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COMMUNITY ACQUIRED PNEUMONIA
A Case Study
Presented to
The Clinical Instructors
AUP College of Nursing
Silang, Cavite
In Partial Fulfillment
Of the Requirements in
NMSN 325
Presented by:
Evans, Mochah M.
July 24, 2012
1
I. DEFINITION
Pneumonia is the inflammation of the lung parenchyma caused by infection. The
inflammation is triggered by many infectious organisms and irritating agent. Due to
inflammation process, fluid accumulates in the lungs hindering gaseous exchange. Community-
acquired pneumonia refers to pneumonia acquired outside of hospitals or extended-care facilities.
(ignatavicius and workman 2010).
The Philippines ranks among the top 10 countries with the most recorded pneumonia
cases. About 9,000 Filipino children die from the disease every year. In 2007, there were
605,471 reported pneumonia cases. Children and babies who develop pneumonia often do not
have any specific signs of a chest infection but develop a fever, appear quite ill, and can become
lethargic. Elderly people may also have few symptoms with pneumonia
Globally, every year, it kills an estimated 1.4 million children under the age of five years,
accounting for 18% of all deaths of children under five years old and elderly worldwide.
Pneumonia affects children and families everywhere, but is most prevalent in South Asia and
sub-Saharan Africa. Ignatavicius and Workmann stated that in the United States 2 to 5 million
cases of pneumonia occur each year and it’s the seventh leading cause of death. The highest
incidence among adult occur in older adult, nursing homes resident, hospitalized patent and those
being mechanically ventilated (p659). The Centers for Diseases Control and Prevention (CDC)
estimate that pneumococcus is the most common community-acquired pneumonia.
(http://www.aahs.org/quality/quality_measures.php?cat=pneu).
2
II. TYPES OF PNEUNONIA
A. ACCODING TO SETTING OF ACQUISITION
a. Community-acquired pneumonia
Community-acquired pneumonia (CAP) occurs either in the community setting or within
first 48 hour of hospitalization or institutionalization. Hospitalization of this condition depends
on the severity of pneumonia. Most people get CAP by breathing in germs (especially while
sleeping) that live in the mouth, nose, or throat. CAP is the most common type of pneumonia.
Most cases occur during the winter. (Bare B. & Smeltzer S.2008).
b. Hospital-Acquired Pneumonia
This is a type of pneumonia is acquired during hospital stay for another illness. It’s also
known as nosocomial pneumonia. Patients are at higher risk of getting HAP if they're on a
ventilator (a machine that helps you breathe). The onset of this pneumonia symptoms starts more
than 48 hours of hospitalization. HAP tends to be more severe compared to CAP because of
existing infections. Also, hospitals tend to have more germs that are resistant to antibiotics
(medicines used to treat pneumonia). (Bare B. & Smeltzer S.2008).
c. Ventilator-associated pneumonia
This type affect patients are intubated and mechanically ventilated. The endotracheal tube
keeps the glottis open, so secretion can be aspired into the lungs. (Williams and hopper 2007)
B. ACCORDING TO CAUSATIVE AGENT
a. Aspiration Pneumonia
3
This refers to the consequences resulting from entry of endogenous or exogenous
substances gaining access to the lower airways. The most common cause is infection from
aspirated bacteria that normally resides at upper respiratory airways.(Williams & Wilkins, 2010).
It can occur in community or hospital. The most common bacteria are Streptococcus pneumonia,
hemophilia influenza, and staphylococcus aureus. Other causes may include, gastric content,
chemical or irritating gases inhale food, drink, vomit, or saliva from your mouth into your lungs.
This may happen if something disturbs your normal gag reflex, such as a brain injury,
swallowing problem, or excessive use of alcohol or drugs. (Joyce M. Black 2009)
b. Bacterial pneumonia :
This type of pneumonia is caused by different types of bacteria. The most pneumonia
inducing bacterium is Streptococcus pneumoniae. This pneumonia types generally affects people
who have weakened immune system for reasons like old age, illness, malnutrition etc. (Lewis, et
al 2008)
c. Viral pneumonia :
This Type of pneumonia can be caused by different types of viruses. The most common
forms of viruses causing viral pneumonia are flu virus, parainfluenza virus, herpes simplex virus,
rhinovirus, adenovirus, Hantavirus, cytomegalovirus and respiratory syncytial virus.(lemone
&burke 2007)
d. Fungal pneumonia :
This is rare types of pneumonia. The fungus causing this type of pneumonia is
Pneumocystis carinii. It’s common among people with weak immune system or
immunosuppressed. Often pneumocystis carinii pneumonia is described as a complication
4
experienced by patients with diseases that weaken the immune system such as AIDS, Cancer etc.
(Leone &burke 2008) .
