Colegio de Kidapawan

Quezon Boulevard, Kidapawan City

College of Nursing

IN PARTIAL FULFILLMENT OF
RELATED LEARNING EXPERIENCES
A CASE STUDY ON
Community Acquired Pneumonia
Presented by:
Noli Galope Jr.
Juvie Rufino

Presented to :

Rizza Faith Chamen , RN

Table of Contents

I ---------- Introduction
II ---------- Subjective Data
III--------- Objective Data
IV ---------- Anatomy and physiology
Introduction
As a student nurse we decided to choose this case because it is
very rampant and common in our society and even globally, this triggers our
mind to make an analysis and manifestation to come up with a great effective
outcome . CAP- MR , can happen to anybody in the society , it’s preventable if
we know the proper measures and protocols to promote one’s wellness , in this
case we will going to investigate and impart knowledge on how to reduce the
risk of the said phenomenon , at Madonna General Hospital ( MGH ) , nurse
station 1 is a combination of pediatric and a trace population of elders , this
consist different cases this includes : Pediatric Community acquired
Pneumonia (PCAP-C) , Dengue Fever , Respiratory Tract infection (RTI) ,
Acute Tonsilar Pharyngitis (ATP), and the CAP-MR , this indicates that
airborne diseases and respiratory linked illnesses , it can be easily invade a
person with an compromised immune system.
Pneumonia can range in seriousness from mild to life-threatening.
It is most serious for infants and young children, people older than age 65, and
people with health problems or weakened immune system.
Pneumonia is an infection in one or both lungs. It can be caused by bacteria,
viruses, or fungi. Bacterial pneumonia is the most common type in
adults. Pneumonia causes inflammation in the air sacs in your lungs, which
are called alveoli. The alveoli fill with fluid or pus, making it difficult to breathe.
Pneumonia and other lower respiratory tract infections are the leading cause of
death worldwide. The WHO Child Health Epidemiology Reference Group
estimated the median global incidence of clinical pneumonia to be 0.28
episodes per child-year. This equates to an annual incidence of 150.7 million
new cases, of which 11-20 million (7-13%) are severe enough to require
hospital admission. Ninety-five percent of all episodes of clinical pneumonia in
young children worldwide occur in developing countries.In the
Philippines, 57,809 pneumonia deaths were reported in 2016, nearly 10
percent of 582,183 registered deaths in 2016. This made pneumonia the 3rd
top killer behind ischemic heart disease and cancer.

The most common symptoms of pneumonia are: Cough (with

some pneumonias you may cough up greenish or yellow mucus, or even
bloody mucus), fever, which may be mild or high (as high as 105 degrees F),
shaking and chills and shortness of breath, which may only occur when you
climb stairs.You may also experience sharp or stabbing chest pain that gets
worse when you breathe deeply or cough, headache, excessive sweating and
clammy skin, loss of appetite, low energy, and fatigue and confusion,
especially in older people.. Risk factors for pneumonia include age—younger
than 5 and older than 65, cigarette smoking and recent viral respiratory
infection—a cold, laryngitis, influenza,

The signs and symptoms of pneumonia vary from mild to

severe, depending on factors such as the type of germ causing the infection,
and your age and overall health. Mild signs and symptoms often are similar to
those of a cold or flu, but they last longer.

Signs and symptoms of pneumonia may include:

Chest pain when you breathe or cough, confusion or changes in mental

awareness (in adults age 65 and older), Cough, which may produce
phlegm ,Fatigue ,Fever, sweating and shaking chills, Lower than normal body
temperature (in adults older than age 65 and people with weak immune
systems) ,Nausea, vomiting or diarrhea, Shortness of breath

Community-acquired pneumonia

Community-acquired pneumonia is the most common type of pneumonia. It

occurs outside of hospitals or other health care facilities. It may be caused by:

 Bacteria. The most common cause of bacterial pneumonia in the U.S.

is Streptococcus pneumoniae. This type of pneumonia can occur on its
own or after you've had a cold or the flu. It may affect one part (lobe) of
the lung, a condition called lobar pneumonia.
 Bacteria-like organisms. Mycoplasma pneumoniae also can cause
pneumonia. It typically produces milder symptoms than do other types of
pneumonia. Walking pneumonia is an informal name given to this type of
pneumonia, which typically isn't severe enough to require bed rest.
 Fungi. This type of pneumonia is most common in people with chronic
health problems or weakened immune systems, and in people who have
inhaled large doses of the organisms. The fungi that cause it can be
found in soil or bird droppings and vary depending upon geographic
location.
 Viruses. Some of the viruses that cause colds and the flu can cause
pneumonia. Viruses are the most common cause of pneumonia in
children younger than 5 years. Viral pneumonia is usually mild. But in
some cases it can become very serious.
  Prevention

To help prevent pneumonia:

