Download - Case Pneumonia
AMA Computer Learning CenterSt. Augustine School of Nursing
A Case Study Presented to the faculty of AMA Computer Learning Center
PNEUMONIA
Submitted to:Mr. John Eric T. Salvador B.S.N, R.N
Submitted by:Almario, Jeanette
Cayanan. Gemmalyn JoySantos, Cariza Joy M.
3k-PN
September ‘09
Table of Content Page
Introduction 1
Personal History 2 Family health history Past health history
Complete Physical Assessment 5-11
Neurological Assessment 12
Laboratory Procedure 13-15
Anatomy and Physiology 16
Pathophysiology of Pneumonia 17
Drug Study 18
Diet and Activity 19
SOAPIE (actual) 20
SOAPIE (potential) 21
Conclusion 22
Recommendations 23
Bibliography 24
NCP(actual) 25
NCP (potential) 26
Introduction
Pneumonia is serious infection and/or inflammation of the lung. The air sacs in the lung which are the alveoli are filled with fluid. Oxygen has trouble reaching the blood. If there is too little oxygen in the body, the body can’t work properly. Because of this and spreading infection through the body pneumonia can cause death.
Symptoms of pneumonia caused by bacteria usually come on quickly. They may include productive cough (greenish phlegm), fever and chills, fast breathing and feeling short of breath, chest pain that often feels worse when you cough or breathe in, body weakness and difficulty of breathing.
Pneumonia is not a single disease. It can have over 30 different causes. There are five main causes of pneumonia; bacterial pneumonia (pneumoccocal pneumonia & legionnaires disease) viruses/viral pneumonia, mycoplasmas pneumonia, fungi (pneumocytis carinii) and other various chemical.
Latest Trend(Medication for Pneumonia)
Macrolids such as azithromycin, clarithromycin, erythromycin. Tetracylines, such as doxycycline. Fluoroquinolones, such as gemifloxacin, levofloxacin and moxifloxocin. If you have to go to the hospital, your doctor may use any of the above antibiotics. Other antibiotics that your doctor may use in this situation include: Cepholosporins , such as ceftriaxone, cefotaxime, ceftazidime or cetepime. Penicillins, such as amoxicillin with clavulanate, ampicillin and tacarcillin with clavulanate and vancomycin.
The adult pneumonia shot, Pneumovax (pneumoccocal vaccination), protects against 23 strains of pneumoccocal bacteria.
1.
2. Personal History
Name: Mr. X Address: San Jose, GuaguaAge: 77 yrs. Old Work: Truck Driver
2.
3.
2.1 Past Health History
Mr. X, past illness was diarrhea (last August 26, 2009) and often, on/off fever (last August 28, 2009). But he was never been confined in the hospital before.
2.2 Present Health History
Mr. X, 77 years old, widowed from San Jose was a patient at DPMMH. He was confined last September 1, 2009 because of difficulty of breathing, productive cough and high grade fever 3 days before confinement.
When he was confined in the hospital, Mr. X said that he experienced body malaise and chills whenever he has a high grade fever. His daughter said that it was her first time that he saw her father experienced high grade.fever of 39.4 during our duty hours of 7-3 pm.
3. Lifestyle and Diet
Mr. X admitted that during his childhood days he used to smoke 30-40 pieces of cigarette per day (1 ½ pack/day). And drink alcohol after his work, usually 4-5 bottles per day. Now, at his age Mr. X said that he already stopped smoking but he said he drink occasionally.
Mr. X verbalized also that he likes to eat meat but because of not enough income he just eat what his family prepared.
4.4. Complete Physical Assessment
Date assessed: September 4, 2009Time Assessed: 9:00 A.MInitial Vital Signs:
Temperature: 37.4CPulse Rate: 70bpmRespiratory Rate: 30cpmBlood Pressure: 110/70 mmHg
General Appearance: The pt. is awake, lying on bed, conscious and coherent with an IVF of
D5W regulated @ 10-15 gtts./min. (KVO) 90ml. level infusing well @ right hand.
