I.

INTRODUCTION
This is a case of a 74 year old woman who was diagnosed with
Community Acquired Pneumonia.

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. This means oxygen cannot reach
the blood and the cells of the body.

Most pneumonias are caused by bacterial infections.The most common

infectious cause of pneumonia in the United States is the bacteria Streptococcus
pneumoniae. Bacterial pneumonia can attack anyone. The most common cause
of bacterial pneumonia in adults is a bacteria called Streptococcus pneumoniae
or Pneumococcus. Pneumococcal pneumonia occurs only in the lobar form.

An increasing number of viruses are being identified as the cause of respiratory

infection. Half of all pneumonias are believed to be of viral origin. Most viral
pneumonias are patchy and the body usually fights them off without help from
medications or other treatments.

Pneumococcus can affect more than the lungs. The bacteria can also cause
serious infections of the covering of the brain (meningitis), the bloodstream, and
other parts of the body.

Community-acquired pneumonia develops in people with limited or no contact

with medical institutions or settings. The most commonly identified pathogens
areStreptococcus pneumoniae, Haemophilus influenzae, and atypical organisms
(ie, Chlamydia pneumoniae,Mycoplasma pneumoniae, Legionella sp). Symptoms
and signs are fever, cough, pleuritic chest pain, dyspnea, tachypnea, and
tachycardia. Diagnosis is based on clinical presentation and chest x-ray.
Treatment is with empirically chosen antibiotics. Prognosis is excellent for
relatively young or healthy patients, but many pneumonias, especially when
caused by S. pneumoniae or influenza virus, are fatal in older, sicker patients.

II. PATIENT PROFILE

Name: E. Costales

Age: 74 years old

Sex: Female

Religion: Roman Catholic

Date Admitted: September 17, 2009 at exactly 11:15 AM

Admission diagnosis: COPD not in exacerbation

Final diagnosis: Community Acquired pneumonia (CAP)moderate Risk

III. PATIENT HISTORY

Chief Complaint: Difficulty of Breathing

General Data:

This is a case of a 74 year old female Filipino, presently residing in

Adelina 3 Binan, Laguna who was admitted in Perpetual Help Hospital on
September 17, 2009.

History of Present Illness:

5 days prior to admission, patient had positive signs and symptoms of

cough, yellowish pleghm, persistent fever and back pain. Knowing that these
signs and symptoms were just forms of little discomforts, she self medicated
with paracetamol. However, she noticed no changes and experienced
difficulty of breathing so she sought medical consultation.

IV. PHYSICAL ASSESSMENT

Date Assesed: September 17, 2009

Time Assessed:

Vital Signs:

Blood Pressure: 110/60

Temperature: 35.7 C

Pulse rate: 78bpm

Respiratory rate: 26 breaths/min

General appearance:

The patient is awake, lying on bed, conscious and coherent with

an IVF of PNSS and side drip of D5W with incorporation of
aminophylline on the right arm.

V. ANATOMIC AND PHYSIOLOGY OVERVIEW

 The Lungs

The lungs are paired, cone-shaped organs which take up most of the space in
our chests, along with the heart. Their role is to take oxygen into the body, which
we need for our cells to live and function properly, and to help us get rid of
carbon dioxide, which is a waste product. We each have two lungs, a left lung
and a right lung. These are divided up into 'lobes', or big sections of tissue
separated by 'fissures' or dividers. The right lung has three lobes but the left lung
has only two, because the heart takes up some of the space in the left side of our
chest. The lungs can also be divided up into even smaller portions, called
'bronchopulmonary segments'.
These are pyramidal-shaped areas which are also separated from each other by
membranes. There are about 10 of them in each lung. Each segment receives its
own blood supply and air supply.

Air enters your lungs through a system of pipes called the bronchi. These pipes
start from the bottom of the trachea as the left and right bronchi and branch many
times throughout the lungs, until they eventually form little thin-walled air sacs or
bubbles, known as the alveoli. The alveoli are where the important work of gas
exchange takes place between the air and your blood. Covering each alveolus is
a whole network of little blood vessel called capillaries, which are very small
branches of the pulmonary arteries. It is important that the air in the alveoli and
the blood in the capillaries are very close together, so that oxygen and carbon
dioxide can move (or diffuse) between them. So, when you breathe in, air comes
down the trachea and through the bronchi into the alveoli. This fresh air has lots
of oxygen in it, and some of this oxygen will travel across the walls of the alveoli
into your bloodstream. Travelling in the opposite direction is carbon dioxide,
which crosses from the blood in the capillaries into the air in the alveoli and is
then breathed out. In this way, you bring in to your body the oxygen that you
need to live, and get rid of the waste product carbon dioxide.
VI. PATHOPHYSIOLOGY
Virulent Microorganism

Streptococcus Pneumoniae

Microorganism eneters the nose( nasal passages)

Passes through the larynx, pharynx, trachea

Microorganism enters and affects both airway and lung parenchyma

Airway damage Lung invasion

Infiltration of bronchi flattening of epithelial cells

Infectious organism lodges macrophages and leukocytes

Stimulation in bronchioles necrosis of bronchial tissues mucus and phlegm production

Alveolar collapse narrowing of air passage COUGHING

Productive/non-productive

Increase pyrogen in the body DIFFICULTY OF BREATHING

FEVER

Necrosis of pulmonary tissue

Overwhelming sepsis

DEATH
VII. Medical Management

VIII. Diagnostic Exam

Chest X-ray Result:

Impression: There are reticolunodular opacities on both
lungfields with upward traction of left hilus. There are dilated thick
walled bronchi noted on both lower lobes. Heart is not enlarged. Aortic
knob is sclerotic other visualized structures are unremarkable.
Findings are suggestive of Extensive PTB, Bilateral with cicatrical
changes, left upper lobe.Bacteriologic correlation is suggested.

