Pneumonia Kembolar

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URDANETA CITY, PANGASINANCOLLEGE OF NURSING

A CASE STUDY ONPNEUMONIA

SUBMITTED BY:Mallar, Adrian G

Bsn-3/ Group 4 SUBMITTED TO:

Maribel Muriio


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I. PATIENT ASSESSMENT DATA BASE

A. GENERAL DATA1. Patients Name: B.C2. Address: Pozzurobio, Pangansinan3. Age: 434. Sex: Female

5. Birth Date: October 2,, 19696. Rank in the Family: Mother7. Nationality: Filipino8. Civil Status: Married9. Date of Admission:August,201310. Order of Admission: Please admin to Medical Ward, secure consent inserted IVF with D5LRS 1L to regulate @ 20-21 gtts/min. Cefuroxime 700 mg IV

q8, Paracetamol 500 mg OD PRN.11. Admitting Diagnosis: PNEUMONIA12. Attending Physician: Dr. Burcas

B. CHIEF COMPLAINTAccording to the patient is experiencing cough fever and dizziness

C. HISTORY OF PRESENT ILLNESS:Present condition started 2days prior to admission

D. PAST HEALTH HISTORY:

1. Childhood Illness: She experienced chicken pox, colds, cough and cold 2. Immunization: Complete3. Major Illness: None4. Current Medications: Paracetamol, Mefenamic Acid5. Allergies:Allergy to Tahong

E. FAMILY ASSESSMENT:

Name Relation Age Sex Occupation Educational Attainment

B.C Pt/Mother 43 Female None College Undergraduate

B.T Father 40 Male None College Undergraduate

B.O Son 20 old Male N/A N/A


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.

F. SYSTEM REVIEW :

1. HEALTH PERCEPTION HEALTH MANAGEMENT PATTERN Clients perception of health: The client perceives health as if we take care of our self, we will be healthy Clients perception about illness : The clientperceives illness as it was really hard to get sick if you dont have money

Health maintenance and habits: In maintaining his health as well as his family, they have their check up and sometimes just have self-medicated of the illness is not severe. Compliance with prescribed medications and treatment: according to the client they always follow the medication and treatment being

prescribed.

2. NUTRITIONAL METABOLIC PATTERN: Appetite : The smell and taste can trigger the clients appetite. According to the client, the usual diet is high in fiber and carbohydrates and eats

3 times a day with 2-3 cups of rice and 1 bowl of dish. Usual Daily Menu:

- Food : vegetables, fish and meet- Water : pt BC drinks 6-8 glasses of water per day- Beverage : she drinks coke and coffee

3. ELIMINATION PATTER Bowel Habits : According to the client, he usually defecates once a day

- Color : Brown- Odor : Aromatic- Consistency : Soft

4. ACTIVITY EXERCISE PATTERN0 Feeding 1- Dressing 0- Grooming0 Bathing 0- Toileting 0- Cooking1 Bed Mobility 1- Home Maintenance

Legend:

0 Full CareI Requires use of assistanceII Requires assistance and supervision by othersIII Requires assistance and supervision from another and equipments and devicesIV Dependent, Doest participate

5. COGNITIVE PERCEPTUAL PATTERN Hearing : Upon interviewing, Mrs. B.C can perceive sounds and hears all the questions that were being asked


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Vision: My client can read books and newspapers clearly. Sensory: Upon applying slight pressure with both arms of Mrs. B.C can differentiate the scent of alcohol from the smell of food. Learning Styles: The client can supervice his learning abilities and level of understanding through watching television and listening in the

radio. In tems of decision making, Mrs. B.C approaches her husband they make their decisions together.

