PNEUMONIA COMMUNITY

ACQUIRED MODERATE
RISK
PLEURAL EFFUSION

P2LT NOEL RODRIGO L DIAPANA NC

BACKGROUND
OF
THE
STUDY

OBJECTIVES
OF
THE
STUDY

SIGNIFICANCE
OF
THE
STUDY

SCOPE
AND
LIMITATION

PATIENT PROFILE
Name:
JPP
Rank:
SSG
Birthday:
06 June 1971
Age:
42 y/o
Sex:
Male
Address:
Barangay
Camacho,Balanga,
Bataan

Status:

Married

Religion:

Roman Catholic

Occupation:

Enlisted Personnel

Branch of Service:
Unit:

PA

GHQ, HSG

Date and Time

Admission
2015
Chief Complaint:

11 1620H February

Productive cough

Admitting Diagnosis: PCA moderate

risk Pleural
Effusion

SCOPE
DEMOGRAPHIC
CHARACTERISTICS
OF THE PATIENT

HISTORY
OF
PRESENT
ILLNESS

PAST
MEDICAL
HISTORY

FAMILY
HISTORY

NURSING HISTORY
GORDONS
FUNCTIONAL
HEALTH PATTERN

11

NUTRITIONAL
METABOLIC PATTERN

ELIMINATION PATTERN

ACTIVITY EXERCISES
PATTERN

SLEEP REST PATTERN

COGNITIVE
PERCEPTUAL
PATTERN

SELF PERCEPTION
SELF CONCEPT
PATTERN

ROLE RELATIONSHIP
PATTERN

SEXUALLY
REPRODUCTIVE
PATTERN

COPING STRESS
PATTERN

10

VALUES BELIEF
PATTERN

PHYSICAL
ASSESSME
NT

VITAL SIGNS
Blood Pressure
110/80mmHg
Heart Rate
82 bpm
Respiratory Rate
20 cpm
Temperature
36 C
Oxygen Saturation 98%
Height
56
Weight
66kgs

Head and Neck

Symmetrical with normal hair distribution
(-) scars, lesions, masses and
tenderness
Smooth movement, full range of motion

Eyes
Pink conjunctiva, (-) lesions and
discharge
Anicteric sclera, smooth and clear
cornea
Pupils are equal, equally round, briskly
and uniformly reactive to light and
accommodation (PERRLA)

Ears
Symmetrical, (-)gross abnormalities
and tenderness
(-) impacted serumen
Symmetrical gross hearing, (-)
hearing deficit

Nose
Nostrils are patent and intact
Nose is on the midline, symmetrical
and proportion to facial features
(-) tender sinuses

Mouth
Lips are pink and not dry
Tongue is pink and even
Tonsils are pink
Tongue and uvula is deviated to the left
side
No halitosis present

Chest and Lungs

Anterior and posterior chest skin color is
consistent with the rest of the body parts,
no cyanosis, jaundice or pallor present
No lesions, lumps or bruises noted
Chest expansion is asymmetrical,
decreased breath sounds on right chest
(+) crackles right chest during
auscultation

Heart
(-) murmurs
Heart rate is regular on 82 bpm

Abdomen
Flat abdomen
Umbilicus is in midline with no signs of
discoloration/inflammation
Skin is consistent with other body parts
No tenderness upon light and deep
palpation of all quarters
With good peristaltic movement

Back and Extremities

Full and equal pulses
(-) spinal deformity
Symmetrical , regular and strong
peripheral pulses
Pinkish nail beds, (-) clubbing,
inflammation, good capillary refill within 2
seconds

Genitals
Not assessed; Patient refused

ANATOMY
AND

PHYSIOLOGY

COURSE IN THE WARD

11 February 2015 Admission
12 February 2015 2nd Hospital Day
14 February 2015 4th Hospital Day
16 February 2015 6th Hospital Day

18 February 2015 8th Hospital Day

23 February 2015 13th Hospital Day
24 February 14th Hospital Day
09 March 2015 27th Hospital Day

20 March 2015 38th Hospital Day

10 April 2015 59th Hospital Day
18 May 2015 98th Hospital Day

LABORATORY
AND
DIAGNOSTICS

Interpretation:
Increasing Segmenters are first to
respond during the start of inflammatory
process and is indicative of beginning
infection like productive cough and fever
signals the doctors to start with the
antibiotic therapy.

Interpretation:
After 3 days of incubation period, blood culture
and sensitivity results are normal with no
significant findings. Blood Culture and
Sensitivity are taken to have a base line of
bacteria or virus that would be present with JPP.

Interpretation:
Serum protein ratio greater than 0.5
results in Exudative type of pleural
effusion meaning fluid analysis is high in
protein oncotic pressure pull water out
from the intravascular spaces, this
resulted to JPPs difficulty of breathing
and productive cough.

Interpretation:
Normal findings, this ABG is done to
assess JPPs ability on how well his lungs
are able to move oxygen into the blood
and remove carbon dioxide from the blood.

Interpretation:
No significant findings, part of routine medical
exam prior to admission to screen for a variety of
disorders.

Interpretation:
As a result of JPPs treatment, pleural fluid
has been reduced to 70ml and will no longer
need to undergo any surgical procedure.

