Community Acquired Pneumonia – Moderate Risk

Ward Nursing Training Program Group 1

Patricia G. Ricarte, RN

Tatiana Jean V. Bautista, RN

Presente d by:
Cristine Gretchen E. Chiew, RN Juvy Anne L. Gubantes, RN Cindy Ruth M. Ypilan, RN

Introduction
You would think that in the light of modern medical treatment and wide availability of antibiotics, pneumonia would no longer kill us, right? Wrong! For adults, this occur mainly as a complication of other chronic diseases like lung cancer, COPD, tuberculosis, and other debilitating illnesses that leave them bedridden most of the time.

Community-acquired pneumonia (CAP) is a disease in which individuals who have not recently been hospitalized develop an infection of the lungs (pneumonia). Pneumonia is an inflammation of the lower air passages and air sacs of the lungs resulting from infection of the parenchyma of the lungs. CAP is a common illness and can affect people of all

Community-acquired pneumonia (CAP) remains a major cause of death worldwide accounting for an estimated five (5) million deaths per year. In developed countries, the antimicrobial era has brought a 66% reduction

Studying this disease will hopefully give us nurses, together with the rest of the health-care team, some more updated information regarding the disease and its proper management, and the different nursing responsibilities that should be taken into consideration when faced with this kind of case. Also, this case study can contribute greatly to the nursing research by providing necessary data that could serve as basis for future studies. Knowledge accumulated from the making of this study helps in the

The study is all about Patient “Mumai”, 33-year old female diagnosed with CAP-Moderate Risk. Information relevant to the disease treatment and prevention are being tackled with complete reliable information during the interview phase relevant to the building of concrete data that further nourished the study. The group hopes to contribute scholarly manuscript that depicts the

“Mumai”
Age: 33 years old Sex : Female Marital Status: Married Height: 5’2” Weight: 68 kilos Address: Dumalag 1, Matina Aplaya Davao City 8000 Religion: Foursquare Birthdate: April 26, 1977 Diagnosis: Community Acquired Pneumonia MR Admitting Physician: Dr. Carl Hill N. Florida

Background of the Study
Patient Mumai is a 33-year old female who was rushed to the Emergency Room of Southern Philippines Medical Center last June 24, 2010 due to onset of cough and an on & off fever for two (2) weeks. She also experienced back pain at the right side. The client was initially seen by Dr. Florida and was admitted under his service at Medicine

Objectives
General Objective: This study aims to provide the nurses, future researchers, readers and general audiences to understand, learn and gain more knowledge regarding the case of our patient; that is CAP-MR.  

Specific Objectives: To establish rapport with the

client and her family in order to develop therapeutic working relationship and gain trust for obtaining significant information; To present the client’s personal and clinical data; To trace the client’s health history (past and present) as well as the family health history through the use of a genogram to relate it to the client’s present condition;

Specific Objectives:

To discuss the etiology and symptomatology of the disease process; To present the diagnostic examinations and their implications; To present the drug studies of all the prescribed medications with the corresponding nursing responsibilities; To develop appropriate

NURSING HEALTH HISTORY

Nursing History
History of Past Illness
The client had completed her immunization from 0-5 years of age. She completed her vaccination from tetanus toxoid and hepatitis B booster during her adolescent years. She had no history of serious illnesses except for common colds, fever and cough. At the age of 5-14 years of age, she acquired common childhood diseases such as measles, mumps and chicken

History of Present Illness Fifteen (15) days prior to admission, the client experienced a cough and a n on & off-low grade fever anytime of the day. She consulted a doctor who prescribed her Salbutamol. This somehow gave relief on her, however, her health condition didn’t subside. Seven (7) days prior to admission, then she experienced a back pain at the right side and, which is also

Sociocultural Background of the Family

Patient Mumai belongs to a Bisaya group wherein her biological parents, Kokoy and Kikay, raised her in the place of Calinan. She has eight (8) siblings and she’s the fourth child. When she decided to get married, she separated with her parents and live together with

