College of Nursing

Concordia College

A Case Study on
Community Acquired
Pneumonia

In partial fulfillment for the requirements

on Related Learning Experience

To be submitted by Ventura, Gerald L

BSN IV-A

To be submitted to Mrs. Mercedes Loo RN, MSN

---
July 9, 2010

I. INTRODUCTION:
Pneumonia is an infection of one or both lungs which is usually caused by bacteria,
viruses, or fungi. Prior to the discovery of antibiotics, one-third of all people who
developed pneumonia subsequently died from the infection.

Some cases of pneumonia are contracted by breathing in small droplets that

contain the organisms that can cause pneumonia. These droplets get into the air
when a person infected with these germs coughs or sneezes. In other cases,
pneumonia is caused when bacteria or viruses that are normally present in the
mouth, throat, or nose inadvertently enter the lung. During sleep, it is quite
common for people to aspirate secretions from the mouth, throat, or nose.
Normally, the body's reflex response (coughing back up the secretions) and their
immune system will prevent the aspirated organisms from causing pneumonia.
However, if a person is in a weakened condition from another illness, a severe
pneumonia can develop. People with recent viral infections, lung disease, heart
disease, and swallowing problems, as well alcoholics, drug users, and those who
have suffered a stroke or seizure are at higher risk for developing pneumonia than
the general population. As we age, our swallowing mechanism can become
impaired as does our immune system. These factors, along with some of the
negative side effects of medications, increase the risk for pneumonia in the elderly.
Community-acquired pneumonia refers to pneumonia acquired outside of hospitals
or extended-care facilities. Community-acquired pneumonia (CAP) is one of the
most common infectious diseases diagnosed by clinicians. Community-acquired
pneumonia develops in people with limited or no contact with medical institutions or
settings.

The pathogens that cause community-acquired pneumonia(CAP) are predictable;

copathogens are involved rarely, if ever. Extrapulmonary clinical features are
helpful in distinguishing between typical and atypical causes of CAP. Various clinical
findings can also point to specific diagnoses, such as Klebsiella pneumonia or
Legionella infection. Severe CAP suggests the presence of underlying problems in
the patient, such as cardiopulmonary dysfunction or impaired splenic functioning.
Empiric therapy should cover typical and atypical pathogens. Oral antibiotics should
be used for as
much of the treatment course as is practicable.

II. OBJECTIVES:

The study aims to impart knowledge regarding community acquired pneumonia and
means to restore or maintain patient’s health status utilizing a holistic approach of
promoting and rehabilitative process of nursing managements.

1. Identify nursing problems and the corresponding nursing considerations and

managements involved for promotion and maintenance of patient’s health.
2. Enumerate therapeutic nursing interventions through formulation of NCP.
3. Specify the appropriate laboratory and diagnostic procedures / examinations and
correlate them with the case presented.
4. Discuss simple pathophysiology of case presented, its predisposing factors,
signs / symptoms, complications and treatments.
 III. PATIENT’S PROFILE

Name: Escalada, Alicia Mendoza

Age: 80 y/o
Religion: Roman Catholic
Birthday: February 22, 1930
Date of Admission: June 3, 2010

History of Present Illness:

Patient is a 80 y/o female unknown hypertensive and asthmatic, who came in due to
decrease in verbal output.

10 days PTA, pt had a history of fall causing her to sustain fracture on the left distal
radius. She was there brought at Delgado Hospital where she was found to have
Colle’s fracture, left. During admission, she started to have altered sensorium and
was noted to have minimal verbal output. Chest X-ray was done showing
pneumonia so she was started on Co-amoxiclav. However, there was persistence of
symptoms now accompanied by left sided weakness so her relatives opted for her
to be transferred at SLML, hence, this admission.

Past Medical History:

(+) HPN
(+) bronchial asthma
(-) DM

Personal and Social History:

Previous Smoker
Previous Alcoholic beverage drinker

Family Medical History:

(+) Allergy to chicken- Siblings
(+) Bronchial Asthma- Siblings
(+) CerebroVascular Accident- Father
(+) Hypertension- Father and Siblings
 IV. PHYSICAL EXAMINATION:

Pt. was awake, not in respiratory distress with no regard, no verbal output.