The pt. can follow instructions and commands.Area Assessed Technique
UsedNormal Findings
Actual Findings
Analysis
SKINcolor Inspection Tan Pallor Due to DOBTexture Palpation Smooth, soft Smooth, soft NormalTurgor Palpation Skin snaps
back immediatelyWhen pinched
When pinched, it slowly snaps back
Due to aging
Hair Distribution Inspection Evenly distributed
Evenly distributed
Normal
Temperature Palpation Warm to touch Warm to touch NormalMoisture Palpation Dry, skin folds
are normally moist
Dry, skin folds are normally moist
Normal
NAILSColor of Nail bed Inspection Pink and clear Pink and clear NormalTexture Palpation Smooth Smooth NormalShape Inspection Convex
curvatureConvex curvature
Normal
Nail base Inspection Firm Firm NormalCapillary refill time
Blanch test 2-3 seconds 4 sec. Due to DOB
HAIRColor Inspection Black (varies)
Black but slightly going to white
Normal due to aging
Distribution Inspection Evenly distributed
Evenly distributed
Normal
Moisture Inspection Neither Neither Normal
excessively dry nor oily
excessively dry nor oily
Texture Inspection Silky, resilient Silky, resilient NormalHEAD
Scalp symmetry Inspection Symmetrical Symmetrical Normal
Skull size Inspection Normocephalic Normocephalic Normal Shape Inspection
and PalpationRound Round Normal
Nodules/ masses Palpation Absence of nodules and masses
Absence of nodules and masses
Normal
FACESymmetry Inspection
Symmetrical Symmetrical Normal
Facial movement Inspection Symmetrical Symmetrical Normal
Skin color Inspection Tan Pale Due to DOBEYESEyebrows Inspection
Symmetrically aligned, equal movement
Symmetrically aligned, equal movement
Normal
Eyelashes Inspection Slightly curved upward
Slightly curved upward
Normal
Eyelids Inspection Smooth, tan, do not cover pupil as sclera, close symmetrically
Smooth, tan, do not cover pupil as sclera, close symmetrically
Normal
Ability to blink Inspection Blinks voluntarily and bilaterally
Blinks voluntarily and bilaterally
Normal
Frequency of blinking
Inspection 20 blinks per min.
17 blinks per min.
Normal
Ocular movement Inspection Eye moves freely
Eye moves freely
Normal
Position Inspection Drawn from lateral angel
Drawn from lateral angel
Normal
Size Inspection Medium Medium Normal Texture Palpation Mobile, firm and
non-tenderMobile, firm and non-tender
Normal
CONJUCTIVAColor Inspection Transparent
with light colorTransparent with light color
Normal
Texture Inspection Shiny and smooth
Shiny and smooth
Normal
Presence of lesions
Inspection No lesions No lesions Normal
APPARATUS
Cornea
Color Inspection Black Black Normal Texture Inspection Shiny and
smoothShiny and smooth
Normal
PUPILSColor Inspection Black Black NormalReaction to light Inspection Pupils Equally
Round and React to Light Accommodation (PERRLA)
Pupils Equally Round and React to Light Accommodation (PERRLA)
Normal
Size Inspection Equal Equal NormalShape Inspection Round and
constrict brisklyRound and constrict briskly
Normal
Symmetry Inspection Equal in size Equal in size Normal Visual Acuity Inspection Able to real
news printAble to real news print
Normal
Visual Fields Inspection When looking straight ahead, client can see objects in periphery
When looking straight ahead, client can see objects in periphery
Normal
Ocular Inspection Eyes move freely
Eyes move freely
Normal
NOSESymmetry, shape, size and color
Inspection Symmetrical, smooth and tan
Symmetrical, smooth and tan
Normal
Mucosa color Inspection Reddish to pinkish
Reddish to pinkish
Normal
NASAL SEPTUMNares
Inspection Oval, symmetrical
Oval, symmetrical
Normal
Nasal discharge Inspection No discharge No discharge Normal Sinuses Inspection Not tender Not tender Normal MOUTHSecretion Inspection (neutral in
color) without mucus production
Mucus production
Abnormal due to inflammation
LipsColor