ANATOMY AND PHYSIOLOGY

The next structure after the larynx is the trachea which leads down to the lower respiratory system. From the trachea are the bronchi, which branch down to the pleural cavity, where both lungs are located. Each lung consists of lobes separated by deep fissures. Click to edit Master text stylesThe right lung has three Second level while the left one has only Third level two. They are made up of Fourth level Fifth level elastic fibers that give the ability to handle large changes in air volume. The diaphragm is the muscle that makes up the floor of the thoracic cavity and plays a major role in the pressure and volume of air moving in and out of the

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PATHOPHYSIOL OGY

narative
Inhalation of the infectious agent causes it to transverse thru the upper respire airways. Damaging toxins are being released and are multiplied within the system downwards causing a disease called pneumonia or the inflammation and edema of the lungs. At the same time, Normal defense mechanisms occur such as the cough reflex, mucocilliary transport, pulmonary macrophage, fever, phagocytosis and increased metabolic demands. If left untreated, this would result to accumulation of debris, fluids and exudates which consolidates the lung tissues, ending up in alveolar collapse, atelectasis, respiratory distress and a possible death. Recovery usually involves focal organization of the lung by fibrosis, returning to normal structure and functioning by resolution through early detection and treatment regimen compliance.

The pathophysiology of community acquired pneumonia PREDISPOSING AND based on the case PRECIPITATING provided may be FACTORS: predisposingly caused by a high risk environment where the patient lives in and several familial histories of respiratory illnesses. However it has most probably been precipitated by inhalation of any among the infectious agents causing pneumonia.

CAUSATIVE AND ETIOLOGIC The said causative and FACTORS: etiologic factors causing this infection are any among streptococcus pneumonia, haemophilus influenzae and atypical organisms such as chlamydia, mycoplasma and legionella via respiratory droplet transmission

SYMPTOMATOLO GY: The subjective data presented on this case was cough, fever, malaise, dyspnea, chest and back pain. However, other symptoms such as chills and palpitations may also be included with the disease’s symptomatology.

CLASSIFICATIO N:
Upon medical admission, patients are being classified to be either low risk, moderate risk or high risk by the use of the pneumonias severity index. It is an assessment based algorithmic method of categorization. Aside from statistical purposes this, aids the health professionals on how to address the patient and how to plan nursing care and treatment regimen for them. The 33 year old female patient in this case was diagnosed of moderate risk community acquired with an

PNEUMONIA SEVERITY INDEX(PSI) Score = total points accumulated below

RISK CATEGORY CLASSIFICATION

*Low Risk CAP - outpatient **Moderate Risk CAP – ward admission ***High Risk CAP – ICU admission

DOCTOR’S ORDER

NURSING ASSESSMENT

Our patient Mumai, 33 year old female, married, a I. General housewife and a Filipino Citizen was admitted at the Survey Southern Philippines Medical Center due to complaints of cough and on and off low grade fever for two week. She was admitted last June 24, 2010 at exactly 7:29 pm. Upon assessment last June 27, 2010, the patient was alert, responsive and coherent to time, place where she was and the person around her. She has an Intravenous Fluid of PNSS 1 liter regulated at 120cc/hr and infusing well at her right II. Vital metacarpal vein. With oxygen inhalation via nasal Signs Click to edit only text styles cannula standby at bedside, Masterused when needed. Second level Hence, the patient is Third level ambulatory.

Nursing Assesment

Fourth level ● Fifth level

III. The Skin Upon inspection, the patient’s skin was warm to touch, slightly moist and smooth. There was no presence of lesion. When we test her skin for mobility and turgor, skin rapidly resumes its original shape after pinching.

IV. The Nails The nails of our patient were intact and welltrimmed. The patient has pinkish nail beds and is smooth in texture. Her capillary refill time was 2 seconds and has a convex curvature of fingernail plate. No lesions were noted around her fingernails and toenails.