6. SLEEP REST PATTERN Sleep habits: Mrs. B.C stated that before she goes to sleep she watches a television program

Hours of sleep: She sleeps at 10pm up to 4am Sleeping alteration: Mrs. B.C had alterations in sleeping because he usually work at night. Sleeping aids: her sleeping aids is only watching television

7. SELF PERCEPTION AND SELF CONCEPT PATTERN Felling about current state : Regardless of his situation Mrs. B.C still believed that God will help him in any situation. Description of self: She described herself as kind, loving mother and wife Known capabilities and weakness: As verbalized by the client my weaknesses are my family Self worth: The client sees herself as kind, loving mother and wife

8. ROLE RELATIONSHIP PATTERNAccording to Mrs. B.C she is doing her responsibility to her son as well as to his husband

9. SEXUALTY REPRODUCTIVE PATTERNPhysical and psychological effect of the clients current health status on sexual expression:

Mrs. B.C stated that she can still performed sexual activity together with her husband but thers a limitation.

10. COPING STRESS TOLERANCE PATTERN Perception of stress and problems : Mrs. B.C perceives stress as a problem as we can easily solve our problems if we think for the solution Coping method and support system according to Mrs. B.C she prays all the time.

11. VALUE BELIEF PATTERN Values, goals and philosophical belief: According to the client she believes that GOD is always there for us

Religious and spiritual beliefs: the client is Roman Catholic and believes that be contented f what GOD gave to you


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G. HEREDO- FAMILIAL ILLNESS

1. Paternal no known illness2. Maternal no known illness

H. DEVELOPMENTAL HISTORY

Theorist Age Sex Patients Description

Erik Erickson 43 Female

INTIMACY vs. ISOLATION- It is involves parenting care and

offers support and praise fordecision making

Jean Piaget 43 Female

Formal operation thought

-First it relates how she really thinks

- 2nd

, how she solved/ handled problemsin a mature though and reasoning andlastly

- On how she accept opinions ofsignificant others

Lawrence Kohlberg 43 Male

Post conventional, Level 3 stages 6- It involves on how an individuals

internalized the standards of conduct andhow he apply/ put the standards conductinto her life


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I. PHYSICAL ASSESSMENTA. General Survey

1. Overall appearance and grooming: The client is conscious and coherent2. Actual height and weight vs. ideal body weight: Height: 5ft and weight 65 kg.3. Symptoms of distress: none4. Posture and gait: The client has a good posture5. Affect and mood:According to the client he still shows great happiness

6. Relevance and organization of thoughts: She can understand and answer all questions appropriately7. Vital signs of the day of physical examination

Temperature: 37.9 degrees Celsius Respiratory rate: 35 beats per minutePulse rate: 89 beats per minute Blood pressure : 100/70

B. Regional exam- utilize IPPA technique

1. Hair: Upon inspection, Hair are evenly distributed, short and no presence of infection

Head : Head is round.

2. Eyes: Upon inspection of the clients eyes, eyebrows are evenly distributed,

3. Nose: there is discharges upon inspection, no cuts, no edema

4. Ears: Symmetrical and no discharges noted upon inspection

5. Mouth and throat: Upon inspection, outer lips are uniform in color, soft and dry. Oral mucosa is also dry.

6. Neck and lymph nodes:The clients neck muscles are equal in size, no visible nodules or masses upon palpation

7. Skin: Brown in color, warm to touch

8. Nails: Fingernail plate shape convex, smooth texture

9. Thorax and lungs: With RR of 34 bpm, fast rhythm breath and has crackles upon inhalation.

10. Cardiovascular: With 89 beats per minute, lub/dub can be heard upon auscultation.

11. Abdomen: no pain upon palpation

12. Extremities: He was able to flex and extend his extremities actively but with weakness noted.


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15. Neurological/Cranial nerves: Not performed

II. PERSONAL/SOCIAL HISTORY

A. Habits:

a. Caffeine: She drinks 2 cups every dayb. Smoking: noc. Alcohol: She drinks alcohol occasionallyd. Tea: Sometimese. Drugs: The drug regimen prescribed to her by the doctor.

B. Lifestyle:According to the patient she does the Activities of Daily LivingC. Social Affiliation: The patient is obeying the rules and regulation in their barangayD. Rank in the family: MotherE. Travel (within 6 months): The patient dint travel to far

F. Educational Attainment: College Undergraduate

III. ENVIRONMENTAL HISTORY

According to his mother, they are living with her husbands family . Their house is located at the rice field. Its made of raw materials like cement andhollow blocks; their using tricycle as their transportation going to market/town which about 5 km away from their house.

