Angeles University Foundation

Angeles City
College of Nursing

In Partial Fulfillment of the Requirement in RLE III

A Case Study on
Pneumonia
Submitted by:
Andes, Arianne Kamille E.
Baron, Justine Anjelica
Canlas, Joseph
Casupanan, Paula Bianca

Submitted to:
Mrs. Dolores T. Pabustan

I. INTRODUCTION
 Pneumonia is an inflammatory illness of the lung. It is often
described as lung parenchyma or alveolar inflammation leading to
abnormal alveolar filling with fluid. Pneumonia can result from a
variety of causes, including infection with microorganisms like bacteria,
viruses, fungi, or parasites, and chemical or physical injury to the
lungs.
Several classifications are made by pathologist for pneumonia.
These are made in accordance with the changes that were observed
during diagnostic procedures. Two common types of pneumonia are: a)
Community-acquired pneumonia (CAP), the most common type, is
pneumonia acquired by a person who has not recently been
hospitalized. b) Hospital-acquired or Nosocomial Pneumonia is acquired
during or after 72 hrs after admission in a hospital for the treatment of
another illness.
Microorganisms that cause pneumonia enter the lung when
airborne droplets are inhaled or via the bloodstream when there is an
infection in another part of the body. These microorganisms invades
the respiratory tract, including the nose, mouth and sinuses, and can
easily be inhaled into the alveoli, invading the spaces between cells
and between alveoli. This stimulates the immune system to send
neutrophils to the lungs to engulf and kill the foreign organism. There
would also be a release cytokines, causing a general activation of the
immune system. This leads to the fever, chills, and fatigue. The
resulting accumulation of neutrophils, bacteria, and fluid from
surrounding blood vessels fill the alveoli and interrupt normal oxygen
transportation.
Pneumonia is a common illness in all parts of the world in all age
groups. Majority of deaths occur in the newborn period in children, with
over two million deaths a year worldwide. The World Health
Organization estimates that one out of three newborn infant deaths is
due to pneumonia. It kills more children than any other illness,
accounting for 19% of all under-five deaths. According to the National
Statistical Coordination Board of the Philippines, there are 776,562 of
pneumonia in the country in 2004 alone. This could be an implication
that pneumonia is one of the leading causes of morbidity and mortality
in the country. World Health Organization notes Invasive Pneumococcal
Disease deaths at 1.6 million people each year. Of these, 700,000 to
one million are children under five years old and over 90 percent of
these deaths occur in developing countries. Pneumonia is a top killer in
India, China, Nigeria, Pakistan, Bangladesh, Indonesia, and Brazil.
Nevertheless, current trends in treating and diagnosing
pneumonia are being presented. Existing antibiotics like Macrolides,
Tetracyclines, Fluoroquinolones, Cephalosporins, Penicillins, and
Vancomycin are widely used. Presently, two vaccines against IPD are
available in the commercial market according to an article
“Vaccination Stops Pneumonia Deaths” by Joy Angelica Subido,
Tuesday, May 13, 2008. These are the 23-valent unconjugated
polysaccharide vaccine and the 7-valent pneumococcal conjugate
vaccine (PCV-7). While both were shown to be effective, PCV-7 is
licensed for use in children under five years old, including infants 12
months or younger, an age group that is greatly at risk for life-
threatening pneumococcal disease.
The primary duty of a nurse is the direct provision of care
especially for those who need it the most. But before one can render
efficient and accurate care, the nurse must be well equipped with basic
knowledge about what concerns the community, the diseases, their
preventions, treatments and medications. For this reason, the
acquisition of knowledge is the motivator of the group. This
opportunity to work on a case study will help each researcher to
expound their knowledge on specific conditions. This will help each
member to carry out the task with full responsibility and accountability
of what has been entrusted to their care.
II. Nursing Assessment
A. Personal History
A.1.Demographic Data
Baby Cucoo is a four - month old baby girl. Together with her
parents Abegail and Rod, they reside in one of the barangay in
Candaba, Pampanga. She was born as a Filipino citizen on February 02,
2008 at their home residence. Baby Cucoo was admitted in a hospital
in the City of San Fernando last June 20, 2008, 1:05 in the afternoon
with the primary complain of difficulty of breathing. Her admitting
diagnosis was Pneumonia Severe with Congenital Heart Disease
acyanotic type, probably Ventricular Septal Defect with Down’s
syndrome.

A.2. Pertinent Family History

Baby Cucoo lives with her average-sized nuclear family
consisting of her parents and her five-year old brother who was born
on 2003 under normal spontaneous delivery. As the first child in the
family, Dion gets all the attention, care and the love he needs. All
measures to ensure his welfare even prior to his delivery were
performed and met. Cucoo was born also under normal spontaneous
delivery. During her time in her mother’s womb, she lacks the
appropriate care and management, in contrary to the current
treatment she gets from her parents.
The family is currently residing in an old house originally
occupied by her grandparents. It is situated in a place where sanitation
is observed and mode of transportation includes public utility vehicles
like tricycles. Cucoo’s father Rod formerly worked as an agent of Lyzon
Officer Agency in Manila that endorses work promotions in Japan where
he earns 350 pesos a day. Presently, he is now working as a sales clerk
at Robinson’s Mall in the City of San Fernando, earning 280 pesos a
day (8,400 pesos a month). This indicates that each member is allotted
2,100 pesos per month, which means the family is considered poor
since the average cost of monthly allowance is 2, 768.60 for each
family member.
The family, especially with regards to health, is practicing certain
beliefs such as: a) when a child is having fever, don’t cut his nails until
he can bath or else his/her condition will worsen, b) Unless he reached
his/her first birthday, a child must never have his/her haircut or else he
will be prone to different kind of illness. These practices were adapted
from older people and were passed on into this generation. They also
embrace the healing powers of “manghihilot” and “herbolarios”. In
times of illness, they practice self-medications for simple cough, colds
and fever but they also resort of visiting a medical practitioner when
necessary.

A.3. Personal History

During her pregnancy, Cucoo’s mother engages herself into
regular exercise in a form of early ambulation and ensures that she
has adequate sleep and rest periods. She is very particular with the
child’s health and restrained herself from eating unhealthy foods such
as eating junk foods and street foods to avoid untoward results of
pregnancy. She avoids jumping as it may harm the baby. In her
pregnancy with Dion, she visits her Ob-gynecologist regularly to
monitor progress.
In her pregnancy with Cucoo, her mother complained of having
headaches, difficulty of breathing and pain in the pubic region.
Incidence of collapse and dizziness were also noted. She only has a
total of 2 visits to her Ob-gynecologist during the entire pregnancy as
she was working at that time as a sales clerk in SM Pampanga. Cucoo
was born at via NSD 14 days prior to the EDC and weighed 6.5 lbs. The
entire duration of labor lasted for 3 hours.
 The two children, Dion and Cucoo had undergone mixed feeding.
Dion had pure breastfeeding for 2 months then mixed feeding for the
next period of lactation. Cucoo was purely breastfed for a month and is
being bottle-fed currently.
Both have incomplete immunization, with Cucoo having BCG only
until this time.
 Stages of Growth and
Development
(Theory of Trust and
Normal Untoward
Mistrust) Client’s response
Response Response
Infancy-1 year old

This is the period of Currently, baby

The infant The infant failed
infancy through the Cucoo is within this
would be able to develop a
first one or two Trust vs. Mistrust
to gain a sense sense of trust
years of life. The stage.
of trust with his with his
child, well - handled, As observed, she is
parents, parents,
nurtured, and loved, capable of
particularly with particularly the
develops trust and developing her trust
her mother mother because
security and a basic with her parents,
because they they are not
optimism. Badly especially with her
are able to able to provide
handled, he mother. This is
meet their basic support
becomes insecure evident when Baby
responsibility to failure to meet
and mistrustful. Cucoo stops crying
provide warmth, infants’ needs.
after being cuddled
comfort,
by her mother.
security,
When sensed she
sensory
will be held lying on
stimulation,
bed without a bottle
food to the
on her mouth, she
infant.
will cry.

