Introduction

a. Background

Community-acquired pneumonia (CAP) is infectious pneumonia in a person who

has not recently been hospitalized. CAP is the most common type of pneumonia.

The most common causes of CAP vary depending on a person's age, but they

include Streptococcus pneumoniae, viruses, the atypical bacteria, and

Haemophilus influenzae. Overall, Streptococcus pneumoniae is the most

common cause of community-acquired pneumonia worldwide. Gram-negative

bacteria cause CAP in certain at-risk populations. CAP is the fourth most

common cause of death in the United Kingdom and the sixth in the United

States. The term "walking pneumonia" has been used to describe a type of

community-acquired pneumonia of less severity (because of the fact that the

sufferer can continue to "walk" rather than require hospitalization). Walking

pneumonia is usually caused by the atypical bacteria mycoplasma pneumonia.

Pneumonia is an inflammatory illness of the lung. Frequently, it is described as

lung parenchyma/alveolar inflammation and abnormal alveolar filling with fluid

(consolidation and exudation).

The alveoli are microscopic air-filled sacs in the lungs responsible for absorbing

oxygen. Pneumonia can result from a variety of causes, including infection with

bacteria, viruses, fungi, or parasites, and chemical or physical injury to the lungs.

Its cause may also be officially described as idiopathic—that is, unknown—when

infectious causes have been excluded.

Pneumonia is a common illness which occurs in all age groups, and is a leading

cause of death among the elderly and people who are chronically and terminally

ill. Additionally, it is the leading cause of death in children under five years old

worldwide. Vaccines to prevent certain types of pneumonia are available. The

prognosis depends on the type of pneumonia, the appropriate treatment, any

complications, and the person's underlying health.

Pneumonia can be caused by microorganisms, irritants and unknown causes.

When pneumonias are grouped this way, infectious causes are the most

common type.

The symptoms of infectious pneumonia are caused by the invasion of the lungs

by microorganisms and by the immune system's response to the infection.

Although more than one hundred strains of microorganism can cause

pneumonia, only a few are responsible for most cases. The most common

causes of pneumonia are viruses and bacteria. Less common causes of

infectious pneumonia are fungi and parasites.

Pneumonia is an inflammation of the lungs caused by an infection. It is also

called Pneumonitis or Bronchopneumonia. Pneumonia can be a serious threat to

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.

There are many kinds of pneumonia that range in seriousness from mild to life-

threatening. In infectious pneumonia, bacteria, viruses, fungi or other organisms

attack your lungs, leading to inflammation that makes it hard to breathe.

Pneumonia can affect one or both lungs. In the young and healthy, early

treatment with antibiotics can cure bacterial pneumonia. The drugs used to fight

pneumonia are determined by the germ causing the pneumonia and the

judgment of the doctor. It’s best to do everything we can to prevent pneumonia,

but if one do get sick, recognizing and treating the disease early offers the best

chance for a full recovery.

A case with a diagnosis of Pneumonia may catch one’s attention, though the

disease is just like an ordinary cough and fever, it can lead to death especially

when no intervention or care is done. Since the case is a toddler, an appropriate

care has to be done to make the patient’s recovery faster. Treating patients with

pneumonia is necessary to prevent its spread to others and make them as

another victim of this illness.

To be able for me to present this case, I gathered the patient's medical history,

psychosocial history, the activities of daily living before and during his

hospitalization and medical management. The anatomy and physiology of the

affected part, nursing diagnosis and nursing management are also discussed for

better understanding of his condition and implement a necessary action to help

the patient recover.

b. General Objective

At the completion of this case, student/s will be able to:

> Determine the risk factors that precipitate the formation of pneumonia from the

patient which can be taken through his health history and his activities of daily

living before hospitalization.

> Formulate a nursing diagnosis regarding on his condition.

> Formulate nursing intervention to attain a good condition and alleviate the

existing problem.

> Promote teaching to patient’s self care to maintain good health and wellness.

c. Importance of the study

A case with a diagnosis of Pneumonia may catch one’s attention, though the

disease is just like an ordinary cough and fever, it can lead to death especially

when no intervention or care is done. An appropriate care has to be done to

make the patient’s recovery faster. Treating patients with pneumonia is

necessary to prevent its spread to others and make them as another victim of

this illness.

DATABASEClient Profile

Name: Patient LAA

Age: 73 years old

Gender: Female

Race: Brown

Nationality: Filipino

Religion: Roman Catholic

City Address: 78 Brgy. M. Acevida, Sinoluan, Laguna

Marital Status: Widow

Occupation: Business woman

Diagnosis: CAP high risk; HCVD FC II; DM type 2

History

Chief Complaint:D.O.B. - “Difficulty of breathing”

History of Present Illness:

Three days prior to consultation, she had a productive cough, moderate

grade fever with anorexia and vomiting, but due to complaint of difficulty of

breathing he was admitted for further monitoring.

