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I.

INTRODUCTION:
Pneumonia is an inflammation of the lungs usually caused by infection
with bacteria, viruses, fungi or other organism. Pneumonitis as a more general
term that describes an inflammatory process in the lung tissue that may
predispose a patient to or a place at risk of microbial invasion. Spread by infected
respiratory droplets thru person-person contact.
Pneumonia is a particular concern for older adults and people with
chronic illnesses or impaired immune systems, but it also can strike young,
healthy people. Worldwide, it's a leading cause of death in children, many of
them younger than a year old.
There are more than ! kinds of pneumonia ranging in seriousness from
mild to life-threatening. "lthough signs and symptoms vary, many cases of
pneumonia develop suddenly, with chest pain, fever, chills, cough and shortness
of breath. #nfection often follows a cold or the flu, but it also can be associated
with other illnesses or occur on its own.
II. A. OBJECTIVE OF THE STUDY:
# came up with the following ob$ectives of the study. "t the end
%&'!()!) 'idterm coverage, # will be able to*
(. +ind a case study.
). "ssess thoroughly to gather the data needed for our documentation.
,. -etermine the patient.s health history.
/. #dentify the present illnesses.
. Perform an intervention to minimi0e the pain.
1. &onduct a 2eath teaching to help promote wellness.
B. SCOPE AND LIMITATION OF THE STUDY:
The study was conducted to determine the heath needs of "ligsao, 3hod.
The researcher conducted an interview to prioriti0e the necessity especially we
are dealing with the disease that inflicted to the patient. -ue to limited time and
duty, the student only gathered the data necessary for the case study.
III. GROWTH AND DEVELOPMENT (DEVELOPMENTAL HISTORY):
A. Sigmu! F"#u! ($%&'($)*))
Psychosexual Theory
"n "ustrian neurologist developed the Psychoanalytic 4Psychose5ual6
theory which shares an emphasis on personality development and early
childhood e5periences. 2is theory comprises +ive stages, the Oral, Anal,
Phalli, Latent and Genital stage. The Libido changes its location of
emphasis within the body from one stage to another. Therefore, a particular
body area has a special significance to the client at his age right now. "nd in
the Psychoanalytic view, early e5periences shape one.s personality for an
entire lifetime, and psychological problems in adulthood may have their
origins in difficult or traumatic childhood e5perience which we call Fi+,-i.
4the immobili0ation or the inability of the personality to proceed to the ne5t
stage because of an5iety6.
B. E"i/0 E"i/01. ($)23 4 $))')
Psychosocial Theory

"n "merican psychoanalyst, 7rik 7rickson, proposed a related series of
psychosocial stages of personality growth that more strongly emphasi0e
social influences within the family. 2e believes that the greater the task
achievement, the healthier the personality of a person, failure to achieve a
task influences the person.s ability to achieve the ne5t task. 7rickson.s eight
stages span the entire life course, and, contrary to +reud.s stages, each
involves a conflict in the social world with two possible outcomes. 7rickson.s
theory thus emphasi0es the interaction of internal psychological growth and
the support of the social world.
C. J#, Pi,g#- ($%)'($)%2)
Cognitive Developental Theory
Swiss psychologist 8ean Piaget.s &ognitive -evelopment refers to the
manner in which people learn to think reason and use language. 2e defined
four stages of cognitive development within each stage are finer units or
1/5#m,. #t involves a person.s intelligence, perceptual ability to process
information. Piaget claimed that children construct new knowledge by
applying their current knowledge structures to new e5periences and modifying
them accordingly. 2is perspective, called constructivis, emphasi0ed the
active role children play in their own mental growth as in9uisitive thinkers.
S-,g#1 .6 C.gi-i7# D#7#8.9m#-. Piaget identified four stages in cognitive
development*
(. S#1."im.-." 1-,g# 4#nfancy6. #n this period 4which has 1 stages6,
intelligence is demonstrated through motor activity without the use of
symbols. :nowledge of the world is limited 4but developing6 because its
based on physical interactions ; e5periences. &hildren ac9uire ob$ect
permanence at about < months of age 4memory6. Physical development
4mobility6 allows the child to begin developing new intellectual abilities.
Some symbolic 4language6 abilities are developed at the end of this stage.
). P"#(.9#",-i.,8 1-,g# 4Toddler and 7arly &hildhood6. #n this period
4which has two substages6, intelligence is demonstrated through the use
of symbols, language use matures, and memory and imagination are
developed, but thinking is done in a nonlogical, nonreversible manner.
7gocentric thinking predominates
,. C./"#-# .9#",-i.,8 1-,g# 47lementary and early adolescence6. #n this
stage 4characteri0ed by < types of conservation* number, length, li9uid,
mass, weight, area, volume6, intelligence is demonstrated through logical
and systematic manipulation of symbols related to concrete ob$ects.
=perational thinking develops 4mental actions that are reversible6.
7gocentric thought diminishes.
/. F."m,8 .9#",-i.,8 1-,g# 4"dolescence and adulthood6. #n this stage,
intelligence is demonstrated through the logical use of symbols related to
abstract concepts. 7arly in the period there is a return to egocentric
thought. =nly ,> of high school graduates in industriali0ed countries
obtain formal operations? many people do not think formally during
adulthood.
D. R.:#"- H,7ig5u"1-
Developental Tas!
2avighurst believes that learning is basic to life and that people continue to
learn throughout life. 2e describes growth and development as occurring during
si5 stages, each associated from a task to be learned. 2avighurst promoted the
-evelopmental Task in (@!.s which arises at a certain period in the life of an
individual. Successful achievement of the task leads to happiness and to
succeed in the ne5t task. +ailure to achieve a task leads to sadness of an
individual, disapproval in the society and difficulty with later task.
