I.

INTRODUCTION Breathing is the greatest pleasure in life. ~Giovanni Papini Breath is sometimes used as a metaphor for life itself because it takes

in the oxygen needed by the body and the carbon dioxide out of the body. It is one of the human persons vital functions to maintain and sustain life. One of the most common illness that disrupts the normal breathing pattern of a person is Pneumonia. Pneumonia is an infection and inflammation of the alveoli in the lungs that is usually caused by infection with bacteria, viruses, fungi or other organisms. Pneumonia is a particular concern for older adults and people with chronic illnesses or impaired immune systems, but it can also strike young, healthy people. Pneumonia may be of bacterial in origin (pneumococcal, streptococcal, staphylococcal, or chlamydial) or viral in origin, such as respiratory synctial virus (RSV). (http://mayoclinic.com; August 27, 2008; 6:45pm ) Worldwide, Pneumonia is the 7th leading cause of death in 1999 and 2000 according to CDC. In the United States, the incidence extrapolations of pneumonia is 4,800,000 per year, 400,000 per month, 92,307 per week, 13,150 per day, 547 per hour, 9 per minute, 0 per second. In the Philippines, Pneumonia is the 5th cause of mortality according to the 2003 Philippine Health Statistics with a rate of 15,831 for males and 16, 224 for females or 32, 055 per 100, 000 population. ( http://doh.gov.ph; August 28, 2008; 8:30pm) A study suggests that antipsychotic drugs increase the risks of developing pneumonia in the elderly. Elderly patients who use antipsychotic drugs have a 60 percent increased risk of developing pneumonia compared to non-users. This risk is highest in the first week following prescription and decreases gradually thereafter. Antipsychotic drugs are frequently used in elderly patients for the treatment of psychosis and behavioral problems

associated with dementia and delirium. This study is the first to show that the development of pneumonia is associated with antipsychotic drug use. (www.sciencedaily.com; Apr. 16, 2008) Researchers at Children's Hospital of Pittsburgh of UPMC have identified a key protein target that may be a crucial factor in the development of a vaccine to prevent and new therapies to treat pneumonia, the leading killer of children worldwide. Identified for the first time is the importance of a protein known as interleukin 22 (IL-22) in the immune response to a strain of bacterial pneumonia. In the laboratory, the researchers were able to effectively treat mice with pneumonia by using purified IL-22. IL-22 and interleukin 17A (IL-17A) are produced by a recently discovered lineage of cells known as T Helper Type 17 (Th17). Children's researchers found evidence that the Th17 cell lineage and its cytokines IL-22 and IL-17A have evolved to promote host defense against certain infections in the lung caused by extracellular pathogens. (www.sciencedaily.com; February 12, 2008) Much of the learning of student nurses is derived from the exposure in the hospital setting. Reinforcement in the actual setting is important for learning to be truly effective. As student nurses, it is important that the care provided bring satisfaction to patients. To be able to provide outmost care, knowledge about the disease condition must be well founded. It is one of the objectives of the group to be familiar with the common disease conditions that may be encountered in the hospital setting. Knowing that Pneumonia is one of the common cases evident in the area, which is Medical Surgical, the group decided to make this as their topic for case study.

II. NURSING ASSESSMENT A. Personal History To secure confidentiality, the patient would be referred as Monia throughout the study. Monia is the primary source of information. Monia is a 31 year old married Filipina who lives in a barrio in San Vicente, Magalang Pampanga. She was born on August 2, 1974. She is the 2 nd among five siblings. Monia was admitted on August 12, 2008 at 12:05 pm in a district hospital in Magalang with complaints of fever, chills and cough. The admitting diagnosis is Community Acquired Pneumonia and was discharged on August 16, 2008 with a final diagnosis of CAP. Monia lives in a barrio which has limited accessibility to the hospital. She and her family earn a living by planting different plant crops like camote. Her activities of daily living include cooking, cleaning the house, doing the laundry, taking good care of her five children and helping her husband in planting and selling crops. Monia was not able to finish her schooling due to the location of their place. She was only able to reach grade six because the school in their barrio only offers elementary schooling and her family cannot send her to high school due to financial constraints. Monia and her family are devoted Missionaries. At present, they live in a house which has concrete walls, sawali for the roof and a flooring which is still not cemented. She describes her community as a peaceful one and her neighbors are hospitable. One of the cultural practices done in their community is the practice of using herbal plants like bayabas, bawang, ginger and ampalaya for medicines.

B. Pertinent Family Health-Illness History Paternal Side Maternal Side

Lolo 89 y/o

Lola 85y/o

Lolo Ulcer 1996

Lola Stroke 2002

S1

S2

S3

Pap a
67 y/o

S5

S6

S7

S8

S1

S2

S3

Mama 62y/o

S5

S6

S7

S8

MONIA 34y/o CAP

LEGEND: Male

Female

Deceased Sibling

Explanation: The illnesses present in the in the family tree of Monia are ulcer, which was the cause of death of her grandfather, and stroke, which caused the death of her grandmother last 2002 both on the mother side. On her paternal side, Monia stated that her grandparents are still living and has no known illness. Monia has no history of pneumonia on both maternal and paternal sides.

C. History of Past Illness When Monia was 3 years old, she had tigdas or measles which her mother treated with some herbal plants. She also had chickenpox when she was 25 years old. Monia did not experience any major illness in the past and was never hospitalized before. She only experienced cough, colds and fever occasionally especially during cold weather. During these situations, she only self-medicates and uses herbal plants like oregano and takes drugs like Biogesic and Neozep. D. History of Present Illness On July 29, 2008, Monia is supposed to go with her husband to sell their root crops but her body malaise prevented her from doing so. The following day, she experienced fever, which subsides after sweating. Her fever had became recurrent and caused her to have difficulty sleeping at night. She also lost her appetite, which led to lost of weight of 6.6 pounds (from 125.4 lbs to 118.8 lbs). She also had cough, which she said gave her the difficulty of breathing. She felt that there is mucus in her throat but she cannot cough it out. Her condition prevented her from doing her usual chores of helping in the planting and selling of their root crops and taking good care of her five children. At first, Monia thought that it is just a usual fever which she got possibly because of the prevalence of fever and cough in their barrio. But after two weeks of having fever, she decided to ask her husband to bring her to the district hospital which she had not thought before because of the

distance of their house to the said medical institution and also because of financial constraints. While on their way to the hospital, her husband had to carry her because she cannot walk properly due to body malaise and high fever. So on August 12, 2008, Monia was admitted with an admitting diagnosis of Community Acquired Pneumonia and was discharged after 5 days on August 16, 2008 with a final diagnosis of Pneumonia.

E. Physical Examination 2 weeks prior to admission (+) fever 1 week prior to admission (+) cough, productive 2 days prior to admission fever on and off low appetite (+) body weakness few hours prior to admission (+) chills and fever

Date: August 12, 2006 (Admission) Lifted from the Chart pink palpebral conjunctiva anecteric sclerae adynamic pericardium (-) murmurs flabby abdomen (+) chills and fever with temperature of 40.50C/axilla (+) body weakness (+) cough, nonproductive First Student Nurse-Patient Interaction (August 12, 2008) General Survey: Received patient wearing a white colored shirt and blue jogging pants, in high fowlers position, awake and conscious,; with an IVF of #1 D5NM 1L regulated at 30 to 31 gtts/min. at 550 cc level infusing well on the right hand.

Signs and symptoms include (+) nonproductive cough, (+) difficulty of breathing, febrile. Vital Signs: Temperature 37.80C/axilla Pulse rate 86 bpm Respiratory rate 34bpm Blood pressure 110/70 mmHg Skin:

Brown in color, no altered pigmentation, no edema or swelling upon palpation.

Head:

Hair and Scalp: Black in color, slightly thick, silky and

resilient and hair equally distributed on scalp area, No infestation or infection noted.

Skull: Rounded, smooth skull contour and no masses or nodules noted. Face: symmetrical facial feature and symmetric facial movements.

