CAP Group8B MaamAngela

ANGELES UNIVERSITY FOUNDATION
Angeles City
COLLEGE OF NURSING
AY 2015-2016
COMMUNITY-ACQUIRED PNEUMONIA
_________________________________
IN PARTIAL FULLFILLMENT OF THE REQUIREMENT FOR NCM 104 - RLE
Submitted by:
Layug, Jaymes
Mesina, Maja Kasmere
Miclat, Karla
Ramos, Justine Kenneth
Silvestre, Celeste
BSNII-B/Group 8
Submitted to:
Angela Apostol, RN. MN.
(NCM 104 RLE Clinical Instructor- Angeles University Foundation Medical Center)
1
I. INTRODUCTION
“We are the custodians of our bodies. We must take action to employ healthy lifestyle habits
to prevent, reduce, and/or manage disease and illness.”
― Bridgette L. Collins
Pneumonia is an inflammatory condition affecting the lungs, primarily the

microscopic sacs known as aveoli. Typical signs and symptoms include a varying severity
and combination of productive or dry cough, chest pain, fever, and trouble breathing,
depending on the underlying cause. Pneumonia is usually caused by infection
with viruses or bacteria and less commonly by other microorganisms,
certain medications and conditions such as autoimmune diseases. Risk factors include
other lung diseases such as cystic fibrosis, COPD, and asthma, diabetes, heart failure, a
history of smoking, a poor ability to cough such as following a stroke, or a weak immune
system.
The disease may be classified by where it was acquired with community, hospital,
or health care associated pneumonia. It can also be classified as viral pneumonia,
aspiration pneumonia, and fungal pneumonia. Complications of pneumonia are more
common in young children, the elderly, and those with pre-existing health conditions, such
as diabetes. Possible complications include pleurisy, lung abscess, and blood poisoning
(septicaemia). Diagnosis is often based on the symptoms and physical examination. Chest
X-ray, blood tests, and culture of the sputum may help confirm the diagnosis.
A researcher at the University of Alabama by the name of Moon Nahm developed a

vaccine for pneumonia that is more affordable, especially in developing countries. In the
article, Nahm says that he wants to reduce the cost from $100 a dose to less than $10, and
is estimated to protect 1.6 million children around the world under the age of 5, who die
yearly from S. pneumoniae infections. One of Nahm's crucial discoveries was a method to
rapidly and inexpensively test whether a vaccine candidate effectively elicits antibodies that
can kill the S. pneumoniae bacteria. The test -- developed, improved and validated through
years of painstaking work by Nahm's research team -- is vital in Korean, Chinese, Indian
and other efforts to develop new generic vaccines.
2
In another article, a study was conducted at the Icahn School of Medicine at Mount
Sinai, that has shown that lung ultrasound is highly effective and safe for diagnosing
pneumonia in children and can be a potential substitute for chest X-ray. Researchers found
a 38.8 percent reduction in chest X-rays in the investigational arm compared to no reduction
in the control arm, with no missed pneumonia cases and no increase in any other adverse
events. In the article, the research team leader, Dr. Tsung, says that the “Ultrasound is
portable, cost-saving, and safer for children than an X-ray because it does not expose them
to radiation.”
Statistics:
Worldwide
 Pneumonia accounts for 16% of all deaths of children under 5 years old, killing
920 136 children in 2015.
 Children living in these top 15 high burden countries by estimated number of

pneumonia deaths for children under age 5 in 20133 : India (174,000), Nigeria
(121,000), Pakistan (71,000), DRC (48,000), Ethiopia (35,000), China (33,000),
Angola (26,000), Indonesia (22,000), Afghanistan (20,000), Kenya (18,000),
Bangladesh (17,000), Sudan (17,000), Uganda (16,000), Niger (15,000),
Tanzania (14,000).
 Pneumonia is the #1 infectious killer of children under age 5 globally: Every year
nearly 1 million children die of pneumonia worldwide
 Pneumonia is most prevalent in sub-Saharan Africa and South Asia, of which

India, Nigeria, Pakistan, DRC, Ethiopia, and China account for 50 percent of total
deaths.
Philippines:
3
 According to the latest WHO data published in may 2014, Influenza and
Pneumonia Deaths in Philippines reached 51,889 or 9.95% of total deaths.
 Pneumonia is still considered as one of the leading cause of morbidity and mortality
in the Philippines
 In a 5 year average from 2001-2005, the number of people that die from pneumonia
is 33,764, with a mortality rate of 41.5 per 100,000.
As student nurses, we chose this patient diagnosed with pneumonia as our case
study, because it is considered as one of the leading causes of mortality in the Philippines
and worldwide. This means that we will most likely be dealing with a lot of patients that are
diagnosed with pneumonia, therefore, it is our duty to learn everything there is to know
about pneumonia. Pneumonia is caused by bacteria, viruses, or fungi, therefore can spread
easily, so as nurses, we should teach patients and members of the community preventive
measures, and ways to treat it.
D. Objectives:
A. Nurse-centered
At the end of the study, the student nurses will be able to:
General Objective:
To better understand the disease process, how the disease is acquired and how it
progresses, the signs and symptoms that are manifested, the treatment for the condition,
and the nursing responsibilities.
Specific Objectives:
 Define what Pneumonia is

 Trace the pathophysiology of Pneumonia
 Enumerate the different signs and symptoms of Pneumonia
 Formulate and apply nursing care plans utilizing the nursing process
 Learn new clinical skills as well as sharpen current clinical skills required in
the management of Pneumonia
B. Patient-centered
At the end of the study, the client will be able to:
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General Objective:
Gain knowledge on how the client developed the disease, the different kinds of
treatments involved, and comply to instructions prescribed to treat the disease.
Specific Objectives:
 Understand how the disease may have been acquired
 Gain better understanding of the treatment involved for Pneumonia
 Identify different alternative treatment methods
 Demonstrate compliance to the treatment management
 Determine the effectiveness and the appropriateness of the treatment given.
II. NURSING PROCESS

A. ASSESMENT
1. Personal History
a. Demographic Data
Mrs. Pneumonia, the client’s pseudonym for confidentiality purpose, is a 41 year old
Female who was born on December 20, 1974 and is married to Mr. Pneumonia 41 year old
Filipino. Mrs. Pneumonia is a wife to Mr. Pneumonia for 16 years now, a Mother of 4
children. She is the 7th child among her siblings. Mrs. Pneumonia is a full blooded Filipino
citizen who was raised as a Roman Catholic and he is currently residing in Mabalacat,
Pampanga. Mrs. Pneumonia was admitted last November 28, 2016 at 2:47 am at AUF MC
with a chief complaint of Coughing for 2 months, chest pain and Fever for 3 consecutive
days. The admitting diagnosis of Mrs. Pneumonia was Community-Acquired Pneumonia
and was not even discharge during the duty.
b. Socio-Economic and Cultural Factors

B.1. Income and Expenses
Mrs. Pneumonia is a plain housewife and taking good care of her children while Mr.
Pneumonia working in UPS in the cargo department and earns Php 25,000.00 a month.
Their 4 children are still going to school which are in College, Grade 8, Grade 3 and
Kindergarten accordingly. According to Mrs. Pneumonia their family income is Php
5
25,000.00 in a month. The family’s expenses includes their food, electricity, allowances,
water, rent to own house and for transportation.
EXPENSES OF THE FAMILY

FOOD PHP 300 / DAY
ELECTRICITY PHP 1,800
WATER PHP 400
ALLOWANCE PHP 200 / DAY
TRANSPORTATION PHP 1000
RENT TO OWN HOUSE PHP 6,500
The family’s income Php 25,000. 00 per month, Php 4,166.67 is allotted per family
member. According to National Economic Development Authority, each family member
should have Php 2,873.33 per month in order to meet the basic needs. The family is
considered not poor, since each family member receives Php 4,166.67 per month which is
more than the required amount of NEDA (2014) per month which is Php 2,873.33
B.2. Educational Attainment
Mrs. Pneumonia is a High School graduate at Mabalacat. During her college years
she took up BSBA at Mabalacat but unfortunately she didn’t have the opportunity to finish
her college due to financial constraints.
B.3. Religious Affiliation
Mrs. Pneumonia is a Roman catholic and according to her, She and her family
always go to church every Sunday to attend the mass. Mrs. Pneumonia also is an avid
member of Couples for Christ, she used to sing every meeting as for praising the lord
because she is the leader of their choir, they usually offer in mass every 2nd Sunday of the
month and they have to meet every Saturday to plan and organize their next agenda.
B.4. Cultural factors affecting health of the family
According to Mrs. Pneumonia, she verbalized that they do not believe in herbolarios
but they do believe in hilots that is why whenever they have strain they usually go to them
to seek for help. Whenever they have simple sickness like cough, colds, and fever, they
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would usually self medicate and they will sometimes also utilized herbal medications. But
when major sickness occurs they would decide to seek medical checkup and go to
Hospitals.
c. Environmental Factors
The neighbors of Mrs. Pneumonia are ready to help whenever the family needs
support. Mrs. Pneumonia told the researchers that their neighbors lend them money when
Mrs. Pneumonia was in the hospital.
The place where the patient resides is just near from commercial establishments
such as hospitals, public market, grocery stores and pharmacy. Mrs. Pneumonia mainly
buy their necessities from nearby grocery stores that have almost everything they need.
Generally speaking, they are contented from where they are situated, according to the Mrs.
Pneumonia commentary.
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2. Family Health-Illness History
According to Mrs. Pneumonia, her Grandparents from both side died due to old age.
The Father of Mrs. Pneumonia died because of Brain Tumor while her Mother died because
of Accident. According to Mrs. Pneumonia the eldest among her siblings has Diabetes
Mellitus while the 5th child has Asthma. The 3rd child among them died due to massive
bleeding. The rest of the Family member has no know illnesses.
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3. History of Past Illness
According to Mrs. Pneumonia, she never experience chickenpox, mumps, measles