IV. HEALTH HISTORY:
A. P,-i#-;1 P".6i8#
N,m#: "ligsao, 3hod
D,-# .6 Bi"-5: -ecember )A, )!!@
Ag#: ( Bear old
S#+: 'ale
Ci7i8 S-,-u1: &hild
H#ig5-: (!/ cm
W#ig5-: @.) kg
M.-5#": :athleen "ligsao
O//u9,-i.: 2ousekeeper
F,-5#": 7mmanuel "ligsao
O//u9,-i.: Ta5i -river
A!!"#11: Carangay (A, &agayan de =ro &ity
R#8igi.: 3oman &atholic
A88#"gi#1: %o known allergies
D,-# A!mi--#!: %ovember )), )!!@
Tim# A!mi--#!: !*!! pm
A!mi--ig Di,g.1i1: Pneumonia
A--#!ig P5<1i/i,: -r. -affodil ". 'acatol
V. HISTORY OF PRESENT ILLNESS:
3" had suffered cough most often times. ( day prior to admission he
suffered cough and shortness of breath. Thereafter her mother decided to admit
3" to %orthern 'indanao 'edical &enter 4%''&6. Dpon assessment, the
following data were obtained*
Caseline Eital Signs
Temperature ,<.,F&
Pulse 3ate (/, beats;min
3espiratory 3ate /! cycles;min
+inal -iagnosis* Pneumonia
"dmitting Physicians* -r. 'acatol
VI. MEDICAL MANAGEMENT
A. D./-."1 O"!#" R,-i.,8#
$$( 33( 322)
TP3 every /hrs G to monitor patients vitals
-iet* -iet as tolerated G to supplement necessary nutrients as required for
growth and development
Hab e5ams*
CBC G to rule out any infection and other hematologic disorders. A sharp
increase in the number of white blood cells indicates infection.
URINALYSIS to determine kidney function & extent of infection. Determine
the causative agent so that appropriate antimicrobial agents can be
prescribed.
FECALYSIS to determine astro !ntestinal condition and any parasitic
infection.
CHEST =RAY G to determine the physical condition of the lungs.
#E* - #'C !!cc to regulate I /cc;hr G
'eds*
&larythromycin- "n antibiotic inhibits protein synthesis in susceptible Cacteria,
causing cell death.
Salbutamol 4-uavent6 G A bronchodilator. "reatment for broncho#spasm
associated with pneumonia.
#;= Sheet G to monitor intake and output, and prevent hyper $hypovolemia.
Weight patient daily pre breakfast G to determine changes in weight and
helps predict total fluid status.
2ydrotherapy for fever G to help reduce elevated body temperature.
'onitor Eital signs to include respiratory status every /hrs and refer
accordingly G %lose monitoring of vital signs and detect every signs of
respiratory compromise.
$$( 3*( 322)
&ontinue 'eds - compliance of treatment regimen
VII. DIAGNOSTIC > LABORATORY E=AMINATIONS AND SIGNIFICANCE
U"i,8<1i1:
&olor - Bellow
Transparency - &lear
Specific gravity - (.!)!
Ph - .!
Sugar - %egative
Protein - Trace
3C& - !-/
PDS - )-1
7pithelial cells - +ew
Cacteria - +ew
&&&&& 'ossible sign of infection &&&&&
H#m,-.8.g<:
W&& - ((.1
Hymphocyte - ,<
&&&&& 'ossible sign of infection &&&&&
=RAY:
2a0e density seen at the inner lung 0ones.
2eart is not enlarged.
-iaphragm intact.
&&&&& 'neumonia, bilateral. (ollow up is suggested &&&&&
VIII. NURSING SYSTEMS REVIEW CHART
PHYSICAL ASSESSMENT:
%ame* "ligsao,3hod -ate*
Eital Signs* Pulse* (/, CP' 33* /! &P' Temp* ,<.,F&
2eight* (,@ cm Weight* @.):J
EENT:
K L impaired vision K L blind
K L pain K L reddened K L drainage
K L gums K L hard of hearing K L deaf
K L burning K L edema K L lesion K L teeth
"ssess eyes, ears, nose, and throat
+or abnormality K5L no problem
RESPIRATORY
K L asymmetric K5L tachypnea
K L apnea K L rales K5L cough K L barrel
K L bradypnea K L shallow K L rhonchi
K L sputum K L diminished K5L dyspnea
K L orthopnea K L labored K L whee0ing
K L pain K L cyanotic
"ssess resp.rate, rhythm, depth, and
Creath sounds, comfort K L no problem
CARDIOVASCULAR
K L arrhythmia K L tachycardia
K L diminished pulses K L edema K L fatigue
K L irregular K L bradycardia K L murmur
K L tingling K L absent pulses K L pain
"ssess heart sounds, rate, rhythm, pulse, CP,
&irculation, fluid retention, comfort K5L no
problem
GASTRO INTESTINAL TRACT
K L pain K L urine color K L vaginal bleeding
K L hematuria K L discharge K L noctoria
"ssess urine fre9., control, color, odor,
comfort ;
Jyn-bleeding, discharge K5L no problem
NEURO
K L paralysis K L stuporous K L unsteady K L
sei0ures
K L lethargic K L comatose K L vertigo K L tremors
K L confused K L vision K L grip
"ssess motor function, sensation, H=&,
strength
Jrip, gait, coordination, orientation,
Speech K5L no problem
MUSCULOS?ELETAL ,! S?IN
K L appliance K L stiffness K L itching K L petechiae
K5Lhot K L drainage K L prosthesis K L swelling
K L lesion K L poor turgor K L cool K L deformity
K L wound K L rash K L skin color K L flushed
K L atrophy K L pain K L eccymosis
K L diaphoretic K L moist
"ssess mobility, motion, galt, alignment, $oint function;
Skin color, te5ture, turgor, integrity K L no problem
Productive cough Productive cough
Warm skin? ,<&
Pale and thin in
appearance
#E Hine > #'C
Tachypnea;-yspnea
Nu"1ig A11#11m#- II
SDC87&T#E7 =C87&T#E7
C.mmui/,-i.:
K L hearing loss K L visual changes
K5L denied
&omments* %ot "pplicable
K L glasses K L language
K L contact lens K L hearing aide
3 H
Pupil si0e * )mm
3eaction* Pupils are e9ually round and
reactive to light accommodation.
