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Introduction This is a case of a 74 year old woman diagnosed with Community Acquired Pneumonia at Moderate Risk. 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. Its 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. Community Acquired Pneumonia Develops in people with limited or no contact with medical institutions or settings. The most commonly identified pathogens are Streptococcus Pneumoniae, Haemophilis Influenzae and atypical organisms like Chlamydia Pneumonia, Mycoplasma Pnemoniae, Legionella Sp. Symptoms and signs are fever, cough, pleuritic chest pain, dyspnea, tachypnea and tachycardia. Diagnosis is based on clinical presentation and Chest X-ray. Treatment is with empirically chosen antibiotics. Prognosis is excellent for healthy patients, but many pneumonias, especially when caused by S.Pneumoniae or Influenza virus are fatal in older, sicker patients. A case with a diagnosis of Pneumonia may catch ones 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 geriatric, an appropriate care has to be done to make the patients recovery faster. Treating patients with pneumonia is necessary to prevent its spread to others and make them as another victim of this illness.

Specific Objectives After the completion of this study, I will be able to achieve the following objectives: o o o o o o o o Define what is Pneumonia Trace the pathophysiology of Pneumonia Enumerate the different sign and symptoms of Pneumonia Identify and understand different types of medical treatmentnecessary for the treatment of Pneumonia Formulate and apply nursing care plans utilizing the nursing process Thoroughly discuss, explain, and elaborate the nature of the disease process. Provide appropriate and proper nursing diagnosis in line with the clients medical condition. Appraise the effectiveness and efficacy of nursing interventions rendered to the client.

Scope and Limitation This Case Study will attempt to cover and discuss the disease process and present condition of the patient as assessed in my 1 whole shift of assessment and nursing care at Polymedic General Hospital. It will also present the nursing and medical care as provided during 8 hours of duty (February 11, 2014). This case will only be limited to the patients verbalizations and significant others who partly served as informant, laboratory results, signs and symptoms as evidenced by and observed from the patient within the shift. II. Patients Profile

Name: Ebalang, Salome Sex: Female Birthday: October 23, 1939 Age: 74 years old Address: Carmen, Cagayan De Oro City Religion: Roman Catholic Nationality: Filipino Occupation: Housewife Civil status: Married

Spouse name: Occupation: Educational Attainment: Date of admission: February 11, 2014 Diagnosis: Community Acquired Pneumonia Moderate Risk

Heredo-Familial Disease

Gynecological History The client had her menarche at the age of 11, with a duration of about a week. But with the onset of her puberty her monthly decreased to just 3 days.

Food and Drug allergy Patient has no known food and drug allergies.

Diet and Lifestyle

History of Admission She was previously admitted last January 2014 at Maria Reyna Hospital because of cough and difficulty in breathing.

CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS Patient X seeks medical attention at Polymedic General Hospital last February 11, 2013 due to cough and she was then diagnosed with PCAP-MR and was advised for admission by Dr. Radaza. 1 week prior to admission Patient complains of cough, fever, dizziness, headache and decrease in appetite. Her husband sates that she is taking medications as prescribed by her physician prior to admission but failed to enumerate and name the drugs being taken by her wife. Patients chief complaint is cough. III. IV. Developmental Data Medical Management


a. Medical Orders with Rationale Date/time 2-11-2014 @ 8:55 am Secure consent to care Doctors Order Please admit to ROC under Dr.Radaza Rationale of Order To provide management fitted for patient To provide understanding in the part of the client including significant others for any medical, surgical, and nursing intervention and also for legal documentation purposes. To provide immediate access to the vascular system for the rapid delivery of specific solutions Is a Hypertonic solutions raises intravascular osmotic pressure and provides fluid, electrolytes and calories for energy.