Erik Erikson
(Theory of shame
and doubt) Normal Untoward Client’s Response
2 to 3 years old Response Response

Children show a The infant will The infant will The possibility for
Family Health History

PATERNAL SIDE MATERNAL SIDE

Grandfather, LUIS, 51 y.o,

Grandfather, deceased with EMPHYSEMA
CERVANO, 57 y.o

Grandmother,
CLARA,49 y.o
Grandmother,
ANNIE, 56 y.o
Aunt, CAROLINE, 30
y.o

Uncle, JOSHUA,
33 y.o Aunt, MICHELLE, 29
y.o

Cousin,
Uncle, MIGUEL, BUBUY, with Aunt, JENNY, 26 y.o
31 y.o Down’s
Syndrome
Father, ROD, 25 y.o,
Aunt, DENNISE,
29 y.o

Uncle, HARVEY, 21
y.o
Mother, ABEGAIL,
27 y.o
Brother, DION, 5 y.o Uncle, JOHN, 17 y.o

Aunt, JAMIE, 21 y.o,

Aunt, SHEENA, 25 deceased with
y.o, with Asthma BRAIN TUMOR

Patient, BABY CUCOO, 4

Uncle, MARKY, months, with Pneumonia,
CHD probably VSD and Uncle, BOB, 11 y.o
21 years old
Down’s Syndrome
Uncle, BRUNO, 21
Uncle, MATT, 9 y.o,
years old
A.4. History of Past Illness
Baby Cucoo was formerly diagnosed of having a Down’s syndrome and
a history of cyanosis as manifested by bluish color of the skin when coughing
and crying. The family managed to consult a private medical doctor for
treatments like medicines for cough.

A.5. History of Present Illness

Two months prior to admission, baby Cucoo was noted to have noisy
breathing so she was brought to her Private Medical Doctor for consultation
and was diagnosed with Down’s syndrome with Congenital Heart Disease.
Her mother was advised to have her follow – up check up to a cardiologist
however, due to financially constraint, this was not done.
One month prior to admission, baby Cucoo had persistent cough. She
was brought again to a Private Medical Doctor and was given Cefalexin and
Ambroxol.
One day prior to admission, baby Cucoo had persistent dry cough and
was advised by her Medical Doctor to be transferred and admitted into the
hospital.

A.6. Physical Examination

o Upon admission: June 20, 2008 (Lifted from the chart)
VITAL SIGNS
Temperature= 37°C
Pulse rate= 138 beats per minute
Respiratory rate= 41 cycles per minute
PHYSICAL EXAMINATION
SKIN: Upon inspection, jaundice was noted, good skin turgor, temperature
within normal limit
EYES: Pink palpebral conjunctiva, anicteric sclera, no epicanthal folds in the
eyes
EARS: Low-set ears
LYMPH NODES: No cervical lymphadenopathy
LUNGS: symmetrical chest expansion, with rales on both lung fields
CARDIOVASCULAR: With murmurs heard 3/6 systolic
ABDOMEN: Globular, soft and non-tender

o First Nurse – Patient Interaction: June 26, 2008

VITAL SIGNS
Temperature= 38.4°C
Pulse rate= 102 beats per minute
Respiratory rate= 49 cycles per minute
PHYSICAL EXAMINATION
SKIN: Upon inspection, jaundice was noted, good skin turgor, temperature
above normal limit
NAILS: Capillary refill test of 3 seconds
EYES: Pink palpebral conjunctiva, pupils equally react to light
EARS: Low-set ears
NOSE: With secretions upon inspection, nasal flaring
MOUTH: With moist mucous membrane
TONGUE: magenta red in color
LYMPH NODES: No cervical lymphadenopathy
LUNGS: symmetrical chest expansion, adventitious breath sounds: with rales
on both lung fields
ABDOMEN: Globular, soft and non-tender
 Description Appeara Disappear Baby
Reflexes
nce ance Cucoo

Babinski Toes fan upward when sole of the Birth 9 months Absent
foot is stroke.

Galant Swinging towards the side when the Birth Neonatal Absent
skin along the side of an infant's Period
back is stroked

Moro Sudden outward extension of arms Birth 4 months Absent

(Startle) with midline returns when startled
by loud noise or rapid change in
position or temperature.

Righting Attempting to maintain head in an Birth 24 months Present

upright position.

Rooting Turning head toward anything that Birth 6 months Present

strokes the cheek or mouth.

Sucking instinctive sucking at anything that Birth Indefinite Present

touches the roof of the mouth

Palmar Grasp The closing of fingers to grasp Birth 4 months Present

object that is placed in the infant's
hand

Attempting to walk when soles of 4-5 8-12 Absent

Walking
the feet touch a flat surface months months

A.7. Diagnostic and Laboratory Procedures

DIAGNOSTIC DATE
OR OREDER ANALYSIS
LABORATOR ED INDICATIONS RESULT NORMAL AND
Y DATE OR PURPOSES S VALUES INTERPRET
PROCEDURE RESULT ATION
S S IN

COMPLETE Date ▪ HGB 187 M: 125- Hemoglobin

BLOOD Ordered: >> to monitor 175g/l level is
COUNT (CBC) June 22, Hgb value in the F: 115- increased.
OR 2008 RBC 155g/l This is
HEMATOLOGY >> measures the caused by
Date oxygen – carrying an increased
Results capacity of the compensa-
In: blood tory
June 23, mechanism
2008 brought by
decreased
oxygen level
in the blood.

▪ HCT 0.56
>> to aid M: 0.40- RBC
diagnosis of 0.52 concentra-
abnormal states F:0.38-0.48 tion in the
of hydration, blood is
polycythemia and increased.
anemia. This is
It measures the caused by
concentration of an increased
RBC within the compensator
blood volume y
mechanism
brought by
hypoxemia.

9.5
The WBC
▪ WBC count 5-10 x 109/L count is
 >> to detect within
infection or normal
inflammation range. this
>>this blood test means there
evaluates the is low risk for
number of the spread
condition and of infection
differentiates and there is
causes of no sign of
alteration in the inflammation
total WBC count
including
inflammation,
infection and
tissue necrosis.

0.10

▪ Neutrophils 0.45- Neutrophil is

>> to 0.85ml/L low so it is
differentiate harder for
between the her body to
various types of fight
WBCs for infection
diagnosing health since
problems neutrophils
-first line defense are type of
responsible for WBC
pus formation, responsible
phagocytize for the
microorganism phagocytosis
of
microorga-
nisms.

0.10

▪ Lymphocytes 0.20-0.35 Lymphocyte

>> to determine s are low
bacterial infection which
 >> produces suggest that
antibodies; the body will
responsible for have a
allergic reactions difficulty to
compensate
during
allergic
reactions.

476

150-400 x Platelet
▪ Platelet count 109/L count is
>> to evaluate higher than
platelet the normal
production range which
>> to diagnose suggests a
and monitor lower
severe chances of
thrombocytosis or bleeding
thrombocytopeni tendencies
a
>> Platelets are
a type of blood
cell. They play a
key role in normal
blood clotting.
During the
clotting
process, platelets
clump together to
plug small holes
in damaged blood
vessels. The
purpose of
clotting is to stop
bleeding.

CHEST X-RAY Date >> it is used to Hazy Heart is not Presence of

(APL) Ordered: identify infiltrate enlarged for pneumonia
 June 20, abnormalities of s noted the client’s
2008 the lungs and in both age, lungs
structures in the inner are not
Date thorax, including lung collapsed,
Results the size of the zones diaphragm
In: heart and and sulci
June 27, abnormalities in intact, no
2008 the ribs and other
diaphragm structure or
object
>> serial chest X- present
ray may be used
to evaluate the
status of the
respiratory
abnormalities and
cardiac conditions

SERUM Date Sodium 139- Result is

ELECTROLYTE Ordered: >> to monitor 142.1 145mmOl/L within
S ANALYSIS June 19, detect Na level normal
2008 and imbalance range. There
>> this serum is no
Date test for Na levels presence of
Results evaluate fluid and hyponatre-
In: electrolyte mia
June 20, balance as well as
2008 renal or adrenal
disorder.

Potassium
>> to check 5.28 3.50-
potassium level 5.50mmOl/L Result is
and to detect within
presence of normal
hypokalemia or value. There
hyperkalemia and is no
to monitor presence of
potassium level hypokalemia
during health or
problems.
>> this serum
test for K levels
evaluate fluid and
 electrolyte
balance as well as
renal or adrenal
disorder.

Hematology & Serum Analysis:

1. PRIOR

• Note current drug therapy before procedure.

• Check the physician’s order.

• Identify the client.

• Prepare the needed materials.

• Explain the procedure to the SO, its purpose and how it is done.

• Inform the SO that there are no food or fluid restrictions.

• Proper hand washing.

2. During

• Collect approximately 5 to 10 ml of venous blood in a purple top

tube.

• Avoid hemolysis.

• Maintain aseptic technique.

3. After

• Apply pressure to the punctured site to prevent bleeding.

• Discuss with SO signs of inflammation of punctured site and

advice to report immediately.

• Check the site for bleeding after procedure.

• Wash hands.
Chest X-Ray:

Prior
• Check the doctor’s order.
• Identify the client.
• Describe the procedure to the SO.
• Explain to the mother that this test assesses respiratory status.
• Tell the mother that no fasting is required.
• Inform the mother that the test takes 5 to 10 minutes.
• Describe the test to the mother including who will perform it and
when will it take place.
• Assist client and SO in going to the x-ray room.
1. During
• If the patient is intubated, check that no tubes have been
dislodged during positioning.
• To avoid exposure to radiation, leave the room or the immediate
area while the films are being . If you must stay in the area, wear
a lead-lined apron.
2. After

• Inform the mother the possible need for additional x-ray.