Eyes: Eyebrows and eyelashes evenly distributed; eyelids have no discharge, no discoloration and lids close symmetrically. Palpebral conjunctiva is pink in color.

Vision: (+)PERRLA

Client

can

see

objects

in

the

periphery.

Illuminated pupil constricts while non-illuminated dilates.

Ear: Color of the auricles same as the facial skin. Symmetrical and aligned with outer canthus of eye, mobile, firm and not tender, pinna recoils after it is folded.

Nose: Centrally located, uniform in color, no discharges noted, not tender, no lesions and air moves with slight difficulty as the client breaths through the nares because of presence of nasal secretions.

Mouth: (+) Mild drying of lips and oral mucosa

Neck:

Head is centered, head movement is coordinated with no discomfort. No swelling and masses noted and no enlargement of lymph nodes upon palpation.

Thorax:

No tenderness and masses on the chest skin, skin intact and uniform temperature. (+) Fast shallow breathing.

Lungs:

(+) Rales heard upon auscultation. Normal rhythm and rate noted upon auscultation, no murmurs. Flabby, no pain when palpated. Intact nail beds, good capillary refill, no deformities, no tenderness or swelling,

Heart:

Abdomen:

Upper Extremities:

Lower Extremities:

Intact toenail beds, has upright posture and steady gait, walks unaided and maintains balance.

Second Student Nurse-Patient Interaction (August 13, 2008) General Survey: Received patient wearing yellow colored shirt and brown shorts, in right side-lying position, sleeping; with an IVF of #3 D5NM 1L regulated at 30 to 31 gtts/min. at 650 cc level infusing well on the right hand. Vital Signs: Temperature 380C/axilla Pulse rate 81 bpm Respiratory rate 26 bpm Blood pressure 120/70 mmHg

Skin:

Brown in color, no altered pigmentation, no edema or swelling upon palpation.

Head:

Hair and Scalp: Black in color, slightly thick, silky and

resilient and hair equally distributed on scalp area, No infestation or infection noted.

Skull: Rounded, smooth skull contour and no masses or nodules noted. Face: symmetrical facial feature and symmetric facial movements.

Eyes: Eyebrows and eyelashes evenly distributed; eyelids have no discharge, no discoloration and lids close symmetrically. Palpebral conjunctiva is pink in color.

Vision: (+)PERRLA

Client

can

see

objects

in

the

periphery.

Illuminated pupil constricts while non-illuminated dilates.

Ear: Color of the auricles same as the facial skin. Symmetrical and aligned with outer canthus of eye, mobile, firm and not tender, pinna recoils after it is folded.

Nose: Centrally located, uniform in color, no discharges noted, not tender, no lesions and air moves with slight difficulty as the client breaths through the nares because of presence of nasal secretions.

Mouth: (+) Mild drying of lips and oral mucosa

Neck:

Head is centered, head movement is coordinated with no discomfort. No swelling and masses noted and no enlargement of lymph nodes upon palpation.

Thorax:

No tenderness and masses on the chest skin, skin intact and uniform temperature. (+) Fast shallow breathing.

Lungs:

(+) Rales heard upon auscultation. Normal rhythm and rate noted upon auscultation, no murmurs. Flabby, no pain when palpated. Intact nail beds, good capillary refill, no deformities, no tenderness or swelling,

Heart:

Abdomen:

Upper Extremities:

Lower Extremities:

Intact toenail beds, has upright posture and steady gait, walks unaided and maintains balance.

10

F. Diagnostic and Laboratory Procedures Diagnostic/ Date Ordered Indications Laboratory Date Results Or Procedures In Purposes Hemoglobin Date Ordered: To evaluate the 08/12/08 hemoglobin Date Results In: content, the iron 08/12/08 status, and oxygen carrying capacity of the blood.

Results 10.2 mg%

Normal Values Male: 13.5 18 Female: 12-16

Analysis and Interpretation of Results Less than normal. The Oxygen carrying capacity of the blood is inadequate due to the inflammatory reaction that occurs in the alveoli, producing exudates that interfere with the diffusion of oxygen and carbon dioxide. Less than normal. It indicates insufficient blood volume composed of RBCs and an abnormal status of patients hydration due to the excessive sweating experienced by

Hematocrit

Date Ordered: 08/12/08 Date Results In: 08/12/08

This is to measure the percentage of the patients red blood cells in the total volume of blood. It aids in the diagnosis of any abnormal status of patients hydration.

33.0 vol. %

Male: 40-54 Female: 37-47

11

the patient after each onset of fever. WBC Count Date Ordered: 08/12/08 Date Results In: 08/12/08 To determine infection or inflammation and also to determine and evaluate the bodys physiologic capacity to resist and overcome infection To determine the number of platelets in the patient's blood and to assist in the diagnosis of bleeding disorders To determine infection or inflammation To determine viral infection or inflammation 10.750/cu. mm. Adult: 5-10 x 103 There is presence of inflammation or infection due to the invasion of microorganisms in the lungs.

Platelet Count

Date Ordered: 08/12/08 Date Results In: 08/12/08

280/cu. mm.

Adult: 150 - 450

Value is within normal range which could indicate that the patient does not have bleeding disorders. Increase in value can be a result of bodys response to infection. Decreased capability of carrying out the activities of the immune system or there is a decreased ability to produce

Segmenters

Lymphocytes

Date Ordered: 08/12/08 Date Results In: 08/12/08 Date Ordered: 08/12/08 Date Results In: 08/12/08

87%

50-70

13%

25-40

12

antibodies. Nursing Responsibilities: Before 1. Explain the procedure to the SO and the purpose of the procedure. 2. Inform the SO that there is no food/fluid restriction needed. 3. Inform the SO that the test requires blood sample, tell who will do the test and when. 4. Inform that there will be a discomfort from needle puncture and pressure from the tourniquet. During: 1. Support the patients arm upon insertion of the needle. 2. Be sure the patient remains still upon insertion of needle. After: 1. Apply pressure to the punctured site. 2. Observe the venipuncture site for bleeding. 3. Explain that some bruising, discomfort, and or swelling maybe experienced at the site. Instruct to apply warm, moist compress. 4. Send the specimen to the laboratory.

Diagnostic/

Date Ordered

Indications

Results

Normal

Analysis and

13

Laboratory Procedures Chest X-Ray

Date Results In Date Ordered: 08/12/08 Date Results In: 08/12/08

Or Purposes This is done to obtain or detect pulmonary diseases and the status of respiratory problems or trauma There are hazy infiltrates in the Right lower lung zone. The heart is normal in size and configuration. Diaphragms, costophrenic angles & visualized bones are intact. Impression: Pneumonitis, Right Lower Lung

Values Clear lung fields

Interpretation of Results With continuous formation of exudates, the involved lobe undergoes Consolidation of the tissue caused by filling w/ exudates. In chest x-ray, the lung should appear as black because the lung is not dense and it permits the passage of xrays. But in lungs w/ pneumonia, consolidated parts become dense and

14

appear as white areas on the chest x-ray film. Nursing Responsibilities: Before:

1. Explain the procedure to the patient, its purpose and how it is done. 2. Inform the patient that there are no foods or fluid restriction.
3. Remove all jewelries and metal objects from the area to the image.

4. Ask the patient to remove her clothes and put on a hospital gown. 5. Assist the patient.
During: 1. Ensure the patients safety at all times. 2. Position the patient for specific views needed. 3. Ensure that the patient will remain motionless during the imaging. After: 1. Assist the patient in dismounting from the radiography table and getting dressed.

15

III. ANATOMY AND PHYSIOLOGY

ANATOMY 1. The SINUSES (frontal, maxillary, and sphenoidal) are hollow spaces in the bones of the head. Small openings connect them to the nose. The functions they serve include helping to regulate the temperature and humidity of air breathed in, as well as to lighten the bone structure of the head and to give resonance to the voice. 2. The NOSE (nasal cavity) is the preferred entrance for outside air into the respiratory system. The hairs that line the wall are part of the air-cleaning system. 3. Air al so enter through the MOUTH (oral cavity), especially in people who have a mouth-breathing habit or whose nasal passages may be temporarily obstructed, as by a cold or during heavy exercise.