Inspection Pinkish to slightly brown
Pinkish to slightly brown
Normal
Symmetry Palpation Symmetrical Symmetrical Normal Texture Palpation Soft, moist,
smoothSoft, moist, smooth
Normal
Moisture Palpation Soft and moist Soft and moist Normal GUMSColor Inspection Pinkish Pinkish Normal Moisture Palpation Moist Moist Normal
BUCCAL MUCOSAColor Inspection Glistening pink Glistening pink Normal Texture Palpation Soft Soft Normal Moisture Palpation Moist Moist Normal TOUNGEColor Inspection Pinkish Pinkish Normal
Size Inspection Medium Medium Normal Symmetry Inspection Symmetrical Symmetrical Normal Mobility Inspection Moves freely Moves freely NormalUVULALocation Inspection At the midline At the midline Normal Symmetry Inspection Symmetrical Symmetrical Normal TONSILSColor Inspection Pinkish Pinkish NormalDischarges Inspection No discharges No discharges Normal TEETHColor Inspection Ivory/yellowish Yellowish NormalNumber of teeth Inspection 32 28 Due to tooth
decay (teeth extraction)
NECKPosition Inspection Head-centered Head-centered Normal Movement Inspection Moves freely Moves freely Normal Range of motion Inspection Full range Full range NormalConsistency Inspection No enlargement No enlargement Normal HEARTHeart rate Auscultation 60-100bpm 70bpm Normal Heart sounds Auscultation Clear, without
cracklesCrackling Due to the
presence of phlegm and increased mucus production
Lung field Auscultation Resonant With crackles Due to secretions
THORAX & LUNGS POSTERIOR THORAXSymmetry Inspection Symmetrical Symmetrical Normal
Respiratory rate Inspection 12-20cpm 30cpm Due to blockage of secretions
Spinal Alignment Inspection Spine vertically align
Spine vertically align
Normal
Skin integrity Inspection Skin intact Skin intact Normal ANTERIOR
THORAXBreathing pattern Auscultation Breathing is
automatic and effortless, regular and even and produces no noise
Breathing is with effort, produces noise when breathing
Due to secretions in the lungs
Lung/ breath sounds
Auscultation Bronchia-vesicular
crackles Due to the constriction of the bronchus
ABDOMENContour Inspection Flat Flat NormalTexture Palpation Smooth Smooth Normal Frequency and character
Auscultation Audible; soft gurgling sound occur irregularly and rages from 5-30 mins
Audible; soft gurgling sound occur irregularly and rages from 5-30 mins
Normal
UPPER EXTREMITY Skin color Inspection Tan Pale Due to
decrease oxygen
Size (arms) Inspection Equal Equal Normal Symmetry Inspection Symmetrical Symmetrical Normal Hair distribution Inspection Evenly
distributedEvenly distributed
Normal
LOWER EXTREMITY
Skin color Inspection Tan Pale Due to decrease oxygen
Size (legs) Inspection Equal Equal Normal Symmetry Inspection Symmetrical Symmetrical NormalHair distribution Inspection Evenly
distributedEvenly distributed
Normal
NEUROLOGICALLevel of consciousness
Interview Can follow instructions and commands
Can follow instructions and commands
Normal
Behavioral and appearance
Interview Makes eye contact with the examiner
Makes eye contact with the examiner
Normal
Mood Interview Expresses feelings which corresponds to the examiner
Expresses feelings which corresponds to the examiner
Normal
MANNERISMS &
ACTIONS LANGUAGEVoice inflection Interview Clear and
strongClear and strong
Normal
Tone Interview Fluent and articulated
Fluent and articulated
Normal
Manner and speech
Interview Can give appropriate answer to questions
Can give appropriateanswer to questions
Normal
MENTAL STATUSOrientation Interview Oriented with
timeOriented with time
Normal
TIMERecall recent and remote memory
Interview Recall events readily, immediate recall of remote information
Recall events readily, immediate recall of remote information
Normal
Judgments and thoughts
Interview Can make logical decisions
Can make logical decisions
Normal
11.