• Document.
III. Anatomy and Physiology

The sole purpose of the Respiratory System of the human body is

primarily the facilitating of respiration. These includes the following
processes : Ventilation, or breathing which is the movement of air into and
out of the lungs; Exchange of oxygen and carbon dioxide between the air in
the lungs and the blood; Transport of oxygen and carbon dioxide in the
blood; and exchange of oxygen and carbon dioxide between the blood and
the tissues.
Other than respiration, the human body’s respiratory system is also
responsible for regulation of blood pH, voice production, olfaction, and innate
immunity.
The respiratory system is divided into two, namely: the upper and the
lower respiratory tract. Under the upper respiratory tract refers to the nose,
nasal cavity, and pharynx. While the lower respiratory tract refers to the
larynx, bronchi, the trachea, and the lungs; Pneumonia, a very serious
disease causes inflammation in the lungs. The air sacs in the lungs fill with
pus and other liquid. Oxygen has trouble reaching your blood. If there is too
little oxygen in your blood, your body cells can't work properly. Because of
this and spreading infection through the body pneumonia can cause death.

Bronchi and Bronchial Tree

The trachea divides into the left and right main bronchi, each of which
connects to a lung. The left main bronchus is more horizontal than the right
main bronchus because the heart displaces it. Foreign object that enter
trachea usually lodge in the right main bronchus, because it is more vertical
than the left main bronchus and therefore more in direct line with the
trachea. The main bronchi extend from the trachea to the lungs. Like the
trachea, the main bronchi are lined with pseudostratified ciliated columnar
epithelium and are supported by C-shaped pieces of cartilage.
Lungs
 The lungs are the principal organs of respiration. Each lung is cone-
shaped, with its base resting on the diaphragm and its apex extending
superiorly to a point about 2.5 cm above the clavicle. The right lung has
three lobes called the superior, middle, and inferior lobes. The left lung has
two lobes called the superior and inferior lobes. The lobes of the lungs are
separated by deep, prominent fissures on the surface of the lung. Each lobe
is divided into bronchopulmonary segments separated from one another by
connective tissue septa, but these separations are not visible as surface
fissures. Individual diseased bronchopulmonary segments can be surgically
removed, leaving the rest of the lung relatively intact, because major blood
vessels and bronchi do not cross the septa.
The main bronchi branch many times to form the tracheobronchial
tree. Each main bronchus divides into lobar bronchi as they enter their
respective lungs. The lobar bonchi, two in the left lung and three in the right
lung, conduct air to each lobe. The lobar bronchi in turn give rise to
segmental bronchi, which extend to the bronchopulmonary segments of the
lungs. The bronchi continue to branch many times, finally giving rise to
bronchioles. The bronchioles also subdivide numerous times to give rise to
terminal bronchioles, which then subdivide into respiratory bronchioles. Each
respiratory bronchiole subdivides to form alveolar ducts, which are like long,
branching hallways with many open doorways. The doorways open into
alveoli, which are small air sacs. The alveoli become so numerous that the
alveolar duct wall is little more than a succession of alveoli. The alveolar
ducts end as two or three alveolar sacs, which are chambers connected to
two or more alveoli. There are about 300 million alveoli in the lungs,
The lungs are contained within the thoracic cavity. In addition, each
lung is surrounded by a separate pleural cavity. Each pleural cavity is lined
with a serous membrane called the pleura. The pleura consists of a parietal
and visceral part. The parietal pleura, which lines the walls of the thorax,
diaphragm, and mediastinum, is continuous with the visceral pleura, which
covers the surface of the lung.
 A Diagram showing the Trachoebronchial Tree and the Diaphragm

Oxygen Transport System

The flow of air in and out of the lungs is controlled by the nervous
system, which ensures that humans breathe in a regular pattern and at a
regular rate. Breathing is carried out day and night by an unconscious
process. It begins with a cluster of nerve cells in the brain stem called the
respiratory center. These cells send simultaneous signals to the diaphragm
and rib muscles, the muscles involved in inhalation. The diaphragm is a
large, dome-shaped muscle that lies just under the lungs. When the
diaphragm is stimulated by a nervous impulse, it flattens. The downward
movement of the diaphragm expands the volume of the cavity that contains
the lungs, the thoracic cavity. When the rib muscles are stimulated, they also
contract, pulling the rib cage up and out like the handle of a pail. This
movement also expands the thoracic cavity. The increased volume of the
thoracic cavity causes air to rush into the lungs. The nervous stimulation is
brief, and when it ceases, the diaphragm and rib muscles relax and
exhalation occurs. Under normal conditions, the respiratory center emits
signals 12 to 20 times a minute, causing a person to take 12 to 20 breaths a
minute. Newborns breathe at a faster rate, about 30 to 50 breaths a minute.

The diaphragm works by creating a negative pressure area. When

pulling downward it makes the thoracic cavity have a substantially lower
internal pressure than what exists out side the cavity. Air rushes into the
respisrtory system.
When the diaphragm relaxes it pushes upward causing the pressure in
the thoracic cavity to become greater than exists outside the cavity. Air is
forced out of the respiartory system.
The rhythm set by the respiratory center can be altered by conscious
control. The breathing pattern changes when a person sings or whistles, for
example. A person also can alter the breathing pattern by holding the
breath. The cerebral cortex, the part of the brain involved in thinking, can
send signals to the diaphragm and rib muscles that temporarily override the
signals from the respiratory center. The ability to hold one’s breath has
survival value. If a person encounters noxious fumes, for example, it is
possible to avoid inhaling the fumes.

A person cannot hold the breath indefinitely, however. If exhalation

does not occur, carbon dioxide accumulates in the blood, which, in turn,
causes the blood to become more acidic. Increased acidity interferes with
the action of enzymes, the specialized proteins that participate in virtually all
biochemical reaction in the body. To prevent the blood from becoming too
acidic, the blood is monitored by special receptors called chemoreceptors,
located in the brainstem and in the blood vessels of the neck. If acid builds
up in the blood, the chemoreceptors send nervous signals to the respiratory
center, which overrides the signals from the cerebral cortex and causes a
person to exhale and then resume breathing. These exhalations expel the
carbon dioxide and bring the blood acid level back to normal.

A person can exert some degree of control over the amount of air
inhaled, with some limitations. To prevent the lungs from bursting from
overinflation, specialized cells in the lungs called stretch receptors measure
the volume of air in the lungs. When the volume reaches an unsafe
threshold, the stretch receptors send signals to the respiratory center, which
shuts down the muscles of inhalation and halts the intake of air.

In pulmonary circulation, deoxygenated blood returning from the

organs and tissues of the body travels from the right atrium of the heart to
the right ventricle. From there it is pushed through the pulmonary artery to
the lung. In the lung, the pulmonary artery divides, forming the pulmonary
capillary region of the lung. At this site, microscopic vessels pass adjacent to
the alveoli, or air sacs of the lung, and gases are exchanged across a thin
membrane: oxygen crosses the membrane into the blood while carbon
dioxide leaves the blood through this same membrane. Newly oxygenated
blood then flows into the pulmonary veins, where it is collected by the left
atrium of the heart, a chamber that serves as collecting pool for the left
ventricle. The contraction of the left ventricle sends blood into the aorta,
completing the circulatory loop. On average, a single blood cell takes roughly
30 seconds to complete a full circuit through both the pulmonary and
systemic circulation.
 A Diagram showing both the process of Pulmonary Circulation
and Systemic Circulation

Gas exchange or respiration takes place at a respiratory surface - a

boundary between the external environment and the interior of the body. For
unicellular organisms the respiratory surface is simply the cell membrane,
but for large organisms it usually is carried out in respiratory systems.

In humans and other mammals, respiratory gas exchange or

ventilation is carried out by mechanisms of the lungs. The actual exchange
of gases occurs in the alveoli.

Convection occurs over the majority of the transport pathway.

Diffusion occurs only over very short distances. The primary force applied in
the respiratory tract is supplied by atmospheric pressure. Total atmospheric
pressure at sea level is 760 mm Hg, with oxygen (O2) providing a partial
pressure (pO2) of 160 mm Hg, 21% by volume, at the entrance of the nares,
and an estimated pO2 of 100 mm Hg in the alveoli sac, pressure drop due to
conduction loss as oxygen travels along the transport passageway.
Atmospheric pressure decreases as altitude increases making effective
breathing more difficult at higher altitudes.
 A Diagram showing gas exchange that occurs only at pulmonary and
systemic capillary beds near the alveoli.