V. The Head and Skull The Skull was normocephalic and had symmetrical facial features. There were no deformities noted such as masses, bulges and tenderness upon palpation. There was symmetrical facial expression when the group asked the patient to raise her eyebrow, puff her cheeks, smile and frown, close her eyes tightly and showing

VI. The Hair Our patient has a long black hair, slightly dry, and evenly distributed. No presence of infection or any infestations noted upon inspection at the back of the ears and along the hairline in the neck. Hair on the body was fine and evenly distributed.

VII. The Eyes
Both eyes were symmetrical upon inspection; it can follow the direction of our finger when we test her visual acuity. The patient’s eyebrows were evenly distributed. It was symmetrically aligned and has equal movement. Eyelashes curled slightly outward. The eyelid on the other hand has no discharges and discoloration. The sclera on both eyes was yellow and clear, irises are black and round. Pupils are equally round, reactive to light and constrict simultaneously with 2mm in size when passed by a light. The Conjunctivas are pinkish in color. There was no tenderness noted upon palpation of the lacrimal duct. The patient was able to see objects in periphery when we test her ocular eye movement.

VIII. The Ears
Symmetrical auricles on both ears were noted. Pinnas were in line with the outer canthus of her eyes. There was no tenderness noted upon palpation. Auricle had the same color with the facial skin. Thus, it is firm and non tender. The external canal of her ear has no discharges, inflammation nor impacted cerumen noted upon inspection. Ears were elastic and coils back to its original shape after being folded. Patient was able to hear and respond to a normal tone of

IX. The Nose
No discharges noted upon inspection. Nasal flaring was noted upon early monitoring of the vital signs. Both nostrils are present, and no tenderness and masses or nodules noted upon palpation. The mucosa is pinkish with hair. Thus, no tenderness on sinuses noted upon palpation. There was good patency on both nasal cavities as the group instructed the patient to occlude of her nares and breathe.

X. The Mouth Lips were pinkish in color, moist in texture, with no cracks noted on the upper and lower lips; gums are pinkish in color; tongue is located in the midline. No missing teeth noted. No dentures present. Uvula and tonsils are not inflamed and gag reflex is present.

XI. The Neck The patient’s neck has no evident masses, unusual swelling, or any pulsations. Upon letting her neck move such as flexing, extending, right and left rotation, and hyperextension, she was able to move it easily without pain or discomfort. The thyroid was not visible upon inspection and is smooth, without nodules, masses or

XII. The Thorax and Lungs
The thorax is symmetrical from posterior and lateral views. There was no presence of masses or tenderness upon palpation. At the early vital sign monitoring, the respiratory rate of the patient was 30 cycles per minute, use of accessory muscles were noted. Increase tactile fremitus on the right side of the lung was noted upon percussion. There was presence of crackles upon auscultation. Rapid shallow breathing pattern was also noted.

XIII. The Heart

XIV. Breast and Axilla
Breasts are round in shape and asymmetrical. Areola is round and dark brown color. Nipples are round and inverted, and brown in color. No discharges or lesions noted. No masses or tenderness noted upon palpation on both breast and axilla. Upon inspecting the axilla, there were no rashes or any signs of infection such as redness or swelling observed. The axilla is smooth, light brown with moderate amount of hair. The lymph nodes were also not palpable.

The heart sounds are distinct and regular with the rate of 90 beats per minute. The point of maximal impulse is best heard at the left mid clavicular line, 5th intercostal space

XV. The Abdomen

XVI. Genitourinary

Upon inspection, there no scars or lesions noted. There are no evident signs of infection of the umbilicus such as redness, pus formation, discoloration or swelling. No abdominal distention noted.

Voiding pattern of the client is usually done early in the morning, between the day and before going to sleep. Voiding usually ranges from 3 to 4 times a day. Urine is light yellow in color; amount of urine usually ranges from 570cc to 800cc.

XVII. Extremities
Upper Limb The patient has equal strength on both upper extremities. Full range of motion was observed when asked to move her arms in a circular motion. There was no presence of swelling or deformity.

Lower Limb There were no deformities noted on both legs. Her legs and knees can do all the range of motion such as extending and flexing without feeling of discomfort.