Clinical Chemistry Result:

Sodium: 124.9 mmol/L Normal: 135.0-148mmol/L

Hematology Result:
Hct: 0.29 Normal: 0.37-0.47

WBC: 23.5x10 Normal: 5.0-10.0x10

Segmenters: 0.87

Lymphocytes: 0.13

Urinalysis:
Color: Light Yellow

Transparency: Slightly Hazy

Reaction: (pH) 6.0

Protein: +1

Glucose: negative

Specific Gravity: 1.010

Pus cells: 3-4/HPF

RBC: 2-3/hpf
Crystals: A Urates: Many

Mucus threads: few

Cast: Fine Granular cast : 1-2/HPF

IX. Drug Study

Generic Name: Hydrocortisone Sodium succinate

Brand Name: Solu-Cortef

Classification: Corticosteroid, short acting

Dosage: 100mg IV, q 6 hours

Pharmacokinetics:
Metabolism: Hepatic; half life 80-120min.
Distribution: Crosses Placenta; enters breast milk
Excretion: Urine
Indications:
Replacement therapy in adrenal cortical insufficiency
Hypercalcemia; associated with cancer
Short term inflammatory disorders
Contraindications:
Infections, especially tuberculosis, fungal infections, amoebiasis,
hepatitis B, liver disease, liver cirrhosis, active or latent peptic ulcer.

Adverse Reaction:
Vertigo, headache, hypotension, shock, thin, fragile skin, petechiae,
amenorrhea, muscle weakness.

Nursing Considerations:
1. Give daily before 9AM to mimic normal peak diurnal corticosteroid
levels and minimize HPA suppression.

2. Space multiple dose evenly throughout the day.

3. Use minimal dose for minimal duration to minimize adverse effects.

4. Use alternate day maintenance therapy with short acting

corticosteroids whenever possible.

Generic Name: Acetylcysteine

Brand Name: Fluimucil

Classification: Mucolytic Agent

Dosage:

Pharmacokinetics:
Metabolism: Hepatic; half life 6.25 hr
Excretion: Urine (30%)
Indications:
Mucolytic Adjuvant therapy for abnormal, viscid, or inspissated mucus
secretion in acute and chronic bronchopulmonary disease
(pneumonia,asthma,TB).
Contraindications:
Contraindicated with hypersensitivity to acetylcysteine; use caution
and discontinue if bronchospasm occurs.
Adverse Reaction:
Nausea, rhinorrhea, bronchospasm especially in asthmatics,
stomatitis,and urticaria.

Nursing Considerations:
1. dilute with normal saline solution or sterile water for injection.

2. Administer the ff drugs separately because they are incompatible

with acetylcysteine: tetracyclines, hydrogen peroxide, trypsin.

3. Use water to remove residual drug solution on the patient’s face

after administration by face mask.

4. Inform patient that nebulization may produce an initial disagreeable

odor, but will soon disappear.
 X. NURSING CARE PLAN

Problem: Difficulty of breathing

Diagnosis: Ineffective Airway Clearance related to increased mucus production.

ASSESSME DIAGNOSI SCIENTIFI OBJECTIV INTERVENTI RATIONAL EVALUATI

NT S C ES ON E ON

REASON
Subjective: Ineffective Increased Short term Independent: Goal half
airway mucus goal: met.
“nagrereklamo clearance production is 1.Assessed 1.Tachypnea,
nga yang si related to often caused After 3-4 hours rate/depth of shallow After 4 hours of
nanay na increase by an of intervention, respiration and respiration are nursing
nahihirapan mucus underlying patient will chest movement. usually intervention,
siya huminga, production illness. If expectorate present. patient
dami din kasi mucus is the secretions expectorated
plema eh” as effectively and 2.Lowers
most 2.Elevated head diaphragm, secretion and
verbalized by prevalent RR will of bed and RR decreased
relative. decrease from promoting
symptom, it is changed position chest from 26/min to
usually 26 to normal frequently. 22/min.
Objective: range of 16- expansion,
caused by mobilization
*RR- 26 something 20/min.
and
simple like expectoration
allergies or of secretion.
the common Long term
*Dyspnea cold. Other goal:
illnesses that
*(+)non- result in After 3 days of
productive excessive intervention,
cough mucus patient will
production maintain 3.Deep
*Use of patent airway
accessory include breathing
as evidenced 3.Assisted patient facilitates
muscle pneumonia,
by normal RR. with frequent maximum
flu and
deep breathing expansion of
bronchitis
exercises. the lungs and
smaller
airways.

4.Fluids aid in
4. Encouraged mobilization
increase in fluid and
intake. expectorations
of secretions

Collaborative:
5.Aids in
5.Administered mobilization of
mucolytics as secretion.
indicated.
(Fluimucil)

6.Fluids are
required to
6.Provided replace
supplemental insensible loss
fluids. and aids in
(IVF: PNSS) mobilization of
secretions.

7.Follows
progress and
effects of
7.Monitored
disease
chest Xray, ABG
process.
and pulse
oximetry results.