during her childhood. There is no known allergy to any food and drugs. As common illness,
she suffers from colds, coughs and fever. In times when she feels any aforementioned
illness: she will just increase her oral fluid intake and she would usually take over the
counter drugs such as paracetamol for fever and Ambroxol for severe coughs until her
condition minimizes. In the year 2008, Mrs. Pneumonia manifested increase appetite,
urination, and excessive thirst. According to her, these manifestations happened when she
was pregnant with her 3rd child. She was able to consult from a physician and told her that
it is normal. Last 2009 she was also hospitalized due to fever for 3 consecutive days and
there she was hospitalized in St. Ralph in Mabalacat and they suspected it as Dengue she
manifested Fever and rashes all over her body. She undergone BTL last 2010. The rest
of the hospitalizations of Mrs. Pneumonia were due to her children, the delivery of them.
The last hospitalization of Mrs. Pneumonia was the her present illness which is November
28, 2016 due to Pneumonia.
OBSTETRIC HISTORY
Mrs. Pneumonia is still in reproductive age which is 41 years old but she already
had menopausal period. She has an obstetrical history of G4P4T4P0A0L4M0. She had
four pregnancies and all passed the age of viability. All children were delivered via normal
spontaneous delivery and they were all born in hospitals. All of them reached their full term
of 38 weeks and are all living. Mrs. Pneumonia has received complete doses of Tetanus
Toxoid immunization from their barangay health center in Mabalacat, Pampanga.
Mrs. Pneumonia had her 1st menstruation at age of 12. She has a menstrual cycle
of 28 days and menstrual period of 3-4 days and it is regular since she was 12 years old.
She experiences mild to moderate menstrual flow and uses 4-5 sanitary pads per day. She
added that she experience slight pain or dysmenorrhea during her menstrual period.
1st, 2nd, 3rd and 4th child

During Mrs. Pneumonia pregnancies, she had experienced nausea and vomiting.
She did crave of something sweet during her 1st pregnancy. During her 2nd pregnancy, she
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did not crave for anything. She did crave of Buko during her 3 rd pregnancy. For her
succeeding pregnancies, she did not disregard her responsibility towards proper diet and
nutrition needed by a pregnant woman. Mrs. Pneumonia had complete prenatal check-ups
at the Brgy. Health center in Mabalacat, Pampanga for all the pregnancies. All babies were
born via normal spontaneous delivery, all at full term without any complication.
4. History of Present Illness

According to Mrs. Pneumonia, 2 months prior to her hospitalization she had positive
signs and symptoms of productive cough with greenish phlegm followed with fever and
chest pain while experiencing this symptoms she will just increase her oral fluid intake and
take paracetamol to be subside. Last November 27, 2016 before her hospitalization she
experienced severe cough, fever and chest pain while she was attending the Holy Mass in
their Brgy. When she got home she took her temperature and the result was 39.5 c upon
knowing the result she then took Paracetamol to get better, at exactly 10:00 PM she
experienced chilling, all she did was to asked her husband to get a piece of cloth and soak
it in water then perform TSB to her. These symptoms happened again at 12:00 midnight
and she do the same interventions again, but when she noticed that there is no changes
upon doing the same thing and noticing that their intervention is no longer effective she
then asked her husband to bring her in the hospital because she can no longer tolerate the
manifestation. At 2:47 am they arrived at AUF MC and was diagnosed of Pneumonia and
because of the severity of the condition, she was admitted. She was given initial
medications and has her further observations and laboratory exams.
5. Physical Examination (Cephalocaudal Approach)
November 28, 2016 (FIRST DAY ADMISSION)

Mrs. Pneumonia
LIFTED FROM THE CHART
GENEREAL APPEARANCE:
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SKIN:
(+) pale
(+) dry skin
(+) Fever
(+) Chills
HEENT
Pale palpebral conjunctiva
Headache (Frontal and Occipital area)

LUNGS
(-) DOB
(+) Crackles located at left lung upper field upon auscultation
Normal lung expansion
Normal lung rhythm
ABDOMEN
(+) Hypogastric Pain
 Tingling sensation on lower extremities
 (+) Dysuria
 (+) Chest Pain
VITAL SIGNS OBTAINED:
Blood Pressure = 90/60 mmHg Respiratory Rate = 20cpm
Heart Rate=76 bpm Temperature=39.5 C
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1st day of Nurse-Patient Interaction (November 28, 2016) – 1st day of Hospitalization
General Survey
Mrs. Pneumonia has a complaint of coughing, fever, (+) crackles as observed and
chest pain by the student nurse. She was conscious and coherent, oriented to time, place,
and person. She was on a sitting position. Mrs. Pneumonia has an ongoing IVF of PLRS
1L at 300 cc level regulated at 26-27 drops per minute infusing well on the Left hand.
Appears relax, calm and participate in comfort measures of choice (DBE and Positioning)
With a Vital Signs of: Temperature: 37.8c, Pulse Rate: 74bpm, Respiratory Rate: 20 cpm
and Blood Pressure: 100/70mmhg. Feels weak and has loss appetite.
Integumentary System
Skin: The skin has uniform color, with fair complexion, with absence of lesions and
jaundice. Absence of nodules upon palpation, no signs of inflammation such as swelling
or edema, skin is warm to touch, and appears dry and pale.
Nails: The fingernails are short and clean same as the toenails. No clubbing observed.
Nails are intact on the epidermis, purplish and smooth.
Head
Scalp: Hair is black with brown highlights and evenly distributed, absence of lice and
flakes. With intact skin. No masses noted upon palpation
Skull: Normocephalic. No masses, nodules or tenderness upon palpation.
Face: Facial expressions are symmetrical with intact skin absence of lesions. No masses
noted upon palpation
Eyes
Eyes: Normal position and alignment in relation to the tip of the pinna.
Visual field: He can see and read clearly. As observed by the student nurse by asking
the patient to read the newspaper and the client said that he cannot see clearly
12
Eyebrows: With black, thin hair evenly distributed. Alignment is symmetrical with intact
skin and equal movement
Eyelids: Symmetrical with intact skin. Absence of lesions and with present blink reflex.
Eyelashes: Equally distributed black hair.
Cornea: Transparent, smooth and shiny; blink reflex is observed upon introduction of the
cotton ball to the cornea.
Iris: Black in color
Lacrimal apparatus: No tenderness and edema noted
Conjunctiva: Bulbar conjunctiva is transparent, smooth and the palpebral conjunctiva

is pale.
Pupils: Pupils are equal in size.
Ears
Auricle: The color is uniform with the facial skin, absence of redness or swelling and with
intact skin. Aligned with the outer canthus of the eye. It recoils after folding with no pain
felt upon application of pressure behind the ear.
External ear canal: Absence of discharge, moisten with earwax.
Hearing acuity: Able to hear normal voice tone
Nose and Sinuses
Nose: The external part has intact skin, the nasal septum is intact and in midline position.
No masses noted upon palpation.
Sinuses: No pain noted upon palpation of facial sinuses. No redness and swelling
observed.
Mouth and Throat
Lips: Dry, pale and symmetrical with intact skin.
Oral Mucosa: with intact skin, Dry with uniform in color. No lesions or redness noted.
13
Gums: No tenderness
Teeth: The upper and lower sets of teeth are complete, strong, and whitish.
Palate and uvula: Moist, smooth, light pink. The anterior palate is hard whereas the
posterior palate is soft. Uvula is positioned in midline of the soft palate.
Tongue: Is centrally positioned, moves freely with no tenderness or swelling or lesions

observed.
Floor of the mouth: No lesions observed.
Pharynx: Absence of redness and swelling and with non-inflamed, pink tonsils.
Neck
Neck: No masses observed upon inspection. Absence of palpable lymph nodes. The
neck muscles are equal in size and smooth movement without discomfort is observed.
The head is centrally positioned.
Trachea: Centrally located, can be displace and returns to its normal position.
Thyroid Gland: Not visible during inspection and ascends during swallowing. With
absence of nodules or tenderness upon palpation.
Thorax and Lungs
Respirations: Presence of crackles located at left upper lung field upon

auscultation. No Difficulty of breathing with no inspiratory retraction of the
supraclavicular areas or no chest retractions were noted during inspiration.
Posterior chest: The spinal column is centrally aligned, without any deviations. With no
retractions of the intercostal muscles upon respiration. Upon palpation there were no
tenderness observed. With symmetrical expansion and even tactile fremitus palpated. No
dullness observed upon the percussion of the chest.
Anterior chest: Symmetrical chest expansion and with no intercostal retractions

observed during inspirations with intact skin. Upon palpation there is no tenderness seen.
Even tactile fremitus observed.
14
Cardiovascular system
Jugular vein: Not distended.
Carotid artery: no bounding pulse observed, fast full pulsation. Carotid pulse: adequate
pulsation, no bruit observed.
Heart: with normal heart rate.
Abdomen
There is no lesion and the skin is intact and unblemished. Has symmetric contour and
with symmetrical movements during inspiration. No pulsations seen. No evidence of
enlargement of liver and spleens. Upon auscultation bowel sounds are audible with
absence of arterial bruits. Tympanic over the stomach is observed and dullness on the
right upper quadrant. Pain on the hypogastric region.
Peripheral Vascular system
Upper extremities: symmetric, absence of swelling with palpable pulsation. Hair is

evenly distributed, muscles are equal in size, no contractures, no tremors, no bone
deformities, no tenderness palpated.
Lower extremities: symmetric, absence of swelling with palpable pulsation. Hair is

deformities, no tenderness palpated. With palpable pulse. Pain.
Muscles:
Muscle weakness noted.
Tendons: No contractures observed.
Motor Function
Fine motor test: Can repeatedly and symmetrically touch the nose. Can rapidly touch
each finger by the thumb of the same hand in finger to thumb test.
Bones and joints
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No deformities noted. No tenderness or swelling noted.
Mental status:
Orientation: oriented to person, time and place.
2nd day of Nurse-Patient Interaction (November 29, 2016) – 2nd day of