16

4. The ADENOIDS are lymph tissue at the top of the throat. When they enlarge and interfere with breathing, they may be removed. The lymph system, consisting of nodes (knots of cells) and connecting vessels, carries fluid throughout the body. This system helps to resist body infection by filtering out foreign matter, including germs, and producing cells (lymphocytes) to fight them. 5. The TONSILS are lymph nodes in the wall of the throat (pharynx) that often become infected. They are part of the germ-fighting system of the body. 6. The THROAT (pharynx) collects incoming air from the nose and mouth and passes it downward to the windpipe (trachea). 7. The EPIGLOTTIS is a flap of tissue that guards the entrance to the windpipe (trachea), closing when anything is swallowed that should go into the esophagus and stomach. 8. The VOICE BOX (larynx) contains the vocal chords. It is the place where moving air being breathed in and out creates voice sounds. 9. The ESOPHAGUS is the passage leading from the mouth and throat to the stomach. 10. The WINDPIPE (trachea) is the passage leading from the throat (pharynx) to the lungs. 11. The LYMPH NODES of the lungs are found against the walls of the bronchial tubes and windpipe. 12. The RIBS are bones supporting and protecting the chest cavity. They move to a limited degree, helping the lungs to expand and contract.

17

13. The windpipe divides into the two main BRONCHIAL TUBES, one for each lung, which subdivide into each lobe of the lungs. These, in turn, subdivide further. 14. The right lung is divided into three LOBES, or sections. Each lobe is like a balloon filled with sponge-like tissue. Air moves in and out through one opening -- a branch of the bronchial tube. 15. The left lung is divided into two LOBES. 16. The PLEURA are the two membranes, actually one continuous one folded on itself, that surround each lobe of the lungs and separate the lungs from the chest wall. 17. The bronchial tubes are lines with CILIA (like very small hairs) that have a wave-like motion. This motion carried MUCUS (sticky phlegm or liquid) upward and out into the throat, where it is either coughed up or swallowed. The mucus catches and holds much of the dust, germs, and other unwanted matte that has invaded the lungs. You get rid of this matter when you cough, sneeze, clear your throat or swallow. 18. The DIAPHRAGM is the strong wall of muscle that separates the chest cavity from the abdominal cavity. By moving downward, it creates suction in the chest to draw in air and expand the lungs. 19. The smallest subdivisions of the bronchial tubes are called BRONCHIOLES, at the end of which are the air sacs or alveoli (plural of alveolus). 20. The ALVEOLI are the very small air sacs that are the destination of air breathed in. The CAPILLARIES are blood vessels that are imbedded in the walls of the alveoli. Blood passes through the capillaries, brought to them by the PULMONARY ARTERY and taken away by the PULMONARY VEIN.

18

While in the capillaries the blood gives off carbon dioxide through the capillary wall into the alveoli and takes up oxygen from the air in the alveoli.

Physiology The exchange of gases (O2 & CO2) between the alveoli & the blood occurs by simple diffusion: O2 diffusing from the alveoli into the blood & CO2 from the blood into the alveoli. Diffusion requires a concentration gradient. So, the concentration (or pressure) of O2 in the alveoli must be kept at a higher level than in the blood & the concentration (or pressure) of CO2 in the alveoli must be kept at a lower lever than in the blood. We do this, of course, by breathing - continuously bringing fresh air (with lots of O2 & little CO2) into the lungs & the alveoli. Breathing is an active process - requiring the contraction of skeletal muscles. The primary muscles of respiration include the external intercostal muscles (located between the ribs) and the diaphragm (a sheet of muscle located between the thoracic & abdominal cavities).

19

The external intercostals plus the diaphragm contract to bring about inspiration:

Contraction of external intercostal muscles > elevation of ribs & sternum > increased front- to-back dimension of thoracic cavity > lowers air pressure in lungs > air moves into lungs

Contraction of diaphragm > diaphragm moves downward > increases vertical dimension of thoracic cavity > lowers air pressure in lungs > air moves into lungs:

To exhale:

relaxation of external intercostal muscles & diaphragm > return of diaphragm, ribs, & sternum to resting position > restores thoracic cavity to preinspiratory volume > increases pressure in lungs > air is exhaled

Intra-alveolar pressure during inspiration & expiration As the external intercostals & diaphragm contract, the lungs expand. The expansion of the lungs causes the pressure in the lungs (and alveoli) to become slightly negative relative to atmospheric pressure. As a result, air moves from an area of higher pressure (the air) to an area of lower pressure (our lungs & alveoli). During expiration, the respiration muscles relax & lung volume descreases. This causes pressure in the lungs (and alveoli) to become slight positive relative to atmospheric pressure. As a result, air leaves the lungs. The walls of alveoli are coated with a thin film of water & this creates a potential problem. Water molecules, including those on the alveolar walls, are more attracted to each other than to air, and this attraction creates a force called surface tension. This surface tension increases as water molecules come closer together, which is what happens when we exhale & our alveoli become smaller (like air leaving a balloon). Potentially, surface

20

tension could cause alveoli to collapse and, in addition, would make it more difficult to 're-expand' the alveoli (when you inhaled). Both of these would represent serious problems: if alveoli collapsed they'd contain no air & no oxygen to diffuse into the blood &, if 're-expansion' was more difficult, inhalation would be very, very difficult if not impossible. Fortunately, our alveoli do not collapse & inhalation is relatively easy because the lungs produce a substance called surfactant that reduces surface tension. Pulmonary Surfactant

Surfactant decreases surface tension which:

o

increases pulmonary compliance (reducing the effort needed to expand the lungs) reduces tendency for alveoli to collapse

Exchange of gases:

External respiration:
o

exchange of O2 & CO2 between external environment & the cells of the body efficient because alveoli and capillaries have very thin walls & are very abundant (your lungs have about 300 million alveoli with a total surface area of about 75 square meters)

Internal respiration - intracellular use of O2 to make ATP occurs by simple diffusion along partial pressure gradients

Partial Pressure

it's the individual pressure exerted independently by a particular gas within a mixture of gasses. The air we breath is a mixture of gasses: primarily nitrogen, oxygen, & carbon dioxide. So, the air you blow into a balloon creates pressure that causes the balloon to expand (& this pressure is generated as all the molecules of nitrogen, oxygen, & carbon dioxide move about & collide with the walls of the balloon).

21

However, the total pressure generated by the air is due in part to nitrogen, in part to oxygen, & in part to carbon dioxide. That part of the total pressure generated by oxygen is the 'partial pressure' of oxygen, while that generated by carbon dioxide is the 'partial pressure' of carbon dioxide. A gas's partial pressure, therefore, is a measure of how much of that gas is present (e.g., in the blood or alveoli). Factors involved in increasing respiratory rate

Chemoreceptors - located in aorta & carotid arteries (peripheral chemoreceptors) & in the medulla (central chemoreceptors) Chemoreceptors (stimulated more by increased CO2 levels than by decreased O2 levels) > stimulate Rhythmicity Area > Result = increased rate of respiration

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IV. THE PATIENTS ILLNESS (Book-Based) Synthesis of the Disease Community Acquired Pneumonia 1. Definition of the disease Community-acquired pneumonia (CAP) is a disease in which individuals who have not recently been hospitalized develop an infection of the lungs (Pneumonia). CAP is a common illness and can affect people of all ages. CAP often causes problems like breathing, fever, chest pains and a cough. CAP occurs because the areas of the lung which absorb oxygen (alveoli) from the atmosphere become filled with fluid and cannot work effectively. CAP occurs throughout the world and is a leading cause of illness and death. Causes of CAP include bacteria, viruses, fungi, and parasites. CAP can be diagnosed by symptoms and physical examination alone, though x-rays, examination of the sputum and other tests are often used. Individuals with CAP sometimes require treatment in a hospital. CAP is primarily treated with antibiotic medication. Some forms of CAP can be prevented by vaccination. 2. Non-modifiable and Modifiable Factors Non-modifiable Factors: >Age Pneumonia is more common among infants, young children, and the elderly. With age, mucus accumulates within the respiratory passageways. The mucus-cilia escalator is less able to move the mucus because it becomes more viscous and the number of cilia as well as their rate of movement decreases. This leads to increase susceptibility of the elderly to respiratory infections such as pneumonia. In children, their immune system is not yet well developed making them susceptible in acquiring pneumonia.

