A CASE STUDY OF COMMUNITY ACQUIRED PNEUMONIA

SUBMITTED BY:
ANELIZA B. DE VERA
BSN 4Y2-2F
SUBMITTED TO:
MS. SHARON CAJAYON

INTRODUCTION

This is a case of a 58 year old woman who was diagnosed with Community
Acquired Pneumonia.
Pneumonia is an inflammation or infection of the lungs most commonly
caused by a bacteria or virus. Pneumonia can also be caused by inhaling vomit or
other foreign substances. In all cases, the lungs' air sacs fill with pus, mucous, and
other liquids and cannot function properly. This means oxygen cannot reach the
blood and the cells of the body.
Most pneumonia are caused by bacterial infections. The most common
infectious cause of pneumonia in the United States is the bacteria Streptococcus
pneumoniae. Bacterial pneumonia can attack anyone. The most common cause of
bacterial pneumonia in adults is a bacteria called Streptococcus pneumoniae or
Pneumococcus. Pneumococcal pneumonia occurs only in the lobar form.
An increasing number of viruses are being identified as the cause of
respiratory infection. Half of all pneumonias are believed to be of viral origin. Most
viral pneumonias are patchy and the body usually fights them off without help from
medications or other treatments.
Pneumococcus can affect more than the lungs. The bacteria can also cause
serious infections of the covering of the brain (meningitis), the bloodstream, and
other parts of the body.
Community-acquired pneumonia develops in people with limited or no
contact with medical institutions or settings. The most commonly identified
pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and atypical
organisms (ie, Chlamydia pneumoniae, Mycoplasma pneumoniae, 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 relatively young or
healthy patients, but many pneumonias, especially when caused by S.
pneumoniae or influenza virus, are fatal in older, sicker patients.
PATIENT PROFILE
Name:
Age:
Sex:
Religion:
Date Admitted:
Admission diagnosis:

Patient IBA
58 years old
Female
Roman Catholic
November 21, 2015
Community Acquired Pneumonia

PATIENT HISTORY
Chief Complaint: Fever
General Data:
This is a case of a 58 year old female, married, Filipino, Catholic, and
presently residing in Marulas, Valenzuela City who was been admitted for the first
time in FUMC.
History of Present Illness:
Few hours prior to admission, patient suddenly developed fever (38 C)
associated with dizziness and joint pain, not associated with cough, abdominal pain,
urinary frequency, dysuria, loose bowel movement, nausea and vomiting. Patient
self medicated with paracetamol 500mg/tab. One tab was taken but there was no
relief of symptoms noted hence patient sought consult and was subsequently
admitted.
Past Medical and Surgical History:
(-) HPN
(+) Appendectomy (1990)
(-) DM
(-) Asthma
(-) Goiter
(-) PTB
(-) Allergies
Family Medical History:
(+) HPN (father)
(-) Asthma
(-) DM
(-) Goiter
Personal and Social History
(-) Smoker
(-) Alcoholic drinker
(-) Illicit drug use

IV. PHYSICAL ASSESSMENT

Date Assesed:
Time Assessed:
Vital Signs:
Blood Pressure:

November 21, 2015

6:59 pm
100/60

Temperature:
Pulse rate:
Respiratory rate:

39 C
96 bpm
20 breaths/min

General appearance:
The patient is conscious and coherent not in cardiopulmonary distress.
HEENT:
Anicteric sclera, pink palpebral conjunctiva, no naso-aural discharge, no
tonsillo-pharyngeal, no cervical lumphadenopathy.
Chest and Lungs:
Symmetrical chest expansion, decreased breath sounds, left lung field,
decreased tactile fermitus
Heart:
Adynamic pericardium, normal rate, regular rhythm, no murmur
Abdomen:
Flabby, soft, non tender
Extremities:
Grossly normal extremities, no cyanosis, no edema
Skin:
Fair, flushing, both upper extremities, good turgor

ANATOMIC AND PHYSIOLOGY OVERVIEW

The Lungs
The lungs are paired, cone-shaped organs which take up most of the space in
our chests, along with the heart. Their role is to take oxygen into the body, which
we need for our cells to live and function properly, and to help us get rid of carbon
dioxide, which is a waste product. We each have two lungs, a left lung and a right
lung. These are divided up into 'lobes', or big sections of tissue separated by
'fissures' or dividers. The right lung has three lobes but the left lung has only two,
because the heart takes up some of the space in the left side of our chest. The
lungs can also be divided up into even smaller portions, called 'bronchopulmonary
segments'.
These are pyramidal-shaped areas which are also separated from each other
by membranes. There are about 10 of them in each lung. Each segment receives its
own blood supply and air supply.
Air enters your lungs through a system of pipes called the bronchi. These
pipes start from the bottom of the trachea as the left and right bronchi and branch
many times throughout the lungs, until they eventually form little thin-walled air
sacs or bubbles, known as the alveoli. The alveoli are where the important work of
gas exchange takes place between the air and your blood. Covering each alveolus is
a whole network of little blood vessel called capillaries, which are very small
branches of the pulmonary arteries. It is important that the air in the alveoli and the
blood in the capillaries are very close together, so that oxygen and carbon dioxide

can move (or diffuse) between them. So, when you breathe in, air comes down the
trachea and through the bronchi into the alveoli. This fresh air has lots of oxygen in
it, and some of this oxygen will travel across the walls of the alveoli into your
bloodstream. Travelling in the opposite direction is carbon dioxide, which crosses
from the blood in the capillaries into the air in the alveoli and is then breathed out.
In this way, you bring in to your body the oxygen that you need to live, and get rid
of the waste product carbon dioxide.