Past Medical History:

Client was diagnosed before at Philippine General Hospital, Laguna

of pneumonia. Client was confined for 3 weeks and later on continues the

medicines as prescribed by the doctor.

Family Medical History:

No hereditary disease can be attributed from her family. However, relatives from

his father side like uncle and cousins encountered illnesses such as

hypertension. Other than the latter, no hereditary diseases from both of his

parents are within the patient’s knowledge.

Social History:

As we know client runs a small business as a door-to-door sweets. Being

a business owner, client’s knows how to mingle and interact with her customers.

In consideration the client’s social environment are also good with her relatives

and neighbors.

Physical Assessment

Body Part Method of Assessment

Actual Findings Normal Findings

Interpretations

1. Head

Hair

Scalp

Face

Inspection

Palpation

Hair color is gray with some black hair. Wavy hair.

No dandruff

No lesions and masses palpated

Evenly distributed hair, silky and no infection.

Smooth skull contour, smooth and evenly toned skin on face

Normal findings

2. Skin Inspection

Palpation

Pallor

Rough texture and dry skin, slow skin turgor. Secondary skin lesions noted on left arm and masses palpated on different parts of his body.

Varies from light to deep brown; from ruddy pink to light pink.

Moisture in skin folds and axillae. Skin springs back to previous state when pinched.

Pallor in elderly, skin loses its elasticity and wrinkles due to decreased collagen formation. Skin is also dry and flaky because sebaceous glands and sweat glands are less active.

3. Eyes Inspection Pupils are brown in color, equal pupils, pale conjunctiva

Grossly normal visual activity

Pupil is black in color, equal in size, and round. External eye structures should not manifest edema nor is sunken; Sclera and Conjunctiva should be white. Normal visions are 20/20.

Normal findings

4. Ears Inspection

Palpation

Symmetrical external pinae,

Symmetrical external pinae and gross hearing, pinna

Normal findings

Symmetrical Gross hearing

recoils after it is folded.

5. Nose Inspection

Palpation

Brown in color, no discharge or any lesions;

Able to breathe without restriction in both nares.

Pinkish mucosa, absence of discharges

No lesions, symmetrical gross smelling

Sense of smell is still perfect for his age.

6. Mouth Inspection

Palpation

Pale lips, pinkish gums, no abrasions, swelling and ulceration.

Uniform pink color lips, slight-pinkish gums, 32 teeth intact, no swelling, no abrasions ulceration.

Normal findings

7. Pharynx Inspection

Palpation

Midline pharynx

No tonsillitis noted

Midline pharynx

Un-inflamed tonsils

Normal findings

8. Neck Inspection

Palpation

Midline trachea

Non-palpable thyroids, no swelling or masses, coordinated and free range of motion and movements, with some difficulty or discomfort, no nodules.

Midline trachea

Non-palpable thyroids, no discomforts and has equal muscle strength- free range of motions and movements without discomfort.

Normal findings

9. Chest and Lungs

Inspection

Palpation auscultation

Irregular breathing pattern

Regular breathing pattern (Quiet rhythmic, and effortless respirations),

Patient’s breathing is altered due to his present condition

Vesicular and bronchovesicular breath sounds should be audible.

10. Heart Auscultation No visible pulsations noted. Normal Heart Sounds (S1, S2) on four sites of pericardium sites: aortic, pulmonic, tricuspid, and apical.

No visible pulsations, lifts or heaves, S1 usually heard at all sites and louder at apical area, S2 usually heard at all sites and louder at base of heart.

Normal findings

11. Breast and axilla

Inspection Not Assessed Breast surface is generally even with the chest wall; smooth and intact skin, no inflammation, no redness and swelling.

Not Assessed

12. Abdomen Inspection

Auscultation

Palpation

Percussion

No rashes, masses and tenderness with bowel sound that carry on every tympany.

No rashes, no masses, no tenderness, with bowel sound that persist for every (tympany)

Normal findings

13. Back and extremities

Inspection

Palpation

Equal size on both sides of the body, no contractures, to tremors, firm muscle tone, less movements on the right lower extremities, equal strength on each body side

Equal size on both sides of the body, no contractures, to tremors, firm muscle tone, smooth coordinated movements, equal strength on each body side

Less movements on the right lower extremities due to age.

DIAGNOSTIC STUDIES

Chest x-ray: Identifies structural distribution (e.g., lobar, bronchial); may

also reveal multiple abscesses/infiltrates, empyema (staphylococcus);

scattered or localized infiltration (bacterial); or diffuse/extensive nodular

infiltrates (more often viral). In mycoplasmal pneumonia, chest x-ray may

be clear.