 Get vaccinated. Vaccines are available to prevent some types of

pneumonia and the flu. Talk with your doctor about getting these shots.
The vaccination guidelines have changed over time so make sure to
review your vaccination status with your doctor even if you recall
previously receiving a pneumonia vaccine.
 Make sure children get vaccinated. Doctors recommend a different
pneumonia vaccine for children younger than age 2 and for children ages
2 to 5 years who are at particular risk of pneumococcal disease. Children
who attend a group child care center should also get the vaccine. Doctors
also recommend flu shots for children older than 6 months.
 Practice good hygiene. To protect yourself against respiratory
infections that sometimes lead to pneumonia, wash your hands regularly
or use an alcohol-based hand sanitizer.
 Don't smoke. Smoking damages your lungs' natural defenses against
respiratory infections.
 Keep your immune system strong. Get enough sleep, exercise
regularly and eat a healthy diet.
Patients Data

Patients code name : Patient M

Date of admission : July 15 2019

Age : 57 yrs old

Gender : Female
 Birthday :June 6 1962

Nationality : Filipino

Address : Balindog , Kidapawan City

Status : Married

Religion : Catholic

Chief Complain : Cough ,Fever and Dyspnea

Admitting diagnosis : CAP -MR , HPN

Attending physician : Dr. Chua S. Chen , Jr. MD

Chapter 2 - Subjective Data

Review of system

A. Skin - “ naa koy gamay na ila dra maam .”

B. Hair - “ wala man koy kuto.”

C. Nose : "panagsa malisdan ko ug ginhaw maam .”

D. Nails - “ wala may problema na akon kuko maam .”

E. Head - “ wala man naga sakit akong ulo maam .”

F. Face - “ wala man naga hubag akong nawong maam.”

G. Neck - “ wala may sakit maam.”

H. Eyes -” maka kita man kog tarung maam.”

I. Ears - “madungan man taka maam.”

J. Mouth - “ murag medyo pait akong baba maam.”

K. Thorax and lungs - “ nag lisod ko ug ginhawa gabi e maam.” .

L. Abdomen - “wala may sakit maam, “

M. Upper extremities - wala may problema.”

N. Bladder - naka ihi naman ko maam , medyo daghan pud .”

A. Present illness

One week prior to admissions , the patient experienced dyspnea , fever

of 38.2 degree centigrade,running nose and colds, she also has a worry about
her intermittent fever , his cough for a week affects her occupation , she was
not able to attend check up because of financial shortage.

B . Medication and allergies

 Drug for hypertension

Amlodipine 5mg daily

Losartan

C. Habits and Exposures \ Lifestyle \ Diet

At age of 17 he exposed and try to drink alcohol , in her 18 years she

started going home late at night from fiestas and birthdays drunk and in
influence of alcohol.in that time she was not able to exposed her self to any
illegal drugs, she also loves to drink soft drinks , after every meal . She couldn’t
stop her self because since college she use to do it . When she was on 19 yrs
old she smoke a lot she could even smoke 2 packs of cigarette she could
spent 80 pesos a day that time . When the time she started a family she forced
her self to stop such vises , but her husband didn’t stop and in present his
husband still smoking a lot ,and even her couldn’t tell to her husband to stop to
minimize it for good .Patient M diet is comprises of food are rice , vegetable ,
dried fish and meats ( pork , fish , chicken , and beef) but according to her .
Patient M was fun of eating pork meat and read meat such us corn beef and
her favorite food is adobo pork and pork penakbet. And after eating she was
also fun of drinking soft drinks ( Pepsi ) .

D. Past illness

Patient M , was admitted last November 28 2018 on KDI ( Kidapawan

Doctors Incorporated ) due to acute hypertension , she stayed on the hospital
for 3 days , and at present she is now maintaining her due medications
( Losartan and Amlodephine ) , and actively compliant.
D. Family History

Patient M has a log cutting business beside on there home , and

a small store in there premises , Patient M is a third 2nd daughter among 3
siblings her 2 children is currently has there own families near them . Her
husband is 53 yrs old working as a log cutter owned by them, her husband is
also a smoker ,drinker and absence of any substance abuse during his
teenage days according to her watcher ( her husband ),Her eldest son is 24
years old a smoker ,he smoke 1-2 packs of “marlboro” if he is in his work
together with his father . her 2nd child is female a graduate of bachelor of
secondary education , she is now teaching at Kidapawan City National High
School, as a volunteer , her daughter don’t have any vises but according to
patient M when she was on 2 yrs old , her daughter admitted because of
asthma , but in present episodes of asthma to her daughter is no longer seen .
 E. Genogram

Legends :
Hypertension
Pneumonia
Cancer
Gastric Ulcer
Male
Female

Grand Parents
Hypertension Cancer Hypertension

Male Deceased Male Female

Deceased Deceased Deceased

Father Mother

Pneumonia Hypertension

Male Female

Deceased Deceased

Patient M Sibling

Siblings Female 57 yrs old Female 38 yrs old

Hypertension CAP -MR

Male 42, yrs old Hypertension

Chapter 3 - Objective Data

Physical examination and General survey.