e. Hypostatic pneumonia
This type is related to patients who hypoventilate because of bed rest, immobility or
shallow respiration. Secretions pools in dependent areas of the lungs and can lead to
inflammation and infection (Williams and hopper 2007)
f. Chemical pneumonia
Inhalation of toxic chemicals can cause inflammation and tissue damage, which will lead
to chemical pneumonia. (Williams and hopper 2007)
g. Atypical Pneumonia (Walking Pneumonia)
This refers to pneumonia that is mild enough so that you are not bedridden. The
condition can be treated without hospitalization. It is caused by mycoplasma pneumonia
Legionella pneumophila, mycoplasma pneumonia, and Chlamydophila pneumoniae It is known
as atypical because its presentation and its course significantly differ from other bacterial
pneumonia (lemone and Burke, 2008)
C. ACCORDING TO THE PART IT AFFECT
a. Lobar pneumonia
As the name suggest, this types affect one or more lobes of the lungs. It can be anywhere
in the lobe and may include both lobes. (Tampano, and Lewis, 2012)
b. Bronchopneumonia or lobular pneumonia
5
This type affects the epithelial cells of distal airways and alveoli part of the lungs causing
consolidations thereby decreasing gaseous exchange. (Tampano, and Lewis, 2012)
c. Interstitial pneumonia
This type is characterized by progressive scarring of both lungs. (Tampano, and Lewis, 2012)
III. DEMOGRAPHIC PROFILE
Name: Rachel (not real name)
Address: 391 Summitville Putatan municipality
Sex: Female
Civil status: widowed
Academic attainment: unknown
Birthdate: December 18, 1918
Nationality: Filipino
Religion: Baptist
Date of admission: June 29, 2012
Time of admission: 2:15 pm
Admitting diagnosis: community acquired pneumonia t/c PTB
Chief complaint: difficulty of breathing and fatigue
6
Admitting vital signs:
Temperature 37.7 oC , Respiratory rate 32, Pulse rate 89, Blood pressure 90/110, Oxygen
saturation 93%
VI. FAMILY MEDICAL HISTORY
V. PAST MEDICAL HISTORY
7
Rachel past medical history was hard to retrieve since the watcher did not know. This is due
to the patient age. Since the patient has advance age no one had exact information regarding
to the Patient. But as much as the watcher could recall, Rachel has never been hospitalized.
VI. HISTORY OF PRESENT ILLNESS
Seven (7) days prior to admission, the patient developed difficult of breathing together with
productive cough which attacked more during the night time. Expectorate was greenish brown.
This was associated with undocumented fever. She decided to seek medical attention at Alabang
medical center where she was treated.(Pulmo-dual nebulization) and allowed to go home. Hours
prior to admission, had difficult of breathing and severe cough, that prompted her to seek
medical attention at Ospital ng Muntinlupa (and was subsequently admitted).
VII. GORDON’S PHYSICAL ASSESSMENT
a. Health Maintenance – Perception Pattern
Rachel has no history of smoking or drinking alcoholic beverages. She was active before this
ailment. She used to walking around their compound with her grandchildren, this gave her
happiness. Prior to admission, she complains of cough, which usually occurs during the night.
No allergies on medications were documented.
b. Nutritional – Metabolic Pattern
Before admission, Rachel was not under any special diet. She used to have 3 meals a day
with good appetite. She was not taking any dietary supplements. During hospital confinement
she had a decreased appetite and she was under soft diet. Her ability to swallow is not impaired.
c. Elimination Pattern
8
Before hospitalization Rachel had 2 times bowel movement, but during hospitalization, under my
care the patient she had no bowel elimination. Patient had urinary incontinence and she was
wearing a diapers. Normally the diaper was changed once under my shift.
d. Activity and Exercise
Before hospitalization, the Patient was able to go to the comfort room with minimal
assistance. As it was reported by the significance others, assistance was needed to accompany
her to prevent injury and falls. Patient also did not need assistance during feeding. However, she
needs assistance when walking far distances and when climbing the stairs. During
hospitalization, the patient was fully dependent in all aspect of daily living. She is now
immobilized which put her at risk of developing complications.
e. Rest/Sleep Pattern
Before Rachel used to sleep is 6-7 hours. She was normally sleep between 8- 9 PM and
wakes up early at 6:00 in the morning. Prior to admission, her sleeping pattern was altered due to
frequent episodes of coughing, which usually occurs during the night. During hospital stay her
sleeping pattern was disturbed minimally. She started sleeping only for 5 hour but with some
episodes of waking up by nurses and doctor. But it was tolerable. Also she complained of the
environment, which looked strange to her.
f. Cognitive-Perceptual Pattern
Rachel has a problem with speech and hearing. She was alert but was not able to respond
appropriately because of lack of teeth. Before admission, her usual complaints are cough and
difficulty of breathing. She also had episodes of chest pain prior to admission.
g. Role-Relationship Pattern
9
She was a widow for several years now. She seems to treasure the relationship she had. This
is evidenced by the fact that she still has a wedding ring. It was reportedly that she normally says
that by not throwing the ring it’s because she still loves her husband. She usually stays in their
house with her grandchildren.
h. Sexuality-Reproductive Pattern
N/A
i. Coping-stress Tolerance / Self-Perception / Self-Concept Pattern
Rachel has to deal with loss when her husband died. She talks with her grandchildren during
and that time to find comfort.
j. Value-Belief Pattern
Rachel is a passive member of Baptist church. She does not attend church services but she
does her routine prayers.
VIII. DEVELOPMENTAL TASKS
Developmental task Theorist Status
Integrity versus despair Erikson The developmental task at this time,
according to Erikson, is ego integrity versus
despair. People who attain ego integrity view life
with a sense of wholeness and derive satisfaction
from past accomplishments. They view death as
an acceptable completion of life. For my patient,
i had no chance to have her views about life due
language incoherent. But from my assessment
she seemed to take hospitalization as a
10
punishment in life. (Kozier and Erb, 2008, p.
416).
Genital Stage Freud Rachel is 93 years old, in which she can be
categorized in the Genital Stage. In this stage,
the client is expected to have her energy directed
toward full sexual maturity and function and
development of skills needed to cope with the
dynamic environment. This implies that the
patient should have the full independence and
has the capability of making decisions for
herself.
The patient is unable to make sound
judgment. She cannot perform tasks without
assistance such as, going to the bathroom. There
is also negative implication due to loss of
spouse. At this age, they are supposed to support
and encourage each other (Kozier and Erb, 2008)
Formal operation Piaget Use of rational thinking and reasoning is
deductive and futuristic. The patient used to
achieve this stage since the range of the age ids
from 11-15years old. She is not futuristic right
11
now. She does not know what could possibly
happen to her because she is not yet ready to
accept the fact that the reality that she is sick.