BP=180/90 HR= 90 bpm, regular RR=36 T=39oC

Pink palpebral conjunctivae, anicteric sclerae, pupils 3mm RTL, right 2mm RTL, left.

Supple neck, no cervical Lymphadenopathy, no neck vein distention, thyroid gland

palpable but not enlarged.

Symmetrical chest expansion, (+) ronchi on mid to base, both lungs adynamic
precordium, apex at 5th Lics mcl, normal rate and regular rhythm, no murmur.
Flabby, normoactive bowel sounds, soft abdomen.

Full and equal pulses, no bipedal edema.

V. LABORATORY WORKS:

CBC/PLT CT.: Date Received:6/19/2010

Hematology
Test Result Reference Range
Hemoglobin 115.0 120.00-150.00 g/L
Hematocrit 0.33 0.37-0.45 L
Erythrocyte No Conc. 3.89 4.00-5.00X(10) 12/L

LEUCOCYTE DIFFERENTIAL
Segmenters 0.71 0.55-0.65
Lymphocytes 0.24 0.25-0.40
Eosinophil 396.0 150-400.00X(10) 9/L
Total Protein 63.6 66.00-87.00 g/L
Albumin 29.2 34.00-48.00 g/L
Albumin/Globulin ratio 0.85:1 1.8:1-2.3:1

INTERPRETATION: The result of her CBC/PLT CT is abnormal like the hemoglobin,

hematocrit and erythrocyte that are low comparing from the baseline.

G/S Date Received:6/19/2010

Bacteriology
Source ENDOTRACHEAL ASPIRATE
Gram Staining Epithelial cells = <10/lpf
Absence of any microorganism
Final Report NO GROWTH AFTER 48 HRS. OF INCUBATION
Source ENDOTRACHEAL ASPIRATE

INTERPRETATION: the result shows that there are no bacterial infection after the
incubation.
X-ray
Examination of left wrist Date Received:6/22/10

A complete transverse fracture of the distal radius is seen with slight impaction of
the fractured segments.
Fracture of the ulnar styloid is also noted.
Osteoporosis of the osseous structure is likewise seen.

INTERPRETATION: the result shows that the pt. has a fracture at her left distal
radius.

Examination of chest port Date Received:6/19/10

Hazy infiltrates are seen in both lower lobes.
Heart is magnified.
Tracheostomy tube is seen.
Left CP sulcus is blunted
NGT is noted.
Impression: Pneumonia, both lower lobs with minimal pleural effusion in the left.
S/P tracheostomy tube insertion.

INTERPRETATION: the pt has pneumonia.

VI. ANATOMY AND PHYSIOLOGY

The respiratory system consists of all the organs involved in breathing. These
include the
nose, pharynx, larynx, trachea, bronchi and lungs. The respiratory system does two
very important
things: it brings oxygen into our bodies, which we need for our cells to live and
function properly;
and it helps us get rid of carbon dioxide, which is a waste product of cellular
function. The nose,
pharynx, larynx, trachea and bronchi all work like a system of pipes through which
the air is
funneled down into our lungs. There, in very small air sacs called alveoli, oxygen is
brought into the
bloodstream and carbon dioxide is pushed from the blood out into the air. When
something goes
wrong with part of the respiratory system, such as an infection like pneumonia, it
makes it harder
for us to get the oxygen we need and to get rid of the waste product carbon
dioxide. Common
respiratory symptoms include breathlessness, cough, and chest pain.

The Upper Airway and Trachea

When you breathe in, air enters your body through your nose or mouth. From
there, it
travels down your throat through the larynx (or voice box) and into the trachea (or
windpipe) before entering your lungs. All these structures act to funnel fresh air
down
from the outside world into your body. The upper airway is important because it
must
always stay open for you to be able to breathe. It also helps to moisten and warm
the
air before it reaches your lungs.