XVIII. Neurological Assessment

Language. The patient had no difficulty communicating to us. She was able to answer our questions well which made our interaction brief and concise. Orientation. Patient was oriented, she knows that she was admitted on June 24, 2010 at Southern Philippines Medical Center. She was also of the time during our assessment. Memory. Patient has no problem in recalling memory. She remembers her birthday and the day she was admitted.

EVALUATION:
The patient’s overall attitude towards the assessment was good since she was able to cooperate and answer the questions when asked. She is very participative and willing to submit oneself for the welfare of everyone involve in the assessment that includes her. The only abnormalities noted were observed during the vital signs monitoring early at 8:00 am. Moreover, such abnormalities noted were respiratory rate of 30 cycles per minute, temperature of 38.2 degree Celsius, patient’s skin was warm to touch, presence of nasal flaring, crackles upon auscultation of patient’s lungs, presence of rapid shallow breathing,

DIAGNOSTIC LABORATORY STUDIES

CBC + PLATELET Date: June 25,2010
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BLOOD CHEMISTRY Date: June 25,2010
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URINALYSIS Date: June 25,2010
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SPUTUM AFB Date: June 27, 2010
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CHEST X-RAY
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NURSING THEORIES

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Prob lem

Scientific Basis

G o al

Interven tion

Ratio nale

Evalua tion

NURSING CARE PLAN

Nursing Diagnosis: Ineffective Airway Clearance related to Retained Mucus Secretions

Nursing Diagnosis: Altered Thermoregulation related to disease process

Nursing Diagnosis: Fatigue related to Sleep Deprivation

Nursing Diagnosis: Altered Tissue Perfusion related to Impaired Transport of Oxygen across Alveolar Membrane

DRUG STUDY

AMPICILLIN SULBACTAM (UNASYN) Classification: Anti-infective Drugs/Penicillin Dosage: 750 mg 2 vials every 8 hours ANST Indication: It is a combination penicillin antibiotic. Ampicillin kills bacteria that cause infection, or stops the growth of bacteria. Sulbactam helps the ampicillin to work better. They fight bacteria in the body. It is used to treat many different types of infections caused by bacteria. Mechanism of action: Ampicillin exerts bactericidal action on both gram-positive and gram-negative organisms. Its spectrum includes gram-positive organisms e.g. S pneumoniae and other Streptococci, L monocytogenes and gramnegative bacteria e.g. M catarrhalis, N gonorrhoea, N meningitidis, E coli, P mirabilis, Salmonella, Shigella, and H influenzae. Ampicillin exerts its action by inhibiting the synthesis of bacterial cell wall. Sulbactam inhibits β-lactamases and extends the spectrum of ampicillin to include β-lactamase producing

Contraindications: Allergy to penicillins; infectious mononucleosis Adverse Reactions: Pain at Injection site, thrombophlebitis, diarrhoea, itching, nausea, vomiting, flatulence, candidiasis, fatigue, malaise, headache, chest pain, glossitis, abdominal distention, dysuria, urinary retention, oedema, erythema, epistaxis, mucosal bleeding. Potentially Fatal: Fatal anaphylaxis
Nursing Responsibility: •Check drug three times and with another nurse. Follow the 10 Drug Rights. •Check patient for hypersensitivity •Obtain specimen for culture and sensitivity tests before giving first dose •Watch for bleeding tendency and hemorrhage. •Check patient’s temperature and watch for other signs and symptoms of superinfection, especially oral and rectal candidiasis •Instruct pt. to immediately report signs and symptoms of hypersensitivity reaction, such as rash, fever, or chills. •Monitor liver function test results during therapy, especially in patients with impaired liver function

PARACETAMOL (TYLENOL)
Classification: Non-narcotic analgesic Dosage: Paracetamol 500mg every 4 hours PRN or ↑37.7 Indication: To reduce fever in bacterial or viral infections. It also control pain due to headache, earache, arthralgia, myalgia, musculoskeletal pain, arthritis, teething Mechanism of action: Decreases fever by a hypothalamic effect leading through sweating and vasodilation. Also inhibits the effect of pyrogens on the hypothalamic heat-regulating centers. May cause analgesia by inhibiting CNS prostaglandin synthesis; however, due to minimal effects on peripheral prostaglandin synthesis, acetaminophen has no antiinflammatory or uricosuric effects. Does not cause any anticoagulant effect or ulceration of the GI tract. Antipyretic and analgesic effects are comparable to those of aspirin.