Neurological Assessment
Olfactory Nerve (sense of smell) Can smell on both nostrils.
Optic Nerve Without 20/20 vision due to aging.
Occulomotor Nerve PERRLA (test by the used of penlight).
Abducens Nerve Lateral movement
Trochlear Nerve Up & Down gaze
Trigeminal Nerve (+) face sensation
Facial Nerve Can smile, can frown, and roof his /her cheeks.
Acoustic/Vestibulocochlear Nerve Can hear on both ears (clapping the hand)
Glossopharyngeal Nerve Can swallow
Vagus Nerve (+) gag reflex
Spinal Accessory Nerve With a little strength on both shoulder.
Hypoglossal Nerve Can taste sweet, bitter & salty.
12.
5. Laboratory ProceduresLaboratoryProcedure
Date Done
Normal Values
Result Nursing Interpretatio
n
NursingResponsibilities
Hematology September 2,2009
Hemoglobin120-70g/l
153g/l Abnormal due to presence of infection
Pretest:Explain the procedure to the patient.
Instruct the patient to wear easily manipulated clothing to get blood samples easily.
Erythrocyte4.0-5.0 x 10
g/l
5.3 x g/l
Abnormal due to presence of infection
Tell the pt. to relax because the procedure is painless.
Hematocrit0.37-0.54
g/l
0.46 g/l
Normal Intra-test:Instruct the patient to look away when the needle is being inserted.
Leucocytes5-10 x 10
g/l
21.1 x 10 g/l
Abnormal due to infection weakened immune response.
Post-test:Put cotton balls on the puncture site to avoid bleeding.
Platelets150-450 x
10/l
252 x 10/l
Normal Tell the patient to rest after the test.
13.
LaboratoryProcedure
Date Done
Normal Values
Result Nursing Interpretation
NursingResponsibilities
URINALYSIS Sept. 3, 2009
ColorStraw/ yellow amber
Yellow Normal Pre-test:Explain the procedure to the pt. and how he can cooperate.
TransparencyClear
Turbid Due to infection
Provide privacy.
Reaction4.5-8.0
6.0 Normal Intra-test:Instruct the pt. on how to get urine samples (it should be midstream/ sterile technique).
Specific Gravity1.010-1.025
1.010 Normal Tell the pt. that the procedure is painless.
SugarNegative
Negative Normal Post-test:Bring the urine samples in the laboratory.
Albumin Negative
Negative Normal
MicroscopicExamination
Sept. 03, 2009
E cells:None
Few Abnormal due to infection.
Mucus Thread:None
Many Abnormal due to infection.
Red Blood Cell:4.0-5.0 x 10 g/l
0.1 Abnormal due to infection.
PLS Cells 4 Normal
4.5-5.5Bacteria:None
Few Abnormal due to infection.
14.
Diagnostic Procedure
Date Done
Result Impression Nursing Responsibilities
Sept. 4, 2009
There is haziness in right lower lung zone. Nodular densities in the trachea-bronchial region. The heart is in normal size and configuration. Diaphragm, costophrenic angle and the visualized bone are intact.
Pneumonia, right lower lung.
Pretest:Inform the client prior to the exam if you are pregnant, may be pregnant or have an IUD inserted.
Remove all jewelry and wear hospital gown because certain metal or clothing can obscure the image.
Intra-test:Provide privacy.
Post-test:Provide time for the client to change his clothing.
15.
6. Anatomy and Physiology of the Respiratory System
Lungs
The lungs are the body's major organs of respiration. The two vital parts that make up the lungs are located on each side of the chest within the rib cage. They are separated by the heart and other contents of the mediastinum - the tissues and organs of the middle chest (e.g., the heart and large vessels, windpipe, etc.). The lungs are shaped rather like an upside-down butterfly. The top, or apex, of each lung extends into the lowest part of the neck, just above the level of the first rib. The bottom, or base, of each lung extends down to the diaphragm, which is the major breathing-associated muscle that separates the chest from the abdominal cavity. Each lung is divided into upper and lower lobes, although the upper lobe of the right lung contains another triangular subdivision known as the middle lobe. The right lung is larger and heavier than the left lung, which is somewhat smaller in size because of the position of the heart. At birth, the lungs are pinkish-white in color; however, with age, the lungs darken to gray or mottled black because of deposits of carbon and other particles that are inhaled over the years.