23

>Genetic Factors A number of genetic disorders can predispose a person to pneumonia, such as: Sickle cell anemia, cystic fibrosis, and Kartageners syndrome. Modifiable Factors: >Smoking and second-hand smoking People who smoke have a much higher risk of developing pneumonia. Also, those who regularly exposed to second-hand smoking are at risk for pneumonia. In the case of the patient, she is exposed to second hand smoking due to her husband who is a smoker. >Alcohol and Drug Abuse Alcohol and drug abuse makes a person more susceptible to pneumonia. >Crowded Living Conditions The risk of pneumonia is increased among people living in crowded conditions just like the area where the patient is exposed. >Environmental Factors Occupation exposure to toxic chemical fumes and smoke can weaken the lungs defenses making a person susceptible in acquiring pneumonia. Monia is exposed to smoke because of her husband who is a smoker. 3. Signs and Symptoms >Fever and chills An increase in body temperature accompanied by chills is due to the invasion of microorganisms in the lungs that causes inflammation. The body increases its temperature in order to kill the microbes. Monia experienced recurrent fever and chills from July 30, 2008 to August 14, 2008.

>Pleuritic chest pain

24

This is due to the constant irritation of the pleural membrane brought about by inflammation, which stimulates the release of prostaglandin (pain mediator) that acts on the pain receptors that causes pain. >Cough and sputum production There is an increase production of mucus due to the constant inflammation of the epithelial lining of the bronchi and alveoli. Coughing is the bodys mechanism to get rid of microorganisms and excess mucus. The patient experienced cough from July 30, 2008 to August 15, 2008. >Hemoptysis Forceful coughing brought about by constant irritation of the respiratory tract and consolidated alveolar exudates; damage the capillaries in the lungs causing the production of blood-tinge sputum. >Dyspnea Difficulty in breathing is due to inflamed and fluid filled alveolar sacs cannot exchange oxygen and carbon dioxide effectively. The patient experienced dyspnea from July 30, 2008 to August 15, 2008. >Headache Impairment of oxygen and carbon dioxide exchange results in a decrease in oxygenation in the brain that causes headache. >Fatigue Accumulation of lactic acid in tissues and muscles due to poor oxygen perfusion brought about by impaired gas exchange in the lungs. The patient experienced fatigue from July 29, 2008 to August 14, 2008.

4. Prevention and Health Promotion Immunization against influenza and increasingly resistant pneumococci can play a critical role in the prevention of pneumonia, particularly in

25

immunocompromised and older adults. The influenza vaccine is formulated and administered annually. Also, it is recommended that the vaccine be offered to persons aged > 50 years; residents of chronic-care facilities; patients who have chronic heart or lung disorders, and patients with chronic metabolic diseases (including diabetes mellitus), renal dysfunction, hemoglobinopathies, or immunosuppression. Consequently, to prevent the development of pneumonia, one should live a healthy lifestyle. Elimination of smoking habits, alcohol and drug abuse; wearing of PPEs (such as mask) for persons who are exposed in smoke and other chemicals; and adapting a regular exercise regimen are indeed a great help in minimizing the incidence of pneumonia. Stopping smoking is the best way to prevent pneumonia. Some pneumonia can be prevented by vaccination. Oseltamivir or zanamivir can be given to prevent influenza in household contacts of people who have influenza and in people with heart or lung disorders who have not been vaccinated because these people would be at risk of severe pneumonia if they developed influenza. (http://mayoclinic.com/health/pneumonia) (http://www.lungusa.org/site)

26

27

V. THE PATIENT AND HIS CARE A. MEDICAL MANAGEMENT a. IVF Medical Management/ Treatment D5NM 1L x 30 to 31 gtts/min Date Ordered Date Performed Date Changed D.O: 08/12/08 D.P: 08/12/08 D.C: 08/15/08 General Description It is a hypertonic solution and it contains Dextrose 5 gm NaCl 234mg, Potassium Acetate 128mg, Sodium Bisulfate 30mg. Indications Or Purposes Multiple electrolyte maintenance solution for use in routine daily IV therapy. It is given to Monia in amount sufficient to meet her ordinary daily water needs. It is also a route of administration of her IV medicines. Nursing Responsibilities: Before: 1. Verify the doctors order. Clients Response to Treatment Monias hydration status was maintained and there were no signs and symptoms of hypersensitivity.

2. Explain the procedure to the patient.

3. Obtain necessary materials. Acquaint the SO and patient with the requirements needed for IV infusion.

28

During 1. Check IV level. 2. Check for patency of tubing as well as infiltrations. 3. Check if the IVF is infusing well. 4. Practice aseptic technique. After 1. Adjust rate of flow of fluids appropriate to patients needs as prescribed. 2. Monitor IVF flow and patients response. 3. Monitor patient for evidence of local IV complications such as pain, swelling and tenderness. 4. Check for the presence of air in the tubing. 5. Record all procedure done.

b. Drugs Name of Drugs: Date Ordered Date Route of Administration Indications Or Specific Foods taken Clients Response to

29

Generic Name Brand Name Generic Name: Cefuroxime Brand Name: Ceftin

Performed Date Changed Date Ordered: August 12, 2008 Dates Taken: August 12-14, 2008

, Dosage and Frequency of Administration 200 mg IV q 12 hours

Purposes

the Meds with Actual Side Effects The patient did not show any allergic reactions. After taking the drug for 3 days, Monia was relieved from productive cough which can be a sign that the bacteria that invades the lungs was inhibited.

Cephalosporin antibiotics. - It works by stopping the growth of bacteria which invades the lungs causing pneumonia.

Rice, fish, vegetable, meat, banana, water.

Nursing Responsibilities: Before: 1. Explain the action of the drug to the client

30

2. Check doctors order for the time, dosage and route of the drug. 3. Perform skin testing before administration 4. Obtain specimen for culture and sensitivity test. During: 1. Re-check doctors order 2. Observe sterile technique 3. Slowly push the medication to avoid irritation of the IV line. After: 1. Educate client about the possible side effects 2. Document the action done 3. Observe for signs and symptoms of adverse or allergic reactions

Name of Drugs: Generic Name Brand Name

Date Ordered Date Performed Date Changed

Route of Administration , Dosage and Frequency of

Indications Or Purposes

Specific Foods taken

Clients Response to the Meds with Actual Side

31

Generic Name: Paracetamol IV Acetylcysteine Brand Name: Parvolex, Lysox

Date Ordered: August 12, 2008 Date Taken: August 12, 2008 Date Changed: August 13, 2008 (shifted to tab)

Administration 300 mg IV

Analgesic and Antipyretic. Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or other substances that sensitize pain receptors to stimulation. The drug may relieve fever through central action in the hypothalamic heat regulatory center. Analgesic and Antipyretic. -

This is indicated for mild pain and fever experienced by the patient.

Effects The patient responded positively to the medication. The patients recurrent fever decreased from 40.50C to 37.80C to 37.20C on August 12, 2008.