Hospitalization
General Survey
Mrs. Pneumonia has a complaint of coughing, fever and (+) crackles as observed
by the student nurse. She was conscious and coherent, oriented to time, place, and
person. She was on a sitting position. Mrs. Pneumonia has an ongoing IVF of PLRS 1L
at 800 cc level regulated at 26-27 drops per minute infusing well on the Left hand. Appears
relax, calm and participate in comfort measures of choice (DBE and Positioning) With
Vital Signs of: Temperature: 36c, Pulse Rate: 79bpm, Respiratory Rate: 20 cpm and
Blood Pressure: 100/70mmhg.
Integumentary System
Skin: The skin has uniform color, with fair complexion, with absence of lesions and
jaundice. Absence of nodules upon palpation, no signs of inflammation such as swelling
or edema, skin is warm to touch, and appears dry and pale.
Nails: The fingernails are short and clean same as the toenails. No clubbing observed.
Nails are intact on the epidermis, purplish and smooth.
Head
Scalp: Hair is black with brown highlights and evenly distributed, absence of lice and
flakes. With intact skin. No masses noted upon palpation
Skull: Normocephalic. No masses, nodules or tenderness upon palpation.
Face: Facial expressions are symmetrical with intact skin absence of lesions. No masses
noted upon palpation
Eyes
16
Eyes: Normal position and alignment in relation to the tip of the pinna.
Visual field: He can see and read clearly. As observed by the student nurse by asking
the patient to read the newspaper and the client said that he cannot see clearly
Eyebrows: With black, thin hair evenly distributed. Alignment is symmetrical with intact
skin and equal movement
Eyelids: Symmetrical with intact skin. Absence of lesions and with present blink reflex.
Eyelashes: Equally distributed black hair.
Cornea: Transparent, smooth and shiny; blink reflex is observed upon introduction of the
cotton ball to the cornea.
Iris: Black in color
Lacrimal apparatus: No tenderness and edema noted
Conjunctiva: Bulbar conjunctiva is transparent, smooth and the palpebral conjunctiva

is pale.
Pupils: Pupils are equal in size.
Ears
Auricle: The color is uniform with the facial skin, absence of redness or swelling and with
intact skin. Aligned with the outer canthus of the eye. It recoils after folding with no pain
felt upon application of pressure behind the ear.
External ear canal: Absence of discharge, moisten with earwax.
Hearing acuity: Able to hear normal voice tone
Nose and Sinuses
Nose: The external part has intact skin, the nasal septum is intact and in midline position.
No masses noted upon palpation.
Sinuses: No pain noted upon palpation of facial sinuses. No redness and swelling
observed.
17
Mouth and Throat
Lips: Dry, pale and symmetrical with intact skin.
Oral Mucosa: with intact skin, Dry with uniform in color. No lesions or redness noted.
Gums: No tenderness
Teeth: The upper and lower sets of teeth are complete, strong, and whitish.
Palate and uvula: Moist, smooth, light pink. The anterior palate is hard whereas the
posterior palate is soft. Uvula is positioned in midline of the soft palate.
Tongue: Is centrally positioned, moves freely with no tenderness or swelling or lesions

observed.
Floor of the mouth: No lesions observed.
Pharynx: Absence of redness and swelling and with non-inflamed, pink tonsils.
Neck
Neck: No masses observed upon inspection. Absence of palpable lymph nodes. The
neck muscles are equal in size and smooth movement without discomfort is observed.
The head is centrally positioned.
Trachea: Centrally located, can be displace and returns to its normal position.
Thyroid Gland: Not visible during inspection and ascends during swallowing. With
absence of nodules or tenderness upon palpation.
Thorax and Lungs
Respirations: Presence of crackles located at left upper lung field upon

auscultation. No Difficulty of breathing with no inspiratory retraction of the
supraclavicular areas or no chest retractions were noted during inspiration.
Posterior chest: The spinal column is centrally aligned, without any deviations. With no
retractions of the intercostal muscles upon respiration. Upon palpation there were no
18
tenderness observed. With symmetrical expansion and even tactile fremitus palpated. No
dullness observed upon the percussion of the chest.
Anterior chest: Symmetrical chest expansion and with no intercostal retractions

observed during inspirations with intact skin. Upon palpation there is no tenderness seen.
Even tactile fremitus observed.
Cardiovascular system
Jugular vein: Not distended.
Carotid artery: no bounding pulse observed, fast full pulsation. Carotid pulse: adequate
pulsation, no bruit observed.
Heart: with normal heart rate.
Abdomen
There is no lesion and the skin is intact and unblemished. Has symmetric contour and
with symmetrical movements during inspiration. No pulsations seen. No evidence of
enlargement of liver and spleens. Upon auscultation bowel sounds are audible with
absence of arterial bruits. Tympanic over the stomach is observed and dullness on the
right upper quadrant. No masses or tenderness noted upon palpation.
Peripheral Vascular system
Upper extremities: symmetric, absence of swelling with palpable pulsation. Hair is

deformities, no tenderness palpated.
Lower extremities: symmetric, absence of swelling with palpable pulsation. Hair is

deformities, no tenderness palpated. With palpable pulse.
Muscles:
Muscle weakness noted.
Tendons: No contractures observed.
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Motor Function: fine motor test: Can repeatedly and symmetrically touch the nose. Can
rapidly touch each finger by the thumb of the same hand in finger to thumb test.
Bones and joints
No deformities noted. No tenderness or swelling noted.
Mental status:
Orientation: oriented to person, time and place.
6. DIAGNOSTIC AND LABORATORY PROCEDURES
7. ANATOMY AND PHYSIOLOGY
RESPIRATORY SYSTEM
The respiratory
system (also referred to
as the ventilator system)
is a complex biological
system comprised of
several organs that
facilitate the inhalation
and exhalation of oxygen
and carbon dioxide in
living organisms (or, in
other words, breathing).
For all air-