K L speech difficulties
O+<g#,-i.:
K 5L dyspnea
K L smoking history
K5L cough K5 L sputum
K L denied
&omments* %ot "pplicable
3espiratory KL regular K5L irregular
-escribe* Patient had abnormal respiration of
/! &P'
3 3ight lung is symmetrical with left lung.
H Heft lung is symmetrical with right lung.
Ci"/u8,-i.:
K L chest pain K L leg pain
K L numbness of e5tremities
K5 L denied
&omments* %ot "pplicable
2eart 3hythm K5L regular K Lirregular
"nkle 7dema* none
Pulse &ar. 3ad. -P. +em.M
3 N N N N
H N N N N
&omments* Pulse in the specified area is
palpable.
Nu-"i-i.: Di#- ,1 -.8#",-#!
&haracter
K L recent change in weight, appetite
K L swallowing difficulty K5 L denied
&omments* %ot "pplicable
K L dentures K5L none

+ull Partial With Patient
Dpper K L K L K L
Hower K L K L K L
E8imi,-i.:
Dsual bowel pattern Drinary fre9uency
)5 a day ,5 a day
constipation remedy K L urgency
%=%7 K L dysuria
-ate of last C' K L hematuria
((-(A-!@ K L incontinence
-iarrhea character K L polyuria
%=%7 K L foley in place
K5L denied
Cowel sounds* %ormal bowel sounds
"bdominal -istention
Present K L yes K5L no
DrineM 4color, consistency, odor6
Mif they are in place
&omments* Patient don.t have +oley bag
catheter in place and was using a diaper.
M,,g#m#- .6 H#,8-5 ,! I88#11:
K L alcohol K 5L denied
4amount, fre9uency6
&omments* %ot applicable
K L SC7 Hast Pap Smear* %ot applicable
H'P* %ot applicable
Criefly describe the patient.s ability to follow
treatments 4diet, meds, etc.6 for chronic
health problems 4if present6.
Patient is following therapeutic regimen with
assistance of significant others as prescribed
by physician..
SDC87&T#E7 =C87&T#E7
S0i I-#g"i-<:
K L dry KL itching K L other K5 L denied
&omments? %ot "pplicable
K L dry K L cold K L pale K L flushed
K5L warm K L cyanotic
Mrashes, ulcers, decubitus 4describe si0e,
location, drainage6
A/-i7i-<@ S,6#-<:
K L convulsion K L di00iness
K L limited motion of $oints
Himitation inability to*
K L ambulate K L bathe self
K L other K5L denied
&omments* %ot "pplicable
H=& and orientation*
Patient is disoriented to time and place.
Jait* K L walker K L cane K L other
K Lsensory and motor losses in face or
e5tremities
K L3=' limitations* patient is able to
move.
C.m6."-@ S8##9@ AA,0#
K L pain 4location, fre9uency, remedies6
K L nocturia
K L sleep difficulties K5 L denied
&omments) %ot "pplicable
K L facial grimaces
K L guarding
K L other signs of pain* #rritable
K L siderail release form signed 4 1! N
years 6
%ot "pplicable
C.9ig:
=ccupation* child
'embers of household* / members
'ost supportive person* 'rs. :athleen
"ligsao
=bserved non- verbal behavior*
Patient is active and fre9uently smiles at
significant others.
The person and his phone number that
can be reached any time* %=%7
PATHOPHYSIOLOGY
PNEUMONIA
-efinition* Pneumonia has long been known as the old man.s friend. #t is an
#nflammation of the lungs caused by an infection.
Precipitating +actors Predisposing +actors
- Prolonged immobility - "ge
- "ir pollution - prolong hospitali0ation
- Smoking - chronic lung disease
- #nfections
- #nhalation of to5ic chemicals, smoke, dusts, or gases.
"irborne pathogenic or direct contact spread
-efect in defense and immunity =verwhelming
e5posure
Eirulent microorganism
#nfectious organism lodges in bronchioles
"lveolar collapse
#nflammation of interstitial tissues of lungs
Eascular engorgement of alveoli with fluid
3CS.s and fibrin move into alveoli
+ibrin accumulates
-isintegration of 3C&.s and fibrin
75udate digested by en0ymes
"ction provides e5cellent culture media to increase spread of organism
&onsolidation
3emoval of pathogenic mucus by coughing,
'acrophagic action
"ntimicrobial therapy
37S=HDT#=%
Sig1 ,! 1<m9-.m1 Ri10 F,/-."1
&ough 4with mucus-like,
greenish, or pus-like sputum
chills with shaking 6,
+ever,
7asy fatigue,
&hest pain 4sharp or stabbing
increased by deep breathing or
increased by coughing6,
2eadache, loss of appetite,
%ausea and vomiting,
Jeneral discomfort, uneasiness,
or ill feeling 4malaise6,
8oint stiffness 4rare6; muscular
stiffness 4rare6,
3ales, shortness of breath,
&lammy skin,
%asal flaring, coughing up
blood,
Tachypnea, apnea,
Smoking
"ir pollution
Dpper respiratory infection
Tracheal intubation
Prolonged immobility
#mmunosuppressive therapy
%on functional immune system
Severe periodontal disease
Prolonged e5posure especially to
virulent organisms
'alnutrition
-ehydration
&hronic disease
Prolonged debilitating disease
#nhalation of no5ious substances
"spiration of oral; gastric material.