Alveoli
An alveolus (alveoli is plural) is a tiny air sac located within the lungs. The exchange of oxygen and carbon dioxide takes place within these sacs.The basic structure of the respiratory system can be envisioned as an upside-down tree. Air is breathed into the trachea, which is the tree trunk, and thus the broadest part of the respiratory tree. The trachea divides into two major tree limbs, the right and left bronchi, each of which branches off into multiple smaller bronchi, which course through the tissue of the lung. Just as a tree's limbs branch off into ever-smaller branches and twigs, so each bronchus divides into tubes of smaller and smaller diameter, finally ending in the terminal bronchioles. The air sacs of the lung, in which oxygen-carbon dioxide exchange actually takes place, are clustered at the ends of the bronchioles like the leaves of a tree at the ends of the smallest twig-like branches, and are called alveoli.
16.
8. Drug Study
Drugs Date Order
Classification Indication Side Effect
Nursing Responsibility
Generic Name:RoxithromycinBrand Name:Macrol
Sept. 01, 2009
Antibacterial Upper and lower respiratory tract infections and otitis media due to S. Pneumonea, Mycoplasmas Pneumonea, Legionella pneumophila
Nausea, Abdominal pain and Diarrhea
Perform Skin Test
Generic Name:DiphenhydramideBrand Name:Benadryl
Sept. 01, 2009
Antihistamine Preventing or treating symptoms of high fever and other respiratory allergies, common colds and runny nose
Tiredness, Sleepiness and Disturb coordination
Tell the pt about the side effect that he may feel.Assist the pt from sitting position to lying position
Generic Name:ParacetamolBrand Name:Aeknil
Sept. 01, 2009
Antipyretic Pyrexia of unknown origin and for symptomatic relief of fever and pain associated with common disorders like lower and upper respiratory tract infection
Skin Eruption, Leucopenia
Perform TSB to help reduce fever.Instruct the pt to decrease fluid intake
Generic Name:CefuroximeBrand name:Axcef
Sept. 01, 2009
Antibacterial For the treatment of apnea and lower respiratory tract infection
Nausea and vomiting, Erythema Multiforms and Steven Johnson Syndrome
Perform Skin Test before giving antibiotics
Generic Name:AmbroxolBrand Name:Mucoslovan
Sept. 01, 2009
Expectorant Dissolved the phlegm and clear the airways
GastroIntestinal side effects
It is advisable to avoid use during the first trimester of pregnancy
18.
9. Diet and Activity
Activity Date Ordered Indication Nursing Responsibilities
Turn side to side (every 2 hrs.)
September 2, 2009
To mobilize secretions& to
prevent bed sores
Accompany the relative and the pt whenever the pt
feels body malaise
Diet Date Ordered Indication Nursing Responsibilities
Low Fat Low Salt Diet
September 1, 2009
To prevent hypertension.
Instruct the pt. and relative to follow the diet of the pt.
Tell the pt. to eat food rich in vitamins and minerals.
Increase fluid intake.
September 1 , 2009
To liquify secretions.
Tell the pt. and relative about the benefit of drinking water.
Tell the relative to use calibrated bottle to make about intake.
19.
11. SOAPIE (actual)
Subjective“Madalas pa rin akong umuubo at nahihirapqan din akong huminga
parang bumabara ang plema”, as verbalized by the patient.
ObjectiveReceived patient on semi-fowler’s position, conscious and coherent with
on going D5W 1L regulated @ 10-15gtts/min. (KVO) @90 ml. level infusing well @ right hand.