CO2 is a result of cellular respiration. The concentration of this gas in

the breath can be measured using a capnograph. As a secondary
measurement, respiration rate can be derived from a CO2 breath waveform.

Trace gases present in breath at levels lower than a part per million
are ammonia, acetone, isoprene. These can be measured using selected ion
flow tube mass spectrometry.

Blood carries oxygen, carbon dioxide and hydrogen ions between

tissues and the lungs.

The majority (70%) of CO2 transported in the blood is dissolved in

plasma (primarily as dissolved bicarbonate; 60%). A smaller fraction (30%) is
transported in red blood cells combined with the globin portion of
hemoglobin as carbaminohemoglobin.

Hemoglobin in the red blood cells increases the carrying capacity of

oxygen hundreds of times greater than plain water.
 CO2 that diffuses into the blood enters red blood cells where an
enzyme converts the CO2 into bicarbonate ions (HCO3-). Converting the CO2
into Bicarbonate ions increases the carrying capacity of CO2 molecules.
IV. The Patient’s Illness
SYNTHESIS OF THE DISEASE
(Book-Based)

Body’s defense is lowered/ low immune system

Failure of the respiratory tree to be free of infection

Exposure to an environment with microorganisms

Acquisition of microorganisms (bacterial, viral, fungal)

Inhalation of M.O.s and retention Aspiration of foreign body, food, vomit or

in nasopharyngeal wall other irritating substances

Invasion of microorganisms
in the nares

Infection Starts

Microorganisms reach the

tracheobronchial tree

Microorganisms travel to the lungs

Microorganisms lodge in the

alveoli
 Rapid multiplication of
microorganisms

Irritation of the airway mucosa Immune system response

and lung parenchyma

Lymphocytes activates cytokines

Desquamation or the peeling of and histamines
the mucous membrane in the
lungs

Movement of phagocytotic cells

into the site of inoculation
Increase mucus production on
the nasal cavity and
tracheobroncial tract to stop
invading microorganisms Phagocytotic cells engulf the
microorganisms

Production of mucous by the

Goblet cells Continues phagocytosis on
Signals Prostaglandin to release the microorganisms by the
pyrogens macrophages

Secretions move
Decreased airwayvia cilia
patency
Increase in basal
Change in the pathologic
Increase in
metabolic body
rate
tissue of the lungs
temperature or
Hyperthermia
Dysnea (difficulty Alterations to oxygen
of breathing) exchange
(Patient- based)

Modifiable Factors: Non-Modifiable Factors

- Place of Residence - Age
- Poor diet - Sex

Body’s defense is lowered/ low immune system

Failure of the respiratory tree to be free of infection

Exposure to an environment with microorganisms

Acquisition of microorganisms (bacterial, viral, fungal)

Inhalation of M.O.s and retention

Invasion of microorganisms
in the nares

Infection Starts

Microorganisms reach the

tracheobronchial tree

Microorganisms travel to the lungs

Microorganisms lodge in the

alveoli
 Rapid multiplication of
microorganisms

Irritation of the airway mucosa Immune system response

and lung parenchyma
Platelets activate and
Lymphocytes activates cytokines aggregate to release
and histamines cytokines and bradykinins
Desquamation or the peeling of
the mucous membrane in the
lungs
Increased platelet count
Movement of phagocytotic cells (June 23, 2008)
into the site of inoculation
Increase mucus production on
the nasal cavity and
tracheobroncial tract to stop
invading microorganisms Phagocytotic cells engulf the
microorganisms

Production of mucous by the

Goblet cells Continues phagocytosis on
Signals Prostaglandin to release the microorganisms by the
pyrogens macrophages

Secretions move via cilia

Decreased airway Increase in basal metabolic
patency rate Change in the pathologic
tissue of the lungs
Increase in body
temperature or
Hyperthermia
(June 26, 2008)
 Adventitious
Dysnea (difficulty breath
Alterations to oxygen
of breathing) sounds
exchange
(June 20, 2008) (Rales and
Wheezes) ss
(June 27, 28,
2008)

Pallor
(June 28, 2008)
 A. Definition of the Disease

Pneumonia is an inflammatory illness of the lung. It is often described as

lung parenchyma or alveolar inflammation leading to abnormal alveolar
filling with fluid. Pneumonia can result from a variety of causes, including
infection with microorganisms like bacteria, viruses, fungi, or parasites, and
chemical or physical injury to the lungs.

B. Predisposing/Precipitating Factors

Modifiable and Non-modifiable Factors

1. Poor Diet is a modifiable factor in which this is crucial in the

strengthening of the immune system of the client. Without the
sufficient intake of vitamins and minerals that are present in the diet,
the defense mechanism of the body is weakened; making it susceptible
to infection and invasion of possible microorganisms that are present
in the environment. This can be attributed to the possibility that these
microorganisms are dwelling in the environment itself.
2. Place of residence is underdeveloped is another modifiable factor since
crowdedness of the people living in a particular geographical area
would facilitate direct contact mode of transmission of possible
microorganisms or through droplet infection, as well. This will make the
client susceptible for acquiring a disease from someone proximal to
him; therefore, a disease may or may not develop depending on the
distance of the client from an infected person and the virulence of the
disease.
3. Age is a non-modifiable factor in which the client’s immunity against
possible diseases is not that developed in comparison to adults.
4. Sex is a non-modifiable factor in which the occurrence of the said
disease in prevalent in males more it is in females.
C. Signs and Symptoms

1. Cough an important way to keep your throat and airways clear.

However, excessive coughing may mean you have an underlying
disease or disorder. Some coughs are dry, while others are considered
productive; a reflex which is said to be a natural defense mechanism
because of its action of expulsing bacteria out of the tracheobronchial
tree.
2. Dyspnea is the difficult or labored breathing; shortness of breath. It is
a sign of serious disease of the airway, lungs, or heart.
3. Chills refers to feeling cold after an exposure to a cold environment.
The word can also refer to an episode of shivering, accompanied by
paleness and feeling cold
4. Fever isn't an illness itself, but it's usually a sign that something out of
the ordinary is going on in your body. Fevers aren't necessarily bad. In
fact, fevers seem to play a key role in helping your body fight off a
number of infections.
5. Vomiting is seldom related to food intake, is usually the result of
irritation of the vagal centers in the medulla
6. Chest pain or angina, uncomfortable pressure, squeezing or fullness
in substernum, radiation to arms and hands is described as numbness,
tingling, or aching
7. Cyanosis refers to a blue or purple hue to the skin. It is most easily
observed on the lips, tongue and fingernails. Cyanosis indicates there
may be decreased oxygen in the bloodstream. It may suggest a
problem with the lungs, but most often is a result of mixing blue and
red blood due to defects of the heart or great vessels. Cyanosis is a
finding based on observation, not a laboratory test. Cyanosis is usually
caused by either serious lung or heart disease, or circulation problems.
8. Loss of Appetite is a result of decrease in the brain impulses that
stimulates the function of the taste buds. It is because of the vascular
 changes in the cephalic area. Since the alveoli where filled with fluids
and exudates, gas exchange was not accomplished well; so what
happened was, there was diminished Oxygen in the body, as it was
manifested by the presence of cyanosis. Hypoxemia had erupted
resulting to low oxygen in the brain and muscles which eventually lead
to the vascular changes.
9. Abdominal pain: the patient experiences pain on his/hers stomach
10. Decreased activity: decrease in activity patter
11. Loss of appetite (in older children) or poor feeding (in
infants)
12. In extreme cases, bluish or gray color of the lips and
fingernails
13. Headache is the outcome when there is low oxygen in the brain.
There are vascular changes in the cephalic area.
14. Body Malaise had resulted out of low oxygen content in the muscles.
Since the cells in the body require sufficient amount in oxygen, it
cannot work properly if its level is decrease resulting to malaise.

Preventive Measures

 Get vaccinated. A vaccine known as pneumococcal conjugate

vaccine can help protect young children against pneumonia. It's
recommended for all children younger than age 2 and for children 2
years and older who are at particular risk of pneumococcal disease,
such as those with an immune system deficiency, cancer,
cardiovascular disease or sickle cell anemia. Side effects of the
pneumococcal vaccine are generally minor and include mild soreness
or swelling at the injection site.
 Wash hands. Hands are in almost constant contact with germs that
can cause pneumonia. These germs enter your body when you touch
your eyes or rub the inside of your nose. Washing your hands
thoroughly and often can help reduce your risk. When washing isn't
possible, use an alcohol-based hand sanitizer, which can be more
effective than soap and water in destroying the bacteria and viruses
that cause disease. What's more, most hand sanitizers contain
ingredients that keep your skin moist. Carry one in your purse or in
your pocket.

 Don't smoke. Smoking damages your lungs' natural defenses

against respiratory infections.