(Kozier and Erb, 2008, ).
Late maturity Havighurst Robert Havighurst believed that learning is basic
to life and that people continue to learn
throughout life. He described growth and
development as occurring during six stages, each
associated with six to ten tasks to be learned. In
relation with the patient’s age, she has to develop
specific tasks, and one of which is adjusting to
physical strength and health. Patient has been
diagnosed with community-acquired pneumonia.
This gives her hard time to adjust to hospital
confinement. Other tasks include, adjusting to
death of spouse, establishing an explicit
affiliation with one’s age group. (Kozier and
Erb, 2008).
Post conventional:
universal focus
Kohlberg This theory specifically addresses moral
development in children and adults. The morality
of an individual’s decision was not Kohlberg’s
12
concern; rather, he focused on the reasons an
individual makes a decision.
Rachael is in the Post conventional Level of
Kohlberg’s theory as she “lives autonomously
and defines moral values and principles that are
distinct from personal identification with group
values” (Kozier and Erb, 2008, p. 359). At her
age now she is impaired judgment due to
advance in age.
IX. PHYSICAL ASSESSMENT
a. Vital signs
Date 6/29/2012 7/2/2012 7/3/2012 7/4/2012
Time 2.15 PM 8:00
AM
12:00 PM 8:00 AM 8:00
AM
12:00 PM
T 38.0 37.2 36.7 36.9 37.2 37.4
PB 89 86 86 84 80 82
RR 33 26 32 28 26 28
BP 90/110 110/70 100/70 110/70 120/80 110/70
b. Systemic assessment
Systems Normal findings Actual patient Significance
13
findings
Physical
appearance
- Well appearance, body
symmetry, no obvious
deformity.
-Limbs should appear
proportional.
-Speech should be clear
and understandable.
- Breathing should be
effortless, without cough
or wheezing.
-Patient should be willing
to move all body parts
freely.
- Vital Signs:
RR= 12-20 bpm
PR= 60-100 bpm
Temp= 36.5PC – 37.2PC
BP= 90-130/60-90
-Patient appears
skinny and weak.
-Limbs are thin
with prominent
blood vessels.
-Speech was
slurred.
- Patient was
unable to move.
-Struggle while
breathing
- Vital Signs:
RR= 32
PR= 89
Temp= 37.4.PC
BP= 110/70
(7/4 2012)
- An increase in RR is
present in hyper metabolic
and hypoxic states due to
bacilli damaging the alveolar
cell lining thus impairing the
gas exchange which then
results to an increase RR for
the body to meet the body’s
demands. (Weber and Kelly
2007)
A
Neurological
system
-Clean and well groomed
wearing appropriate
clothing for age, and
weather.
- Client is well
groomed and
dressed
appropriately.
- Poor clothing may be an
indication of depression.
- Cognitive impairment is
caused by a number of
14
-Smooth coordinated
movements.
-Expresses good feelings
appropriate to situations
-Expresses full and free
flowing thoughts during
interview
-Aware of self, others,
place and time
-Correctly answers
questions about current
days activities; recalls
significant past events
- Client is alert,
and incoherent.
-weak motor
response
- confused utter
understandable
words
syndromes such as dementia.
- Elderly speech and motor
function degenerate as they
advance in age. The is
caused due to decrease of
nerve myelination (Weber
and Kelly 2007)
Gastrointestinal
system
-The contour of the
abdomen should be
rounded or flat and
symmetrical
- No masses or nodules.
- Uniform in color and
pigmentation.
- Normal wt. 128-156 lbs.
or 58-70kg.
- No masses or
nodules present.
- Abdomen is
unsymmetrical not
uniform in color
and pigmentation.
- Bloated is
observed.
-decreased bowel
- decreased bowel sound
signify signs of constipation
or likelihood of developing
constipation(Weber and
Kelly 2007)
15
movement
Integumentary
system
-Skin is uniform whitish
pink or brown color,
depending on the patient`s
age.
-Temperature should be
warm and equal bilaterally
-Pitched-up skin returns
immediately to original
position
-No swelling, pitting or
edema
-Hair varies from dark
black to plonde based on
the amount of melanin
present and should be
evenly distributed
-The nails have pink cast
in light-skinned
individuals and are brown
in dark-skinned
individuals with capillary
refill returning to its
- Skin is dark
brown and not
uniform.
- Hair white and
evenly distributed.
- Skin is warm to
touch.
-skin and nail bed
pale,
-pale conjunctiva
-decreased skin
turgor,
-increased skin
pigmentation,
-thin and dry skin,
-Capillary refill 4
seconds
- An increase in temperature
may be caused by infection,
trauma, sunburn, or
windburn.
- Skin crust is a serum/blood
that has been dried in the
surface of the skin.
-.increased pigmentation is
cause due to the decrease of
melanin in the body(Waugh
A. and grant A. 2008)
16
normal within 2-3
seconds.
Urinary system - The bladder should not
be distended.
-There should be no
problem urinating, no
presence of hematuria or
dysuria.
- Color should be amber
yellow.
- OU should not be
30cc/hr
- Patient’s bladder
is not distended.
- There’s no
hematuria, or
dysuria when
urinating.
- OU is 100cc the
whole shift.
(total intake is
250cc)
The urine output
should be almost or
equal to the input. If
there is a deviation it
may signify fluid
accumulation(Weber
and Kelly 2007)
Circulatory
system
-No vibrations or
pulsations are palpated in
aortic, pulmonic or
tricuspid area
-Rhythm should be
regular
-Rate is 60-100 beats per
minute
-Radial pulse and apical
- Radial pulse
weak and apical
pulse, strong and
irregular.
-Capillary refill is
within 4 seconds.