Generic Name: Paracetamol,

Date Ordered: August 13,

500 mg/tab

This is indicated for mild pain

The patient responded

32

Acetaminophen Brand Name: Tylenol, Tempra

2008 Dates Taken: August 13-14, 2008

Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or other substances that sensitize pain receptors to stimulation. The drug may relieve fever through central action in the hypothalamic heat regulatory center

and fever experienced by the patient.

positively to the medication. The patients recurrent fever decreased from 380C to 37.30C on August 13, 2008 and from 380C to 36.90C on August 14, 2008.

Nursing Responsibilities: Before:

1. Obey the 10 rights of giving medications

33

2. Check the physicians order on the patients chart 3. Identify the patient 4. Warn the patient or SO that high doses or unsupervised long term use can cause liver damage
During:

1. Follow standard precautions during administration of the medication 2. Observe proper sterile technique 3. Administer right dose
After:

1. Check for the presence of adverse reactions such as vomiting, abdominal pain, drowsiness, rash and
urticaria

2. Record all procedures done and time of drug administration 3. Monitor temperature q 15 minutes after administration

Name of Drugs: Generic Name Brand Name

Date Ordered Date Performed Date Changed

Route of Administration , Dosage and Frequency of Administration

Indications Or Purposes

Specific Foods taken

Clients Response to the Meds with Actual Side Effects

34

Generic Name: Ambroxol Brand Name: Seropram

Date Ordered: August 12, 2008 Date Taken: August 12-15, 2008

30 mg/tab

A mucolytic agent. - Which has antioxidant properties and stimulates the release of pulmonary surfactant, against influenza-virus proliferation in the airway was investigated in mice.

It is administered for the breakdown of acid mucopolysaccharide fibers and to make the sputum thinner and less viscous and therefore more easily removed by coughing.

Patient responded well to treatment without signs of adverse reactions or complications such as superinfection. After taking the drug for 4 days, the patient was relieved from dyspnea and her respiratory rate decreases from 34bpm upon admission to 26 bpm on August 13 to 24 bpm on August 14 to 21 bpm on August 15 and 19 bpm upon discharge.

35

Nursing Responsibilities: Before:

1. Obey the 10 rights of giving medications 2. Check the physicians order on the patients chart
3. Identify the patient. 4. Make sure that the patient is not pregnant which is one of the contraindications of the drug.

5. Strictly follow aseptic technique in preparation of IV medication

During

1. Caution to patient that the drug could cause gastric ulceration. 2. Observe proper sterile technique.
After:

1. Check for the presence of adverse reaction such as nausea and vomiting and mild gastric irritation. 2. Record all procedures done and time of drug administration.
c. Diet Date Ordered Type of diet Date Performed Date Change D.O: 08/12/08 D.P: 08/12/08 General Description Regular diet based of the 4 basic food groups as long Indications or Purposes For patients whose condition does not necessitate a Specific food taken Fish, meat, bread, fruits, vegetables, and water. Clients Response and or Reaction to the Diet The patient was able tolerate the diet as the patient did not

DAT

36

as the patient can tolerate it.

modified diet

developed any allergies. There is a boost in the patients energy level and nourishment is increased as evidenced by patients ability to perform her self-care needs and absence of body malaise and fatigue upon discharge.

Nursing Responsibilities: Before: 1. Explain the diet or type of diet to patient 2. Feed patient in upright-position to prevent aspiration. 3. Give small frequent feeding. 4. Instruct strict compliance on the diet program given.

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d. Activity/Exercise Date Ordered Type of Exercise Bed Rest Date Performed Date Change Date Ordered: 08/12/08 General Description A type of activity wherein the patient is in supine position with his body lying flat on bed with the head raised using Indications or Purposes This is indicated to reduce the patients oxygen demand, to facilitate fast recovery and avoid complications. Rest Clients Response and or Reaction to the Exercise The patient was able to take adequate amount of rest and sleep as evidenced by absence of body malaise, fatigue and

38

pillows as support to the head.

decreases the bodys metabolic rate.

normalization of respiratory rate from 34bpm upon admission to 26 bpm on August 13 to 24 bpm on August 14 to 21 bpm on August 15 and 19 bpm upon discharge.

Nursing Responsibilities: 1. Check for the doctors order 2. Explain to the SO the type of activity needed by the patient and why it is necessary 3. Ensure safety precautions by instructing SO not to leave patient alone at the bed since side rails are not present or by putting pillows at the side of the patient to prevent the patient from falling 4. Stretch bed linens 5. Assist the patient in position changes to prevent bed sore formation

Date Ordered Type of Exercise Deep Breathing Exercise Date Performed Date Change Date Ordered: 08/12/08

General Description Designed to improve the

Indications or Purposes To promote oxygenation and

Clients Response and or Reaction to the Exercise Monia was able to demonstrate Deep

39

efficiency of ventilation, decrease the work of breathing, increase of excursion of the diaphragm, and improve the gas exchange and oxygenation

prevent respiratory complications.

Breathing Exercise/DBE and had relief of her difficulty of breathing as evidenced by normalization of respiratory rate of 34bpm upon admission to 26 bpm on August 13 to 24 bpm on August 14 to 21 bpm on August 15 and 19 bpm upon discharge

Nursing Responsibilities: 1. Explain the reason and rationale and aims of bed rest. 2. For DBE, have the patient assume a comfortable position and looses constrictive clothing. 3. Instruct the patient to place hands below the anterior costal margin and ask the patient to breathe slowly and deep through the nose. Have patient keep shoulder related and upper chest quite allowing the abdomen to rise. Tell patient to practice this three to four times for her to rest.

40

41

2. NURSING MANAGEMENT 1. Nursing Care Plan Problem # 1: Ineffective Airway Clearance r/t Retained Secretions AEB Ineffective or Absent Sputum Assessment Nursing Diagnosis Subjective Cues > Objective Cues Patient manifested: > pursed lip breathing > increased respiratory rate (34 bpm on August 12, 2008) >nonproductive Ineffective Airway Clearance r/t Retained Secretions AEB Ineffective or Absent Sputum Scientific Explanation Pneumonia is an inflammation of the lung parenchyma caused by various microorganisms including bacteria and viruses. It affects both ventilation and diffusion. Areas of the lungs are not adequately ventilated because of Long Term: > After 1 to 3 days of NI, patient will Short Term: > After 4 hours of NI, patient will demonstrate behaviors to improve airway such as deep breathing and coughing Planning Nursing Intervention s 1. establish rapport 2. monitor vital signs 3. elevate head of bed and change position every 2 hours. 4. encourage deep breathing and coughing exercises. 5.provided TSB 1. to gain cooperation 2. to obtain baseline data 3. to enhance drainage and ventilation to different lung segments. 4. to maximize respiratory effort. Long Term: > patient shall have demonstrated absence of congestion Rationale Expected Outcome Short Term: > patient shall have demonstrated behaviors to improve airway such as deep breathing and coughing

42

cough > rales heard upon auscultation > irritability > restlessness >hyperthermi a (380C/axilla on August 12, 2008) Patient may manifest: > difficulty of breathing > altered chest excursion > use of accessory muscles to breathe > nasal flaring

secretions. If a patient is unable to clear secretions from the respiratory tract, ineffective airway clearance occurs. The signs and symptoms include (+) DOB due to the presence of secretions, nonproductive cough which indicates retained secretions, high RR which indicates the mechanism of the body to gain oxygen and fever which occurs

demonstrate absence of congestion with breath sounds clear and improved oxygen exchange.

6. encourage increase fluid intake 7. encourage warm versus cold liquids 8. demonstrate pursed lip and diaphragmatic breathing 9. encourage opportunities for rest 10. regulate IVF as ordered

5. to lessen fever. 6. to help liquefy secretions 7. to help liquefy secretions 8. to improve airway

with breath sounds clear and improved oxygen exchange.

9. to prevent or lessen fatigue 10. to keep

11. administer meds as ordered.

the patient properly hydrated 11. to comply with the

43

> pale conjuctiva and mucous membranes > cyanosis

because of the presence of microbes in the body. It acts as the bodys defense mechanism.

therapeutic regimen.

