UNIVERSITI TEKNOLOGI MARA

HS110- DIPLOMA IN HEALTH SCIENCE

NUR 155 RESPIRATORY NURSING
NAME OF LECTURE : LIEW SIEW KEE
TOPIC : CARE OF PATIENT WITH PNEUMONIA
STUDENT NUMBER
1. 2014640076
2. 2014848964
3. 2014434226
DUE DATE SUBMISSION : 19 MARCH 2015

TABLE OF CONTENTS

CONTENTS
1. INTRODUCTION
1.1 Brief Information

PAGES
About

the

Disease
2. BIODATA
3. HEALTH STATUS
3.1 Medical History
3.2 Surgical History
3.3 Family History
3.4 Social History
4. Information On ADL
4.1 Diet/Appetite
4.2 Sleep
4.3 Urination
4.4 Bowel Movement
4.5 Mobility
4.6 Hearing
4.7 Vision
5. Present Complaint/ Diagnosis
6. Health Status
6.1 vital sign
6.2 General Condition
6.3 Urine Testing
7. Investigation
8. Treatment
9. Nursing Care Plan
10. Conclusion
11. References

INTRODUCTION
For our case study, we will investigate about the pneumonia. We choose one patient for our case
study, that is MR. M.M.B.I. He was diagnosed with pneumonia when he was admitted in the
hospital.
1.1 Brief Information About Disease
Pneumonia is an inflammatory condition of the lung affecting primarily the microscopic air sacs
known as alveoli. It is usually caused by infection with viruses or bacteria and less commonly
other microorganisms, certain drugs and other conditions such as autoimmune diseases.

2.BIODATA OF CLIENT
Name : Mr. M.M.B.I
Age : 61 year old
Gender : Male
Race : Islam
Register Number : 2015/4911

3.HEALTH STATUS
3.1 Medical History
1.
2.
3.
4.
5.
6.

Underlying hypertension
No Known allergies
Under Tab Gliclazide 160mg, BD
Only started coughing a month ago with yellowish sputum
No ill contact
With MDIs
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3.2Surgical History
1. NIL

3.3 Family History

1. This patient has no family history and he is the first family that get peunmonia.

3.4 Social History

1. Non alcohol consumer
2. Ex smoker 60pack years.

Information of ADL
4.1 Diet/Appetite
Patient is on high protein diet.The patient appetite is good and he is not skipping his meals.He
always eat right on time.He also always finish his meal and taking a lot of fluid like mineral
water.

4.2 Sleep

Patient is having a shortness of breath(SOB) so,the patient are not having a good and nice
sleep.Sometimes he awake in the middle of his sleep and try catching up his breath.

4.3 Urination
Patient is not using catheter or Pauls tube. He can go to the toilet and past urine himself.His
urine output is 725mls per day.

4.4 Bowel movement

This patient is having a constipation.We have to insert the enema to the patient so that the patient
can BO.

4.5 Mobility
The patient can walk but he cannot stand too long and walk so far because of the shortness of
breath. He can walk but need someone to assist him.When he want to go to the toilet,his daughter
always help him walk from the bed to the toilet. Sometime he use wheelchair.

4.6 Hearing
The patient did not have any trouble of hearing.He can hear very well and give a response when
the nurse or doctor ask and talk to him.

4.7 Vision
He can see very well because this patient did not use any spectacles.

5.Present complain / Diagnosis

1. Patient with worsening short of breathless (SOB).
2. Sore throat
3. Coughing with yellowish sputum
4. Chest Pain
5. Orthopnea

6.HEALTH STATUS
6.1 Vital sign
B/P : 147/65 mmHg
Pulse : 92/min
Respiration : 21/min
Temperature : 36.5
SPO2 : 94%
Pain score : 0/10

6.2 General condition

Currently, the patient is well and comfortable. The patient can sitting over the bed and no
active complaint.

6.3 Urine testing

UFEME
Ketone : negative

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