The Lungs
Structure
The lungs are paired, cone-shaped organs which take up most of the space in
our
chests, along with the heart. Their role is to take oxygen into the body, which we
need
for our cells to live and function properly, and to help us get rid of carbon dioxide,
which is a waste product. We each have two lungs, a left lung and a right lung.
These
are divided up into 'lobes', or big sections of tissue separated by 'fissures' or
dividers.
The right lung has three lobes but the left lung has only two, because the heart
takes up
some of the space in the left side of our chest. The lungs can also be divided up into
even smaller portions, called 'bronchopulmonary segments'.

These are pyramidal-shaped areas which are also separated from each other
by
membranes. There are about 10 of them in each lung. Each segment receives its
own
blood supply and air supply.

How they work

Air enters your lungs through a system of pipes called the bronchi. These
pipes start
from the bottom of the trachea as the left and right bronchi and branch many times
throughout the lungs, until they eventually form little thin-walled air sacs or
bubbles,
known as theal veol i. The alveoli are where the important work of gas exchange
takes
place between the air and your blood. Covering each alveolus is a whole network of
little
blood vesselcal l ed capillaries, which are very small branches of the pulmonary
arteries.
It is important that the air in the alveoli and the blood in the capillaries are very
close
together, so that oxygen and carbon dioxide can move (or diffuse) between them.
So,
when you breathe in, air comes down the trachea and through the bronchi into the
alveoli. This fresh air has lots of oxygen in it, and some of this oxygen will travel
across
the walls of the alveoli into your bloodstream. Traveling in the opposite direction is
carbon dioxide, which crosses from the blood in the capillaries into the air in the
alveoli
and is then breathed out. In this way, you bring in to your body the oxygen that you
need
to live, and get rid of the waste product carbon dioxide.

VII. PATHOPHYSIOLOGY:
Predisposing Factors: Precipitating Factor:
Age Environment
(+) alcohol drinker
(+) smoker

Streptococc
al
Pneumoniae

Enters through nose or

mouth by inhalation

Passes to the Pharynx,

Larynx and Trachea

Microorganism enters
and affects both airway
and lung parenchyma

Airway damage Lung invasion

Infiltration of Flattening of
bronchi Epithelial Cells

Infectious organism Necrosis of

lodges stimulation in bronchial tissues
bronchiole
 Flattening of
Epithelial Cells

Alveolar wall collapse

Narrowing of Macrophages
air passage and Leukocytes
Increase pyrogens in the
body
Mucus and
FEVER DIFFICULTY
phlegm
OF
production
BREATHING
COUGHING
Necrosis of Productive/Non-
pulmonary tissue Productive

DEATH

VIII. NURSING MANAGEMENT:

• Care given to patient includes nebulization.

• Performed tepid sponge bath.
• Also instructed SO to give paracetamol to patient when pt’s temperature is
above normal limits. Provided a clean environment for the patient to prevent
exacerbation of patient condition.
• Vital signs taking was also monitored every 4 hours.
• I and O taken every shift.
• Positioning the patient in Fowler’s position.
IX. DISCHARGE PLANNING:

• MEDICATION
Advise client to take medicine as prescribed by the Physician. Medicines used to
treat pneumonia may include antibiotics to cure the infection.

• EXERCISE
Take adequate rest. If tolerated, do light exercises such as walking. And also do
deep breathing and coughing

• TREATMENT
Medications should be taken exactly as prescribed by a physician. If it is not
helping, call the doctor. Do not quit taking it unless told to do so by a doctor.
Nebulization as ordered by the doctor. Increase fluid intake to 2,500to 3000ml per
day to help liquefy secretion.

• HEALTH TEACHING
Comply with the treatment regimen: place the client in a comfortable position.
Encourage deep breathing and cough exercises.

• OUT-PATIENT
Comply with the scheduled follow-up check up.

• DIET
Eat healthy and nutritious food. Eat fruits rich in vitamin C or take vitamin C to
increase the resistance of the client against infection. Increase fluid intake if not
contraindicated to the patient.

• SPIRITUAL
Pray for faster recovery.