Contraindications: Renal insufficiency, anemia. Clients with cardiac or pulmonary disease are more susceptible to acetaminophen toxicity. Adverse Reactions: •Hematologic: methemoglobinemia, hemolytic anemia, •Allergic: urticarial, erythematous, skin reaction •Miscellaneous: CNS stimulation, hypoglycemic coma, jaundice, drowsiness Nursing Responsibility: •make sure that the drug is given at the right time as ordered •make sure that is drug is not expired •Observe for adverse reaction of the drug •Encouraged patient to drink plenty of water •Document on patients medication sheet •Check urine for occult blood and albumin to assess for nephritis •Report pallor, weakness, and palpitations; S&S of hemolytic anemia, dyspnea, rapid, weak pulse; cold extremities; unexplained bleeding, bruising, sore throat, malaise, feeling clammy or sweaty; or subnormal temperatures may also be symptoms of chronic poisoning; •Document presence of fever. Rate pain, noting type, onset, location, duration, & intensity. •Recheck temperature after 15 minutes

BUTAMIRATE CITRATE (Sinecod Forte) Classification: Antitussive Dosage: Butamirate Citrate 1 tablet TID Indication: For dry cough of any aetiology(including in pertussis) and cough caused by bronchoscopy. Mechanism of action: Butamirate citrate belongs to the anti cough medicines of central action. Sinecod exerts antitussive(antitussic),  expectorant, moderate bronchodilatory action with antiinflammatory effects. Sinecod lowers the resistance of airways and improves blood oxygenation and spirometery indexes. Contraindications: Hypersensitivity, Pregnancy and Breastfeeding

Adverse Reactions: Rash, nausea, diarrhoea and vertigo have been observed in a few rare cases (a total of approximately 1% of treated cases in clinical trials), resolving after dose reduction or treatment withdrawal.

Nursing Responsibility:

Assess cough type and frequency •Assess patient’s Vital Signs •Assess sleep pattern. •Instruct patient to take drug exactly as prescribed •Monitor for adverse reactions •Advise patient to take each dose with one glass of water •Encourage patient to increase fluid intake •Encourage deep-breathing exercises

Indication: For dry cough of any aetiology(including in pertussis) and cough caused by bronchoscopy. AZITHROMYCIN (ZITHROMAX) Dosage: Azithromycin 500mg 1 tablet OD

Classification: Agent for atypical mycobacterium, antiinfectives Mechanism of action: Butamirate citrate belongs to the anti cough medicines of central action. Sinecod exerts antitussive(antitussic),  expectorant, moderate bronchodilatory action with antiinflammatory effects. Sinecod lowers the resistance of airways and improves blood oxygenation and spirometery indexes.

Contraindications: Contraindicated with hypersensitivity to azithromycin, erythromycin, or any macrolide antibiotic

Adverse Reactions: •CNS: Dizziness, headache, vertigo, somnolence, fatigue •CV: Palpitations, chest pain •GI: Diarrhea, abdominal pain, nausea, vomiting, diarrhea, dyspepsia, flatulence, vomiting, melena, pseudomembranous colitis •Hepatic: Cholestatic jaundice •Skin: rash, photosensitivity •Other:Superinfec tions, angioedema, rash, photosensitivity, vaginitis
Nursing Responsibility: •Asses patient for infection (vital signs; appearance of wound, sputum, urine and •stool; WBC) •Obtain specimens for culture and sensitivity before initiating therapy •Observe signs and symptoms of anaphylaxis •Administer 1 hr before or 2 hr after meals. Food affects the absorption of this drug •Instruct client not to take azithromycin with food or antacids. May cause stomach cramping, discomfort, diarrhea and etc. •Report any adverse effects felt by the patient. •Advise patient to take drug as prescribed, even after he feels better •Advise patient to avoid excessive sunlight and to wear protective clothing and use sunscreen when outside