breathing vertebrates, respiration is handled by the lungs, but these are far from the only
components of the respiratory system. In fact, the system is composed of the following
biological structures: nose and nasal cavity, mouth, pharynx, larynx, trachea, bronchi and
bronchioles, lungs and the muscles of respiration.
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A properly functioning respiratory system is a vital part of our good health.
Respiratory infections can be acute and sometimes life threatening. They can also be
chronic, in which case they place tremendous long term stress on the immune system,
endocrine system, HPA axis, and much more.
Nose and Nasal Cavity
The nose and nasal cavity constitute the main external opening of the respiratory
system. They represent the entryway to the respiratory tract – a passage through the
body which air uses for travel in order to reach the lungs. The nose is made out of bone,
muscle, cartilage and skin, while the nasal cavity is, more or less, hollow space. Although
the nose is typically credited as being the main external breathing apparatus, its role is
actually to provide support and protection to the nasal cavity. The cavity is lined with
mucus membranes and little hairs that can filter the air before it goes into the respiratory
tract. They can trap all harmful particles such as dust, mold and pollen and prevent them
from reaching any of the internal components. At the same time, the cold outside air is
warmed up and moisturized before going through the respiratory tract. During exhalation,
the warm air that is eliminated returns the heat and moisture back to the nasal cavity, so
this forms a continuous process.
Oral cavity
The oral cavity, more commonly referred to as the mouth, is the only other external
component that is part of the respiratory system. In truth, it does not perform any
additional functions compared to the nasal cavity, but it can supplement the air inhaled
through the nose or act as an alternative when breathing through the nasal cavity is not
possible or exceedingly difficult. Normally, breathing through nose is preferable to
breathing through the mouth. Not only does the mouth not possess the ability to warm
and moisturize the air coming in, but it also lacks the hairs and mucus membranes to filter
out unwanted contaminants. On the plus side, the pathway leading from the mouth is
shorter and the diameter is wider, which means that more air can enter the body at the
same speed.
Pharynx
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The pharynx is the next component of the respiratory tract, even though most
people refer to it simply as the throat. It resembles a funnel made out of muscles that acts
as an intermediary between the nasal cavity and the larynx and esophagus. It is divided
into three separate sections: nasopharynx, oropharynx and laryngopharynx. The
nasopharynx is the upper region of the structure, which begins at the posterior of the
nasal cavity and simply allows air to travel through it and reach the lower sections. The
oropharynx does something similar, except it is located at the posterior of the oral cavity.
Once the air reaches the laryngopharynx, something called the epiglottis will divert it to
the larynx. The epiglottis is a flap that performs a vital task, by switching access between
the esophagus and trachea. This ensures that air will travel through the trachea, but that
food which is swallowed and travels through the pharynx is diverted to the esophagus.
Larynx
The larynx is the next component, but represents only a small section of the
respiratory tract that connects the laryngopharynx to the trachea. It is commonly referred
to as the voice box, and it is located near the anterior section of the neck, just below the
hyoid bone. The aforementioned epiglottis is part of the larynx, as are the thyroid cartilage,
the cricoid cartilage and the vocal folds. Both cartilages offer support and protection to
other components, such as the vocal folds and the larynx itself. The thyroid cartilage also
goes by a more common name – the Adam’s apple – although, contrary to popular belief,
it is present in both men and women. It is typically more pronounced in adult males. The
vocal folds are mucous membranes that tense up and vibrate in order to create sound,
hence the term voice box. The pitch and volume of these sounds can be controlled by
modifying the tension and speed of the vocal folds.
Trachea
The trachea is a longer section of the respiratory tract, shaped like a tube and
approximately 5 inches in length. It has several C-shaped hyaline cartilage rings which
are lined with pseudostratified ciliated columnar epithelium. Those rings keep the trachea
open for air all the time. They are C-shaped in order to allow the open end to face the
esophagus. This allows the esophagus to expand into the area normally occupied by the
22
trachea in order to permit larger chunks of food to pass through. The trachea, more
commonly referred to as the windpipe, connects the larynx to the bronchi and also has
the role of filtering the air prior to it entering the lungs. The epithelium which lines the
cartilage rings produces mucus which traps harmful particles. The cilia then move the
mucus upward towards the pharynx, where it is redirected towards the gastrointestinal
tract in order for it to be digested.
Bronchi
The lower end of the trachea splits the respiratory tract into two branches that are
named the primary bronchi. These first run into each of the lungs before further branching
off into smaller bronchi. These secondary bronchi continue carrying the air to the lobes of
the lungs, then further split into tertiary bronchi. The tertiary bronchi then split into even
smaller sections that are spread out throughout the lungs called bronchioles. Each one
of these bronchioles continues to split into even smaller parts called terminal bronchioles.
At this stage, these tiny bronchioles number in the millions, are less than a millimeter in
length, and work to conduct the air to the lungs’ alveoli. The larger bronchi contain C-
shaped cartilage rings similar to the ones used in the trachea to keep the airway open.
As the bronchi get smaller, so do the rings that become progressively more widely
spaced. The tiny bronchioles do not have any kind of cartilage and instead rely on
muscles and elastin.
This system creates a tree-like pattern, with smaller branches growing from the
bigger ones. At the same time, it also ensures that air from the trachea reaches all the
regions of the lungs. Besides simply carrying the air, the bronchi and bronchioles also
possess mucus and cilia that further refine the air and get rid of any leftover environmental
contaminants. The walls of the bronchi and bronchioles are also lined with muscle tissue,
which can control the flow of air going into the lungs. In certain instances, such as during
physical activity, the muscles relax and allow more air to go into the lungs.
Lungs
The lungs are two organs located inside the thorax on the left and right sides. They
are surrounded by a membrane that provides them with enough space to expand when
23
they fill up with air. Because the left lung is located lateral to the heart, the organs are not
identical: the left lung is smaller and has only 2 lobes while the right lung has 3. Inside,
the lungs resemble a sponge made of millions and millions of small sacs that are named
alveoli. These alveoli are found at the ends of terminal bronchioles and are surrounded
by capillaries through which blood passes. Thanks to an epithelium layer covering the
alveoli, the air that goes inside them is free to exchange gasses with the blood that goes
through the capillaries.
Muscles of Respiration
The last component of the respiratory system is a muscle structure known as the
muscles of respiration. These muscles surround the lungs and allow the inhalation and
exhalation of air. The main muscle in this system is known as the diaphragm, a thin sheet
of muscle that constitutes the bottom of the thorax. It pulls in air into the lungs by
contracting several inches with each breath. In addition to the diaphragm, multiple
intercostal muscles are located between the ribs and they also help compress and expand
the lungs.
Physiology of the Respiratory System
The respiratory system has a complex physiology and is responsible for multiple
functions. There are multiple roles performed by the respiratory system: pulmonary
ventilation, external respiration, internal respiration, transportation of gases and
homeostatic control of respiration.
Pulmonary Ventilation
Pulmonary ventilation is the main process by which air flows in and out of the lungs.
This is done through the contraction of muscles, as well as through a negative pressure
system that is accomplished by the pleural membrane covering the lungs. When the lungs
are completely sealed in this membrane, they remain at a pressure that is slightly lower
than the pressure of the lungs at rest. As a result of this, the air passively fills the lungs
until there is no more pressure difference. At this point, if necessary, additional air can be
inhaled by contracting the diaphragm as well as the surrounding intercostal muscles.
24
During exhalation, the muscles relax and this reverses the pressure dynamic, increasing
the pressure on the outside of the lungs and forcing air to escape them until both
pressures equalize again. Thanks to the elastic nature of the lungs, they revert back to
their state at rest and the entire process repeats itself.
External Respiration
External respiration is a process that allows an exchange of gases to take place

between the air located in the alveoli and the blood that is traveling through the capillaries.
This is possible through a difference in pressure between the oxygen and carbon dioxide
located in the air, and the oxygen and carbon dioxide in the blood. As a result of this,
oxygen from the air is transferred to the blood while carbon dioxide from the blood goes
into the air. The useful oxygen is then carried out throughout the body while the carbon
dioxide is dispelled through exhalation.
Internal Respiration
Internal respiration is a similar process except it involves gas exchange between

the blood in the capillaries and body tissue. Again, a difference in pressure allows oxygen
to leave the blood and enter the tissue while carbon dioxide does the opposite.
Transportation of Gases
This function of the respiratory system enables oxygen and carbon dioxide to travel
throughout the body to wherever they are needed. Most of the gases are carried through
blood attached to transport molecules such as hemoglobin, although blood plasma will
also have a minimal content of gas. Almost 99% of the entire oxygen found in the human
body is transported by hemoglobin. Most of the carbon dioxide is transported from all
areas of the body back to the lungs by plasma in the form of bicarbonate ions. This is
created from a catalytic reaction (caused by a carbonic anhydrase enzyme) between
water and carbon dioxide, which combine to form carbonic acid. The carbonic acid then
splits into hydrogen and bicarbonate ions, with the latter eventually being transformed
into carbon dioxide again, taken to the lungs and exhaled.
25
Homeostatic Control of Respiration
The last physiological role of the respiratory system is the homeostatic control of
respiration or, in other words, the body’s ability to maintain a steady breathing rate. This
is termed eupnea. This state should remain constant until the body has a demand for
increased oxygen and carbon dioxide levels due to increased exertion, most likely caused
by physical activity. When this happens, chemoreceptors will pick up on the increased
partial pressure of the oxygen and carbon dioxide and send triggers to the brain. The
brain will then signal the respiratory center to make adjustments to the breathing rate and
depth in order to face the increased demands.
26
8. THE PATIENT AND HIS ILLNESS
PATHOPHYSIOLOGY OF PNEUMONIA (BOOK-CENTERED)
Non modifiable Risk Modifiable Risk Factors

Factors
 Smoking
 Race  Alcoholism
 Gender  Presence of underlying
 Age conditions
 Medications
 Immunosuppression
 Prolonged immobility
 Tracheal intubation
 Malnutrition
 Upper Respiratory Tract
Infection
Inflammation of the lung tissues
27
Hypertrophy of mucous Increased alveocapillary Inflammation Inflammatory
membrane lining membrane permeabilty of pleura response
Increased respiratory Excess fluid in Chest pain on Increased WBC

secretions interstitial space inspirations
Cough
Decreased surface area Chills
Pleural
for gas exchange
effusion
Increased
Sputum Fever
Hypoxemia
Dullness on
Bronchospasm percussion
Respiratory acidosis
Decreased
Wheezing
breath
dyspnea
sounds
Low arterial blood pH
Decreased
vocal fremitus
28
SYNTHESIS OF THE DISEASE (Book-Centered)
Pneumonia is an acute infection of the lung parenchyma that commonly impairs

gas exchange. The prognosis is usually good for people who have normal lungs and
adequate host defense before the onset of pneumonia.
A lot of different factors may have a contribution in the development of the disease.
These have been labeled as risk factors that cannot be altered (non-modifiable) and those
that can be changed by lifestyle changes (modifiable). Among the modifiable factors are
smoking, alcoholism, presence of underlying conditions, medications
immunosuppression, prolonged immobility, tracheal intubation, malnutrition and upper
respiratory tract infection. Also, in addition to that is the presence of non-modifiable
factors such as age, gender, and race.
Pneumonia results from inflammation of lung tissue. The inflammatory process

may involve different anatomical areas of the lung parenchyma and the pleurae.
Inflammatory response includes increased WBC, chills and fever.
In pneumonia, hypertrophy of mucous membrane lining results in hypersecretions

leads to increased sputum production and cough. Bronchospasms from increased
secretions, leads to localized or diffuse wheezing dyspnea.
Generally, alveocapillary membrane exchanges oxygen and carbon dioxide. In

pneumonia, there is an increased permeability resulting in an increased fluid in the
interstitial space that decreased surfaced area for gas exchange that leads to hypoxemia.
Hypoventilation and respiratory acidosis leads to decreased chest expansion and low
arterial blood pH.
Normally pleura maintains close approximation of lungs and chest wall, minimizes
friction during lung expansion and contraction. In pneumonia, there is an inflammation of
the pleura which shows, chest pain, especially on inspiration, pleural effusion, dullness
on percussion, decreased breath sounds and decreased vocal fremitus.
29
Non-modifiable risk factors:
 Race – Pneumonia is more prevalent (threefold to fivefold higher) in black as