IV. INTRODUCTION

Pneumonia is an inflammatory condition of the lungaffecting primarily the microscopic air sacs known as alveoli. It is usually caused by infection with

viruses orbacteria and less commonly othermicroorganisms, certain drugs and other conditions such as autoimmune diseases. Pneumonia can be a serious threatto our health. Although pneumonia is a special concern for older adults and those with chronic illnesses, it can also strike young, healthy people as well. It is a

common illness that affects thousands of people each year in the Philippines, thus, it remains an important cause of morbidity and mortality in the country.

Pneumonia is an inflammation or infection of the lungs most commonly caused by a bacteria or virus. Pneumonia can also be caused by inhaling vomit or

other foreign substances. In all cases, the lungs , air sacs fill with pus, mucous and other liquids and cannot function properly. The most common cause of bacterial

pneumonia in adult is a bacteria called streptococcus pneumonia or pneumococcal. Most viral pneumonias are patchy and the body usually fights them off without
https://en.wikipedia.org/wiki/Inflammationhttps://en.wikipedia.org/wiki/Lunghttps://en.wikipedia.org/wiki/Virushttps://en.wikipedia.org/wiki/Bacteriahttps://en.wikipedia.org/wiki/Microorganismhttps://en.wikipedia.org/wiki/Medicationhttps://en.wikipedia.org/wiki/Autoimmune_diseasehttps://en.wikipedia.org/wiki/Autoimmune_diseasehttps://en.wikipedia.org/wiki/Medicationhttps://en.wikipedia.org/wiki/Microorganismhttps://en.wikipedia.org/wiki/Bacteriahttps://en.wikipedia.org/wiki/Virushttps://en.wikipedia.org/wiki/Lunghttps://en.wikipedia.org/wiki/Inflammation


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help from medication or other treatments. Pneumococcus can affect more than the lungs. The bacteria can also cause serious infection of the covering of the brain

(meningitis ), the bloodstream, and other parts of the body.

V. ANATOMY AND PHYSIOLOGY

The lungs constitute the largest organ in the respiratory system. They

play an important role in respiration, or the process of providing the body

with oxygen and releasing carbon dioxide. The lungs expand and contract uo

to 20 times per minute taking in and disposing of those gases. Air that is

breath in is filled with oxygen and goes to the trachea, which branches off

into one of two bronchi. Each bronchus enters a lung. There are two lungs,

one on each side of the pumped by the heart throughout the body. The

alveoli also take in carbon dioxide, which is then exhaled from the body.


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VI. Pathophysiology

Virulent Microorganism

Streptococcus Pneumoniae

Microorganism enters the nose (nasal passages )

Passes through the larynx, pharynx, tracheas

Microorganism enters and affects both airway and lung parenchyma

Airway damage Lung invasion

Infiltration of bronchi Flattening of epithelial

Infectious organism lodges Necrosis of bronchial tissues Macrophages and leukocytes

Stimulation in bronchioles Narrowing of air passage Mucus and phlegm production

Alveolar collapse Coughing

Increase pyrogen in the body DIFFICULTY OFBREATHING (Productive/ non-productive)

Fever


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VII. Laboratory Test

HEMATOLOGY

Test Result Normal values Significance

Hemoglobin 95 130.00 180.00 g/L Decreased hemoglobin levelsimply decrease oxygen carrying

capacity of the blood

Hematocrit 0.31 0.42 0.52 g/L A low hematocrit referred to as

being anemic caused by loss ofblood or dietary deficiency

Segmenters 0.59 0.50-0.70 Within normal range

Lymphocyte 0.39 0.20-0.40 Within normal range

Monocyte 0.02 0.00-0.07 Within normal values

Platelet 177 150-400 x 10 g/L Within normal values


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IX. DRUG STUDY

Generic Name:CefuroximeBrand Name:Kefox

Drug Classification:Cephalosporin second generationDosage:750mg SIVP q8 ANST ( - )Indication: for bone and joint infections

Mechanism of Action Contraindication Adverse Effect Side Effects Nursing Consideration

Bactericidal: Inhibitssynthesis of bacterialcell wall, causing celldeath.