Received Patient M on bed on comfort ,in sitting position

conscious ,oriented ,rational , and coherent . with an ongoing IVF bottle #3
D5LR (Lactated Ringer's and 5% Dextrose )1000cc level to run in120 gtts
per minute ,patent and well infused @ his left metacarpal with an IV catheter of
gauge 20 . With a vital signs of
Temperature - 38.2c

Pulse - 85 bpm

Respiratory rate - 25 cycles per min

BP- 130 / 90

O2 saturation - 96 %

 Was on good appetite.

 On good hygiene.

 Cardiopulmonary distress noted .

Head

 Head is on symmetrical size.No masses noted upon inspection.No lice

manifestation , no head trauma or injuries noted.Skull and scalp are
equally intact.

Eyes Conjunctiva are pinkish and moist .Pupils are equally round reactive to
light accommodation.Sclera are whitish .Good and clear visual on both
eyes.Pupiliary size of 2-3 mm.Able to move his eyes in all different dimension
upon using the method of cardinal six gazes.

Ears

Minimal amount of cerumen noted upon using light on inspection.Ears are

patent. No masses or abstraction noted .No secretions noted.

Nose
Nares are dry and patent. symmetrical No abnormal distention of tissues
inside .No mucous secretions noted. Cranial nerve 1 ( olfactory) is accurately
functional.

Mouth

Lips are normally dry and buccal mucousa are dry, tooth decays noted.No
inflammation of gums noted. Tongue was reddish. Able to swallow foods
without discomfort.

Neck

CN 5 ( abducens) is functional.No neck vein and jugular vein distention.

Shoulder and upper extremities

Able to shrug her shoulder with resistant.Arms was on good mobilization.Birth

mark noted @ her right arm from the wrist to the middle of the forearm.Was on
good skin turgor .No edema noted.

Thorax and Lungs

On chest breathing with crackle lung sound noted . Rib cage are intact and in
complete set. 12 pairs.

Abdomen

No rashes noted.No straie and scars noted .Borborigmi sound noted upon
auscultation.No abnormal distention noted.No complain of pain upon palpation
and percussion.Resonance sound noted upon percussion.

Back

No lesions and discoloration noted.No bed sores and ulceration

noted .Symmetrically formed.

Lower extremities

Able to walk without assistance.

Chapter 4 Anatomy and Physiology

The cells of the human body require a constant stream of

oxygen to stay alive. The respiratory system provides oxygen to the body’s
cells while removing carbon dioxide, a waste product that can be lethal if
allowed to accumulate. There are 3 major parts of the respiratory system: the
airway, the lungs, and the muscles of respiration. The airway, which includes
the nose, mouth, pharynx, larynx, trachea, bronchi, and bronchioles, carries air
between the lungs and the body’s exterior. The lung sac as the functional units
of the respiratory system by passing oxygen into the body and carbon dioxide
out of the body. Finally, the muscles of respiration, including the diaphragm
and intercostal muscles, work together to act as a pump, pushing air into and
out of the lungs during breathing.
As we breathe, oxygen enters the nose or mouth and passes the sinuses,
which are hollow spaces in the skull. Sinuses help regulate the temperature
and humidity of the air we breathe. The trachea, also called the windpipe,
filters the air that is inhaled, according to the American Lung Association. It
branches into the bronchi, which are two tubes that carry air into each lung.
(Each one is called a bronchus.) The bronchial tubes are lined with tiny hairs
called cilia. Cilia move back and forth, carrying mucus up and out. Mucus, a
sticky fluid, collects dust, germs and other matter that has invaded the lungs.
We expel mucus when we sneeze, cough, spit or swallow.The bronchial tubes
lead to the lobes of the lungs. The right lung has three lobes; the left lung has
two, according to the American Lung Association. The left lung is smaller to
allow room for the heart, according to York university. Lobes are filled with
small, spongy sacs called alveoli, and this is where the exchange of oxygen
and carbon dioxide occurs. The alveolar walls are extremely thin (about 0.2
micrometers). These walls are composed of a single layer of tissues called
epithelial cells and tiny blood vessels called pulmonary capillaries.Blood
passes through the capillaries. The pulmonary artery carries blood containing
carbon dioxide to the air sacs, where the gas moves from the blood to the air.
Oxygenated blood goes to the heart through the pulmonary vein, and the heart
pumps it throughout the body.

The diaphragm, a dome-shaped muscle at the bottom of the lungs, controls

breathing and separates the chest cavity from the abdominal cavity, the
American Lung Association noted. When a breath it taken, it flattens out and
pulls forward, making more space for the lungs. During exhalation, the
diaphragm expands and forces air out.