ABGs/pulse oximetry: Abnormalities may be present, depending on extent

of lung involvement and underlying lung disease.

Gram stain/cultures: Sputum collection; needle aspiration of empyema,

pleural, and transtracheal or transthoracic fluids; lung biopsies and blood

cultures may be done to recover causative organism. More than one type

of organism may be present; common bacteria include Diplococcus

pneumoniae, Staphylococcus aureus, ahemolytic streptococcus,

Haemophilus influenzae; cytomegalovirus (CMV). Note: Sputum cultures

may not identify all offending organisms. Blood cultures may show

transient bacteremia.

CBC: Leukocytosis usually present, although a low white blood cell (WBC)

count may be present in viral infection, immunosuppressed conditions

such as AIDS, and overwhelming bacterial pneumonia. Erythrocyte

sedimentation rate (ESR) is elevated.

Electrolytes: Sodium and chloride levels may be low.

ANATOMY & PHYSIOLOGY

A respiratory system functions to allow gas exchange. The gases that are exchanged, the anatomy or structure of the exchange system and the precise physiological uses of the exchanged gases vary depending on the organism. In humans and other mammals, for example, the anatomical features of the respiratory system include airways, lungs, and the respiratory muscles. Molecules of oxygen and carbon dioxide are passively exchanged, by diffusion, between the gaseous external environment and the blood. This exchange process occurs in the alveolar region of the lungs.

THE NOSE

•   Air enters through two openings, the external nares or nostrils.

•     Just inside each nostril is an expanded vestibule containing coarse hairs.

•     A midsagittal nasal septum divides the nasal cavity.

•    The maxillary, nasal, frontal, ethmoid and sphenoid bones form the lateral and superior walls of the nasal cavity.

•    The hard and soft palate forms the floor of the cavity. (The posterior part of the soft palate is the uvula)

•     The external portion of the nose is composed of cartilage that forms the bridge and the tip of the nose.

•     The superior, middle and inferior nasal cochae are bony shelves that project from the lateral walls of the nasal cavity.

•     The spaces between the conchae are the meatuses.

•      Posteriorly the internal nares open into the nasopharynx.

THE PHARYNX

•     Is a chamber shared by the digestive and respiratory systems.

•   It extends between the internal nares and the entrances to the larynx and esophagus.

•    A stratified squamous epithelium lines the pharynx.

  The throat of pharynx is divided in three regions:

1.       Upper naso-pharynx

2.       Middle oropharynx

3.       Lower laryngopharynx

THE NASOPHARYNX

•     Lies superior to the soft palate

•    Serves a passageway for airflow from nasal cavity

•    It contains the pharyngeal tonsils (adenoids) in posterior wall, and the opening of the eustaquian tubes (auditory tube)

THE OROPHARYNX

•          Extends front soft palate down to the epiglottis (base of the tongue)

•          It contains the palatine and lingual tonsils.

THE LARYNGOPHARYNX

The narrow zone between the hyoid bone and the entrance to the esophagus.

 THE LARYNX

•     Joins the laryngopharynx with the trachea.

•     It consist of cartilage

•     It is called the voice box.

•     The three main cartilage are: thyroid cartilage (Adams’s apple), epiglottis, and the cricoid cartilage.

•     Other cartilage is: arytenoids cartilage, corniculate cartilage and the cuneiform cartilage.

•     The epiglottis is a piece of elastic cartilages that falls over the opening (GLOTTIS) during swallowing to prevent ingested food from entering the respiratory tract.

•    The corniculate cartilage are involve the opening and closing of the epiglottis, and in the production of sounds

•    Two pairs of folds span the glottal opening. The ventricular folds (false vocal cords) are inelastic but the tension in the vocal cords can be adjusted by voluntary muscle movements.

•     During expiration air flowing through the larynx vibrates the vocal cords (true vocal cords) and produces sound waves.

•     Coughing and laryngeal spasms are protective reflex that protect the glottis and trachea from objects and irritants.

 

THE TRACHEA

•     Extends from the level of the sixth cerebral vertebra, at the base of the larynx, to the level of the fifth thoracic vertebra.

•     is a tubular structure with 4.25 inch length and 1 inch in diameter.

•     At its caudal limit the trachea divides to form primary bronchi.

•     Lies anterior to the esophagus.

•     Along the length of the trachea are 15-20 c-shapes in pieces of hyaline cartilage (tracheal cartilages)

•      The tracheal muscle holds the two sides of the c-shaped c

•      Trachea is lined with pseudo stratified ciliated columnar epithelium.  

•  The trachea branches within the mediastum, forming the left and right bronchi.