compared with whites.
 Age –Infants who are two years old or younger because their immune systems are
still developing during the first few years of life. People who are 65 years old or
older because their immune systems begin to change as a normal part of aging.
 Gender – pneumonia was generally higher for males than females.
Modifiable risk factors:
 Smoking – both active and passive, cigarette smoke disrupts both mucociliary and
macrophage activity.
 Alcoholism– alcohol suppresses the body’s reflexes, maybe associated with
aspiration, and decreases white cell mobilization and tracheobronchial ciliary
motion.
 Presence of underlying conditions – conditions that produce mucus or bronchial
obstruction and interfere with normal lung drainage such as cancer and chronic
obstructive pulmonary disease (COPD). Chronic diseases such as chronic lung
disease, diabetes mellitus, heart disease, uremia, cancer may also increase the
risks of acquiring pneumonia.
 Medications – general anesthetic, sedative, or opioid preparations that promotes
respiratory depression, which causes a shallow breathing pattern and predisposes
to the pooling of bronchial secretions and potential development of pneumonia.
 Immunosuppression increasing numbers of patients who have compromised
defense against infections are susceptible to pneumonia.
 Immobility–immobility can lead to pulmonary congestion, as patient remains
immobile pulmonary secretions build up in the chest and cause pneumonia.
30
 Air pollution– it may increase the risk for pneumonia by impairing the function of
pulmonary alveolar macrophages and epithelial cells.
 Tracheal intubation– The endotracheal tube can have direct effects on the airway
that result in a reduction in local host defenses. Thus, mucosal injury can reduce
mucociliary function, while upper airway defenses are bypassed and the
effectiveness of cough is reduced.
 Malnutrition– the body's immune system can be weakened by malnutrition.
 Upper Respiratory Tract Infection (URTI) – Upper respiratory tract infection due
to viral pathogens may lead to bacterial sinusitis, bronchitis, or pneumonia.
Signs & Symptoms:
 Increased Sputum – hypertrophy of mucous membrane lining results in

hypersecretions that stimulates increased sputum production.
 Cough – increased respiratory secretions stimulates cough reflex.
 Consolidation in chest x–ray – increased permeability of the alveocapillary
membrane results to excess fluid in interstitial space shows consolidation in chest
x–ray films.
 Respiratory acidosis – the lungs cannot expand maximally resulting to
hypoventilation that leads to respiratory acidosis.
 Low arterial blood pH – increased permeability of the alveocapillary membrane
results to excess fluid in interstitial space and decreased surface area for gas
exchange that leads to hypoxemia.
 Wheezing dyspnea – bronchospasm from increased secretions leads to localized
or diffused wheezing dyspnea.
 Chest pain on inspirations – inflammation of the pleura results to friction during
lung expansion and contraction that causes chest pain during inspiration.
 Decreased breath sounds – inflammation of the pleura results to decreased
breath sounds.
 Dullness on percussion – inflammation of the pleura shows dullness on
percussion.
31
 Decreased vocal fremitus – inflammation of the pleura results to decreased
fremitus.
 Increased WBC – inflammatory response.
 Chills – inflammatory response.
 Fever – inflammatory response.
32
8. THE PATIENT AND HER ILLNESS
PATHOPHYSIOLOGY OF PNEUMONIA (PATIENT-CENTERED)
Modifiable Risk Factors

Non modifiable Risk
 Upper Respiratory Tract
Factors Infection
 NONE
Inflammation of the lung tissues
Hypertrophy of mucous Inflammation Inflammatory

membrane lining of pleura response
33
Increased respiratory Chest pain on Increased WBC
secretions inspirations
Chills
Cough
Increased Fever
Sputum
34
SYNTHESIS OF THE DISEASE (Patient-Centered)
According to Mrs. Pneumonia she was having cough and fever for 3 days (Novemeber 25 –28, 2016) until she
experienced chest pain last November 28, 2016 so she decided to consult to physician.
The patient was diagnosed with community acquired pneumonia (CAP). Her disease process was started from
inhalation of infectious agent acquired from the community. The infection initiates inflammatory response. It then results to
inflammation of the lung tissues.
The only risk factor she had was having upper respiratory tract infection.
She experienced chest pain due to inflammation of the lungs pleura that produces friction whenever the lung expands
during inspirations. She also experienced cough due to stimulation of gag reflex from increased respiratory secretions and
increased sputum. Increased WBC, chills and fever were caused by inflammatory response.
Modifiable risk factors:
Upper Respiratory Tract Infection (URTI) – she was experiencing cough and colds for two months prior to admission.
Signs & Symptoms:
 Increased Sputum – together with cough she experienced increased sputum.

 Cough – she experienced cough for two months.
 Chest pain on inspirations – two hours prior to admission she experienced chest pain.
 Increased WBC – her laboratory results shows an increased WBC for two days.
 Chills – the night before the day of admission she experienced chills.
 Fever – three days prior to admission she was having fever of 39 C.
35
B. PLANNING (NURSING CRE PLAN)
PROBLEM #1: Ineffective airway Clearance
Assessment Diagnosis Scientific Objectives Nursing Rationale Expected

Explanation Interventions Outcome
S: The patient Ineffective Ineffective airway STG: >Establish >to gain STG:
verbalized: airway clearance is the After 2 hours of rapport patient’s trust The patient
“kahit clearance inability to clear nursing shall have
nakapahinga related to secretions or interventions, >Take and >to obtain identified
lang ako retained obstructions from the patient will record vital baseline data potential
hinihingal ako.” secretion as the respiratory tract identify signs complications
evidenced to maintain a clear potential and how to
O: by crackles airway. Community complications >Assist client to >position helps initiate
The patient on lungs acquired and how to position his maximize lung appropriate
manifests: upon pneumonia is a initiate head expansion and preventive or
>changes in auscultation disease in which appropriate appropriately decrease corrective
respiratory rate individuals who preventive or for age/ respiratory actions
>Clear, watery have not recently corrective condition. effort. Maximal
and retained been hospitalized actions. Assist patient ventilation may
secretions develop an with coughing promote
infection of the LTG: and deep movement of LTG:
lungs. It is an acute
36
>(-) crackles inflammatory After 5 days of breathing secretion into The patient
on both lung condition that nursing exercise. larger airways. shall have
fields results from interventions, >increase fluid >high fluid demonstrated
aspiration of the patient will intake of intake helps absence or
nasopharyngeal demonstrate patient unless thin secretions, reduced
secretions or absence or contraindicated making them congestion
stomach contents reduced easier to with breath
in the lungs. congestion expectorate. sounding clear
with breath noiseless
Irritant is inhaled by sounding clear >keep >Precipitators respirations
the patient which noiseless environment of allergic type and improved
triggers the respirations allergen free of respiratory oxygen.
inflammatory and improved reactions can
response leading to oxygen trigger or
increased exchange. exacerbate
production of onset of acute
secretions which episodes.
leads to ineffective
airway clearance. >administer >to widen and
bronchodilators relax air
as physician passages. To
required, and reduce
37
use of viscosity of
nebulization as secretions.
necessary.
38
PROBLEM #2: Hyperthermia
Assessment Nursing Scientific Objectives Nursing Rationale Expected

Diagnosis Explanation Intervention Outcome
Subjective: Hyperthermia In hyperthermia STG: After 3 >Assess and >Temperature may STG: After 3
the presence of hours of monitor client’s suggest acute hours of
microorganisms Nursing temperature and infectious disease Nursing
Objective: stimulates the Intervention the note for presence of process. Intervention the
The patient release of pyrogen patient will be chills patient shall
manifested the from the able decrease have decreased

leukocytes body >Adjust and monitor >Room temperature body
ff:
resetting the temperature environmental may be accustomed temperature
>Fever (39.5C) to near normal body
body’s thermostat from 39.5 C to factors like room from 39.5 C to
>Pale and dry to febrile level and 37 C. temperature and temperature and 37 C.
skin then there would bed linens as blankets and linens
be activation of the indicated. may be adjusted as

>Chills
hypothalamus, indicated to regulate
>Weakness temperature of
which will result in LTG: After 2
vasoconstriction of client.
>Elevated days of Nursing
LTG: After 2
WBC the cutaneous Intervention the
days of Nursing
vessels. The heat patient will
39
will be produced maintain >Apply tepid sponge >It could help in Intervention the
as peripheral normal body bath. reducing patient shall
The patient
dilation reslting in temperature of hyperthermia; avoid have
may manifest
skin is warm to 37 C. using alcohol and maintained
>Infection touch. In iced water which normal body
>Fever pneumonia may even produce temperature of
convulsions Inflammatory chills and increase 37 C.

response of the client’s temperature.
lungs follow which
results to fever.
>Administer >Antipyretics acts on
antipyretics as the hypothalamus,
prescribed by the reducing
physician, utilizing hyperthermia.
the 10 Rs in giving
medication.
>Provide cooling >It is helpful in

blanket as indicated. reducing increased
body temperature
especially with
40
temperatures of
39.5ᴼC – 40ᴼC.
>Encourage client
to increase fluid >Water regulates
intake. body temperature.
>To ensure client’s

>Raise the side rails
safety even without
at all times.
the presence of
seizure activity.
>Start intravenous
>To replenish fluid
normal saline
losses during
solutions or as
shivering chills.
indicated.
>Provide high >To meet the

caloric diet or as metabolic demand
indicated by the of client.
physician.
41
>Educate client of
signs and symptoms >Providing health
of hyperthermia and teachings to client
help him identify could help client
factors related to cope with disease
occurrence of fever; condition and could
discuss importance help prevent further
of increased fluid complications of
intake to avoid hyperthermia
dehydration.
42
Problem #3: ACUTE PAIN
ASSESSMENT NURSING SCIENTIFIC EXPECTED INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS EXPLANATION OUTCOME
S: Acute Pain related Pneumonia is a ST >Assess pain >Chest pain, ST