44

Problem # 2: Ineffective Breathing Pattern r/t Presence of secretions secondary to Pneumonia Assessme nt Subjective Cues > Objective Cues Patient manifested : > pursed lip breathing > increased respiratory rate (34 bpm on August 12, 2008) >nonproductive Nursing Diagnosis Ineffective Breathing Pattern r/t Presence of secretions secondary to Pneumonia Scientific Explanation Inspiration and/or expiration that do not provide adequate ventilation are termed as having an ineffective breathing pattern. In patients with pneumonia, inflamed and fluid-filled alveolar sacs cannot exchange oxygen and carbon-dioxide effectively. Air Long Term: >After 5 days of NPI, patient will display improved condition as 5. Perform (CPT) Chest Physiotherap 4. To prevent exacerbation of 4. Keep back dry Short Term: >After 2 hours of NPI, the patient will manifest improved breathing pattern thru proper positioning of the patient 3. Position patient on high back rest or elevate Head of Bed. 3. To facilitate proper breathing pattern and promote physiologic ease of maximal inspiration Long Term: >Patient shall have displayed improved condition as evidence by diminished 2. Monitor vital signs 2. Provides comparative baseline Planning Nursing Intervention s 1. Assess patients condition 1. To determine proper plan of action and interventions to provide Rationale Expected Outcome Short Term: >Patient shall have manifested improved breathing pattern thru proper positioning of the patient

45

cough Patient may manifest: > difficulty of breathing > altered chest excursion > use of accessory muscles to breathe > nasal flaring > pale conjuctiva and mucous membranes

filled lungs are being covered with mucus secretions causing the air flow to be blocked, therefore difficulty of breathing may appear and to compensate, the patient will exert effort to breath rapidly causing more carbon dioxide to be inhaled than oxygen leading cyanotic manifestations.

evidence by diminished rales on Lung fields upon auscultation and improved respirations.

y 6. Encourage increase fluid intake

cough 5. To mobilize secretions 6. To facilitate

rales on Lung fields upon auscultation and improved respirations.

7. Encourage adequate rest periods between activities 8. Assist client to learn breathing exercises 9. Administer medications as ordered

hydration 7. To limit fatigue which would increase oxygen demand 8. To facilitate effective breathing pattern 9. For pharmacological management

46

Problem # 3: Hyperthermia Assessme nt Subjective Cues > Objective Cues Patient manifested : > pursed lip breathing > increased respiratory rate (34 bpm on August 12, 2008) Nursing Diagnosis Hyperthermi a Scientific Explanation Pyrogens are released in the inflammation process. Pyrogens are chemicals that stimulate fever production. Pyrogens affect the body temperatureregulating mechanism in the hypothalamus of the brain. As a consequence, heat Long Term: >After 5 days of NPI, patient will be free from development of possible complication 4. Explain diet modifications such as: increase protein, carbohydrates and vitamin C, small frequent 4. To promote adequate nutritional Planning Short Term: >After 3-4 hours of NPI, patient will be able to maintain body temperature within normal range 3. Ascertain understanding of individual nutritional needs 3. To determine what information to provide to SO Long Term: Patient shall have been free from development of possible complication s 2. Provides comparative baseline 2. Monitor vital signs Nursing Interventions 1. Establish rapport Rationale 1. To gain patients confidence and cooperation in treatment regimen Expected Outcome Short Term: Patient shall have been able to maintain body temperature within normal range

47

>nonproductive cough Patient may manifest: > difficulty of breathing > altered chest excursion > use of accessory muscles to breathe > nasal flaring > pale conjuctiva and mucous membrane s

production and conservation increase, and body temperature increases. Fever promotes the activities of the immune system, such as phagocytosis, and inhibits the growth of some microorganism s. In the presence of infection, fever is concomitant especially when it has become systemic.

feedings, avoidance of solid foods that may lead to indigestion 5. Promote pleasant/relaxin g environment, including socialization when possible 6. Note presence and absence of sweating as body attempts to increase heat loss by evaporation, conduction and diffusion

intake 5. To promote rest which decreases the metabolic demand 6. Evaporation is decreased by environmental factors of humidity and high ambient temperature as well as body factors 7. To lower body temperature 8. To facilitate hydration status

48

7. Promote surface cooling by tepid sponge baths 8. Discuss importance of adequate fluid intake 9. Administer medications as ordered

9. For pharmacological management

49

Problem # 4: Risk for infection r/t to inadequate primary and secondary defenses Assessme nt S> O O> Pt. manifeste d: >hyperthe rmia >nonproductive cough >dyspnea Nursing Diagnosis Risk for infection r/t to inadequate primary and secondary defenses. Scientific Explanation Pneumonia involves the inflammation of the lung parenchyma which eventually leads to decreased cilliary action and may further lead to stasis of respiratory Patient may manifest: secretions the client is at risk for spread of Long Term: After 3 days of NI the patient will achieve timely >provide for isolation as Objectives Short Term: After 4-6 of NI the patient will be able to prevent/ reduce risks of spread of infection. >encourage proper hand washing techniques by all caregivers between therapies/ clients > reduces risk of cross contamination Long Term: After 3 days of NI, patient shall have achieved timely >monitor and recorded V/S > a first line defense against nosocomial infections >serve as baseline data Nursing Interventions >establish rapport Rationale >for patient cooperation Expected Outcomes Short Term: After 4-6 of NI, patient shall have prevented/ reduced risks of spread of infection.

50

> irritability > restlessne ss

infection since the continuous production of mucous secretions is a perfect breeding place for microorganism. The secondary defense mechanism of the immune system is also inadequate since the client is suffering from a deceased hemoglobin level.

Resolution of current infection.

indicated >change position every 2 hours

> to facilitate secretion movement and drainage >to help boost

resolution of current infection without complications .

>encourage intake of foods rich in Vit. C such as oranges.

the immune system

>To liquefy >encourage increase of fluid intake >To comply >administer/mon itor medication regimen with the therapeutic regimen secretion and to avoid stasis

51

Problem #5: Deficient diversional activity r/t long term hospitalization AEB clients statement of boredom & inability to perform ADL Assessment S> maynip na ku O> pt. manifest: Weakness Irritability Decrease performan ce Restlessne ss Boredom With VS as follow: T- 37 OC P- 83 bpm R- 21 bpm B.P- 110/70 Nursing Diagnosis Deficient diversional activity r/t long term hospitalizatio statement of boredom & inability to perform ADL Scientific Explanation Prolong hospitalizatio n may cause boredom especially for is use to doing chores or ADLs. Any life change that requires numerous readjustments can be perceived as stressful. The emotions & physiological arousal Long Term: After 3 days of NI, pt. will recognize own psychologica Note impact of illness on life style by comparing with precious/norma Planning Short Term: After 4 hr. of N.I, pt. will engage in satisfying activities within personal limitations such as chatting with SO Provide am and pm care To validate reality of environment al deprivation Long Term: After 3 days of NI, pt. shall have recognized Acknowledge reality of the situation & feelings of pt. To provide comfort Monitor and record VS To establish therapeutic relationship Nursing Interventions Establish rapport To have baseline data Rationale To gain trust Expected Outcome Short Term: After 4 hr. of N.I, pt. shall have engaged in satisfying activities within personal limitations such as chatting with SO

n AEB clients a person who

52

mmHg Pt. may manifest: Hostility Withdrawa l Crying Flat affect Lack of interest in eating

created by stressful situation are highly uncomfortabl e& discomfort motivates the individuals to do something to alleviate it.

l response & initiate appropriate coping actions

l activity level Encourage diversional activity like talking to SO and reading newspaper Encourage the SO to be with the pt. within the whole process of the situation Encourage the SO to provide the pt. adequate rest periods

To lessen boredom

own psychological response & initiate appropriate

To provide comfort and to ensure that the pt. is not alone

coping actions

To prevent fatigue and for the pt. to gain maximum strength

53

2. Actual SOAPIEs August 12, 2008 S> maskup ku salu O> Received patient on high fowlers position with an IVF of #1 D5NM 1L regulated at 30 to 31 gtts/min at 550cc level; signs and symptoms include: (+)DOB, (+)nonproductive cough; with vital signs taken and recorded as follows: T- 37.80C/axilla, PR- 86 bpm, RR 34 bpm, BP 110/70mmHg A>Ineffective Airway Clearance related to Retained Secretions AEB Ineffective or Absent Sputum. P> After 4 hours of NI, patient will demonstrate behaviors to improve airway such as deep breathing and coughing. I> establish rapport >monitor vital signs >elevate head of bed and change position every 2 hours. >encourage deep breathing and coughing exercises. >provided TSB >encourage increase fluid intake > encourage warm versus cold liquids >demonstrate pursed lip and diaphragmatic breathing >encourage opportunities for rest > regulate IVF as ordered >administer meds as ordered E> Goal met AEB patients ability to demonstrate behaviors to improve airway such as deep breathing and coughing.