 Proper rest and a diet. Foods rich in fruits, vegetables and whole
grains along with moderate exercise can help keep the immune system
strong.

 Protect others from infection. Try to stay away from anyone with
a compromised immune system. When that isn't possible, help protect
others by wearing a face mask and always coughing into a tissue.
 V. The Patient and his Care

A. MEDICAL MANAGEMENT

a. IVF, Nebulization, Oxygen therapy

MEDICAL DATE GENERAL INDICATION( CLIENT’S

MANAGEMEN ORDERED DESCRIPTIO S) OR RESPONSE TO
T/ DATE N PURPOSE(S) THE TREATMENT
TREATMENT PERFORMED
DATE
CHANGED/
D/C

Intravenous DO: 6-20-08 It is a It is use to Client fluid loss was

Fluids DP: 6-20-08 hypertonic supply the prevented and
D5IMB 315cc DC:6-25-08 solution, necessary maintains the
x2° @ 13-14 which makes nutrients. hydration status of
gtts/min. the cells And this the patient as
shrink, solution is evidence by
composes of given usually patient’s Sodium
water and when serum level of
carbohydrates osmolality 142.1mmol/L and
, as source of has Potassium level of
energy and decreased to 5.28 mmol/L
both cations dangerously
and anions. low levels.
NURSING RESPONSIBILITIES:

PRIOR TO THE PROCEDURE:

• Check doctor’s order.
• Check for ordered IVF.
• Check for the patency of the IV tubing, expiration date and
cloudiness.
• Explain the procedure to the client/SO

DURING THE PROCEDURE:

• Clean the site to be administered.
• Choose a vein on the distal arm.
• Support the hand of the client and observe aseptic technique.

AFTER THE PROCEDURE:

• Monitor rate, flow and patency.
• Document.
 MEDICAL DATE GENERAL INDICATION( CLIENT’S
MANAGEMEN ORDERED DESCRIPTIO S) OR RESPONSE TO
T/ DATE N PURPOSE(S) THE TREATMENT
TREATMENT PERFORMED
DATE
CHANGED/
D/C

Oxygen DO: 6-20-08 The The purpose Client’s respiratory

Therapy DP: 6-20-08 administratio is to increase distress (dyspnea)
02 Cannula @ DC:6-22-08 n of oxygen oxygen was relieved as
2-3LPM for at a saturation in evidence by a
respiratory concentration tissues where decrease in
distress greater than the saturation patient’s respiratory
that found in levels are too rate of 42cpm to
the low due to 35cpm
environment illness or
atmosphere. injury.
Breathing
prescribed
oxygen
increases the
amount of
oxygen in the
blood,
reduces the
extra work of
the heart, and
decreases
shortness of
breath.
NURSING RESPONSIBILITY:

PRIOR TO THE PROCEDURE:

• Verify written order for oxygen therapy, including methods of
delivery and flow rate.
• Wash hands properly.
• Explain procedure to client/SO.

DURING THE PROCEDURE:

• Assess client for obstruction of the nasal passages.
• Adjust flow rate to the prescribed amount.

AFTER THE PROCEDURE:

• Periodic assessment and documentation of oxygen saturation
levels
• Follow-up monitoring includes blood gas measurements and
pulse oximetry tests.
• Water-based lubricants can be used to relieve dryness of the
lips and nostrils.
NAME OF DATE ROUTE GEN. ACTION INDICATION OR CLIENTS
DRUGS, ORDERED OR FXNAL CLASS’N PURPOSE(S) RESPONSE
GENERIC DATE ADMIN. MECHANISM OF TO THE
NAME TAKEN/GIV DOSAGE ACTION MEDICATI
BRAND EN DATE AND ON W/
NAME CHANGED/ FREQUEN ACTUAL
D/C CY OF SIDE
ADMIN. EFFECT

ALBUTER DO:6-20-08 1 nebule Fxnal class’n: Salbutamol is used After each

OL DP:6-20-08 every 4 Sympathomimeti in cases of medication
Salbutamo hours c bronchospasm in the patient
l patients with feels relief,
DC:6-24-08 1 nebule Mechanism of reversible airway and her
every 6 action: obstruction: mild respiratory
hours Stimulates beta- and moderate rhythm falls
2 receptors of attacks of dyspnea back to
DC:6-27-08 1 nebule to the bronchi, in patients normal rate
8 hours leading to suffering from as evidence
bronchodilation. bronchial asthma; by a
Causes less mild and moderate decrease in
tachycardia and bronchoobstructio patient’s
is longer-acting n in patients with respiratory
than chronic bronchitis rate of
isoproterenol. and lung 42cpm to
Has minimal emphysema. 35cpm
beta-1 activity.
NURSING RESPONSIBILITIES:

PRIOR TO THE PROCEDURE:

• Check for doctor’s order.
• Before administration assess for the lung sounds, pulse and
blood pressure.
• Warn the S.O for possible paradoxical bronchospasm.
DURING THE PROCEDURE:
• Clear throat and nasal passages.
• Put the medication into the inhaler and shake it well.
• Place the mouthpiece well into mouth as dose from the
inhaler is released. Perform chest-physio therapy.
AFTER THE PROCEDURE:
• Instruct the S.O on how to perform nebulisation.
• Do not increase the dose or frequency of dosage.
• Document.
 NAME OF DATE ROUTE GEN. INDICATIO CLIENTS
DRUGS, ORDERED OR ACTION N OR RESPONSE
GENERIC DATE ADMIN. FXNAL PURPOSE( TO THE
NAME TAKEN/GIV DOSAGE CLASS’N S) MEDICATI
BRAND NAME EN DATE AND MECHANIS ON W/
CHANGED/ FREQUEN M OF ACTUAL
D/C CY OF ACTION SIDE
ADMIN. EFFECT

ACETAMINOPH DO: 6-20-08 52mg. IV Fxnal class’n: It is a The

EN DP:6-21-08 every 4 Non-narcotic common patient’s
Paracetamol DC:6-21-08 hours prn analgesic analgesic body
for fever and temperatur
with temp. Mechanism antipyretic e decreases
> 37.8 of Action: drug that is from 38.1
Decreases used for degree
fever by a the relief of Celcius to
hypothalamic fever, 36.9 degree
effect leading headaches, Celcius
to sweating and other
and minor
vasodillation aches and
and inhibits pains.
the effect of
pyrogens on
the
hypothalamu
s heat
regulating
centers.
Nursing Responsibilities:

Prior to the procedure:

• Check for the doctor’s order.
• Explain the action of the drug to the SO.
• Assess fever, note signs like diaphoresis, tachycardia and
malaise.
During the procedure:
• Cleanse the IV port before injecting the medication.
• Inject slowly the drug.

After the procedure:

• Encouraged the S.O to check concentrations of liquid
preparations. Errors may result to liver damage
• Monitor vital signs
• Document.
NAME OF DATE ROUTE GEN. ACTION INDICATION CLIENTS
DRUGS, ORDERED OR FXNAL OR RESPONSE TO
GENERIC DATE ADMIN. CLASS’N PURPOSE(S) THE
NAME TAKEN/GIV DOSAGE MECHANISM MEDICATION
BRAND EN DATE AND OF ACTION W/ ACTUAL
NAME CHANGED/ FREQUEN SIDE EFFECT
D/C CY OF
ADMIN.

Cefuroxi DO:6-20-08 175mg./IV Fxnal Class’n: For lower The patient was
me DP:6-20-08 every 8 Cephalosporin respiratory tract prevented from
Ceftin. DC: 6-27-08 hours , second infection, further growth
generation UTI’s,skin and of certain types
skin structure of
Mechanism of infection, microorganisms
action: septicemia,meni as manifested
Bactericidal: ngitis and bone by absence of
inhibits joint infection. fever and
synthesis of patient’s
bacterial cell temperature of
wall, causing 36.9 degree
cell death Celsius

NURSING IRESPONSIBILITIES:

PRIOR TO PROCEDURE:
• Check for the doctor’s order.
• Explain the action of the drug to the SO.
 • Warn the client/SO for side effects like diarrhea, N/V,
abdominal pain.