The patient may: to persistent common illness After 4 - 6 hours characteristics: usually present After 4 - 6 hours
-Report a pain coughing that affects of nursing sharp, constant, to some degree of nursing
scale As evidenced by millions of interventions, stabbing. with pneumonia, interventions,
-Verbalize that reports of pleuritic people each the patient will Investigate may also herald the patient shall
they are in pain chest pain year in the be able to changes in the onset of be able to
United States. verbalize a character, complications of verbalize a
Germs called decrease in location, or pneumonia, such decrease in
bacteria, pain scale from intensity of pain. as pericarditis pain scale from
O: viruses, and 6/10 to 4/10 and endocarditis. 6/10 to 4/10
The patient may fungi may
manifest: cause
-Guarding pneumonia. In
behavior adults, bacteria >Monitor vital >Changes in
-discomfort are the most LT signs. heart rate or BP LT
- VS as follows: common cause After 1 - 2 days may indicate that After 1 - 2 days
T - 36.4 C/axilla of pneumonia. of nursing patient is of nursing
PR - 82 bpm One of its interventions, experiencing interventions,
RR - 24 cpm symptom is the patient will pain, especially the patient shall
43
BP - 120/80 Sharp or be able to when other be able to
stabbing chest demonstrate a reasons for demonstrate a
pain that gets relaxed and changes in vital relaxed and
worse when relief manner signs have been relief manner
you breathe ruled out
deeply or
cough. >Provide comfort > Non-analgesic
measures: back measures
rubs, position administered
changes, quite with a gentle
music, massage. touch can lessen
Encourage use of discomfort
relaxation and/or
breathing
exercises.
>ffer frequent oral >Mouth

hygiene. breathing and
oxygen therapy
can irritate and
dry out mucous
membranes,
44
potentiating
general
discomfort.
>Instruct and >Aids in control

assist patient in of chest
chest splinting discomfort while
techniques during enhancing
coughing effectiveness of
episodes. cough effort.
45
PROBLEM #4: Activity Intolerance Level IV
Assessment Diagnosis Scientific Objectives Nursing Rationale Expected

Explanation Interventions Outcome
S: The patient Activity Activity Intolerance STG: >establish >to gain STG:
verbalized: Intolerance is a state in which After 3 hours of rapport patient’s trust The patient
“kahit Level IV an individual has nursing shall have
nakapahinga insufficient interventions, >Take and >to obtain identified
lang ako physiologic or the patient will record vital baseline data negative
hinihingal ako.” psychological identify signs factors
energy to endure or negative affecting
O: complete required factors >Perform >Provides activity
The patient or desired activities affecting general cooperative tolerance and
manifests: which may be activity assessment. baseline data eliminated or
>dyspnea and caused by low tolerance and Evaluate and reduced their
fatigue at rest oxygen supply in eliminate or clients actual information effects when
>The patient the blood vessels reduce their and perceived about needed possible.
receives and then manifests effects when limitations and education or
oxygen therapy as body weakness possible. severity of interventions
via nasal deficit in light of regarding
cannula at 2- LTG: usual status. quality of life. LTG:
3LPM After 4 days of The patient
nursing shall have
46
>(-) crackles on interventions, >reduce >to prevent reported
both lung fields the patient will intensity level overexertion measurable
report or discontinue increase in
measurable activities that activity
increase in cause tolerance.
activity undesired
tolerance. physiological
changes
>increase >to conserve

activities energy
gradually.
>plan care to >To reduce

carefully fatigue
balance rest
periods with
activities.
>assist with >to protect

activities and patient from
provide or injury
47
monitor client’s
use of assistive
devices.
>plan for >promotes the

maximal idea of
activity within normalcy of
client’s ability progressive
abilities in this
area.
>encourage >to promote

deep breathing maximal
exercises. expansion of
lungs.
48
PROBLEM #5: RISK FOR IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS
Assessment Nursing Scientific Objectives Nursing Rationale Expected

Diagnosis Explanation Intervention Outcome
Subjective: Risk for Imbalanced STG: >Assess weight >To establish STG: The
“Wala akong Imbalanced nutrition less than baseline parameter patient shall
After 1 hour of
ganang nutrition: less body requirements have
nursing
kumain” as than body is defined as intake demonstrated
interventions,
verbalized by requirements of nutrients >To stimulate behaviors,
the patient will >Encourage patient
the patient related to insufficient to meet appetite. lifestyle
demonstrate to choose foods or
loss of metabolic needs. have family member changes to
behaviors
appetite Loss of appetite of bring foods that regain and or
,lifestyle
Objective: the patient with maintain
changes to seam appealing.
The patient pneumonia maybe appropriate
regain and or
manifested the related to use of weight
maintain
ff: antibiotic that can
appropriate LTG: The
>Helps determine
affect taste buds
>fever weight >Note age, body patient shall
nutritional needs.
and the patient
build,strength,activity have maintained
>loss of feels the food as LTG:
level and current or regained
appetite tasteless which After 2 days of
condition or desired body
makes the food nursing
>weakness treatment needs. weight
that much more interventions,
49
>decreased undesirable. the patient will
potassium level Persistent maintain or
>Promote >To enhance intake
coughing can also regain desired
>pale mucous pleasant,relaxing
cause loss of body weight
membrane environment,
appetite.
including
>coughing
socialization when
possible
The patient
may manifest
>Prevent or minimize
>weight loss >May have a
unpleasant odors or
negative effect on
>excessive hair sights
appetite and eating.
loss
>decreased
serum albumin >Good oral hygiene
>Provide good oral enhances appetite
>confusion or hygiene before and
mental after meals.
irritability
>These measures
>Provide small,
may enhance intake
frequent meals,
50
including dry foods eventhough appetite
(toast,crackers) maybe slow to
and/or foods that are return.
appealing to patient
>Evaluate general
>Presence of
nutritional state,
chronic conditions or
obtain baseline
financial limitations
weight
can contribute to
malnutrition, lowered
resistance to
infection and/or
delayed response to
therapy
51
C. IMPLEMENTATION
1. MEDICAL MANAGEMENT
A. IVFS, BT, NGT FEEDING, NEBULIZATION, TPN, OXYGEN THERAPY, ETC.
> Intravenous Fluid
Date Ordered,
Medical Date Client’s
Management/ Performed, General Indication(s) response to
Treatment Date Changed Description or Purpose(s) the treatment
0.9% NaCl This Mrs.

PNSS DO: solution intravenous Pneumonia
(0.9 NaCl 1 L x November,28 Sodium fluid is to hydration and
80ml/hr 2016 chloride is an maintain energy status
electrolysis hydrostatic was
DP: supplement stability, treat maintained as
November,28 agent; Sodium hyponatremia, evidenced by
2016 and chloride and go with improved
are important blood energy in doing
DC: electrolysis for transfusions. ADLs.
November 28, the human Also, it is
2016 body and indicated for
mainly exist in the
extracellular administration
fluid, which of intravenous
play an medications.
important role
in maintaining
normal volume
of blood, and
extracellular
fluid and
52
osmosis
pressure.
Date
Medical Ordered, Client’s
Management/ Date General Indication(s) or response to
Treatment Performed, Description Purpose(s) the
Date treatment
Changed
Ringer’s Lactate It is used to treat Mrs.
solution is a solution dehydration, Pneumonia
PLRS DO: that is isotonic with burns,lower GI hydration
(1L x 80cc/hr) November,28 blood. It is grouped fluid loss, acute and energy
2016 with intravenous fluids blood loss, status was
known as crystalloids hypovolemia due maintained
DP: which include saline to blood loss and as
November,28 and dextrose solution. replacement of evidenced
2016 It also used because fluid and by good skin
November the by-products of electrolytes turgor and a
29,2016 lactate metabolism in good
the liver counteract capillary refill
acidosis, which is time of less
imbalance that occurs than 3
with acute fluid loss. seconds
NURSING RESPONSIBILITIES:
Before the Procedure:
53
 Verify doctor’s order.
 The 10 rights of the patient must be observed.
 Explain the procedure to the patient and why it has to be done.
During the Procedure:
 Instruct patient to relax especially the hand where the needle is to be inserted (to
avoid reinsertion and facilitate easy insertion)
 Check IV level and the patency of the tubing if it is infusing well.
After the Procedure:
 Secure the site with micropore.