PATHOPHYSIOLOGY
Virulent Microorganism
Streptococcus Pneumoniae

Microorganism enters the nose( nasal passages)

Passes through the larynx, pharynx, trachea

Microorganism enters and affects both airway and lung parenchyma

Airway damage
invasion

Lung

Infiltration of bronchi
flattening of epithelial cells
Infectious organism lodges
leukocytes
Stimulation in bronchioles
phlegm production
Alveolar collapse
COUGHING

macrophages and
necrosis of bronchial tissues

mucus and

narrowing of air passage

Productive/non-

productive
Increase pyrogen in the body

DIFFICULTY OF BREATHING

FEVER
Necrosis of pulmonary tissue
Overwhelming sepsis

DEATH

Diagnostic Exam
Chest X-ray Result:
Lungfields are clear.
Heart is not enlarged.
Tortous aorta.
Diaphragm and costophrenic sulci are intact.
Bony structures are unremarkable.
Clinical Chemistry Result:

Sodium:
Potassium:
Chloride:
Creatinine:
BUN:

Result
139.00
3.91
101.00
102.3
5

Normal Value
136-145 mmol/L
3.50-5.10 mmol/L
98-107.00 mmol/L
45.00-84.00 umol/L
2.14-7.14 mmol/L
Hematology Result:

WBC
Hgb
Hct
RBC
Platelet

Result
7.8
124
0.37
4.4
161

Normal Value
5.00-10.00 10^9/L
123.00-152.00 g/L
0.37-0.42
4.50-5.50 10^12/L
150.00-450.00 10^9/L
Urinalysis:

Color:
Transparency:
Reaction:
Protein:
Glucose:
Specific Gravity:
Pus cells:
RBC:
Leukocytes:
Crystals: A Urates:

Yellow
Turbid
(pH) 6.0
+3
Negative
1.025
30-35/HPF
0-2/HPF
+3
+2

X. NURSING CARE PLAN

Problem: Difficulty of breathing
Diagnosis: Ineffective Airway Clearance related to increased mucus production.
ASSESSME
DIAGNO SCIENTIFI OBJECTIV INTERVENTI RATIONALE EVALUATIO
NT
SIS
C
ES
ON
N
REASON
Subjective: Ineffecti Increased Short
Independen
Goal half
nagrerekla
ve
mucus
term goal: t:
1.Tachypne
met.
mo nga
airway
productio After 3-4
1.Assessed
a, shallow
After 4
yang si
clearanc n is often hours of
rate/depth
respiration
hours of
nanay na
e related
caused
interventi of
are usually
nursing
nahihirapan
to
by an
on,
respiration
present.
interventio
siya
increase underlyin patient
and chest
n, patient
huminga,
mucus
g illness. will
movement.
2.Lowers
expectorat
dami din
producti
If mucus expectora
diaphragm,
ed
kasi plema
on
is the
te
2.Elevated
promoting
secretion
eh as
most
secretions head of bed chest
and RR
verbalized
prevalent effectively and
expansion,
decreased
by relative.
symptom and RR
changed
mobilizatio
from
Objective:
, it is
will
position
n and
26/min to
*RR- 26
usually
decrease
frequently.
expectorati
22/min.
caused
from 26 to
on of
*Dyspnea
by
normal
secretion.
*(+)nonsomethin range of
productive
g simple 16cough
like
20/min.
3.Deep
allergies
breathing
or the
Long term 3.Assisted
facilitates
common goal:
patient with maximum
cold.
After 3
frequent
expansion
Other
days of
deep
of the lungs
illnesses interventi breathing
and smaller
that
on,
exercises.
airways.
result in patient
4.Fluids aid
excessive will
in
mucus
maintain
4.
mobilizatio
productio patent
Encouraged n and
n include airway as increase in
expectorati
pneumon evidenced fluid intake. ons of
ia, flu
by normal
secretions
and
RR.
bronchiti
Collaborativ
s
e:
5.Aids in
5.Administe mobilizatio

red
mucolytics
as
indicated.
(Fluimucil)
6.Provided
supplement
al fluids.
(IVF: PNSS)

7.Monitored
chest Xray,
ABG and
pulse
oximetry
results.

n of
secretion.
6.Fluids are
required to
replace
insensible
loss and
aids in
mobilizatio
n of
secretions.
7.Follows
progress
and effects
of disease
process.