August 13, 2008 S>

54

O>Received patient in right side-lying position, sleeping; with an IVF of #3 D5NM 1L regulated at 30 to 31 gtts/min at 650cc level; infusing well on the right hand; with Hemoglobin of 10.2mg%; hematocrit 33.0 vol%, segmenters 87%, lymphocytes 13% as of 08/12/08; with vital signs taken and recorded as follows: T - 380C/axilla, PR- 81 bpm, RR 19 bpm, BP 120/70mmHg. A> Risk for Infection related to Inadequate Secondary Defenses (decresed Hgb, Hct and Lymphocytes level) P> After 2hours of NI, patient will identify interventions to prevent or reduce risk for infection. I> established rapport >monitored and recorded vital signs >encouraged deep breathing exercises >maintained adequate hydration >emphasized necessity of taking medications (antibiotic) >encouraged increase intake of Vitamin C rich foods >encouraged increase fluid intake >provided adequate rest periods >due meds given >needs attended >referred accordingly E> Goal met AEB patients ability to identify interventions to prevent or reduce risk for infection.

VI. CLIENTS DAILY PROGRESS IN THE HOSPITAL 1. Clients Daily Progress Chart Days Admission August 13 August 14 August 15 Discharge August 16 August 12 Nursing Problems Ineffective

55

Airway Clearance r/t Retained Secretions AEB Ineffective or Absent Sputum Ineffective Breathing Pattern r/t Presence of secretions secondary to Pneumonia Hyperthermia Deficient diversional activity r/t long term hospitalization AEB clients statement of boredom & inability to perform ADL Risk for infection r/t to inadequate primary and secondary defenses.

56

Vital Signs Temperature Pulse Rate Respiratory Rate Blood Pressure Diagnostic and Labora tory Proced ures Hemoglobin Male: 13.5 18 Female: 12-16

40.50 C

37.80

380C 81bpm 26bpm 120/70mmH g

380C 83bpm 24bpm 110/70mmH g

36.80C 90bpm 21bpm 110/80mmH g

36.90C 81bpm 19bpm 120/70mmH g

C 88bpm 34bpm

110/70mmHg

10.2 mg%

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Hematocrit Male: 40-54 Female: 37-47 WBC Count Adult: 5-10 x 103 Platelet Count Adult: 150 - 450 Segmenters 50-70% Lymphocytes 25-40% Chest X-Ray Medical Manag ement D5NM 1L x 30 to 31gtts/ min Drugs Ambroxol Paracetamol IV Cefuroxime Paracetamol tab Diet DAT Exercise Bed Rest Deep Breathing

33.0% vol.

10.750/cu. mm. 280/cu. mm. 87% 13%

Shifted

VII. DISCHARGE PLANNING a. General Condition Upon Discharge

58

Patient was not seen upon discharge on August 16, 2008 at 9:00 in the morning. b. METHOD M> E> Encouraged to perform deep breathing and coughing exercises, prevent patient from engaging in strenuous activity or those that may cause fatigue. T> H> Instructed patient to wear loose clothes to prevent excessive sweating > Imposed proper hand washing before and after eating > Instructed patient to do chest tapping and postural drainage to mobilize secretions >Encouraged patient to eat foods rich in Vitamin C >Encouraged patient to increase fluid intake >Encouraged patient to always keep the back dry > Encouraged patient to have adequate rest periods between activities O> Advised patient to come back 1 week after discharge (August 23, 2008) at the OPD Department D> Encouraged patient to eat foods rich in protein such as meats, eggs and beans. > Encouraged patient to Include vitamin C in diet such as orange juice, calamansi and mangoes > Encouraged increase fluid intake

VIII. CONCLUSION Learning is not attained by chance, it must be sought for with ardor and attended to with diligence.

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-Abigail AdamsKnowledge is not achieved by a mere snap of the fingers. There is so much to learn learning that is very much important to be able to accomplish responsibilities and in one way or another, encourage one to be committed in his chosen profession. The pursuit for knowledge is every persons responsibility. As student nurses, well-founded background knowledge is essential so as to be able to render quality care to every patient. With the completion of this case study, the group has learned a lot about Pneumonia, which is a very prevalent disease in Philippines justified by the statistics conducted by different organizations. It is an illness that could be prevented if precautionary measures are practiced. The group also learned that pneumonia can be a complication of other respiratory diseases like tuberculosis. Early detection and prompt management may drastically lessen the severity of the disease condition. There are preventive measures which the group recommends to lessen the occurrence of pneumonia. The primary prevention is being vaccinated with pneumococcal vaccine although this vaccine does not offer absolute protection especially to people with low immunity. Proper hand washing should also be practiced especially before eating and after using the bathroom. A daily diet that includes foods rich in antioxidants, such as freshdark-colored fruits and vegetables and other nutrients help boost a persons immune system. Brisk walking and other aerobic exercises should be practiced to help increase the lung capacity and breathing exercises which is the taking of slow, deep, relaxed breaths and exhalation through pursed lips, may also be helpful. Lastly, a person should avoid smoking. IX. BIBLIOGRAPHY Seeley, Rod, et. Al. Essentials of Anatomy and Physiology, 6th ed. McGraw-Hill Companies, Inc. New York.

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Patton, Kevin T. Anatomy and Physiology, 5th ed. Mosby Inc. St. Louis, Missouri. 2003. Black, Joyce, and Hawk Jane Hokanson (2005) Medical-Surgical Nursing Yuan, Dr. Sara (2004), Hand Book of Diseases 3rd Edition Professional guide to diagnostic tests, Lippincott Williams and Wilkins Nurses quick check diagnostic tests, Lippincott and Wilkins http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=22576 http://people.eku.edu/ritchisong/RITCHISO/301notes6.htm http://www.childbirths.com/cypress/ivtherapy.htm http://search.live.com/results.aspx? q=decreased+hemoglobin+and+hematocrit&FORM=AWRE2 http://www.childbirths.com/cypress/ivtherapy.htm http://search.live.com/results.aspx? q=decreased+hemoglobin+and+hematocrit&FORM=AWRE2 http://www.diagnosis.com/p/pneumonia/prevalence.htm http://doh.gov.ph/data_stat/html/mortality.htm

http://www.sciencedaily.com/releases/2008/02/080213090516.ht http://www.wddty.com/03363800369751974858/alternative-treatments-forpneumonia.html

http://mayoclinic.com/health/pneumonia/DS00135

X. APPENDICES Appendix A

MORTALITY

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Ten Leading Causes of Mortality by Sex Number, Rate/100,000 Population & Percentage Philippines, 2003 Femal e Both Sexes Number Rate Percent* 17.1 13.1 9.9 8.6 8.1 6.8

Cause 1. Heart Diseases 2. Vascular System Diseases 3. Malignant Neoplasm 4. Accidents 5. Pneumonia 6. Tuberculosis, all forms 7. Symptoms, signs and abnormal clinical, laboratory findings, NEC 8. Chronic lower respiratory diseases 9. Diabetes Mellitus 10. Certain conditions originating in the perinatal