 Check the site of hand where the needle is inserted if bulging is not visible. If so,
reinsertion is to be undertaken.
 Advice patient to avoid scratching the site less movement of the hand where the
needle was inserted to keep it in place.
 Instruct patient and significant others to inform the nurse on duty if bulging of the
site is visible, if there is back flow of blood of if IVF is not infusing well.
 Observe the IV site for signs of infiltration or other complications fluid or electrolyte
overload and air embolism.
 IVF regulation should be checked and monitored upon receiving patient.
 Always check the doctor’s order for new orders regarding the IVF supplement of
the patient.
 Always check if the IVF is infusing well and intact.
 Instruct client to support this therapy by increasing his oral fluid intake.
 Document.
54
a. Drugs
Drugs Date Route or General Indication Clients
(generic, ordered, admin, action response
brand name) date dosage (functional
taken/give and classificatio
n, date frequency n)
changed/
D/C
Generic Date 500mg/tab Antipyretic Decreases The
Name:Paraceta ordered: every 4 fever by patient’s
mol hours PRN inhibiting the body
November
Brand Name: effects of temperatur
28,2016
Biogesic pyrogens on e
Date given: the decreased
November hypothalamu from 39.5
28,2016 s heat to 37.

regulating
centers & by
Date a
discontinued: hypothalami
c action
November
leading to
29,2016
sweating &
vasodilatatio
n.
Before:
55
 Check doctor’s order for the medication, route, dosage and frequency of
administration.
 Check the medication properly and read labels properly.
 Know the reason for which patient is receiving the medication.
 Check the label three times before administering.
 Asses patient’s history of allergic reaction to the drug
 Ask for the clients name and check the ID band before giving the medications
 Calculate correctly the dose and check the required amount to be given
 Check that the patient is not taking any other medication containing
paracetamol.
During:
 Keep to the recommended dose
 Instruct the patient to take with food or milk to minimize GI upset
 Instruct patient to report any discomfort immediately such as shortness of
breath and abdominal pain as these are signs of toxicity.
 Instruct patient to avoid alcohol.
After:
 Observe the patient for any reaction to the drug.
 Monitor patient if there is shortness of breath,abdominal pain and other signs
and symptoms of discomfort or toxicity.
 Chart the medication after administering

brand date dosage and (functional
name) taken/given frequency classificati
, date on)
changed/
D/C
56
Generic Date 2gms/IV OD Antibiotic It useful for WBC was
Name: ordered: the still above
Ceftriaxone treatment of normal
November
Brand Name: a number range as of
28,2016
Rocephin of bacterial November
Date given: infections. 28, 2016
November This although the
28,2016 includes mid patient did

dle ear not manifest
November
infections, e signs and
29,2016
ndocarditis, symptoms of
meningitis, infection
pneumonia, such as
bone and fever and
joint chills.
infections,
intra-
abdominal
infections,
skin
infections, u
rinary tract
infections, g
onorrhea,
and pelvic
inflammator
y disease.
57
Before:
administration.
 Determine history of hypersensitivity reactions to cephalosporins and
penicillins and history of other allergies, particularly to drugs, before therapy is
initiated.
 Perform culture and sensitivity tests before initiation of therapy.
During:
 Instruct patient to report any signs of bleeding.
 Instruct patient to report loose stools or diarrhea promptly.
After:
 Monitor for manifestations of hypersensitivity.
 Watch for and report signs :petechiae, ecchymotic areas, epistaxis, or any
unexplained bleeding.
 Note IV injection sites for signs of phlebitis (redness, swelling, pain).
 Chart the medication after administering.

brand date dosage (functional
name) taken/given, and classification)
date frequency
58
changed/
D/C
Generic Date ordered: 600 Electrolyte It is used to The patient
Name: mg/tab treat or prevent did not
November
Potassium TID low amounts manifest
28,2016
Chloride of potassium in signs and
Brand Date given: the blood. symptoms
Name: K- November of muscle
Lyte/Cl 28,2016 weakness
as
November
evidenced
29,2016
by
improved
energy in
doing
ADL’s
Before:
administration.
 Arrange for serial serum potassium levels before therapy.
During:
59
 Arrange for serial serum potassium levels during therapy.
 Administer oral drug after meals or with food and a full glass of water to
decrease GI upset
 Caution patient not to chew or crush tablets; have patient swallow tablet whole.
After:
date frequency
changed/
D/C
Pantoprazole Date ordered: 40 mg /IV Proton Pump Prophylaxis The
OD Inhibitor for stress patient did
November
ulcer not
28,2016
experience
Date given: abdominal
November pain.
28,2016
November
29,2016
60
Before:
administration.
During:
 Monitor for and immediately report S&S of angioedema or a severe skin
reaction
 Contact physician promptly if any of the following occur: Peeling, blistering, or
loosening of skin; skin rash, hives, or itching; swelling of the face, tongue, or
lips; difficulty breathing or swallowing.
After:
 Chart the medication after administering
date frequency
changed/
D/C
61
Generic Date ordered: 400 mg Antibiotic It is used to treat WBC was
Name: tab/ BID certain infections still above
November
Cefixime caused by normal
28,2016
Brand bacteria such as range as
Name: Date given: bronchitis of
Suprax November (infection of the November
28,2016 airway tubes 28, 2016

leading to the although
November
lungs); the patient
29,2016
gonorrhea (a did not
sexually manifest
transmitted signs and
disease); and symptoms
infections of the of
ears, throat, infection
tonsils, and such as
urinary tract. fever and
chills.
Before:
administration.
62
 Determine previous hypersensitivity reactions to cephalosporins, penicillins,
and history of other allergies, particularly to drugs prior to initiation of therapy.
 Perform culture and sensitivity tests prior to initiation of therapy.
During:
 Instruct patient to report loose stools or diarrhea during drug therapy. Older
adult patients are especially susceptible to pseudomembranous colitis.
 Instruct patient to take this antibiotic for the full course of treatment.
After:
 Discontinue if seizures associated with the drug therapy occur.
 Monitor I&O rates and pattern.
name) taken/given and classification
, date frequenc )
changed/ y
D/C
63
Generic Date ordered: 500 mg Antibiotic Infections WBC was
Name: OD caused by still above
November
Levofloxaci susceptible normal
28,2016
n strains of range as
Brandname Date given: microorganism of
: November s in acute Novembe
Lefex 28,2016 maxillary r 28, 2016
sinusitis, acute although
November
bacterial the
29,2016
exacerbation of patient did
chronic not
bronchitis, manifest
community- signs and
acquired symptoms
pneumonia, of
nosocomial infection
pneumonia, such as
uncomplicated fever and
skin and skin chills.
structure
infections,
complicated
and
uncomplicated
urinary tract
infection (UTI)
and acute
pyelonephritis.
64
Before:
administration.
 Calculate correctly the dose and check the required amount to be given.
 Do C&S test prior to beginning therapy and periodically.
 Assess patient for previous sensitivity reaction and reassess for allergic an
anaphylactic reaction during therapy: rash, urticaria, pruritus, chills, fever, joint
paint.
 Obtain history of seizure disorder or other CNS disease before initiating therapy
During:
 Instruct patient to continue taking drug as prescribed for the length of time
ordered, even if felling better and to avoid taking other medications unless
approved by physician
 Advice patient to take drug with plenty of fluids, at least 2 L/day and to avoid
antacids, sucralfate and products containing iron or zinc for at least 2 hours
before and after each dose
 Teach patient to report: sore throat, bruising, bleeding, joint pain, vaginal
itching, loose foul-smelling stools, furry tongue, itching, rash, pruritus, urticaria,
diarrhea with blood or pus and other adverse reactions.
 Instruct patient to rinse mouth frequently and use sugarless coated candy or
gum for dry mouth.
After:
65
name) taken/given and classification
, date frequenc )
changed/ y
D/C
Generic Date 600mg in Mucolytic Treatment of The patient
Name: ordered: ½ glass of agent respiratory was able to
Acetylcystei water BID affectations expectorat
November
n characterized e
28,2016
Brand by thick and secretions.
Name: Date given: viscous
Fluimuicil November hypersecretions
28,2016 .
November
29,2016
Before:
administration.
66
 Calculate correctly the dose and check the required amount to be given.
During:
 Instruct patient in appropriate use and adverse effects to report
After:
C. DIET
Date Ordered,
Type of Date General Indication(s) Specific Client’s
Diet Performed, Description or foods taken response and/or
Date Changed Purpose(s) reaction to the
diet
Date Ordered: The client This diet is Chicken, green Mrs. Pneumonia
November can eat indicated for leafy ate well in
Diet as 28,2016 anything Mrs vegetables moderation and
tolerated that she can Pneumonia to slowly regained
Date Performed: tolerate with ensure her appetite and
November no food adequate strength.
28,2016 restrictions. nutrition and
November prevent
29,2018 further
complication
Date Changed: of the
On going problem.
67
Before:
 Check the doctors order
 Identify the right client
 Explain the purpose of the diet therapy to the patient and to the patient’s SO
 Talk to the patient’s relatives or SO to closely watch client and to participate in
the given order
 Encourage oral hygiene before and after meals
 Offer the patient assistance with hand washing before and after meals
 Position the patient in a comfortable position, if not contraindicated.
 Inform the patient on what she may and may not eat.
During:
 Monitor intake and output.