Has fast and shallow breathing Easily irritable (+) secretions (greenish phlegm) (+) rales upon auscultation Rr 30cpm
Assessment Ineffective airway clearance related to retain secretions as evidenced by
the patient’s statement.
PlanningAfter 4-6 hrs. of N.I, the patient’s respiratory rate decreased from 30 cpm
to 20 cpm.
Interventions Established rapport. Monitored and recorded vital signs. Positioned the patient in semi-fowler’s or orthopneic position. Thought the pt’s relative about PVD (percussion, vibration and postural
drainage). Instructed the patient to increase fluid intake. Provided comfort and safety measures. Medications compliance on time (with the doctor’s permission).
Evaluation Goal met as evidenced by the client’s respiration is improved.
>Pt. Rr is beyond normal>Rr: 20 cpm 20.
SOAPIE (potential)
Subjective
Objective Received pt. on semi-fowler’s position, conscious and coherent with ongoing D5W 1L regulated @ 10-15gtts/min. (KVO) @ 90 ml. level infusing well @ right hand.
Has fast and shallow breathing irritability (+ greenish phlegm) secretions (+) body malaise (+) rales upon auscultation
Assessment Risk for infection related to retained secretions in the lung.
Planning After 5-6 hrs. of N.I the patient verbalized understanding and
demonstrated techniques on how to reduce the risk for infection.
Interventions
Established rapport. Monitored and recorded vital signs. Provided comfort and safety. Instructed the pt. to increase fluid intake. Educated the pt. about proper using and disposing of tissue. Thought the pt. and relative about proper hand washing. Instructed the pt. to avoid cigarette smoking.
Evaluation
Goal partially met as evidence by the client’s respiratory condition became slightly good.
21.
12. Conclusion
We, therefore conclude that pneumonia is a serious disease in the
respiratory system. It may kill more than hundreds of young infant or older
persons with weak immune response. Pneumonia may lead to other chronic
respiratory system, so early detection or signs of the disease are important to
know the right medications to be given by medical professionals.
22.
13. Recommendations
For Health Care Provider
As the cold weather sets in, we are reminded that it is not only time for flu season but or pneumonia season. Pneumonia is one of the common communicable diseases that most of the Filipino people acquired because of weak immune response. And for the protection of health care provider it is important to b vaccinated against pneumonia, proper hygiene (or simply hand washing is very important) and of course, drinking vitamins and eating healthy food can also contribute in good immune response against any disease not only pneumonia.
For the Institutions/Hospitals
For the hospitals especially in the Government Hospitals fighting against the infectious disease Pneumonia must be also prioritized. Pneumonia vaccination must be spread especially in the urban area where the infection can be spread in just a matter of minute. Certain groups of people are more likely to catch pneumonia and to have complications from it. But because of the Pneumovax, there will be big possibilities to avoid these diseases that cause young children hat are more likely to be expose to bacteria and most of the old age people living in a poor ventilated area. And giving also the knowledge about disease and how it may be acquired or how it may not be must be the agendas of some government officials related o health and life of every young Filipinos.
23.
14. Bibliography
National Center for Health Statistics. National Vital Statistics Report. Deaths: Preliminary Data for 2004. Vol. 54, 19 June 2006.
http://search.medicinenet.com/search/search_results/default.aspx?Searchwhat=1&query=platelets
http://search.medicinenet.com/search/search_results/default.aspx?Searchwhat=1&query=Erythrocyte&I1.x=67&I1.y=10
http://www.lungusa.org/site/apps/nlnet/content3.aspx?c=dvLUK9O0E&b=2060321&content_id={71CC3CFD-4B3E-49C8-AA88-D76EAE1FB9F5}¬oc=1
http.www.WebMD.com
http://www.labtestsonline.org/understanding/analytes/urinalysis/faq.html
http://dynamicnursingeducation.com/class.php?class_id=131&pid=18
http://dynamicnursingeducation.com/class_more.php?class_id=131&more=45
http://en.wikibooks.org/wiki/Human_Physiology/The_respiratory_system
http://library.med.utah.edu/WebPath/TUTORIAL/AIDS/AIDS .html
24.