DURING THE PROCEDURE:

• Clean the IV port before injecting the medication.
• Slowly inject the drug

AFTER THE PROCEDURE:

• Note for any PCN/ATX sensitivity
• Assess for anemia, renal dysfunction.
• Document
NAME OF DATE ROUTE OR GEN. INDICATION CLIENTS
DRUGS, ORDERED ADMIN. ACTION OR RESPONSE
GENERIC DATE DOSAGE FXNAL PURPOSE(S) TO THE
NAME TAKEN/GIV AND CLASS’N MEDICATIO
BRAND EN DATE FREQUEN MECHANIS N W/
NAME CHANGED/ CY OF M OF ACTUAL
D/C ADMIN. ACTION SIDE
EFFECT

Furosemid DO:6-20-08 5g. IV stat. Fxnal For edema

Promoted
e DP:6-20-08 Class’n: associated with diuresis
without
Lasix DC:6-21-08 Diuretic, CHF, nephritic
depleting
loop syndrome, much
electrolytes
hepatic
in the body
Mechanism cirrhosis, and as evidence
by patient’s
of Action: ascites, and for
Sodium
Inhibits the acute level of
142.1mmol/
reabsorptio pulmonary
L and
n of sodium edema. Potassium
level of 5.28
and
mmol/L
chloride in
the
proximal
and distal
tubules as
well as the
ascending
loop of
henle. The
resulting
urine is
more
acidic.
 NURSING RESPONSIBILITY:

PRIOR TO THE PROCEDURE:

• Check for the doctor’s order.

• Explain the action of the drug to the client/SO.

DURING THE PROCEDURE:

• Clean the IV port before injecting the medication.
• Slowly inject the drug

AFTER THE PROCEDURE:

• Monitor CBC and injection site for adverse reactions.
• Monitor vital signs

NAME OF DATE ROUTE OR GEN. ACTION INDICATION CLIENTS

DRUGS, ORDERED ADMIN. FXNAL OR RESPONSE
GENERIC DATE DOSAGE CLASS’N PURPOSE(S TO THE
NAME TAKNE/GIV AND MECHANISM ) MEDICATIO
BRAND EN DATE FREQUEN OF ACTION N W/
NAME CHANGED/ CY OF ACTUAL
D/C ADMIN. SIDE
EFFECT

Amikacin DO: 6-20-08 8omg. IV Fxnal Class’n: Use for short The
Amikin DP: 6-20-08 OD Antibiotic, term infection did
DC: 6-27-08 aminoglycoside treatment of not spread
gram as evidence
Mechanism of negative by the
 Action: bacterial normal
It’s spectrum is infections, leukocyte
somewhat infections of count of the
broader than the patient and
that of other respiratory by absence
aminoglycosides tract. of fever and
. Effective patient’s
against both temperature
penicillinase of 36.9
and non- degree
penicillinase- Celsius
producing
organisms.

NURSING RESPONSIBILITIES:

PRIOR TO THE PROCEDURE:

• Check for the doctor’s order.
• Explain the action of the drug to the client/SO

DURING THE PROCEDURE:

• Clean the IV port before injecting the medication.
• Slowly inject the drug

AFTER THE PROCEDURE:

• Monitor vital signs
• Note reasons for therapy
• Obtain audiometric assessment with high doses or prolonged
use.
• Document
NAME OF DATE ROUTE GEN. ACTION INDICATION CLIENTS
DRUGS, ORDERED OR FXNAL OR RESPONSE
GENERIC DATE ADMIN. CLASS’N PURPOSE(S) TO THE
NAME TAKNE/GIV DOSAGE MECHANISM MEDICATI
BRAND EN DATE AND OF ACTION ON W/
NAME CHANGED/ FREQUEN ACTUAL
D/C CY OF SIDE
ADMIN. EFFECT

Cefotaxim DO:6-27-08 175mg. IV Fxnal Class’n: Used to treat The

e DP:6-27-08 every 8 Cephalosporin gonorrhoea, infection did
claforan hours , third meningitis, not spread
generation and severe as evidence
infections by the
Mechanism of including normal
Action: infections of leukocyte
The the kidney count of the
bactericidal (pyelonephritis patient.
activity of ) and urinary
cefotaxime system. Also
results from used before an
the inhibition operation to
of cell wall prevent
synthesis via infection after
affinity for surgery.
penicillin-
binding
proteins
(PBPs).
Cefotaxime
shows high
affinity for
penicillin-
binding
proteins in the
cell wall
NURSING RESPONSIBILITIES:
PRIOR TO THE PROCEDURE:
• Check for the doctor’s order.
• Explain the action of the drug to the client/SO

DURING THE PROCEDURE:

• Clean the IV port before injecting the medication.
• Slowly inject the drug

AFTER THE PROCEDURE:

• Monitor vital signs
• Monitor lab
• Store dry cefotaxime below 30°c.
• Document
NAME OF DATE ROUTE OR GEN. INDICATION OR CLIENTS
DRUGS, ORDERED ADMIN. ACTION PURPOSE(S) RESPONSE
GENERIC DATE DOSAGE FXNAL TO THE
NAME TAKNE/GIVE AND CLASS’N MEDICATIO
BRAND N DATE FREQUENC MECHANIS N W/
NAME CHANGED/ Y OF M OF ACTUAL
D/C ADMIN. ACTION SIDE
Use for skin and EFFECT
Ampicillin DO: 6-27-08 175mg. IV skin structure
Unasyn. DP:6-27-08 every 8 Fxnal infection, intra- The infection
hours Claas’n: abdominal did not
Antibiotic, infection, spread as
penicillin gynecologic evidence by
infections. the normal
Mechanism leukocyte
of action: count of the
Synthetic, patient.
broad-
spectrum
antibiotic
suitable for
gram-
negative
bacteria.
Acid
resistance
destroyed by
penicillinase.
 NURSING RESPONSIBILITIES:

PRIOR TO THE PROCEDURE:

• Check for the doctor’s order.
• Explain the action of the drug to the client/SO

DURING THE PROCEDURE:

• Clean the IV port before injecting the medication.
• Slowly inject the drug
• Inspect vial for dissolution.

AFTER THE PROCEDURE:

• Monitor vital signs
• With impaired renal function reduce dose
• Note sensitivity reaction to this drug.
• Monitor CBC,cultures,renal and LFTs.
• Document

c.DIET

TYPE OF DATE GENERAL INDICATIO SPECIFIC CLIENTS

DIET. ORDERED DESCRIPTI N OR FOODS RESPONSE
DATE ON PURPOSES AND/OR
TAKNE/GIV REACTION
EN DATE TO THE
CHANGED DIET

NOTHING DO: 6-20-08 Latin for a The patient NO FOODS This avoided
PER OREM DP:6-20-08 medical was the
DC: 6-20-08 instruction ordered in possibility of
meaning to an npo diet aspiration
withhold because that may be
oral food the patient experienced
and fluids have a by the
from a secretions. client.
patient for if the
various patient will
reasons eat, she
(verbatim it might have
translates: difficulty in
"nothing breathing.
through the
mouth" or
"not
through the
mouth").

NURSING RESPONSIBILITIES:

PRIOR TO THE PROCEDURE:

• Check for the doctor’s order.

• Advice the S.O not to give any food to the patient

DURING THE PROCEDURE:

• Stress the importance in complying to the diet.

AFTER THE PROCEDURE:

• Assess the health status of the patient.
• Compare previous health status from the present.
 • Document.

TYPE OF DATE GENERAL INDICATION SPECIFIC CLIENTS

DIET. ORDERED DESCRIPTI OR FOODS RESPONSE
DATE ON PURPOSES AND/OR
TAKNE/GIV REACTION
EN DATE TO THE
CHANGED DIET

BREASTFEED DO: 6-22-08 Breastfeedin During Breastmilk This

ING WITH DP:6-22-08 g is the breastfeedin enabled the
SAP feeding of an g nutrients client to
(breastfeeding infant or and gain
feeding with young child antibodies nourishmen
strict with breast pass to the t the
aspiration milk directly baby and the client’s
precautiion) from a maternal body
woman's bond can requires for
breasts, not also be normal
from a baby strengthened functioning.
bottle or
other
container.

NURSING RESPONSIBILITIES:

PRIOR TO THE PROCEDURE:

• Check for the doctor’s order.
• Advice the S.O to breastfeed the patient
• Advice the SO to breastfeed with strict aspiration precaution
DURING THE PROCEDURE:
• Stress the importance on complying to the diet.