 Monitor if the patient’s SO complies with the given diet.
After:
 Document the type and amount of food taken at each meal.
 Monitor response of the patient.
 Instruct patient to maintain the optimal nutritional status.
3. NURSING CARE MANAGEMENT (Actual FDAR)
NOVEMBER 28, 2016 (1:30 AM) - DATE OF ADMISSION
F- Fever
D- Assessed and seen by Dr. Sibal, CBC, Na, K, RBS, Crea, UA, Cxr, Paracetamol 500
mg tab @ 2 am , ECG, GS/CS, Pt. Is admitted under Dr. M. Garcia as walk in pt., Dr.
Estamislao not available, not accredited with HMO, PNSS/ L x 80 ml/hr. @ 3:10 am,
pantoprazole 40 mg/L @ 3:20 am.
NOVEMBER 28, 2016 (3:45 AM)
F- General Survey
68
D- Received from ER @ ongoing IV PNSS 1L x 80 ml/hr @ full level, signs of
inflammation, afebrile.
A- Assessed general condition; VS taken and recorded; regulated IVF as ordered, needs
attended; Due meds given, provided comfort and safety, informed Dr. Garcia & Dr.
Amanse via sms.
NOVEMBER 28, 2016
F- General Survey
D- Received pt on bed awake and coherent with ongoing IVF #1 PNSS 1L x 80 ml/ hr,
infusing well at 950 cc level, afebrile, (-) flank pain, (-) chills
A- Assessed patient condition, moitored VS and recorded, IVF regulated, provided safety
& comfirt measures, needs attended.
NOVEMBER 29, 2016 (12:50AM)
F- General Survey
D- Received pt on bed with ongoing IVF of #2 PLRS 1 L x 80 cc/ hr @ 900 cc level infusing
well on the left hand; VS stable; afebrile, no pain, no distress.
A- assessed pt condition, VS monitored, IVF regulated, provided comfort, safety

measures,needs attended, endorsed.
NOVEMBER 29, 2016 (7:10 AM)
F- General Survey
D- received pt, awake, coherent, with ongoing IVF #2 PLRS 1 L x 80 cc/ hr, infusing ell at
left hand @ 300 cc level, afebrile, stable VS.
A- assessed pt condition, monitored VS and recorded; IVF regulated, provided safety and
comfort measures, needs attended.
NOVEMBER 29, 2016 (8:00 AM) -FIRST NURSE-PATIENT INTERACTION
F- Readiness for Enhanced Comfort
69
D- Received patient on a sitting position, awake, coherent, and oriented to time, place,
and person with an ongoing IVF of #2 PLRS 1L @300 cc level regulated at 26-27 gtts/min,
infusing well at the left arm. Appears relaxed, calm and participated in comfort measures
of choice DBE & Positioning).
A- Established therapeutic relationship
-Monitored and recorded vital signs
-Assessed general condotion (Assessment and Interview)
-Determined the type of comfort
-Provided AM care
-Ascertained motivation and expectation for improvement
-Determined influence of cultural beliefs and values
-Acknowledged client’s strengths in present situation
-Encouraged adequate rest period
R-The patient verbalized sense of comfort and contentment.
D. EVALUATION
VI. Client’s daily progress in the hospital
Admission
Nursing Problems 11/29/2016
11/28/2016
1. Ineffective Airway
Clearance * *
2. Hyperthermia *
3. Acute Pain * *
4 Activity Intlerance * *
70
5. Risk for Imbalance * *
Nutrition
Vital Signs T= 39.5 C T= 36 C
RR = 20cpm RR = 20cpm
BP = 90/60 mmHg BP= 100/70 mmHg
HR = 76 bpm HR = 79 bpm
Drugs
Paracetamol *
Ceftriaxone * *
Potassium Chloride * *
Pantoprazole * *
Cefixime * *
Levofloxacin * *
Acetylcystein * *
Lab Procedures
Hematocrit 0.35 0.51
Hemoglobin 129 175
RBC 4.06 6.04
WBC 18.4 7.76
MCV 87.2 83.6
MCH 31.8 29.0
MCHC 36.4 34.7
Neutrophils 0.91 0.89
Lymphocytes 0.06 0.10
Monocytes 0.06 0.06
Platelet Count 241 241
Diet
a. DAT * *
Activity/Exercise N/A N/A
71
III. SUMMARY OF FINDINGS
Pneumonia is an infection of the alveolar sacs inside the lungs, which can be
bacterial, fungal, or viral. It can also be classified as either community-acquired or
hospital-acquired pneumonia. It is more commonly seen in young children and the elderly,
although any age group can acquire it. Risk factors for pneumonia include cigarette
smoking, pre-existing lung disease such as COPD and asthma, impaired immune system,
taking PPI, and excess alcohol.
The cardinal signs of pneumonia include frequent chest pain, difficulty of

breathing, and productive cough. Other symptoms include fatigue, fever, lower than
normal body temperature (in adults older than 65 and people with weak immune
systems), nausea, vomiting, and diarrhea.
The clinical features of Pneumonia that patient Mrs. Pneumonia manifested during
our Nurse-Patient interactions:
1. Chest Pain
2. Productive cough
3. Presence of crackles in lungs
Treatment of pneumonia typically includes oral antibiotics, rest, simple analgesics

and fluids. This is done in order to eliminate the microorganism affecting the lungs,
management of pain, and to restore body fluids. Pneumonia is diagnosed during a
physical exam, where the doctor will listen to lung sounds for crackles or wheezing, and
also with a chest x-ray and blood tests.
IV. CONCLUSION
In this study, the patient was diagnosed with Pneumonia due to her symptoms of
productive cough, fever, and presence of crackles in the lungs. She was able to be treated
with medication and fluids in order to manage her condition.
The student nurses have learned the causes, risk factors, signs and symptoms,
diagnosis, and management of Pneumonia. These are important to know during Nurse-
72
Patient interaction, so that the nurse can properly assess the patient and care for them
accordingly. Knowing what microorganisms cause Pneumonia and the different types can
help with the diagnosis and the proper treatment given.
V. RECOMMENDATIONS
To all health care providers, that they may have more knowledge and updated
information about the disease condition and aid in its early detection so that nursing care
may be rendered to be of quality to the patient.
To the nursing administration, that they may conduct seminars on the topic so that
clients may be more aware of the disorder process and thereby, prevent its occurrence.
To the public, that they may become more knowledgeable of the disease condition
risk factors and signs and symptoms. Also, the management involved in its course.
For the patients who are undergoing this kind of condition for them to be more
familiar of their diagnosis, to adhere to the management provided, and to improve their
health status.
This will help the patients and their significant others to have their activities and
lifestyle modified to prevent further complications. Proper maintenance and care for the
patient is essential. Stress the significance of regular check-up so that secondary
complications may be prevented. Advise the family to maintain healthy and harmonious
relationships and provide holistic support to the patient.
VI. LEARNING DERIVED
In this case study, We learned about the signs and symptoms, risk factors,
diagnosis and management of Pneumonia. we also learned which risk groups are
commonly affected, and that it is a leading cause in mortality of children aged younger
than 5 years old. We are glad that we were able to have this disease as our case study,
and will use the information we have gathered on it effectively.
73
Bibliography:
Books:
Black, J. & Hawks, J. Medical-Surgical Nursing: Clinical Management for Positive

Outcomes. 8th ed. Missouri: Elsevier Inc., 2009.
Doenges, M. et. al. Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and
Rationales. 13th ed. Philadelphia: F.A. Davis Company, 2013.
Seeley, R. et. al. Essentials of Anatomy & Physiology. 5th ed. New York: McGraw-Hill,
2005.
Brunner, L. (n.d.). Brunner & Suddarth's handbook of laboratory and diagnostic tests.
74

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ANGELES UNIVERSITY FOUNDATION

Pneumonia is an inflammatory condition affecting the lungs, primarily the

A researcher at the University of Alabama by the name of Moon Nahm developed a

 Children living in these top 15 high burden countries by estimated number of

 Pneumonia is most prevalent in sub-Saharan Africa and South Asia, of which

 Define what Pneumonia is

II. NURSING PROCESS

b. Socio-Economic and Cultural Factors

EXPENSES OF THE FAMILY

B.2. Educational Attainment

B.3. Religious Affiliation

B.4. Cultural factors affecting health of the family

According to Mrs. Pneumonia, she never experience chickenpox, mumps, measles

1st, 2nd, 3rd and 4th child

4. History of Present Illness

5. Physical Examination (Cephalocaudal Approach)

November 28, 2016 (FIRST DAY ADMISSION)

(+) dry skin

Headache (Frontal and Occipital area)

Blood Pressure = 90/60 mmHg Respiratory Rate = 20cpm

Heart Rate=76 bpm Temperature=39.5 C

Skull: Normocephalic. No masses, nodules or tenderness upon palpation.

Eyelashes: Equally distributed black hair.

Iris: Black in color

Lacrimal apparatus: No tenderness and edema noted

Conjunctiva: Bulbar conjunctiva is transparent, smooth and the palpebral conjunctiva

Pupils: Pupils are equal in size.

External ear canal: Absence of discharge, moisten with earwax.

Hearing acuity: Able to hear normal voice tone

Nose and Sinuses

Mouth and Throat

Lips: Dry, pale and symmetrical with intact skin.

Tongue: Is centrally positioned, moves freely with no tenderness or swelling or lesions

Floor of the mouth: No lesions observed.

Thorax and Lungs

Respirations: Presence of crackles located at left upper lung field upon

Anterior chest: Symmetrical chest expansion and with no intercostal retractions

Jugular vein: Not distended.

Heart: with normal heart rate.

Peripheral Vascular system

Upper extremities: symmetric, absence of swelling with palpable pulsation. Hair is

Lower extremities: symmetric, absence of swelling with palpable pulsation. Hair is

Muscle weakness noted.

Tendons: No contractures observed.

Bones and joints

Orientation: oriented to person, time and place.

2nd day of Nurse-Patient Interaction (November 29, 2016) – 2nd day of

Skull: Normocephalic. No masses, nodules or tenderness upon palpation.

Eyelashes: Equally distributed black hair.

Iris: Black in color

Lacrimal apparatus: No tenderness and edema noted

Conjunctiva: Bulbar conjunctiva is transparent, smooth and the palpebral conjunctiva

Pupils: Pupils are equal in size.

External ear canal: Absence of discharge, moisten with earwax.

Hearing acuity: Able to hear normal voice tone

Nose and Sinuses

Lips: Dry, pale and symmetrical with intact skin.

Tongue: Is centrally positioned, moves freely with no tenderness or swelling or lesions

Floor of the mouth: No lesions observed.

Thorax and Lungs

Respirations: Presence of crackles located at left upper lung field upon

Anterior chest: Symmetrical chest expansion and with no intercostal retractions

Jugular vein: Not distended.