Start venoclysis PNSS 1L @ KVO Rate

LABS: o o o o o o o Meds: o o o o Ambroxol 30mg 1 tab BID Tramadol (Maidol) 50mg 1 tab TID PRN for Pain Co-Amoxiclav Coax 625mg 1 tab OD Pizotifin Hydrogen Maleate (Mosegor Vita) + Vit. B 1 tab OD o A non-opiod analgesic for acute to severe pain CBC Urinalysis FBS Creatinine Lipid profile ECG 12 Leads Chest X-ray PA o To check or evaluate any deviation from normal in blood count creatinine is an indicator of the renal function To check patients heart rhythm and abnormalities

o o

Vital signs q 4hours

To monitor the Vital signs of patient for any untoward complications

BP q 4 hours Diet: DAT Refer if with unusualities Repeat BP prior to transport Inform AP 2-11-14 9:30 am Start Aglophin 1 gram q 8 hours IVT ANST Dazomet 500mg q 8 hours IVT ANST Please give O2 inhalation @ 2L/min via Nasal Cannula 2-11-14 1:40pm Will see patient in PM pls prepare CXR film at station For HBAIC Defer Co-amoxiclav PO

b. Drug Study

Generic Name: Date Ordered: Classification: Dose/Frequency/Route: Mechanism of Action: Specific Indication: Contraindication: Side Effects: Nursing Precaution:

Ambroxol February 11, 2014

30mg 1Tab BID, PO

Generic Name: Date Ordered: Classification: Dose/Frequency/Route: Mechanism of Action: Specific Indication: Contraindication: Side Effects: Nursing Precaution:

Co-Amoxiclav February 11, 2014

625mg 1Tab OD PO

Generic Name: Date Ordered: Classification: Dose/Frequency/Route: Mechanism of Action: Specific Indication: Contraindication: Side Effects: Nursing Precaution:

Pizotifin Hydrogen Maleate + Vit. B

February 11, 2014

1Tab OD, PO

Generic Name: Date Ordered: Classification: Dose/Frequency/Route: Mechanism of Action: Specific Indication: Contraindication: Side Effects: Nursing Precaution:

Aglophin February 11, 2014

1gram q 8hours IVTT ANST

Generic Name: Date Ordered: Classification: Dose/Frequency/Route: Mechanism of Action: Specific Indication: Contraindication: Side Effects: Nursing Precaution:

Metronidazole February 11, 2014

80mg q 8hours IVT ANST

Generic Name: Date Ordered: Classification: Dose/Frequency/Route: Mechanism of Action:

Tramadol February 11,2014 Non-Opioid Analgesic 50mg 1tab TID PRN for pain Binds to opioids receptors and inhibits the reuptake of norepinephrine and serotonin.

Specific Indication: Contraindication:

Moderate to severe pain Acute intoxication with opioids or psychoactive drugs

Side Effects:

CNS: Sedation, Dizziness, Headache, and Confusion CV: Hypotension, Tachycardia, Bradycardia Dermatologic: Sweating

Nursing Precaution:

Administer with food if GI upset occurs; Monitor patient response, Give the drug before the pain becomes intense

Generic Name: Date Ordered: Classification: Dose/Frequency/Route: Mechanism of Action:

Paracetamol February 11, 2014 Antipyretic 50mg 1tab q 8hours for fever Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or other substances than sensitize pain receptors to stimulation. The drug may relieve fever through central action in the hypothalamic heat-regulation center.

Specific Indication: Contraindication:

Mild pain and fever. Contraindicated in patients hypersensitive to drug. Use cautiously in patients with long term alcohol use because therapeutic doses cause hepatotoxicity in these patients.

Side Effects:

Jaundice Hypoglycemia Rash Headache Chest pain Dyspnea

Nursing Precaution:

a. Alert: Many OTC and prescription products contain acetominophen; be aware of this when calculating total daily dose.


Test WBC

Results 12.1

Reference (5.0 10.0)x10^9/L

Rationale Indicates infection; acute stress/trauma



(3.69-5.9) x10^12/L

Within normal values




May indicate bleeding; acute stress/trauma




Within normal limits




Within normal limits



(26.10-33.30)pg (32.0 35.0)g/dl

Within normal limits



Within normal limits

Platelet count


(150-390)x10^9/L (55.00 62.00)%



Indicates bacterial infections; inflammation



(20.00 40.00) %

Within normal limits




Within normal limits

Eosinophils Basophils RDW- CV

1.00 0.10 13.3

(1.00-6.00)% (0.00-1.00)% (11.5-14.5)%

Within normal limits Within normal limits Within normal limits









Within normal limits