Hypersensitivity tocephalosporins andrelatedantibiotics;pregnancy(category B),lactation.

o Erythemamultiforme

o Epidermalnecrolysis

o NephrotoxicityPseudomembranous colitis

GI:Diarrhea,nausea, antibiotic-associated colitis.

Skin:Ra sh ,pruritus, urticaria.

Urogenital:Increased serumcreatinine andBUN, decreasedcreatinineclearance.

Hemat:Hemolytic anemia

MISC:Anaphylaxis

Before:

Determine history

of hypersensitivity reactio

ns to cephalosporins,

penicillins, and history of

allergies, particularly to

drugs, before therapy is

initiated.

Lab tests: Perform

culture and sensitivity

tests before initiation of

therapy and periodically

during therapy if

indicated. Therapy may

be instituted pending test


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results. Monitor

periodically BUN and

creatinine clearance.

During:

Inspect IM and IV

injection sites frequently

for signs of phlebitis.

Monitor for

manifestations

of hypersensitivity (see

Appendix F). Discontinue

drug and report their

appearance promptly.

Monitor I&O rates and

pattern: Especially

important in severely ill

patients receiving high

doses. Report any

significant changes.

Report onset of loose


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stools or diarrhea.

Although

pseudomembranous

colitis (see Signs &

Symptoms, Appendix F)

rarely occurs, this

potentially life-threatening

complication should be

ruled out as the cause of

diarrhea during and after

antibiotic therapy.

After: Instruct patient to take

medication around theclock at evenly spacedtimes and to finish themedication completely,even if feeling better

Advise patient to reportsigns of superinfectionand allergy

Instruct patient to notifyhealth professional iffever and diarrhea


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Generic Name:Paracetamol

Brand Name:Biogesic

Drug Classification:Analgesic/ Anti pyretics

Dosage:500mg; 1 tab q4

Indication:For fever

Mechanism of Action Contraindication Adverse Effects Side Effects Nursing Consideration

Paracetamol reducesthe synthesis ofprostaglandin whichare responsible for themediation of pain andfever

Contraindicated tohypersensitivity toparacetamol

o Methemoglobin

emia

o Hemolytic

Anemia

o Neutropenia

o Thrombocytope

nia

o Pancytopenia

o Urticaria

o Hypoglycemiccoma

o Jaundice

o Nausea& Vomiting

o Minimal GI upset

Report Nausea andVomiting these aresigns of toxicity

Take with food or milkto minimize GI upset

Report pain thatpersists for more than

3 5 day


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X. LIST OF IDENTIFIED PROBL EMS ACCORDING TO PRIORITY

a. Hypertermia related to disease process

b. Ineffective airway clearance related to increase mucus production

c . Knowledge deficit related to disease process


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X. Nursing Care Plan

Assessment Nursing

Diagnosis

Scientific

explanation

Objectives Interventions Rationale PLANNING

S> tatlong araw

na akong

nilalagnat

O>

>Flushed warm

skin

>Increase

Temp. of

37.9OC

>irritability

>Diaphoresis

Hyperthermia

related to

disease process

Dengue

Hemorrhagic

Fever is

potentially

deadly

complication that

is characterized

by high fever.

Hyperthermia is

an abnormal rise

in the

temperature of

the human body.

Normal body

temperature is

98.6 OF or 37.5

OC. Fever may

not result only

from a

Short term:

After 4 hours of

Nursing

Interventions the

patient will be

maintaining a

normal bodytemperature.

Long Term:

After 4 days of

NI, the patient

will experience

no associated

>Establish good

working

condition with

the pt and SO.

>monitor v/s q

2hours.

>provide TSB

>Encourage

increase fluid

>to gain

patients trust

>to have

baseline data

>to maintain a

normal body

temperature.

>to replace fluid

loss

Short term:

The patients

body

temperature

shall have a

maintained

normal bodytemperature.

Long Term:

After 4days of


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disturbance of

heat-regulating

mechanism of

the body but

also through

disturbances of

the blood, the

rate of breathing.

