TABLE OF CONTENTS PAGE

TITLE .......................................................................................................... i
APPROVAL SHEET.................................................................................... ii
DISCLAIMER ............................................................................................ iii
ENDORSEMENT ....................................................................................... iv
TABLE OF CONTENTS
I. INTRODUCTION ....................................................................................... 1
II. OBJECTIVES ............................................................................................ 3
III. NURSING ASSESSMENT ......................................................................... 5
3.1 Patients History/Profile ...................................................................... 5
3.2 Nursing/Health History ...................................................................... 5
3.2.1 Present Health History ............................................................ 5
3.2.2 Past Health History .................................................................. 5
3.2.3 Family Health History .............................................................. 6
3.2.4 Gordons Functional Health Patterns ....................................... 6
3.2.5 Physical Assessment ........................................................... 10
3.3 Level of Growth and Development .................................................. 13
3.3.1 Normal Development of a Middle-Aged Adult ....................... 13
3.3.2 The Ill Person at the Middle-Aged Stage .............................. 17
3.4 Diagnostic Result ............................................................................ 17
IV. PATHOPHYSIOLOGY AND RATIONALE .............................................. 20
4.1 Anatomy and Physiology of the Respiratory System ....................... 20
4.1.1 Schematic Diagram of the Respiratory System ................... 20
4.1.2 Physiologic Processes of the Respiratory System ............... 20
4.2 Pathophysiology and Rationale ...................................................... 23
4.2.1 Schematic Diagram Showing the Pathophysiology of
Community-Acquired Pneumonia, Moderate Risk;
Pneumotension, Right .......................................................... 23
4.2.2 Disease Process and its Effects to the Respiratory
System ................................................................................. 24
4.3 Comparative Chart Showing the Classical and Clinical Signs
 and Symptoms of the Community-Acquired Pneumonia,
Moderate Risk; Pneumotension, Right and Rationale .................... 25
V. NURSING INTERVENTION..................................................................... 26
5.1 Care guide of Patient with Community-Acquired Pneumonia,
Moderate Risk; Pneumotension, Right ........................................... 26
5.2 Actual Patient Care ......................................................................... 28
5.2.1 Nursing Care Plan ................................................................ 28
5.2.2 Drug Therapeutic Record ..................................................... 36
5.2.3 SOAPIE/FDAR Charting ...................................................... 44
5.2.4 Health Teaching Plan ........................................................... 49
5.2.5 Discharge Planning ............................................................. 52
VI. EVALUATION AND RECOMMENDATION ............................................. 53
6.1 Prognosis Based on Nursing Assessment and Rationale ............... 53
6.2 Recommendations to Promote Early Recovery and
Rehabilitation .................................................................................. 53
VII. EVALUATION AND IMPLICATIONS
7.1 Nursing Education ........................................................................... 54
7.2 Nursing Practice .............................................................................. 54
7.3 Nursing Research ........................................................................... 54
VIII. REFERRAL AND FOLLOW-UP .............................................................. 56
IX. REFERENCE .......................................................................................... 57