^1059/L
0.0 0.20
92.10
^1/L
80 - 97
MCH
29.60
^pg
MCHC
321.00
RDW
13.40
MFV
7.80
27.0 31.2
318 - 354
11.5 14.5
^1/L
3- 20

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CASESTUDY Withlabresults

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Davao Doctors College

In Partial Fulfilment of the Requirements in Related Learning Experience

THE PATIENTS ILLNESS

THE PATIENT AND HIS/HER CARE

CLIENTS DAILY PROGRESS IN THE HOSPITAL

General Conditions of the Patient Upon Discharge

Pneumonia is an infection of the lower respiratory tract caused by

immobilization. The causative microorganisms influence the symptoms and signs

Pneumonias can be classified into several ways. Pathologists originally

The combined clinical classification, now the most commonly used

Community-acquired pneumonia develops in people with limited or no

characteristics of the individual are important in determining which etiologic

The most common community-acquired pneumonia is caused by

According to the World Health Report by the World Health Organization,

Mr. X is a 43-year old naturally born Filipino. He was born on April

b. Socio-economic and Cultural Factor

Mr. X was a lawyer, he is a frequent smoker. He started smoking

B. SCHEMIC DIAGRAM ON FAMILY HEALTH-ILLNESS HISTORY

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

LABOORATORY AND DIAGNOSTIC PROCEDURE

The result shows that

patient are congruent

information about the

evident in the right size,

lung with traction

and skeletal systems. of the trachea

suspected pulmonary diaphragm

densities are like

wise seen in the

left lungs base.

Inform the patient that the procedure assess cardiopulmonary status

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

Obtain history of results of previously performed laboratory test, surgical

Obtain list of the medication the patient is taking

Review the procedure with the patient.

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

During the Procedure:

Observed standard precautions

Ask the patient to inhale deeply and hold his breath

while the x-ray

After the Procedure:

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

Recognize anxiety related to test result and be supportive of impaired

Reinforce information given by the patient health care practitioner

The result show

WBC within the blood

This test evaluates

The result show

that carries oxygen

and CO2 to and from

The result is with

Test used to detect

The result is with

Red Blood Cell

The result is with

Platelet has essential

Confirm low platelet

The result ind

major role in bodys

Monitor the response

its primary function is

The result is with

than the normal