DRUG STUDY

12 RIGHTS OF
DRUG
ADMINISTRATION

CEFTRIAXONE 2gms/TIV OD

PIPERACILLIN
TAZOBACTAM 4.5grams/
TIV every 8 hours

CEFIXIME 200mg/tab
BID

N-ACETYL CYSTEINE
200mg/sachet
+ 200 ml Water three times a day

AZITHROMYCIN 500mg/tab OD

CELECOXIB 200mg/cap PRN

PARACETAMOL 500 mg/tab PRN

PROBLEM LIST

Nursing Problem

Date Identified

Date Resolved

11 February 2015

14 February 2015

Hyperthermia

18 February 2015

23 February 2015

Acute Pain

10 March 2015

10 March 2015

Ineffective breathing pattern related

to abnormal accumulation of fluid in
the pleural space

LONG TERM
OBJECTIVE

NURSING
CARE PLAN

Assessment

11 February 2015
Subjective
Parang
kinukulang ako
sa hangin as
verbalized by the
patient
Objective
(+) Nasal flaring
(+) Shortness of
breath
(+) Unproductive
cough
(+) Use of
accessory
muscles to breath
RR: 27
PR: 92
O2 sat: 94

Nursing Diagnosis

Planning

Ineffective

After 72 hours of

airway

thorough nursing

clearance

intervention

related to

patient will be

Intervention

accumulation of able to
secretions in

demonstrate

the pleural

normal and

space

effective

respiratory
pattern as
evidence by no

nasal flaring, no
shortness of
breathing,
minimal cough
and not using
accessory
muscles to
breath.

Assessed
respiratory rate and
oxygen saturation
Evaluated airway
patency chest
movement and
auscultation for
bilateral breath
sounds
Instructed on deep
breathing exercises
Elevate head of
bed and encourage
frequent position
changes
Encouraged to
increase oral fluid
intake of warm
water to
3000ml/day
Flumicil 200mg/tab
in 200cc water TID
given
Oxygen therapy
given at 1-2LPM via
nasal cannula
administered PRN

Evaluation

After 72 hour of
nursing
intervention client
was able to
demonstrate
normal breathing
and respiratory
pattern as
evidence by no
nasal flaring, no
shortness of
breathing, minimal
cough and not
using accessory
muscles to breath.
Respiratory rate
from 27 to 22
Pulse rate of 92 to
83
O2 sat 94 to 99

Assessment

18 February2015
1500H
Subjective
Ang init ng
pakiramdam ko
sir tuwing hapon,
minsan umaabot
hanggang gabi
Objective
Temp: 38 C
(+) Chills
Warm to touch
Flushed skin
WBC: 8.79
Segmenters:
0.72

Nursing Diagnosis

Hyperthermia
related to
increase
metabolic rate
secondary to
presence of
infection

Planning

Intervention

After 4 hours of Monitored vital

signs
thorough nursing
Performed tepid
intervention
sponge bath
Provided patient
patient
will be
with warm
able to maintain blanket since
patient is having
normal
body
chills
temperature as Encouraged to
increase fluid
evidence
by
intake to
Temperature of 3000ml/day
Maintained on
37 C and no
bed rest to
chills.
reduce metabolic
demand
Paracetamol
500mg/tab every
4 hours given

Evaluation

After 4 hours of
nursing
intervention,
Goal

met:

as

patient
manifested
Temperature

of

37

no

chills.

and

Assessment

10 March 2015
0900H
Subjective
Masakit sir sa
simpleng pag
hinga ko pa lang
lalo na
pagkatapos ng
procedure

Nursing Diagnosis

Planning

Acute Pain

After 30

related to

minutes to 1

Intervention

thoracocentesis hour of
nursing

intervention
the JPPs pain

will decrease
Objective
(+) Pleuretic pain
(+) Facial
grimaces upon
movement
(+) DOB
Verbalizes pain on
the thoracostomy
area, described as
sharp, provoked
by breathing
BP 140/90
RR 28

from 7 to 3 as
verbalized by
the patient

Assess patients pain

for intensity using a
pain scale for location
and for precipitating
factors.
Assess the response to
medications every 5
minutes
Provide comfort
measures
Establish a quiet
environment
Elevate head of bed
Teach patient relaxation
techniques and how to
use them to reduce
stress
Advise patient to stay at
affected side for 30
minutes to facilitate
expansion of the
affected lung and
respiration
Celecoxib 200mg/cap
PRN given as ordered

Evaluation

Patient
verbalized a
decrease in pain
from a scale of 7
to 3 as stated,
nakakahinga na
ako ng malalim
ng hindi
sumasakit
1. BP : 120/80
2. RR: 24

DISCHARGE
PLANNING

CONCLUSION

BIBLIOGRAPHY
VI
BIBLIOGRAPHY
Electronic Book

Bates Guide to Physical Examination and History Taking 11th Edition;

Linda S. Bickley and Peter G. Szilagyi; Lippincott, Williams and Wilkins
Medical-Surgical Nursing 12th Editon; Brunner and Suddarths
Fast Facts for the Radiology Nurse; Springer
Nursing Care Plans6th Edition

Internet

http://www.pennmedicine.org/health_info/body_guide/reftext/html/resp_sys_fin.html

http://www.innerbody.com/anatomy/respiratory

http://www.innerbody.com/diseases-conditions/pneumonia

http://www.mayoclinic.org/diseases-conditions/pneumonia/basics/definition/con-20020032

http://emedicine.medscape.com/article/80640-overview#a3

http://www.anaesthesiamcq.com/AcidBaseBook/ab6_5.php

http://emedicine.medscape.com/article/2172232-overview

http://www.lung.org/lung-disease/influenza/in-depth-resources/pneumonia-fact-sheet.html

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031442/

THANK YOU!