"n5iety, stress, and tension,
"bdominal pain
#nflammatory reaction can occur in the alveoli, producing e5udate that
interferes with the diffusion of =) and &=). White blood cells, mostly neutrophils
also migrate into the alveoli and fill the normally air-containing space. "reas of
the lungs are not ade9uately ventilated because of secretions and mucosal
edema that cause partial occlusion of the bronchi or alveoli, with a resultant
decrease in alveolar =) tension.
Eenous blood entering the pulmonary circulation passes thru the under
ventilated area and e5its to the left side of the heart poorly o5ygenated. The
mi5ing of o5ygenated and uno5ygenated or poorly o5ygen in the blood eventually
results in arterial hypo5emia.
I=. NURSING MANAGEMENT
A. IDEAL NURSING MANAGEMENT
NURSING DIAGNOSIS: Ai"A,< C8#,",/#B i#66#/-i7#
M,< :# "#8,-#! -.
Tracheal bronchial inflammation, edema formation, increased sputum production
Pleuritic pain
-ecreased energy, fatigue
P.11i:8< #7i!#/#! :<
&hanges in rate, depth of respirations
"bnormal breath sounds, use of accessory muscles
-yspnea, cyanosis
&ough, effective or ineffective? with;without sputum production
DESIRED OUTCOMES@EVALUATION CRITERIACPATIENT WILL:
R#19i",-."< S-,-u1: Ai"A,< P,-#/< (NOC)
#dentify;demonstrate behaviors to achieve airway clearance.
-isplay patent airway with breath sounds clearing? absence of dyspnea, cyanosis.
"&T#=%S;#%T73E7%T#=%S
Ai"A,< M,,g#m#- (NIC)
I!#9#!#-
"ssess rate;depth of respirations and
chest movement.
"uscultate lung fields, noting areas of
decreased;absent airflow and adventitious
breath sounds, e.g., crackles, whee0es.
3"T#=%"H7
Tachypnea, shallow respirations, and
asymmetric chest movement are fre9uently
present because of discomfort of moving
chest wall and;or fluid in lung.
-ecreased airflow occurs in areas
consolidated with fluid. Cronchial breath
sounds 4normal over bronchus6 can also
occur in consolidated areas. &rackles,
rhonchi, and whee0es are heard on
inspiration and;or e5piration in response to
7levate head of bed, change position
fre9uently.
fluid accumulation, thick secretions, and
airway spasm;obstruction.
Howers diaphragm, promoting chest
e5pansion, aeration of lung segments,
mobili0ation and e5pectoration of
secretions.
"&T#=%S;#%T73E7%T#=%S
Ai"A,< M,,g#m#- (NIC)
I!#9#!#-
"ssist patient with fre9uent deep-breathing
e5ercises. -emonstrate;help patient learn
to perform activity, e.g., splinting chest and
effective coughing while in upright position.
Suction as indicated 4e.g., fre9uent or
sustained cough, adventitious breath
sounds, desaturation related to airway
secretions6.
+orce fluids to at least ,!!! mH;day
4unless contraindicated, as in heart failure6.
=ffer warm, rather than cold, fluids.
C.88,:.",-i7#
"ssist with;monitor effects of nebuli0er
treatments and other respiratory
physiotherapy, e.g., incentive spirometer,
#PPC, percussion, postural drainage.
Perform treatments between meals and
limit fluids when appropriate.
"dminister medications as indicated*
mucolytics, e5pectorants, bronchodilators,
analgesics.
Provide supplemental fluids, e.g., #E,
humidified o5ygen, and room
humidification.
'onitor serial chest 5-rays, "CJs, pulse
o5imetry readings. 43efer to %-* Jas
75change, impaired, following.6
"ssist with bronchoscopy;thoracentesis, if
indicated.
3"T#=%"H7
-eep breathing facilitates ma5imum
e5pansion of the lungs;smaller airways.
&oughing is a natural self-cleaning
mechanism, assisting the cilia to maintain
patent airways. Splinting reduces chest
discomfort, and an upright position favors
deeper, more forceful cough effort.
Stimulates cough or mechanically clears
airway in patient who is unable to do so
because of ineffective cough or decreased
level of consciousness.
+luids 4especially warm li9uids6 aid in
mobili0ation and e5pectoration of
secretions.
+acilitates li9uefaction and removal of
secretions. Postural drainage may not be
effective in interstitial pneumonias or those
causing alveolar e5udate;destruction.
&oordination of treatments;schedules and
oral intake reduces likelihood of vomiting
with coughing, e5pectorations.
"ids in reduction of bronchospasm and
mobili0ation of secretions. "nalgesics are
given to improve cough effort by reducing
discomfort, but should be used cautiously
because they can decrease cough
effort;depress respirations.
+luids are re9uired to replace losses
4including insensible6 and aid in
mobili0ation of secretions. *ote) Some
studies indicate that room humidification
has been found to provide minimal benefit
and is thought to increase the risk of
transmitting infection.
+ollows progress and effects of disease
process;therapeutic regimen, and
facilitates necessary alterations in therapy.
=ccasionally needed to remove mucous
plugs, drain purulent secretions, and;or
prevent atelectasis.
NURSING DIAGNOSIS: G,1 E+/5,g#B im9,i"#!
M,< :# "#8,-#! -.
"lveolar-capillary membrane changes 4inflammatory effects6
"ltered o5ygen-carrying capacity of blood;release at cellular level 4fever, shifting
o5yhemoglobin curve6
"ltered delivery of o5ygen 4hypoventilation6
P.11i:8< #7i!#/#! :<
-yspnea, cyanosis
Tachycardia
3estlessness;changes in mentation
2ypo5ia
DESIRED OUTCOMES@EVALUATION CRITERIACPATIENT WILL:
R#19i",-."< S-,-u1: G,1 E+/5,g# (NOC)
-emonstrate improved ventilation and o5ygenation of tissues by "CJs within
patient.s acceptable range and absence of symptoms of respiratory distress.