- Pulmonary stenosis
impedes blood flow form the
right ventricle into the lungs,
causing a bulge.
- A systolic pulsation can
result from the right
ventricular enlargement
secondary to an increased
stroke volume.
17
pulse should be identical
-Bilateral pulses strong
and equal
-Capillary refill within 2-3
seconds
- A capillary refill within ≥3
seconds signifies a poor
blood circulation.
Respiratory
system
-The normal respiratory
rate is 12-20 breaths per
minute being regular and
even in rhythm
-The normal depth of
respiration is non-
exaggerated and effortless
-Thorax rises and falls in
unison in the respiratory
cycle
-Normal inhalation and
exhalation is through the
nose
-light yellow or clear
small amount of sputum
which is odorless
-Normal lung tissue
produces a resonant sound
- Productive cough
without
expectoration.
- RR= 32 bpm
- (+) Crackles
heard upon
auscultation in
lower lobes of both
lungs.
- Difficulty
breathing
- Exaggerated
respiration; use of
accessory muscle
when breathing.
-Bacteria or infection irritates
the endothelium of the lungs
which leads to excessive
mucus production.
-excessive mucus and some
of the fluid accumulation
caused fine crackles
-difficulty of breathing is as a
result of extended
accumulation of fluid in the
pleural space that reduces
lungs compliance(Waugh A.
and grant A. 2008)
18
-Symmetrical structure
and development of
muscles.
LYMPHATIC
SYSTEM
- WBC(5-10 X 10 9/L
- Lymphocytes 0.25-
0.35
- Monocytes 0.03-0.07
- Eosinophils 0.01-0.03
- Basophils 0-0.01
- Neutrophils 0.40-0.60
WBC-17.91
0.08
0.04
0.50
0.00
0.88
Elevation of white blood cell
and lymph nodes are an
indication of infection in the
lungs(Weber and Kelly
2007)
Musculoskeletal - Muscle equal in size
- No tremor
- No protrution of body
prominence
-
Muscle wasting all
over the body.
- Weak muscle
strength.
- protruding body
prominent
Muscles may exhibit
atrophy. Atrophy occurs as
the cells in tissue shrink.
The cause of this cell
shrinking is unknown, but
may be due to reduced
use, decreased workload, or
reduced stimulation by
19
nerves. (Weber and Kelly
2007)
X. Diagnostic Test Results and Significance
NAME OF TEST NORMAL
VALUES
RESULTS SIGNIFICANCE
HEMATOLOGY
WBC
- Lymphocytes
- Monocytes
- Eosinophils
- Basophils
- Segments
- Platelet count
- Reticulocytes
- MCV
- MCH
- MCHC
- RBC
- Hemoglobin
- Hematocrit
5-10x109/L
0.20-0.40
0.25-0.35
0.03-0.07
0.01-0.03
0-0.01
150-450
5-15x109/L
140-450/L
80.0-97
26.0-31.0
4.5-5.5x109/L
125-160g/L
0.38-0.50%
17.91
0.08
0.04
0.50
0.00
0.88
290
0.00
81
78.0
28.2
4.43
122
0.36
-elevated WBC indicates possible
acute infection or inflammation or
pneumonia, meningitis, or
empysema.
- Decreased MCV may indicate
iron and thalassemia deficiency.
-decreased RBC and hemoglobin
indicates reduced tissue
oxygenation.(Keogh J, 2010)
20
OXYGEN
SATURATION
≥95%
(Pagana, 2011)
93% - This indicates that there is
decreased oxygen
concentration to the tissues due
to lungs problem. (Pagana,
2011)
GRAM STAIN and
culture
It is used to differentiate
bacterial species
WBC 5-10x 10/L
Epithelial cells:-
Tiny plemorphic
(+) cocci in singles
and pairs
Presence of bacteria.
Streptococcus
pneumoniae
20-30/Lpf
Gr(+) cocci in pairs
in chains+++
- A Gram stain and culture of
the material from an infected
site are the most commonly
performed microbiology tests
used to identify the cause of
an infection. This will allow
appropriate antibiotic.(Keogh
J, 2010)
X-ray No nodules, no
scarring, no lesions,
no fluid in the
spaces of the lungs
Cardiac shadow is
enlarged with the
chamber enlarged.
Brocho-pulmonary
marking appear
prominent. Course
reticular opacities
seen in both lower
lungs field
associated with
- Presence of nodules and lesion
may predispose consolidation.
The presence of fluid in the
pleural spaces may indicate
pleural effusion. Both
situations decrease the lungs’
compliance.(Keogh J, 2010)
21
haziness. There is
fibro hazed and
calcified densities
noted in the apices
with biapical pleural
thickness.
Aorta is mildly
dilated and tortious.
Its knobs calcified,
both sulci are
blunted, severe
dextroscoliosis n of
the thoracic spine.
XI. ANATOMY AND PHYSIOLOGY
The lungs are sponge like, elastic, cone-shaped organs located in the chest cavity in the chest.
The lung itself is covered with a membrane called the visceral (or pulmonary) pleura. The
visceral pleural is adjacent to the lining of the thoracic cavity which is called the parietal pleura.
22
Between the two membranes is a thin, serous fluid which acts as a Lubricant – reducing friction
as the two membranes slide across one another when the lungs expand and contract with
respiration. The surface tension of the Pleural fluid also couples the visceral and parietal pleura
to one another, thus preventing the lungs from collapsing. Since the potential exists for a space
between the two membranes, this area is called the pleural cavity or pleural space The apex (top)
of each lung extends above the clavicle; the base (bottom) of each lung lies just above the
diaphragm (major muscle for inspiration). McCance K.L. & Huether S.E. (2010).
