I.

INTRODUCTION
This is a case of a 62 year old man who was diagnosed with Community
Acquired Pneumonia.
Pneumonia is an inflammation or infection of the lungs most commonly
caused by a bacteria or virus. Pneumonia can also be caused by inhaling vomit
or other foreign substances. In all cases, the lungs' air sacs fill with pus , mucous,
and other liquids and cannot function properly. This means oxygen cannot reach
the blood and the cells of the body.
Most pneumonias are caused by bacterial infections.The most common
infectious cause of pneumonia in the United States is the bacteria Streptococcus
pneumoniae. Bacterial pneumonia can attack anyone. The most common cause
of bacterial pneumonia in adults is a bacteria called Streptococcus pneumoniae
or Pneumococcus. Pneumococcal pneumonia occurs only in the lobar form.
An increasing number of viruses are being identified as the cause of respiratory
infection. Half of all pneumonias are believed to be of viral origin. Most viral
pneumonias are patchy and the body usually fights them off without help from
medications or other treatments.
Pneumococcus can affect more than the lungs. The bacteria can also cause
serious infections of the covering of the brain (meningitis), the bloodstream, and
other parts of the body.
Community-acquired pneumonia develops in people with limited or no contact
with medical institutions or settings. The most commonly identified pathogens
areStreptococcus pneumoniae, Haemophilus influenzae, and atypical organisms
(ie, Chlamydia pneumoniae,Mycoplasma pneumoniae, Legionella sp). Symptoms
and signs are fever, cough, pleuritic chest pain, 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 or healthy patients, but many pneumonias, especially when
caused by S. pneumoniae or influenza virus, are fatal in older, sicker patients.

II. PATIENT PROFILE

Name: E. S.
Age:

62 years old

Sex:

Male

Religion:

Roman Catholic

Date Admitted: October 1, 2015 at exactly 11:15 AM

Admission diagnosis: COPD not in exacerbation
Final diagnosis: Community Acquired pneumonia (CAP)moderate Risk

III. PATIENT HISTORY

Chief Complaint: Difficulty of Breathing

General Data:
This is a case of a 62 year old male Filipino, presently residing in
Malinta, Valenzuela who was admitted in Valenzuela Medical Center on
October 1, 2015.
History of Present Illness:
5 days prior to admission, patient had positive signs and symptoms of
cough, yellowish pleghm, persistent fever and back pain. Knowing that these
signs and symptoms were just forms of little discomforts, he self-medicated
with Paracetamol. However, he noticed no changes and experienced difficulty
of breathing so he sought medical consultation.

IV. PHYSICAL ASSESSMENT

Vital Signs:

Blood Pressure: 110/60

Temperature:
Pulse rate:

35.7 C
78bpm

Respiratory rate: 26 breaths/min

General appearance:
The patient is awake, lying on bed, conscious and coherent with
an oxygen cannula running at 2LPM

V. ANATOMIC AND PHYSIOLOGY OVERVIEW

The Lungs
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.

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 the alveoli. 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 vessel called capillaries, which are very small
branches of the pulmonary arteries. It is important that the air in the alveoli and
the blood in the capillaries are very close together, so that 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. Travelling 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.

VI. PATHOPHYSIOLOGY
Virulent Microorganism
Streptococcus Pneumoniae

Microorganism eneters the nose( nasal passages)

Passes through the larynx, pharynx, trachea

Microorganism enters and affects both airway and lung parenchyma

Airway damage

Infiltration of bronchi

Infectious organism lodges

Lung invasion

flattening of epithelial cells

macrophages and leukocytes

Stimulation in bronchioles

necrosis of bronchial tissues

Alveolar collapse

narrowing of air passage

mucus and phlegm production

COUGHING
Productive/non-productive

Increase pyrogen in the body

DIFFICULTY OF BREATHING

FEVER
Necrosis of pulmonary tissue

Overwhelming sepsis

DEATH

VII. Diagnostic Exam

Chest X-ray Result:
Impression: There are reticolunodular opacities on both lungfields with upward traction of left hilus.
There are dilated thick walled bronchi noted on both lower lobes. Heart is not enlarged. Aortic knob is
sclerotic other visualized structures are unremarkable. Findings are suggestive of Extensive PTB, Bilateral
with cicatrical changes, left upper lobe.Bacteriologic correlation is suggested.