Participate in actions to ma5imi0e o5ygenation.
"&T#=%S;#%T73E7%T#=%S
R#19i",-."< M.i-."ig (NIC)
I!#9#!#-
"ssess respiratory rate, depth, and ease.
=bserve color of skin, mucous
membranes, and nailbeds, noting
presence of peripheral cyanosis 4nailbeds6
3"T#=%"H7
'anifestations of respiratory distress are
dependent on;and indicative of the degree
of lung involvement and underlying general
health status.
&yanosis of nailbeds may represent
vasoconstriction or the body.s response to
or central cyanosis 4circumoral6.
"ssess mental status.
'onitor heart rate;rhythm.
'onitor body temperature, as indicated.
"ssist with comfort measures to reduce
fever and chills, e.g., addition;removal of
bedcovers, comfortable room temperature,
tepid or cool water sponge bath.
'aintain bedrest. 7ncourage use of
rela5ation techni9ues and diversional
activities.
fever;chills? however, cyanosis of earlobes,
mucous membranes, and skin around the
mouth 4Owarm membranesP6 is indicative of
systemic hypo5emia.
3estlessness, irritation, confusion, and
somnolence may reflect hypo5emia;
decreased cerebral o5ygenation.
Tachycardia is usually present as a result
of fever;dehydration but may represent a
response to hypo5emia.
2igh fever 4common in bacterial
pneumonia and influen0a6 greatly
increases metabolic demands and o5ygen
consumption and alters cellular
o5ygenation.
Prevents overe5haustion and reduces
o5ygen consumption;demands to facilitate
resolution of infection.
"&T#=%S;#%T73E7%T#=%S
R#19i",-."< M.i-."ig (NIC)
I!#9#!#-
7levate head and encourage fre9uent
position changes, deep breathing, and
effective coughing.
"ssess level of an5iety. 7ncourage
verbali0ation of concerns;feelings. "nswer
9uestions honestly. Eisit fre9uently,
arrange for S=;visitors to stay with patient
as indicated.
=bserve for deterioration in condition,
noting hypotension, copious amounts of
pink;bloody sputum, pallor, cyanosis,
change in level of consciousness, severe
dyspnea, restlessness.
C.88,:.",-i7#
'onitor "CJs, pulse o5imetry.
O+<g# T5#",9< (NIC)
"dminister o5ygen therapy by appropriate
means, e.g., nasal prongs, mask, Eenturi
mask.
Prepare for;transfer to critical care setting if
indicated.
3"T#=%"H7
These measures promote ma5imal
inspiration, enhance e5pectoration of
secretions to improve ventilation. 43efer to
%-* "irway &learance, ineffective.6
"n5iety is a manifestation of psychological
concerns and physiological responses to
hypo5ia. Providing reassurance and
enhancing sense of security can reduce
the psychological component, thereby
decreasing o5ygen demand and adverse
physiological responses.
Shock and pulmonary edema are the most
common causes of death in pneumonia
and re9uire immediate medical
intervention.
+ollows progress of disease process and
facilitates alterations in pulmonary therapy.
The purpose of o5ygen therapy is to
maintain Pa=) above 1! mm 2g. =5ygen is
administered by the method that provides
appropriate delivery within the patient.s
tolerance.
#ntubation and mechanical ventilation may
be re9uired in the event of severe
respiratory insufficiency. 43efer to &P*
'echanical Eentilation.6
NURSING DIAGNOSIS: I6#/-i.B "i10 6." D19"#,!E
Ri10 6,/-."1 m,< i/8u!#
#nade9uate primary defenses 4decreased ciliary action, stasis of respiratory
secretions6
#nade9uate secondary defenses 4presence of e5isting infection,
immunosuppression6, chronic disease, malnutrition
P.11i:8< #7i!#/#! :<
K%ot applicable? presence of signs and symptoms establishes an actual diagnosis.L
DESIRED OUTCOMES@EVALUATION CRITERIACPATIENT WILL:
I6#/-i. S-,-u1 (NOC)
"chieve timely resolution of current infection without complications.
?.A8#!g#: I6#/-i. C.-".8 (NOC)
#dentify interventions to prevent;reduce risk;spread of;secondary infection.
"&T#=%S;#%T73E7%T#=%S
I6#/-i. C.-".8 (NIC)
I!#9#!#-
'onitor vital signs closely, especially
during initiation of therapy.
3"T#=%"H7
-uring this period of time, potentially fatal
complications 4hypotension;shock6 may
develop.
#nstruct patient concerning the disposition
of secretions 4e.g., raising and
e5pectorating versus swallowing6 and
reporting changes in color, amount, odor of
secretions.
-emonstrate;encourage good
handwashing techni9ue.
&hange position fre9uently and provide
good pulmonary toilet.
Himit visitors as indicated.
#nstitute isolation precautions as
individually appropriate.
7ncourage ade9uate rest balanced with
moderate activity. Promote ade9uate
nutritional intake.
'onitor effectiveness of antimicrobial
therapy.
#nvestigate sudden changes;deterioration
in condition, such as increasing chest pain,
e5tra heart sounds, altered sensorium,
recurring fever, changes in sputum
characteristics.
C.88,:.",-i7#
"dminister antimicrobials as indicated by
results of sputum;blood cultures* e.g.,
penicillins* erythromycin 47-'ycin6,
tetracycline 4"chromycin6, do5ycycline
hyclate 4Eibramycin6, amikacin 4"mikin6?
cephalosporins* ceftria5one 43ocephin6?
amantadine 4Symmetrel6? sparflo5acin
4Qagam6? macrolide derivatives, e.g,
a0ithromycin 4Qithroma56.