INTRAVENOUS FLUID – PNSS (30-31 gtts/min) Isotonic Solution Indication: Replacement & maintenance of fluid & electrolytes Nursing Responsibilities:   Before hooking to patient, check for any discoloration and expiration date. 1. Make sure when priming the line there is no bubbles 2. Monitor pt. frequently for: a. Signs of infiltration / sluggish flow b. Signs of phlebitis / infection c. Dwell time of catheter and need to be replaced d. Condition of catheter dressing 3. Check the level of the IVF. 4. Correct solution, medication and volume. 5. Check and regulate the drop rate. 6. Change the IVF solution if needed
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PROGNOSIS

General Prognosis
Our patient’s overall prognosis is fair because despite her stay in the hospital she wasn’t able to comply with most of her medications which were essential to her ultimate recovery. In all of our interactions with her, she was very open about lifestyle and concerns which allowed us to render nursing care and health teachings. It made our time with her worthwhile.

MEDICA TIONS

EXER CISE

TREAT MENTS

HEALT H T.

O DI P E D T

SPIRIT UAL

DISCHARGE PLAN

M

EDICATIONS

Explain to the patient an the significant others the importance of the following: the medications name, its action and its potential side effects the right time and route of administering the drug how to manage common side effects of the drugs Instruct the patient to take the entire course of the prescribed medications to prevent recurrence of the illness. Encourage patient to watch out and report any unusualities during taking the prescribed drugs.

E

XERCISE

Encourage patient to take plenty of rest. Adequate rest is important to maintain progress towards full recovery. Encourage patient to lessen doing strenuous activity to avoid fatigue. Encourage patient to do deep breathing exercises.

T

REATMENT

Explain to patient to follow the prescribed medications to promote wellness. Instruct patient to report any signs of side effects of the treatment done. Explain the significance of having a follow-up appointment to the doctor.

H

EALTH TEACHING

Encourage to have a clean and safe environment conducive for wellness. Encourage to have good personal hygiene and to always wash hands. Instruct patient and family to avoid exposing to an environment with too much pollution like smoking. Explain to the patient the importance of protecting others form the infection.

O

UTPATIENT DEPARTMENT

Encourage patient to comply with the therapeutic regimen such as the medications. Instruct patient to have a follow-up check up to the doctor.

D

IET

Encourage patient to eat healthy and nutritious foods. Eat foods rich in calorie and Vitamin C. Encourage patient to drink lots of fluids, especially water.

s

PIRITUAL

Encourage family to provide emotional support to the patient. Encourage patient and family to have time praying together to enhance self concept and hope that could aid in the wellness of the patient. Encourage patient and family to always have an open communication.

INSIGHTS
As nursing graduates, we have encountered many patients with different diseases. We learned and experienced many things throughout our endeavors. In our study about Community Acquired Pneumonia (CAP) Moderate Risk, we learned that for the past years it remained a formidable foe and that it should never be underestimated. It ranked fourth in the Top Ten Leading causes of morbidity in the 2007 survey of the Department of Health and third in the Top Ten Leading cause of Mortality. Prompt treatment is needed to avoid life-threatening complications. People must remember that simple acts of hand washing, covering your mouth and nose when coughing/sneezing and taking your vitamins everyday are vital to disease prevention. These simple acts can make a big difference in our lives. They must be constantly reminded of these steps for disease prevention and early consultation. A lot of patients stop taking their medications the moment they feel better. Since pneumonia patients usually get prescribed antibiotics, it is essential for them to be reminded about medication compliance in terms of schedule and duration to prevent microbial resistance and disease reoccurrence.

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