Gas exchange occurs in the lobule of the lungs. Each lobule is supplied by a branch of a terminal
bronchiole, an arteriole, the pulmonary capillaries and a venule. Gas exchange takes place in the
terminal respiratory bronchioles and the alveolar ducts and sacs, referred to as the respiratory
zone. Blood enters the lobules through a pulmonary artery and exits through a pulmonary vein.
Lymphatic structures surround the lobule and aid in the removal of plasma proteins and other
particles from the interstitial spaces. (Waugh A. and grant A. 2008)
Unlike the larger bronchi, the respiratory bronchioles are lined with simple epithelium rather
than ciliated pseudo stratified epithelium. The respiratory bronchioles also lack the cartilaginous
support of the larger airways. Instead, they are attached to the elastic sponge like tissue that
contains the alveolar air spaces.
The alveoli are the terminal air spaces of the respiratory tract and the primary site of gas
exchange. Each alveolus is a small out pouching of respiratory bronchioles, alveolar ducts, and
alveolar sacs. The alveolar sacs are cup-shaped thin-walled structures that are separated from
each other by thin alveolar septa. A single network of capillaries occupies most of the septa, so
blood is exposed to alveolar air on both sides of the capillary. Unlike the bronchioles, which are
tubes with their own separate walls, the alveoli are interconnecting spaces that have no separate
23
walls. As a result of this arrangement, there is a continual mixing of air in the alveolar structures.
Small holes in the alveolar walls, the pores of Kohn, also contribute to the mixing of air.
The alveolar epithelium is composed of two types of cells: type I and type II alveolar cells. The
alveoli also contain brush cells and macrophages. The brush cells, which are few in number, are
thought to act as receptors that monitor the air quality of the lungs.( McCance K.L. & Huether
S.E. (2010).
The type I alveolar cells, also known as type I pneumocytes, are extremely thin squamous cells
with a thin cytoplasm and flattened nucleus that occupy about 95% of the surface area of the
alveoli. They are joined to one another and to other cells by occluding junctions. These junctions
form an effective barrier between the air and the components of the alveolar wall. Type I
alveolar cells are not capable of cell division.
The type II alveolar cells, also called type II pneumocytes, are small cuboidal cells located at the
corners of the alveoli. The type two cells synthesize pulmonary surfactant, a substance that
decreases the surface tension in the alveoli and allows for greater ease of lung inflation. They are
also the progenitor cells of type I cells. After lung injury, they proliferate and restore both type I
and type II alveolar cells.
Pulmonary surfactant is a complex mixture of phospholipids, neutral lipids and protein that is
synthesized in the type II alveolar cells. The surfactant molecules produced by the type II
alveolar cells reduce the surface tension at the air-epithelium interface and modulate the immune
functions of the lung. Recent research has revealed four types of surfactant, each with different
molecular structure: surfactant proteins A (SP-A), B (SP-B), C (SP-C), and D (SP-D). SP-B and
SP-C reduce the surface tension at the air-epithelium surface and increase lung compliance,
which increases volume of air entering the lung and decreases the work of inhalation. SP-A and
24
SP-D do not reduce surface tension, but contribute to host defenses that protect against
pathogens that have entered the lung. Collectively, they opsonize pathogens, including bacteria
and viruses, to facilitate phagocytosis by macrophages. They also regulate the production of
inflammatory mediators evidence also suggests that SP-A and SP-D are directly bactericidal,
meaning they can kill bacteria in the absence of immune system effector cells. (Ignatavicius D.
& Workman M. L (2010).
XII. Pathophysiology of the Disease Entity
Upper airway characteristics normally prevent potentially infectious particles from reaching
the normally sterile lower respiratory tract. Pneumonia arises normally from present flora in a
patient whose resistance has been altered, or it results from aspiration of flora present in the
oropharynx. Another route of infection is through the inhalation of microorganisms that have
been released into the air when an infected individual coughs, sneezes, or talks, or from
aerosolized water, such as that from contaminated respiratory therapy equipment. (Joyce M.
Black 2009)
Pneumonia can also occur when bacteria are spread to the lungs in the blood from bacteremia
that can result from infection elsewhere in the body or from intravenous drug abuse. Loss of the
cough reflex, damage to the ciliated endothelium that lines the respiratory tract, or impaired
immune defenses predispose to colonization and infection of the lower respiratory system.
Bacterial adherence also plays a role in colonization of the lower airways. The epithelial cells of
the critically and chronically ill persons are more receptive to binding microorganisms that cause
pneumonia.
The initial step in the pathogenesis of streptococcus pneumoniae infection is the attachment
and colonization of the organism to the airway passages. If a microorganism gets past the upper
25
airway defense mechanisms, such as the cough reflex and mucociliary clearance, the next line of
defense is the alveolar macrophage. This phagocyte is capable of removing most infectious
agents without setting of significant inflammatory or immune responses. However, if the
microorganism is virulent or present in large enough numbers, (1) it infects type II alveolar cells,
which are responsible for the production of surfactant. Pulmonary surfactant is a complex
mixture of phospholipids, neutral lipids, and proteins that is synthesized in the type II alveolar
cells. The surfactant molecules produced by the type II alveolar cells reduces the surface tension
at the air-epithelium interface and modulate the immune functions of the lungs. The reduced
surface tension increases lung compliance, which increases volume of air entering the lung and
decreases the work of inspiration. (lenone and burke 2008)
The virulent number of organisms also triggers the organism to (2) release endotoxins, which
stimulates the goblet cells of the epithelial lining to secrete mucus, and triggers the release of
some chemical mediators, including the prostaglandins, histamine, and bradykinin. These
chemical mediators increase the vascular permeability, and specifically with bradykinin attracts
neutrophils. The pathologic process of staphylococcus aurius pneumonia can be divided into the
four stages – congestion, red hepatization, gray hepatization, and resolution. Lewis S.M. et al.