"lthough patient may find e5pectoration
offensive and attempt to limit or avoid it, it
is essential that sputum be disposed of in a
safe manner. &hanges in characteristics of
sputum reflect resolution of pneumonia or
development of secondary infection.
7ffective means of reducing spread or
ac9uisition of infection.
Promotes e5pectoration, clearing of
infection.
3educes likelihood of e5posure to other
infectious pathogens.
-ependent on type of infection, response
to antibiotics, patient.s general health, and
development of complications, isolation
techni9ues may be desired to prevent
spread;protect patient from other infectious
processes.
+acilitates healing process and enhances
natural resistance.
Signs of improvement in condition should
occur within )/G/A hr.
-elayed recovery or increase in severity of
symptoms suggests resistance to
antibiotics or secondary infection.
&omplications affecting any;all organ
systems include lung abscess;empyema,
bacteremia, pericarditis;endocarditis,
meningitis;encephalitis, and
superinfections.
These drugs are used to combat most of
the microbial pneumonias. &ombinations of
antiviral and antifungal agents may be
used when the pneumonia is a result of
mi5ed organisms. *ote) Eancomycin and
third-generation cephalosporins are the
treatment of choice for penicillin-resistant
streptococcal pneumonia.
"&T#=%S;#%T73E7%T#=%S
I6#/-i. C.-".8 (NIC)
C.88,:.",-i7#
Prepare for;assist with diagnostic studies
as indicated.
3"T#=%"H7
+iberoptic bronchoscopy 4+=C6 may be
done in patients who do not respond
rapidly 4within (G, days6 to antimicrobial
therapy to clarify diagnosis and therapy
needs.
NURSING DIAGNOSIS: A/-i7i-< i-.8#",/#
M,< :# "#8,-#! -.
#mbalance between o5ygen supply and demand
Jeneral weakness
75haustion associated with interruption in usual sleep pattern because of
discomfort, e5cessive coughing, and dyspnea
P.11i:8< #7i!#/#! :<
Eerbal reports of weakness, fatigue, e5haustion
75ertional dyspnea, tachypnea
Tachycardia in response to activity
-evelopment;worsening of pallor;cyanosis
DESIRED OUTCOMES@EVALUATION CRITERIACPATIENT WILL:
A/-i7i-< T.8#",/# (NOC)
3eport;demonstrate a measurable increase in tolerance to activity with absence of
dyspnea and e5cessive fatigue, and vital signs within patient.s acceptable
range.
"&T#=%S;#%T73E7%T#=%S
E#"g< M,,g#m#- (NIC)
I!#9#!#-
7valuate patient.s response to activity.
%ote reports of dyspnea, increased
weakness;fatigue, and changes in vital
signs during and after activities.
Provide a 9uiet environment and limit
visitors during acute phase as indicated.
7ncourage use of stress management and
diversional activities as appropriate.
75plain importance of rest in treatment
plan and necessity for balancing activities
with rest.
3"T#=%"H7
7stablishes patient.s capabilities;needs
and facilitates choice of interventions.
3educes stress and e5cess stimulation,
promoting rest.
Cedrest is maintained during acute phase
to decrease metabolic demands, thus
conserving energy for healing. "ctivity
restrictions thereafter are determined by
individual patient response to activity and
resolution of respiratory insufficiency.
"&T#=%S;#%T73E7%T#=%S
E#"g< M,,g#m#- (NIC)
I!#9#!#-
"ssist patient to assume comfortable
position for rest;sleep.
"ssist with self-care activities as
necessary. Provide for progressive
increase in activities during recovery
phase.
and demand.
3"T#=%"H7
Patient may be comfortable with head of
bed elevated, sleeping in a chair, or
leaning forward on overbed table with
pillow support.
'inimi0es e5haustion and helps balance
o5ygen supply and demand.
NURSING DIAGNOSIS: P,iB ,/u-#
M,< :# "#8,-#! -.
#nflammation of lung parenchyma
&ellular reactions to circulating to5ins
Persistent coughing
P.11i:8< #7i!#/#! :<
3eports of pleuritic chest pain, headache, muscle;$oint pain
Juarding of affected area
-istraction behaviors, restlessness
DESIRED OUTCOMES@EVALUATION CRITERIACPATIENT WILL:
P,i: Di1"u9-i7# E66#/-1 (NOC)
Eerbali0e relief;control of pain.
-emonstrate rela5ed manner, resting;sleeping and engaging in activity
appropriately.
"&T#=%S;#%T73E7%T#=%S
P,i M,,g#m#- (NIC)
I!#9#!#-
-etermine pain characteristics, e.g., sharp,
constant, stabbing. #nvestigate changes in
character;location;intensity of pain.
'onitor vital signs.
Provide comfort measures, e.g., back rubs,
change of position, 9uiet music or
conversation. 7ncourage use of
rela5ation;breathing e5ercises.
3"T#=%"H7
&hest pain, usually present to some
degree with pneumonia, may also herald
the onset of complications of pneumonia,
such as pericarditis and endocarditis.
&hanges in heart rate or CP may indicate
that patient is e5periencing pain, especially
when other reasons for changes in vital
signs have been ruled out.
%onanalgesic measures administered with
a gentle touch can lessen discomfort and
augment therapeutic effects of analgesics.
Patient involvement in pain control
measures promotes independence and
enhances sense of well-being.
"&T#=%S;#%T73E7%T#=%S
P,i M,,g#m#- (NIC)
I!#9#!#-
=ffer fre9uent oral hygiene.
#nstruct and assist patient in chest splinting
techni9ues during coughing episodes.
43efer to %-* "irway &learance,
ineffective.6
C.88,:.",-i7#
"dminister analgesics and antitussives as
indicated.
3"T#=%"H7
'outh breathing and o5ygen therapy can
irritate and dry out mucous membranes,
potentiating general discomfort.
"ids in control of chest discomfort while
enhancing effectiveness of cough effort.