AFTER THE PROCEDURE:

• Assess the health status of the patient.
• Compare previous health status from the present.
• Document.
C. Nursing Management - Nursing Care Plans
ASSESSME NURSING SCIENTIFIC OBJECTIVES INTERVENTI RATIONALE EXPECTED
NT DIAGNOSIS EXPLAINATI ONS OUTCOME
ON

Hypertherm When the Short term: 1. Establish 1. To gain Short term:

S> Ø
ia causative After 4° of NI, trust and
After 4° of NI,
agent enters the pt’s Rapport have a nurse
the body and temperature patient the pt’s
invades the will drop relationship
temperature
respiratory from 38.4 °C
system, the to 37 °C 2. Monitor VS 2. To shall drop
O> the
inflammatory establish
from 38.4 °C
patient process is q 4°. baseline
triggered data of the to 37 °C.
manifested
releasing pt’s
>Flushed platelets,
WBC, RBC, 3. Provide TSB
skin
which
Long term:
>skin warm produces as a measure. 3. To lower
exudates of pt’s After 2-3
to touch
fibrin, which Long term: temperature days of NI,
>with body enhances the the patient
After 2-3
spread of shall be free
temperature days of NI,
microorganis from
the patient
of 38.4ºC m, causing 4. Instruct SO hyperthermia
will be free
infection. In 4. To release .
> rales on from
response to hyperthermia to provide heat and to
both lung infection, the provide
.
individual with loose comfort
field
WBC release
pyrogens. clothing.
These
-The
pyrogens
patient may affect the 5. Warm,
5. Assess skin
body
manifest dry, flushed
temperature- temperature
>dehydratio regulating skin may
and color.
mechanism in
n indicate a
the
>Irritability hypothalamus fever.
of the brain.
As a 6. Monitor
ASSESSME NURSING SCIENTIFIC OBJECTIVE INTERVENTI RATIONALE EXPECTED
NT DIAGNOSI EXPLAINATION S ONS OUTCOME
S
 1. Auscultate
Ineffective When the Short term: 1. To Short term:
S> Ø lungs for
Airway causative agent After 3° of
determine After 4° of NI,
Clearance triggers the NI, the pt.’s crackles,
related to inflammatory SO will the the pt’s
consolidation
retained process of the demonstrate
adequacy of temperature
O> the secretions lungs, exudates behaviors to and pleural
of fibrin improve or gas shall drop
patient friction rub.
containing fluid, maintain
exchange from 38.4 °C
manifested polymononuclea clear airway
r leucocytes and and extent of to 37 °C.
>Changes in
erythrocytes is
respiratory airways
produce.
rate and
Furthermore, the obstructed
rhythm
mucous produce
noted with Long term:
joins it by the
(alternate
goblet cells in secretions. After 2-3
shallow and
response to the days of NI,
deep
invading 2. Assess the patient
breathing.)
microorganism, 2. Because shall be free
characteristic
this combination from
>With rales Long term: presence of
produce and s of hyperthermia
on both lung
increase in the After 1-2 infection is .
fields secretions:
tracheo- days of
suspected
bronchial tree. nursing quantity,
> Pink
intervention when
palpebral consistency,
s the patient
conjunctiva secretions
will color, and
expectorate are thick,
odor.
-The secretions
yellow or rust
readily..
patient
in color and
may
manifest foul smelling.
>dyspnea
>cyanosis 3. Keep the 3. To prevent
>chest pain environment allergic
>headache allergen free reactions
according to that may
the individual cause
needs. bronchial
irritation.

4. Encourage 4. As to
the mother to liquefy
increase the secretions so
fluid intake of that they are
the child. easy to
expectorate.

5. Position the 5. To
patient in Facilitate
HOB. optimal
breathing.
 6. To
6. Encourage supplement
eating high the iron
caloric foods, needs of the
food rich in child as well
iron like liver as to
and dark facilitate
green leafy absorption
vegetables, and
and foods rich strengthenin
in vitamin C. g his immune
system.

7. For easy
7. Perform secretion
and instruct expulsion.
chest-
physiotherapy
after
nebulization. 8. To
facilitate fast
8. Administer recovery
meds per
doctor’s
order.
ASSESSM NURSING SCIENTIFIC OBJECTIVES INTERVENTI RATIONALE EXPECTED
ENT DIAGNOSIS EXPLANATI ONS OUTCOME
ON
S>  Risk for infection Immuno- Short term: 1. Monitor v/s 1. To know Short term:
O>the (spread) related suppression After 6 hours closely, potential The patient’s
S.O shall
patient to inadequate due to of nursing especially fatal
have
manifested secondary decrease in interventions during complication verbalized
her
>fever of defenses(decreas hemoglobin, the patient’s initiation of that may
understandin
38.4ºC e hemoglobin, leukopenia, S.O will therapy. occur. g of
individual
>presence hematocrit and and suppress verbalize her
causative/risk
of immunosuppressi inflammator understandin 2. Instruct the 2. To factors and
demonstrate
adventitiou on) y response g of S.O promote
lifestyle
s sounds in gives a individual concerning safety changes to
prevent
both lung greater causative/risk about the disposal of
further
field. opportunity factors and disposition of secretions infection.
>productiv for demonstrate secretions and to
e cough pathogenic lifestyle and report assess for
>skin pale bacteria to changes to changes in the
in color invade and prevent color, amount resolution of
>restlessn inoculate in further and odor of pneumonia Long term:
ess a specific infection. secretions. or The patient
body part of development shall have
-The a susceptible Long term: of secondary been free
patient human body. After 1-2 infection. from possible
days of
may Thus, 3. Encourage spread of
nursing
manifest leading to a interventions good hand 3. To reduce infection.
the patient
>body further washing spread or
will be free
malaise damage or from possible techniques. acquisition
spread of
>activity infection. of infection.
infection.
ASSESSMEN NURSING SCIENTIFIC OBJECTIVE INTERVENTI RATIONALE EXPECTED
T DIAGNOSIS EXPLANATI S ONS OUTCOME
ON
S> Impaired gas Bronchospas Short term: 1. Monitor 1. To Short term:
exchange m, which After 6 hours vital signs and establish The patient
O> the related to occurs in of nursing assess baseline shall have
patient alveolar many interventions patient’s data. demonstrate
manifested capillary pulmonary the patient conditions. d ease in
>restlessnes membrane diseases, will breathing.
s changes reduces the demonstrate 2.Auscultate 2. Determine
>irritability secondary to caliber of ease in lungs for adequacy of
>nasal inflammation. the small breathing. crackles gas
flaring bronchi and , consolidation exchange Long term:
may cause Long term: and pleural and detect The patient’s
-The patient dyspnea, After 2-3 days friction rub. areas of S.O will
may static of nursing consolidatio verbalized
manifest secretions interventions n and understandin
>diaphoresis and the patient’s pleural g of the
>tachycardia infections. S.O will friction rub. causative
>dyspnea Bronchospas verbalize 3. Assess LOC, factors that
m can understanding distress and 3. This signs could
sometimes of the irritability. may indicate aggravate
be detected causative hypoxia. the condition
by factors that 4. Observe and
stethoscope could skin color and 4. Determine appropriate
when aggravate the capillary refill. circulatory factors that
wheezing or condition and adequacy, could help
diminished appropriate which is the patient
breath factors that necessary relive from
ASSESSMEN NURSING SCIENTIFIC OBJECTIVES INTERVENTI RATIONALE EXPECTED
T DIAGNOSIS EXPLANATION ONS OUTCOME

S: Ø Alteration on SHORT TERM 1.To gain

Ineffective SHORT TERM
the client’s After 2-3 hours 1.Establish patient’s
Client shall
O: breathing O2:CO2 ratio of nursing rapport with trust and
verbalize
due to intervention, patient cooperation
pattern understanding
Patient decreased patient will be
and
Manifested: related to absorbed able to 2.Instruct 2.Increased
demonstrate
>Increase in oxygen and verbalize patient to mucus and
presence of proper deep
respiratory poor gas understanding increase oral sputum
breathing
rate of 31 tracheo- exchage and fluid intake to secretions
technique to
cpm related to demonstrate 8-10 glasses can lead to
bronchial facilitate
>Shortness presence to proper deep dehydration;
proper
of breath secretions exudates on breathing increased
oxygenation to
(orthopnea) the alveolar technique to water intake
and nasal alleviate
spaces causes facilitate can help
hyperventilatio
Patient may secretions the body to proper dissolve
n
manifest: cope by oxygenation to secretions
>Dyspnea increasing alleviate
>Use of respiratory rate hyperventilatio 3.Instruct
accessory or by n patient to do
muscles in hyperventilatio deep
breathing n. breathing 3.Deep
LONGTERM
>Altered The increase in LONG TERM exercise after breathing
Patient shall be
chest After 2-3 days demonstratin exercise
respiratory rate
excursion g proper increases free of
of nursing
>Nasal is elicited to technique oxygen
cyanosis and
Flaring intervention, intake and
cause an
>Increased can help establish
patient will be
increase in the alleviate
anterior- normal
free of 4.Keep dyspnea
tidal volume of
posterior environment breathing
cyanosis and
air that in allergen free 4.Presence
diameter pattern
establish (dust, feather may trigger
inspired in
pillows, allergic
normal
order to absorb smoke, response
breathing pollen) that may
more oxygen.
cause further
pattern
The increase in increase in
mucus
respiratory rate
secretion
may need the 5.Take and VS
ASSESSMEN NURSING SCIENTIFIC OBJECTIVES INTERVENTION RATIONALES EXPECTED
T DIAGNOSIS EXPLANATIO S OUTCOME
N