(2005).
Congestion occurs when the chemical mediators attract the white blood cells, especially the
neutrophils, which cause the alveoli to be filled with a protein-rich edema fluid containing
numerous organisms and vasodilation. Marked capillary congestion follows, leading to massive
outpouring of polymorphonuclear leukocytes, bacteria and other exudates. These exudates can
extend into the pleural cavity and cause empyema. Empyema is the accumulation of purulent
26
exudates in the pleural cavity. Exudates may also go to into the bloodstream, causing sepsis and
septic shock.(Mccance K. and Huether E. 2010)
The massive outpouring of the exudates causes a collection of fluid around the alveoli. The
fluid leaks into pleural cavity. Red blood cells and fibrin migrate into the damaged alveoli trying
to repair the destroyed portion. This gives the lung dry, dark-reddish appearance and it is called
the red hepatization stage. Solidification of the lung (consolidation) also occurs during this
stage.( Sharon L, Lewis …et al 2012)
Fibrin, a protein responsible for clotting, causes the lung to be stiff as if forms thread-like fibers.
This causes lungs to decrease its compliance due to its incapability to expand completely. The
amount of air inhaled also decreases, causing a shunt-type ventilation-perfusion mismatch. A
decreased in arterial oxygenation can lead to hypoxemia. However, after two or more days
depending on the success of the treatment, macrophages arrive at the site and ingestion of the
debris occurs. Fibrin and epithelial cells repair the site. Because of fibrin deposition over the
pleural surfaces and the presence of fibrin and leukocytes (neutrophils) in the consolidated
alveoli, where phagocytosis is rapidly taking place, the lungs appear firm and gray color. This is
the gray hepatization stage. With resolution, increasing number of macrophages appears in the
alveolar spaces, the neutrophils degenerate and the exudates are gradually removed. The fibrin
threads and the remaining bacteria are ingested by macrophages and removed by the lymphatic
vessels or becomes a scar.( Lewis et al.. . 2011)
27
28
29
30
XIII. Nursing Care Plan
Problem #1: Difficulty of breathing (July 2, 2012)
31
Subjective
Objectives
Restlessness
Tachpnea
Difficulty vocalizing
Pallor
Pale nail beds
Capillary refill: 4 seconds
Irritability
Positive crackles in both lower lobes
upon auscultation
Productive but non expectorated
cough
Use of accessory muscles
RR-32 Bpm (N-12-20)
CXR reveals: lung consolidation
Nursing diagnosis: Impaired gas exchange related to destruction of the lung tissues secondary to
pneumonia
Rationale: By the process of diffusion, the exchange of oxygen and carbon dioxide occurs in the
alveolar-capillary membrane area. The relationship between air flow and blood flow affects the
efficiency of gas exchange. Conditions that cause changes or collapse of the alveoli would be:
impaired ventilation, presence of secretions, or altered oxygen carrying capacity of the blood
from reduced hemoglobin. Gulanick/Myers, Nursing Care Plans 6th Edition 2007 (Pg.78)
Nursing diagnosis: Ineffective airway clearance related to increased mucus production
secondary to bacterial infection
Rationale: The inflammation and increased secretions seen with pneumonia patients make it
difficult to maintain a patent airway. Joyce M. Black, Medical Surgical Nursing 8th Edition
2009. (Page 1599)
32
Nursing diagnosis: Ineffective Breathing Pattern related to accumulation of bacteria in the
alveolus secondary to pneumonia
Rationale: streptococcus pneumoniae breaks down elastin in the connective tissue of the lungs
resulting to alveolar walls destruction thereby many clients experience compensatory tachypnea
because of an inability to meet metabolic demands. This occurs because affected alveoli cannot
effectively exchange oxygen and carbon dioxide. Joyce M. Black, Medical Surgical Nursing
8th Edition 2009. (Page 1599)
Expected outcomes
NOC: Respiratory Status: Gas Exchange, Ventilation and Airway Patency,
Short term: After 30 minutes of nursing interventions, the patient will be able to demonstrate
ways to relieve from DOB like deep breathing and positioning herself in an upright position,
Long term: After 8hours of nursing intervention, the patient will be able maintain airway
patency.
Nursing interventions:
NIC: Respiratory Monitoring, Ventilation Assistance, and Airway Management
Independent
Assessed lung sounds, respiratory rate and effort use of accessory muscles
-Respiratory rate <12 or >24 may indicate an ineffective pattern or use of accessory
muscles indicates distress.( Gulanick/Myers, 2007)
-Diminished lung sounds indicate possible poor air movement and impaired gas
exchange. ( Gulanick/Myers, 2007)
33
-Crackles and wheezes may indicate excess secretions in airways. ( Gulanick/Myers,
2007)
Elevated head of bed
Upright positioning promotes lung expansion, mobilization and expectoration of
secretions to keep the airway clear.. ( Gulanick/Myers, 2007)
Provided opportunities for rest
To reduce fatigue. ( Gulanick/Myers, 2007)
Monitored amount, color and consistency of sputum
Thick, purulent sputum indicates infection and should be reported to the physician.
( Gulanick/Myers, 2007)
Encouraged small but frequent oral fluid intake
Hydration decreases viscosity of secretions and aids expectoration. ( Gulanick/Myers,
2007)
Encouraged family members to feed client during rest periods.