(Extra pulmonary bronchi)

• Each bronchus enters a lung at groove, The Hilus.

• Each bronchus branches into increasingly smaller passageway to conduct air into the lungs.

• The primary bronchi branch into as many secondary bronchi

(Intrapulmonary bronchi)

• The smallest passageway is the bronchioles.

 

THE LUNGS

•     is pair of cone shaped organs lining in the pleural cavity.

•    The apex is the conical top of each lung, and the broad inferior portion is the base.

•   Each lung has a hilus, a medical slits as the bronchial tubes, vascularization, lymphatic, and nerves reach the lungs.

•    Each lining is divided into lobes by deep fissures.

• Right lungs have three lobes and left lungs have two lobes.

• Left lung is divided by oblique fissure into superior and inferior lobes.

• Right lung is divided into three lobes (superior, middle and inferior)

• Superior and middle lobes are separated by a Horizontal fissure and

• The Oblique fissure separates Inferior and Middle lobes.

 

THE PLEURAL CAVITIES

•     The thoracic cavity is bounded by the ribcage and the muscular diaphragm.

•     The mediastinum divides the region into TWO PLEURAL CAVITIES.

•     The pleural cavity is lined with a serous membrane, THE PLEURA.

•     Parietal pleura line the thoracic wall, diaphragm, and mediastinum.

•     Visceral pleura cover the surfaces of the lungs. 

• The alveolar walls are made of simple squamous pulmonary epithelium.

• Scattered among epithelium are surfactant cells that secretes oil coating to prevent

The alveoli from sticking together after exhalation

• Also the alveolar walls are macrophages that phagocytes debris or potential pathogens.

• Pulmonary capillaries cover the exterior of the alveoli.

PATHOPHYSIOLOGY OF PNEUMONIA

Predisposing Factors Etiology Precipitating Factors:

Age Virulent microorganism Lifestyle Sex Streptococcus Pneumoniae Environment

Microorganism enters the nose (nasal passages)

Passes to the Pharynx, Larynx, Trachea

Microorganism enters andaffects both airway and lung parenchyma

Airway Damage Lung Invasion

Infiltration of Bronchi Flattening of epithelial cells

Infectious organisms lodges in bronchioles macrophages and leukocytes stimulation

Alveolar wall collapse necrosis of bronchial tissue mucus and phlegm production

narrowing of air passages

Increase pyrogen in the body

Necrosis of pulmonary tissue

Overwhelming sepsis

DEATH

FEVER

COUGHING (PRODUCTIVE OR

NON- PRODUCTIVE)

DIFFICULTY IN BREATHING

DISCHARGE PLANNING

Medications: Take the entire course of any prescribed medications.

Medication must be continued according to the doctor’s

instructions, otherwise the pneumonia may recur. Relapses can be far more

serious than the first attack.

Exercise: Get plenty of rest. Adequate rest is important to maintain progress

towards full recovery and to avoid relapse.

Treatment: Give supportive treatment. Proper diet and oxygen to increase

oxygen in the blood when needed.

Health Teaching: Drink lots of fluids, especially water. Liquids will keep

patient from becoming dehydrated and help loosen mucus in the lungs.

Encourage the guardians to wash patient’s hands. The hands come in daily

contact with germs that can cause pneumonia. These germs enter one’s body

when he touch his eyes or rub his nose. Washing hands thoroughly and often

can help reduce the risk.

Tell guardians to avoid exposing the patient to an environment with too much

pollution (e.g. smoke). Smoking damages one’s lungs’ natural defenses

against respiratory infections.

Protect others from infection. Try to stay away from anyone with a

compromised immune system. When that isn’t possible, a person can help

protect others by wearing a face mask and always coughing into a tissue.

Oxygenation and OPD follow-up: Keep all of follow-up appointments. Even

though the patient feels better, his lungs may still be infected. It’s important to

have the doctor monitor his progress.

Diet: Maintain low salt and low sugar diet and obtain foods high in fiber.

Maintain healthy lifestyle.

Spiritual and sexual teaching: Keep close contact in spiritual members of

the church, strengthened faith and belief in God. Beliefs and practices are

associated with all aspects of a person’s life.

References

Medical-Surgical Nursing Clinical Management for Positive Outcomes by

Joyce M. Black and Jane Hokanson Hawks 8th Edition Volume 1 & 2

Fundamentals of Nursing The Art and Science of Nursing Care by Taylor,

Lillis and LeMone 5th Edition

Nursing 2008 Drug Handbook by Wolters Kluwer | Lipincott Williams & Wilkins

PDR Nurse’s Drug Handbook by George R. Spratto & Adrienne L. Woods

http://www.wikipedia.org/

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