S> Ø Risk for The patient Short term: >Ascertain SO’s >SO may not Short term:
Falls suffers from After 4⁰ of NI, knowledge of be aware of After 4⁰ of NI,
O> The sleeplessness the Pt’s SO safety needs/ the proper the Pt’s SO
patient or irritability, will verbalize injury prevention precautions shall verbalize
manifested when a understanding and motivation or may not understanding
the following: person is of individual to prevent injury. have of individual
irritated we risk factors knowledge, risk factors
>Sleeplessnes do a lot of that desire, that
s movements in contribute to resources to contribute to
> Patient is our body, with possibility of attend to possibility of
Unattended an unsafe falls and take safety issues falls and take
on bed environment, steps to >Provide in all setting. steps to
> less than 1 for example a correct information correct
year of age hospital bed situations regarding > To assist situations
with no side client’s SO/
rails plus and disease/conditio caregivers to
irritated n that may result reduce or
patient, this Long term: in increase risks correct Long term:
could be one After 3 days for falls. individual risk After 3 days of
factor that of NI, Pt’s SO factors. NI, Pt’s SO
could lead to will modify >Identify shall modify
fall. environment needed environment
as indicated interventions >to promote as indicated to
to enhance and safety safe enhance
safety devices. environment safety
and individual
safety
ASSESSMEN NURSING SCIENTIFIC OBJECTIVES INTERVENTI RATIONALE EXPECTED
T DIAGNOSIS EXPLANATIO ONS OUTCOME
N

S> Ø Risk for Owing to Short term: >Assess >To asses Short term:
Aspiration inability of the After 4⁰ of NI, amount and contributing After 4⁰ of NI,
O> the epiglottis and SO will consistency of factors. SO shall
patient true vocal identify respiratory identify
manifested cords to move causative/ risk secretions and causative/ risk
the following: close off factors. strength of factors.
trachea and gag/ cough >To clear
>Depressed with the reflex. secretions
cough presence of
>Impaired secretions the Long term: >Suction as Long term:
swallowing patients is at After 3 days of needed >To mobilized After 3 days of
>Difficulty of risk for NI, the pt will thickened NI, the pt shall
Breathing aspiration due experience no >Assist with secretions experience no
>Secretions in to the inability aspirations postural that may aspirations
the nasal of the AEB noiseless drainage interfere with AEB noiseless
cavity epiglottis and respiration, swallowing. respiration,
secretions clear breath clear breath
that will block sounds clear, >Determined >Because sounds clear,
the patients odorless the best upper airway odorless
airway. secretions position, head patency is secretions
of bed facilitated by
elevated to 30 upright
degrees and position and
propped on turning to
right side right side
decreases
likelihood of
drainage into
trachea
ASSESSMEN NURSING SCIENTIFIC OBJECTIVES INTERVENTI RATIONALE EXPETED
T DIAGNOSIS EXPLANATIO ONS OUTCOME
N

S> Ø Delayed Down Short term: >Record >To Short term:

Growth and syndrome a after 4⁰ of NI, height and determine after 4⁰ of NI,
O>the patient Developmen chromosomal the SO will weight individual the SO shall
manifested t r/t Effects disorder verbalize expectations verbalize
the following: of physical caused by the understanding understanding
disability presence of all of growth/ >Note finding >To of growth/
>Altered or part of an developmental of determine developmental
physical extra 21st delay psychological degree of delay
growth chromosome deviation and evaluation of deviation from deviation and
>decreased The condition plans for client and growth/ plans for
responses is interventions family developmental interventions
>Sleep characterized norms
Disturbances by a
>Delay in combination >Aids in
performing of major and Long term: >Monitor evaluating Long term:
movements minor after 3 days of growth effectiveness after 3 days of
differences in NI, SO will of NI, SO shall
structure. perform self- interventions/ perform self-
Often Down care and self promotes care and self
syndrome is control >Note degree identification control
associated activities of individual of needs for activities
with some appropriate deviation additional appropriate
impairment of for age. actions for age.
cognitive
ability and
physical
growth as well
as facial
appearance.
ASSESSMEN NURSING SCIENTIFIC OBJECTIVES INTERVENTI RATIONALE EXPECTED
T DIAGNOSIS EXPLANATIO ONS OUTCOME
N
A child's
S> Ø Risk for physical Short term: >Identify >To assess Short term:
disproportion growth refers After 4⁰ of NI, nature and causative After 4⁰ of NI,
O > the ate growth to the SO will effectiveness factors SO shall
patient increases in verbalize of parenting verbalize
manifested height and understanding understanding
the following: weight and and >Assess > To assess and
other body participate In Condition contributing participate In
>Genetic changes that plan of care factors plan of care
Disorder occur as a appropriate appropriate
>Altered child matures for age/ability >Assist with >To prevent for age/ability
physical eventually all therapy to deviation
growth part of the treat/ correct from growth
>Decreased growth underlying norms
responses process. conditions
>Sleep Kids differ in Long term: Long term:
Disturbances growth and After 3 days >Monitor After 3 days
>Delay in development of NI, SO will growth >Aids in of NI, SO shall
performing during demonstrate evaluating demonstrate
movements childhood techniques to effectiveness techniques to
In our case improve of improve
there is an weight/ interventions/ weight/
impairment of growth promotes growth
cognitive stabilizing or identification stabilizing or
ability and progress of needs for progress
physical toward age- additional toward age-
growth appropriate actions appropriate
size size
 Nursing Management – Actual SOAPIE’s

S =Ø

O = received pt. lying in bed, sleeping with intact heplock @ R foot.

o With pink palpebral conjunctiva
o Changes in respiratory rate and rhythm noted (alternate shallow
and deep breathing.)
o With rales on both lung fields
VS taken and recorded as follows:

T=36.3 °C P=128 bpm

R=42 cpm

A = Ineffective airway breathing r/t retained secretions.

P = After 3° of NI, the pt.’s SO will demonstrate behaviors to improve or

maintain clear airway

I =

o Established Rapport.

o Monitored VS q 4°.

o Assesses airway patency

o Encourage pt’s SO to keep pt’s back dry

o Kept pt’s head elevated and changed pos. every 2°

o Monitored pt’s for feeding intolerance

E = Goal met AEB by SO’s demonstration of behaviors to maintain or

improve pt’s airway

S =Ø

O = received pt being cuddled by mother, with intact heplock @ L hand

o With pink palpebral conjunctiva
o Changes in respiratory rate and rhythm noted
o With rales on both lung fields
o With cough
VS taken and recorded as follows:

T=36.5°C P=105 bpm

R=63 cpm

A = Impaired gas exchange r/t alveolar capillary membrane changes

P = After 3° of NI, the pt’s SO will demonstrate behavioral techniques to

improve ventilation normal rate, rhythm and depth of breathing

I =

o Established Rapport.

o Monitored VS q 4°.

o Assessed pt’s general condition

o Encouraged pos. change and elevated pt’s head on bed q 2°

o Assesses airway patency

o Auscultated breath sounds

o Kepts pt’s backdry

o Encouraged adequate rest

E = Goal not met AEB by pt’s abnormal rate, rhythm and depth of

breating

R = reinforce previous NI
S =Ø

O = receive pt. lying in bed, sleeping with intact heplock @ R hand

o With pink palpebral conjunctiva
o With flushed skin, warm to touch
o With good skin turgor
Vital signs taken and monitored as follows:

T=38.4°C P=102 bpm

R=49 cpm

A = Hyperthermia

P = After 4° of NI, the pt’s temperature will drop from 38.4 °C to 37 °C

I =

o Established Rapport.

o Monitored VS q 4°.

o Provided TSB as a measure to reduce pt’s temperature.

o Instructed SO to provide with loose clothing.

E = Goal partially met AEB a decrease in pt’s temperature from 38.4°C

to 37.6°C; R = reinforced previous NI

Sociogram

Legend:

Patient’s SOanswers

Nurse’s Questions
Bibliography

Brunner and Suddharth’s Textbook of Medical – Surgical Nursing,

Eleventh Edition, Volume 1, Smeltzer et al.

Davis’ Drug Guide for Nurses, Tenth Edition, Deglin and Vallerand

Essentials of Anatomy and Physiology, Sixth Edition, Seeley et al

Mosby’s PDQ for RN, Second Edition, Elsevier

Nurse’s Pocket Guide. Diagnoses, Prioritized Interventions, and

Rationales, Tenth Edition, Doenged et al

PDR Nurse’s Drug Handbook, 2008 Edition, Spratto and Woods.

http://en.wikipedia.org/wiki/Pneumonia

http://health.yahoo.com/infectiousdisease-treatment/pneumonia-
treatment-overview/healthwise--aa35852.html

http://mayoclinic.com/health/pneumonia/DS00135/DSECTION=preventi
on