Rested patients may have less difficulty with swallowing. ( Gulanick/Myers, 2007)
Determined best resting position for the patient e.g. patient propped on right side
after feeding
Upper airway patency is facilitated by upright position and turning to right side
decreases likelihood of drainage into trachea. ( Gulanick/Myers, 2007)
Auscultated breath sounds for development of crackles
Aspiration of small amounts can occur without coughing or sudden onset of respiratory
distress, especially in patients with a decreased level of consciousness. ( Gulanick/Myers,
34
2007)
Dependent
Administered expectorants as ordered (fluimucil)
Expectorants help liquefy secretions and trigger the cough reflex..( Gulanick/Myers,
2007)
Monitored IVF of D5LR 1L x 16o (20-21 gtt/ml)
Promotes hydration that able to enhance ability to do activities, .( Gulanick/Myers, 2007)
Administered oxygen as ordered.
Aid in correcting the hypoxemia that may occur secondary to diminished alveolar lung
surface. ( Gulanick/Myers, 2007)
Administered pneumonia drugs as ordered such as ampicillin 750mg IV every 2 hours
and azithromycin 500mg IV every 4 hours.( Gulanick/Myers, 2007)
Evaluation
Goal met:
Short term: After 30 minutes of nursing interventions, the patient demonstrated ways to relieve
from DOB like deep breathing and positioning herself in an upright position,
Goal partially met:
Long term
Goal met: After 8hours of nursing intervention, the patient was be able to maintain airway
patency but with some exerted effort while breathing.
Problem #2 choking
35
Subjective
Objective
Tachypnea 32bpm (N12-20)
Difficulty of breathing
Feeding while lying supine on bed
Age(93)
Production of secretions(greenish
brown)
Watcher perform oral care as pt is on
supine positions
Nursing diagnosis: Risk for aspiration related to irregular patterns of breathing secondary
to inflammatory response.
Rationale: Patient who has persistent coughing is at risk of aspiration due to the food or liquid
being ingested may go to the airway instead of the stomach. (Brunner & Suddarth’s Medical
Surgical Nursing 10th edition 2008)
Expected outcomes
NOC: Aspiration Control
Short term: After 30 minutes of nursing interventions, the patient will be able to demonstrate
ways on preventing aspiration such as eating on an upright position, small and frequent feeding,
and chewing food thoroughly.
Long term
After 8 hours of nursing intervention the patient will be free from any form of aspiration by
abiding to the guidelines given
Nursing interventions:
NIC: Aspiration precautions
36
Independent
Encouraged family members to do oral care after meals
This removes residual food that can be aspirated at a later time.( Gulanick/Myers, 2007)
Kept head of bed elevated when feeding and for at least a half an hour afterward
Maintaining a sitting position after meals may help decrease aspiration.( Gulanick/Myers, 2007)
Monitored for choking during eating or drinking
Choking indicates aspiration.( Gulanick/Myers, 2007)
Encouraged the patient to chew thoroughly and eat slow during meals
Well-masticated food is easier to swallow. (Gulanick/Myers, 2007)
Evaluated swallowing ability by assessing for coughing, choking and after
swallowing
Coughing and choking are indicative of aspiration.( Gulanick/Myers, 2007)
Assessed patient`s ability to swallow and strength of cough reflex and evaluated
amount of secretions
Helps to determine the presence /effectiveness of protective mechanisms.(
Gulanick/Myers, 2007)
DEPENDENT
Administered oxygen as ordered through cannula rate of 2-3l/min
Aid in correcting the hypoxemia that may occur secondary to diminished alveolar lung
surface.( Gulanick/Myers, 2007)
Evaluation
Short term
37
Goal met: After 30 minutes of nursing interventions, the patient will be able to
demonstrated ways on preventing aspiration such as eating on an upright position, small
and frequent feeding, and chewing food thoroughly
Long term
Goal met: After 8 hours of nursing intervention the patient was free from any form of
aspiration by abiding to the guidelines given.
Problem #3 decreased bowel moment
Subjective
Objective
Hard stool
No defecation for 2 days
Hypoactive bowel sounds -
2bowel sound per minute (N 5-
20)
Urine incontinence
Bloated abdomen
Hard formed stool
Nursing diagnosis: constipation related to abdominal muscle weakness
secondary to advance in age
Rationale:
Expected outcome
NOC: Bowel movement
Short term: After 30 min. of nursing intervention, the patient will be able to understand the
importance to increase fluid intake so as help in softening the impacted or hard stool.
Long term: After 2 days. Of nursing intervention, the patient will be able regain normal pattern
of bowel functioning.
38
Nursing interventions
NIC: constipation management
Independent
Encourage activity and exercise within limit of individual ability
To stimulate the contraction of the intestines.( Gulanick/Myers, 2007)
Determine and Promote adequate fluid intake
To promote passage of soft stool.( Gulanick/Myers, 2007)
Encourage diet of balanced fiber, bulk and fiber supplements
To improve the consistency of stool and facilitate passage through the colon.(
Gulanick/Myers, 2007)
Note the general dental or oral health issues
To evaluate dietary intake.( Gulanick/Myers, 2007)
Monitor input and out put
To evaluate if the hydration of the patient.( Gulanick/Myers, 2007)
Dependent
Monitored IVF of D5LR 1L x 16 (20-21 gtt/ml)
Promotes hydration that able to enhance ability to do activities, .( Gulanick/Myers, 2007)
Evaluation
Short term
Goal met
After 30 min. of nursing intervention, the patient was be able to understand the importance to
increase fluid intake so as help in softening the impacted or hard stool
Long term
39
Goal partially met
After 2 days. Of nursing intervention, the patient was be able regain normal pattern of bowel
functioning but defecated 2 times.
Problem #4: loss of appetite (July 2, 2012)
Subjective
Objective
Appear skinny
bloated abdomen
Difficulty of breathing
loss of appetite (half a bowl of soup/
meal)
Weight 35kgs.