Male 38,67 7 29,05 4 20,63 4 27,72 0 15,83 1 18,36 7 10,74 0 12,99

29,019 67,696 83.5 22,814 51,868 64.0 18,664 39,298 48.5 6,246 33,966 41.9 16,224 32,055 39.5 8,404 26,771 33.0

10,623 21,363 26.3

5.4

5,907 18,905 23.3 8 6,823 7,373 14,196 17.5 8,397 5,725 14,122 17.4

4.8 3.6 3.6

period Source: The 2003 Philippine Health Statistics * percent share from total deaths, all causes, Philippines Last Update: January 11, 2007 Appendix B Antipsychotic Drugs Increase Risk Of Developing Pneumonia In Elderly, Study Suggests

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ScienceDaily (Apr. 16, 2008) Elderly patients who use antipsychotic drugs have a 60 percent increased risk of developing pneumonia compared to non-users. This risk is highest in the first week following prescription and decreases gradually thereafter. Antipsychotic drugs are frequently used in elderly patients for the treatment of psychosis and behavioral problems associated with dementia and delirium. This study is the first to show that the development of pneumonia is associated with antipsychotic drug use. The risk of developing pneumonia is not associated with long-term use, but is the highest shortly after starting the drug, say Drs. Rob van Marum and Wilma Knol, authors of the study. They caution that all antipsychotic drugs may be associated with pneumonia in elderly patients. In nursing homes, up to 40 percent of residents may be prescribed antipsychotics, according to the study. It has been suggested that, for residents of nursing homes who receive antipsychotic therapy, more than half are prescribed for inappropriate reasons. Although literature shows limited efficacy and effectiveness for antipsychotic drug use in the treatment of behavioral problems in dementia patients, these drugs are frequently used for this purpose. In the last few years it has become clear that the use of antipsychotic drugs in elderly patients is also associated with an increased risk of death and morbidity. The underlying mechanism for the association remains unclear. The authors stress that clinicians may need to monitor patients for sedation after initiation of antipsychotic medication and that a careful weighing of the possible risks is recommended before starting antipsychotic treatment in elderly people. This study is published in Journal of the American Geriatrics Society.

Adapted from materials provided by Wiley-Blackwell. Need to cite this story in your essay, paper, or report? Use one of the following formats:

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APA

MLA Wiley-Blackwell (2008, April 16). Antipsychotic Drugs Increase Risk Of Developing Pneumonia In Elderly, Study Suggests. ScienceDaily. Retrieved August 28, 2008, from http://www.sciencedaily.com /releases/2008/04/080415111640.htm

Possible Target For Prevention And Treatment Of Pneumonia Identified ScienceDaily (Feb. 12, 2008) Researchers at Children's Hospital of Pittsburgh of UPMC have identified a key protein target that may be a crucial factor in the development of a vaccine to prevent and new therapies to treat pneumonia, the leading killer of children worldwide. Research led by Jay K. Kolls, MD, chief of the Division of Pediatric Pulmonary Medicine, Allergy and Immunology at Children's, identified for the first time the importance of a protein known as interleukin 22 (IL-22) in the immune response to a strain of bacterial pneumonia. In the laboratory, the researchers were able to effectively treat mice with pneumonia by using purified IL-22. "Currently there is no vaccine that covers all kinds of pneumonia and antibiotic treatment is sometimes limited by antibiotic resistance. As acute respiratory infections are the no. 1 killer of children in the world, progress in the development of novel vaccines or new, more effective treatments is critical," said Dr. Kolls, the Neils K. Jerne Professor of Pediatrics and Immunology at the University of Pittsburgh School of Medicine. "Our results

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raise the possibility of developing new protein-based therapies using IL-22 to limit or prevent pneumonia." Pneumonia causes almost one in five deaths in children under age 5 worldwide -- more than 2 million children each year, according to the World Health Organization. It kills more children than any other disease -- more than AIDS and malaria combined. IL-22 and interleukin 17A (IL-17A) are produced by a recently discovered lineage of cells known as T Helper Type 17 (Th17). Children's researchers found evidence that the Th17 cell lineage and its cytokines IL-22 and IL-17A have evolved to promote host defense against certain infections in the lung caused by extracellular pathogens. This is an important discovery because the Children's research team proposes that by stimulating the Th17 arm of the immune system, they can more efficiently treat bacterial pneumonia. Furthermore, the researchers propose that Th17 is a less critical pathway for intracellular bacteria such as those that cause listeria and tuberculosis -- thus raising the potential to target this pathway in diseases of chronic inflammation such as rheumatoid arthritis or inflammatory bowel disease without increasing susceptibility to these intracellaulr pathogens. Dr. Kolls' laboratory investigates mechanisms of lung host defenses in normal and immunocompromised hosts as well as lung immunology in disease such as cystic fibrosis and asthma. Additional research interests of Dr. Kolls include gene therapy, lung immunology, lung host defenses, tumor necrosis factor, pneumocytis carinii pneumonia, ethanol, gene expression, polymerase chain reaction and molecular biology. Results of the study are published in the February online issue of Nature Medicine.

Adapted from materials provided by Children's Hospital of Pittsburgh, via EurekAlert!, a service of AAAS.

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Need to cite this story in your essay, paper, or report? Use one of the following formats: APA

MLA Children's Hospital of Pittsburgh (2008, February 12). Possible Target For Prevention And Treatment Of Pneumonia Identified. ScienceDaily. Retrieved August 28, 2008, from http://www.sciencedaily.com /releases/2008/02/080211111323.htm

Appendix C Community-acquired pneumonia

Community-acquired pneumonia (CAP) is a disease in which individuals who have not recently been hospitalized develop an infection of the lungs (pneumonia). CAP is a common illness and can affect people of all ages. CAP often causes problems like breathing, fever, chest pains, and a cough. CAP occurs because the areas of the lung which absorb oxygen (alveoli) from the atmosphere become filled with fluid and cannot work effectively. CAP occurs throughout the world and is a leading cause of illness and death. Causes of CAP include bacteria, viruses, fungi, and parasites. CAP can be diagnosed by symptoms and physical examination alone, though x-rays, examination of the sputum, and other tests are often used. Individuals with CAP sometimes require treatment in a hospital. CAP is primarily treated with antibiotic medication. Some forms of CAP can be prevented by vaccination CAUSES Typical Bacterial Pathogens in CAP (approximately 85%)

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Streptococcus pneumoniae Penicillin-sensitive S pneumoniae Penicillin-resistant S pneumoniae H influenzae Ampicillin-sensitive H influenzae Ampicillin-resistant H influenzae Moraxella catarrhalis (all strains penicillin resistant) Atypical Respiratory Pathogens in CAP (approximately 15%) Legionella species Mycoplasma species C pneumoniae Rare Bacterial Pathogens in CAP Klebsiella pneumoniae - Only in those with chronic alcoholism Staphylococcus aureus - Postviral influenza setting Pseudomonas aeruginosa - Only in patients with cystic fibrosis or bronchiectasis Nonpulmonary Pathogens in Pneumonia Nonaeruginosa pseudomonads Stenotrophomonas (Xanthomonas) maltophilia Citrobacter freundii Burkholderia (Pseudomonas) cepacia Citrobacter koseri Enterobacter species Flavobacterium species Enterobacter cloacae Flavobacterium meningisepticum Enterobacter agglomerans Enterococcus species Symptoms

67

Symptoms of CAP commonly include:

problems breathing coughing that produces greenish or yellow sputum a high fever that may be accompanied with sweating, chills, and uncontrollable shaking sharp or stabbing chest pain rapid, shallow breathing that is often painful

Less common symptoms include:

the coughing up of blood (hemoptysis) headaches (including migraine headaches) loss of appetite excessive fatigue blueness of the skin (cyanosis) nausea vomiting diarrhea joint pain (arthralgia) muscle aches (myalgia)

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