These medications may be used to
suppress nonproductive;paro5ysmal cough
or reduce e5cess mucus, thereby
enhancing general comfort;rest.
NURSING DIAGNOSIS: Nu-"i-i.: im:,8,/#!B "i10 6." 8#11 -5, :.!<
"#Fui"#m#-1
Ri10 6,/-."1 m,< i/8u!#
#ncreased metabolic needs secondary to fever and infectious process
"nore5ia associated with bacterial to5ins, the odor and taste of sputum, and certain
aerosol treatments
"bdominal distension;gas associated with swallowing air during dyspneic episodes
P.11i:8< #7i!#/#! :<
K%ot applicable? presence of signs and symptoms establishes an actual diagnosis.L
DESIRED OUTCOMES@EVALUATION CRITERIACPATIENT WILL:
Nu-"i-i.,8 S-,-u1 (NOC)
-emonstrate increased appetite.
'aintain;regain desired body weight.
"&T#=%S;#%T73E7%T#=%S
Nu-"i-i. T5#",9< (NIC)
I!#9#!#-
#dentify factors that are contributing to
nausea;vomiting, e.g., copious sputum,
aerosol treatments, severe dyspnea, pain.
3"T#=%"H7
&hoice of interventions depends on the
underlying cause of the problem.
"&T#=%S;#%T73E7%T#=%S
Nu-"i-i. T5#",9< (NIC)
I!#9#!#-
Provide covered container for sputum and
remove at fre9uent intervals. "ssist
with;encourage oral hygiene after emesis,
after aerosol and postural drainage
treatments, and before meals.
Schedule respiratory treatments at least (
hr before meals.
"uscultate for bowel sounds.
=bserve;palpate for abdominal distension.
Provide small, fre9uent meals, including
dry foods 4toast, crackers6 and;or foods
that are appealing to patient.
7valuate general nutritional state, obtain
baseline weight.
3"T#=%"H7
7liminates no5ious sights, tastes, smells
from the patient environment and can
reduce nausea.
3educes effects of nausea associated with
these treatments.
Cowel sounds may be diminished;absent if
the infectious process is severe;prolonged.
"bdominal distension may occur as a
result of air swallowing or reflect the
influence of bacterial to5ins on the
gastrointestinal 4J#6 tract.
These measures may enhance intake even
though appetite may be slow to return.
Presence of chronic conditions 4e.g.,
&=P- or alcoholism6 or financial
limitations can contribute to malnutrition,
lowered resistance to infection, and;or
delayed response to therapy.
NURSING DIAGNOSIS: F8ui! V.8um#B "i10 6." !#6i/i#-
Ri10 6,/-."1 m,< i/8u!#
75cessive fluid loss 4fever, profuse diaphoresis, mouth breathing;hyperventilation,
vomiting6
-ecreased oral intake
P.11i:8< #7i!#/#! :<
K%ot applicable? presence of signs and symptoms establishes an actual diagnosis.L
DESIRED OUTCOMES@EVALUATION CRITERIACPATIENT WILL:
F8ui! B,8,/# (NOC)
-emonstrate fluid balance evidenced by individually appropriate parameters, e.g.,
moist mucous membranes, good skin turgor, prompt capillary refill, stable vital
signs.
"&T#=%S;#%T73E7%T#=%S
F8ui! M,,g#m#- (NIC)
I!#9#!#-
"ssess vital sign changes, e.g., increased
temperature;prolonged fever, tachycardia,
orthostatic hypotension.
3"T#=%"H7
7levated temperature;prolonged fever
increases metabolic rate and fluid loss
through evaporation. =rthostatic CP
changes and increasing tachycardia may
indicate systemic fluid deficit.
"&T#=%S;#%T73E7%T#=%S
F8ui! M,,g#m#- (NIC)
I!#9#!#-
"ssess skin turgor, moisture of mucous
membranes 4lips, tongue6.
%ote reports of nausea;vomiting.
'onitor intake and output 4#R=6, noting
color, character of urine. &alculate fluid
balance. Ce aware of insensible losses.
Weigh as indicated.
+orce fluids to at least ,!!! mH;day or as
individually appropriate.
C.88,:.",-i7#
"dminister medications as indicated, e.g.,
antipyretics, antiemetics.
Provide supplemental #E fluids as
necessary.
3"T#=%"H7
#ndirect indicators of ade9uacy of fluid
volume, although oral mucous membranes
may be dry because of mouth breathing
and supplemental o5ygen.
Presence of these symptoms reduces oral
intake.
Provides information about ade9uacy of
fluid volume and replacement needs.
'eets basic fluid needs, reducing risk of
dehydration.
Dseful in reducing fluid losses.
#n presence of reduced intake;e5cessive
loss, use of parenteral route may
correct;prevent deficiency.
NURSING DIAGNOSIS: ?.A8#!g#B !#6i/i#- DL#,"ig N##!E "#g,"!ig
/.!i-i.B -"#,-m#-B 1#86(/,"#B ,! !i1/5,"g# ##!1
M,< :# "#8,-#! -.
Hack of e5posure
'isinterpretation of information
"ltered recall
P.11i:8< #7i!#/#! :<
3e9uests for information? statement of misconception
+ailure to improve;recurrence
DESIRED OUTCOMES@EVALUATION CRITERIACPATIENT WILL:
?.A8#!g#: I88#11 C,"# (NOC)
Eerbali0e understanding of condition, disease process, and prognosis.
Eerbali0e understanding of therapeutic regimen.
#nitiate necessary lifestyle changes.
Participate in treatment program.
"&T#=%S;#%T73E7%T#=%S
T#,/5ig: Di1#,1# P"./#11 (NIC)
I!#9#!#-
3eview normal lung function, pathology of
condition.
-iscuss debilitating aspects of disease,
length of convalescence, and recovery
e5pectations. #dentify self-care and
homemaker needs;resources.