Generalized Muscle wasting
Sunken Cheeks
Generalized body weakness
Inability to do ADLs: personal
hygiene
NPO when dyspneaic
Easy fatigability
RBC: 4.43 X 1012/L Normal: 4-6 X
1012/L
Nursing diagnosis: Imbalanced nutrition less than body requirements related to increased
metabolism utilization of energy 2o to infection
Rationale: Any illness can affect a previously hearty appetite. Loss of appetite can cause
unintentional weight loss.
Expected outcomes
NOC: nutritional status: food and fluid intake; nutrient intake
40
Short term: After 30 min. of nursing intervention, the patient will be able to identify factors to
gain weight such as eating well balanced food that are rich in Vitamin C, protein and
carbohydrates.
Long term: After 2 days of nursing intervention, the patient will be able to start eating well
balanced diet such as fruits and vegetables rich in Vitamins and minerals.
Nursing interventions
NIC: Nutritional management; Nutrition therapy
Independent:
Noted age, body build, and strength and activity level.
Helps determine nutritional needs. ( Gulanick/Myers, 2007)
Documented actual weight and height of the patient.
Patients may be unaware of their actual weight and height or weight loss due to
estimating weight.( Gulanick/Myers, 2007)
Obtained nutritional history from his significant others in our assessment
The patient`s perception of actual intake may differ.( Gulanick/Myers, 2007)
Evaluated total daily food intake and obtained diary, patterns and times of eating
To reveal possible causes of malnutrition.( Gulanick/Myers, 2007)
Promoted adequate fluid intake ; limit fluids 1hr prior to meals
to reduce possibility of early satiety.( Gulanick/Myers, 2007)
Encouraged exercise
Metabolism and utilization of nutrients are enhanced by activity.( Gulanick/Myers, 2007)
41
Ensure that client receives small, frequent feedings, including a bedtime snack,
rather than three larger meals.
Large amounts of food may be objectionable, or even intolerable, to the client.(
Gulanick/Myers, 2007)
Encouraged client to eat foods rich in iron and vitamin B12 and C protein and
carbohydrates.
It is important to consume a balanced diet to provide body with the nutrients that it needs
to fight tuberculosis. Vitamin C increases the solubility of iron. Vitamin B12 and folic
acid are necessary for erythropoiesis. .( Gulanick/Myers, 2007)
Dependent
Administered FeSO4 + Folic
This is a drug of choice for treating iron deficiency anemia and for preventing deficiency
when iron needs cannot be met by diet alone.( Gulanick/Myers, 2007)
Monitored IVF of D5LR 1L x 16 (20-21 gtt/ml)
Promotes hydration that able to enhance ability to do activities, .( Gulanick/Myers, 2007)
Consult with dietician for further assessment and recommendations regarding food
preferences and nutritional support-dieticians have a greater understanding of the
nutritional value of foods and may be helpful in assessing specific ethnic or cultural foods
Evaluation
Goal met
42
Short term: After 30 min. of nursing intervention, the patient identified factors to gain weight
such as eating well balanced food that are rich in Vitamin C, protein and carbohydrates.
Goal not met
Long term: After 2 days of nursing intervention, the patient did not start eating well balanced
diet such as fruits and vegetables rich in Vitamins and minerals due to financial constraints.
Problem #5: Body weakness (July 3, 2012)
Subjective
Objective
Restlessness
generalized body weakness
loss of appetite
RR 32 bpm
Needs support during ambulation
Prolonged bed rest
Assisted by significant others in
performing ADLs: personal hygiene
(grooming, eating, toileting)
Poor appetite
RBC: 4.43 X 1012/L Normal: 4-6 X
1012/L
Hgb: 122 normal 140-180 gm/L
Hct: 0.36 normal 0.40- 0.54 gm/L
Nursing diagnosis: activity intolerance related to imbalanced oxygen supply and demand and
decreased oxygen carrying capacity of the blood.
Rationale: A person with insufficient nutrient and supply of oxygen also has insufficient
physical or psychological energy to endure or perform desired physical activities. (Seaback,
2007).
43
Expected outcome
NOC: Activity tolerance;
Short term: After 30 min. of nursing intervention, the patient will be able perform activities
such assisted ROM exercises within capabilities.
Long term: After 2 days of nursing intervention, the patient will be able to apply energy
conserving techniques such as pursed lip breathing, using cups for liquids such as soups when
eating, and adequate rest.
Nursing interventions
NIC: energy management
Independent
Obtained data regarding normal activities and limitations.
Determines the effects of fatigue have on normal functioning . (Seaback, 2007).
Noted patient’s reports of weakness, fatigue and difficulty accomplishing tasks.
Symptoms may contribute to intolerance of activity .( Gulanick/Myers, 2007)
Planned care to carefully balance rest periods with activities
–to reduce fatigue. (Seaback, 2007).
Assess the patients level of mobility
It aids in defining what the patient is capable of which is necessary before setting
realistic goals(Seaback, 2007).
Assess nutritional status
44
Adequate energy reserves are required for activity. (Seaback, 2007).
Plan for progressive increase of activity level
Both activity tolerance and health status may improve with progressive training.
(Seaback, 2007).
Assisted with ADLs as indicated; however, avoid doing for patients what they can
do for themselves.
Assisting the patient with ADLs allows for conservation of energy. (Seaback, 2007).
Provided passive ROM exercises with the patient.
ROM exercise helps in muscle strength. (Seaback, 2007).
Instruct the client and family in the importance of maintaining proper nutrition and
rest.
This is for energy conservation and rehabilitation. (Seaback, 2007).
Evaluation
Goal met
Short term: After 30 min. of nursing intervention, the patient performed activities such assisted
ROM exercises within capabilities.
Long term: After 2 days of nursing intervention, the patient applied energy conserving
techniques such as pursed lip breathing, using cups for liquids such as soups when eating, and
adequate rest.
45
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