Clinical Chemistry Result:

Sodium: 124.9 mmol/L

Normal: 135.0-148mmol/L

Hematology Result:
Hct: 0.29

Normal: 0.37-0.47

WBC: 23.5x10

Normal: 5.0-10.0x10

Segmenters: 0.87
Lymphocytes: 0.13

Urinalysis:
Color: Light Yellow
Transparency: Slightly Hazy

Reaction: (pH) 6.0

Protein: +1
Glucose: negative
Specific Gravity: 1.010
Pus cells: 3-4/HPF
RBC: 2-3/hpf
Crystals: A Urates: Many
Mucus threads: few
Cast: Fine Granular cast : 1-2/HPF

VIII. Drug Study

Generic Name: Acetylcysteine

Brand Name: Fluimucil
Classification: Mucolytic Agent
Dosage:
Pharmacokinetics:
Metabolism: Hepatic; half life 6.25 hr

Excretion: Urine (30%)

Indications:
Mucolytic Adjuvant therapy for abnormal, viscid, or inspissated mucus secretion in acute and chronic
bronchopulmonary disease (pneumonia,asthma,TB).
Contraindications:
Contraindicated with hypersensitivity to acetylcysteine; use caution and discontinue if bronchospasm occurs.

Adverse Reaction:
Nausea, rhinorrhea, bronchospasm especially in asthmatics, stomatitis,and urticaria.

Nursing Considerations:
1. dilute with normal saline solution or sterile water for injection.
2. Administer the ff drugs separately because they are incompatible with acetylcysteine: tetracyclines,
hydrogen peroxide, trypsin.
3. Use water to remove residual drug solution on the patients face after administration by face mask.
4. Inform patient that nebulization may produce an initial disagreeable odor, but will soon disappear.

X. NURSING CARE PLAN

Problem: Difficulty of breathing
Diagnosis: Ineffective Airway Clearance related to increased mucus production.

ASSESSM
ENT

DIAGNOSI
S

Subjective:

Ineffective
airway
clearance
related to
increase
mucus
production

nagrereklamo
nga si tatay na
nahihirapan
siya huminga,
dami din kasi
plema eh as
verbalized by
relative.
Objective:
*RR- 26

*Dyspnea
*(+)nonproductive
cough
*Use of
accessory
muscle

PLANNIN
G
Short term
goal:
After 3-4 hours
of intervention,
patient will
expectorate
secretions
effectively and
RR will
decrease from
26 to normal
range of 1620/min.

INTERVENT
ION
Independent:
1.Assessed
rate/depth of
respiration and
chest movement.

2.Elevated head
of bed and
changed position
frequently.

Long term
goal:
After 3 days of
intervention,
patient will
maintain
patent airway

RATIONAL
E

3.Assisted
patient with

1.Tachypnea,
shallow
respiration are
usually
present.
2.Lowers
diaphragm,
promoting
chest
expansion,
mobilization
and
expectoration
of secretion.

3.Deep
breathing

EVALUATI
ON
Goal half
met.
After 4 hours of
nursing
intervention,
patient
expectorated
secretion and
RR decreased
from 26/min to
22/min.

as evidenced
by normal RR.

frequent deep
breathing
exercises.

facilitates
maximum
expansion of
the lungs and
smaller
airways.

4. Encouraged
increase in fluid
intake.

4.Fluids aid in
mobilization
and
expectorations
of secretions

Collaborative:
5.Administered
mucolytics as
indicated.

5.Aids in
mobilization of
secretion.

(Fluimucil)

6.Provided
supplemental
fluids.

6.Fluids are
required to
replace
insensible loss
and aids in
mobilization of

(IVF: PNSS)

7.Monitored
chest Xray, ABG
and pulse
oximetry results.

secretions.
7.Follows
progress and
effects of
disease
process.