Indeed there are

oral intake

during periods of

illness will result

to further body

weakness

impairing the

patients ability

to perform usual

routines and

ADLs

complications

such as seizures

etc.

intake

>Encourage

food rich in

Vitamin C

>provide client

safety

>maintain bed

rest

>to boost body

resistance to

infection

>to prevent

further injuries

>to preserve

energy

NI, the patient

will experience

no associated

complications

such as seizures

etc.


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ASSESSMENT DIAGNOSIS SCIENTIFIC

REASON

OBJECTIVES INTERVENTION RATIONALE EVALUATION

Subjective:

nahihirapanakong

huminga, dami

ko kasi plemaeh

Objective:

*RR- 26

*Dyspnea*(+)non-productivecough*Use ofaccessory

muscle

Ineffectiveairway

clearancerelated toincreasemucus

production

Increasedmucus

production isoften caused

by anunderlyingillness. If

mucus is themost prevalentsymptom, it isusually causedby something

simple likeallergies or the

common cold.Other illnessesthat result inexcessive

mucusproduction

includepneumonia, fluand bronchitis

Short term goal:

After 3-4 hoursof intervention,patient will

expectoratesecretionseffectively andRR willdecrease from26 to normalrange of 16-20/min.

Long term goal:

After 3 days ofintervention,patient willmaintain patentairway asevidenced bynormal RR.

Independent:1.Assess rate/depth ofrespiration and chestmovement.

2.Elevate head of bedand changed positionfrequently.

3.Assist patient withfrequent deep breathingexercises.

4. Encourage increasein fluid intake.

Collaborative:

5.Administer mucolytics

as indicated.(Fluimucil)

6.Providedsupplementalfluids.(IVF: PNSS)

1.Tachypnea,shallowrespiration areusuallypresent.2.Lowersdiaphragm,promotingchestexpansion,mobilizationandexpectoration

of secretion.

3.Deepbreathingfacilitatesmaximumexpansion ofthe lungs andsmaller

airways.4.Fluids aid inmobilizationandexpectorationsof secretions

Goal half met.

After 4 hours ofnursing

intervention,patientexpectoratedsecretion andRR decreasedfrom 26/min to

22/min.


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7.Monitor chest Xray,

ABG and pulseoximetry results.

5.Aids inmobilization ofsecretion.

6.Fluids are

required toreplaceinsensible lossand aids inmobilization ofsecretions.7.Followsprogress andeffects ofdiseaseprocess.


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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:

anu po ba ang dahilanbakit ako nagkasakit? asverbalized by the patient

Objective:

o Presence of stresso Self focusingo Willing to learn

Knowledge Deficitrelated to diseaseprocess

After 30 minutesof nursingintervention, thepatient will be ableto understandabout the diseaseprocess and toknow the needs ofthe care andtreatment withoutworry

Assess theclientsknowledgeabout thedisease

Explain thediseaseprocess ( signsand symptoms), identifypossiblecauses.

Describe thecondition of theclient

Tell us abouttreatmentprogram andalternativemedicine

Discusslifestylechanges that

may be usedto preventcomplications

Discuss abouttherapies andoptions

Simplify theexplanation tothe client

Increaseknowledgeand reduceanxiety

Facilitateintervention

Preventingdiseaseseverity

Giving an overview oftreatmentoptions that

After 30 minutes ofnursingintervention, thepatient was able todiscuss about thedisease processand to know theneeds of the careand treatmentwithout worry


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Exploration ofpossiblesources thatcan be used /supported.

Instruct whento the ministry

Ask the clientsknowledgeabout thedisease,nursingproceduresand treatment

can be used.

Review


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VII. ONGOING APPRAISAL

The patient shows progressive recovery and is responding well to both medical and nursing intervention. Comfort measures given.

VIII. DISCHARGE PLAN

Medication

Instruct the patient to continue the medications if the doctors order

Exercise

Encourage the patient to have exercise daily

Diet

Advice patient to increase fluid intake Encouraged the patient to eat foods rich in vitamins and minerals

Documents

Pneumonia Kembolar