Provide information in written and verbal
form.
Stress importance of continuing effective
coughing;deep-breathing e5ercises.
7mphasi0e necessity for continuing
antibiotic therapy for prescribed period.
3eview importance of cessation of
smoking.
=utline steps to enhance general health
and well-being, e.g., balanced rest and
activity, well-rounded diet, avoidance of
crowds during cold;flu season and persons
with D3#s.
Stress importance of continuing medical
follow-up and obtaining
vaccinations;immuni0ations as appropriate.
#dentify signs;symptoms re9uiring
notification of healthcare provider, e.g.,
increasing dyspnea, chest pain, prolonged
fatigue, weight loss, fever;chills,
persistence of productive cough, changes
in mentation.
3"T#=%"H7
Promotes understanding of current
situation and importance of cooperating
with treatment regimen.
#nformation can enhance coping and help
reduce an5iety and e5cessive concern.
3espiratory symptoms may be slow to
resolve, and fatigue and weakness can
persist for an e5tended period. These
factors may be associated with depression
and the need for various forms of support
and assistance.
+atigue and depression can affect ability to
assimilate information;follow medical
regimen.
-uring initial 1GA wk after discharge,
patient is at greatest risk for recurrence of
pneumonia.
7arly discontinuation of antibiotics may
result in failure to completely resolve
infectious process.
Smoking destroys tracheobronchial ciliary
action, irritates bronchial mucosa, and
inhibits alveolar macrophages,
compromising body.s natural defense
against infection.
#ncreases natural defenses;immunity, limits
e5posure to pathogens.
'ay prevent recurrence of pneumonia
and;or related complications.
Prompt evaluation and timely intervention
may prevent;minimi0e complications.
POTENTIAL CONSIDERATIONS 6.88.Aig ,/u-# 5.19i-,8iG,-i. (!#9#!#- .
9,-i#-;1 ,g#B 95<1i/,8 /.!i-i.@9"#1#/# .6 /.m98i/,-i.1B 9#"1.,8
"#1.u"/#1B ,! 8i6# "#19.1i:i8i-i#1)
+atigueSincreased energy re9uirements to perform "-Hs, discomfort, effects of
antimicrobial therapy.
#nfection, risk forSinade9uate secondary response 4e.g., leukopenia, suppressed
inflammatory response6, chronic disease, malnutrition, current use of antibiotics.
Therapeutic 3egimen* ineffective managementScomple5ity of therapeutic regimen,
economic difficulties, perceived seriousness;susceptibility.
B. ACTUAL NURSING MANAGEMENT (SOAPIE FORM)
N.7#m:#" 3*B 322)
S : %ot "pplicable.
O : "s evidenced by*
"bdominal breath sounds
&ough
Shortness of breathing
A : #neffective airway clearance related to tracheal inflammation
"nd increased sputum production.
P : "t the end of ,! min, the patient will display patent airway
with breath sounds clearing.
I :
"ssessed rate; depth of respiratory and chest
movement.
7levated head of bed, change position fre9uently.
"ssisted with fre9uent deep breathing e5ercise
#ncreased fluid intake
E : "t the end of ,! minutes after rendering the nursing
#ntervention, the patient displayed patent airway with clear
Creath sounds.
N.7#m:#" 3*B 322)
S : %ot "pplicable
O : "s evidenced by*
Weakness
+atigue
75haustion
A : "ctivity intolerance related to e5haustion associated with
interruption of usual sleep pattern due to discomfort and
e5cessive coughing.
P : "t the end of ( hr, the patient will be able to increase
tolerance in activity.
I :
7valuated patients response to activity
Provided 9uiet environment and limit visitors.
75plained importance of rest in treatment and
necessity for balancing activities.
"ssisted patient to assume comfortable position.
E : "t he end of ( hour after rendering the interventions, the
patient demonstrated a measurable increase intolerance to
activity.
N.7#m:#" 3HB 322)
S : %ot applicable? presence of signs and symptoms establishes
an actual diagnosis.
O : %ot applicable? presence of signs and symptoms establishes
an actual diagnosis.
A : 3isk for infection due to inade9uate primary defenses such
as decreased ciliary action and stasis of respiratory
secretions.
P : "t the end of ( hr, the patient will be able to identify
interventions to prevent; reduce risk; spread of secondary
infection.
I :
#nstructed concerning the disposition of secretions.
7ncouraged good hand washing techni9ue.
Himit visitors as indicated.
7ncouraged ade9uate rest balanced with moderate
activity.
E : "t the end of ( hr in rendering interventions, the patient
identified interventions to prevent; reduce risk of infection.
=. D"ug S-u!<
=I. DISCHARGE PLAN (REFERRAL > FOLLOW(UP)
The patient.s guardian was instructed to have a follow-up check-up a
week after the discharged in order to carefully assess the patient.s physical
status, monitoring for complications and reinforces previous teaching. They must
visit -r. 'acatol at %orthern 'indanao 'edical &enter 4%''&6 for consultation.
=II. EVALUATION AND RECOMMENDATION
The patient was able to follow all the medications given and comprehend
all the instructions and health teachings given to alleviate the pain and for faster
recovery. #nstructed patient about regular breathing e5ercises for proper
breathing, encouraged to have an ade9uate rest and avoid getting fatigue,
increased fluid intake for sufficient hydration and loosening of secretions,
encouraged to eat nutritious foods such as oranges, mangoes which are rich in
vitamin & to prevent infections and boost immune system, high caloric diet which
is a good source of energy and high protein diet which helps maintain integrity of
alveolar walls.
=III. BIBLIOGRAPHY

www.healthcentral.com Pathophysiology, pages ()((-()(,
'edical Surgical Juide by Tuiambao-Ddan, first edition
'edical Surgical by Smelt0er (!
th
edition, Eol. (