I.

INTRODUCTION
This is a case of a 74 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 pneumonias 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
areStreptococcus 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.

II. PATIENT PROFILE

Name: E. Costales

Age: 74 years old

Sex: Female

Religion: Roman Catholic

Date Admitted: September 17, 2009 at exactly 11:15 AM

Admission diagnosis: COPD not in exacerbation

Final diagnosis: Community Acquired pneumonia (CAP)moderate Risk

III. PATIENT HISTORY

Chief Complaint: Difficulty of Breathing

General Data:

This is a case of a 74 year old female Filipino, presently residing in Adelina 3 Binan,
Laguna who was admitted in Perpetual Help Hospital on September 17, 2009.

History of Present Illness:

5 days prior to admission, patient had positive signs and symptoms of cough, yellowish
pleghm, persistent fever and back pain. Knowing that these signs and symptoms were just forms
of little discomforts, she self medicated with paracetamol. However, she noticed no changes and
experienced difficulty of breathing so she sought medical consultation.

IV. PHYSICAL ASSESSMENT

Date Assesed: September 17, 2009

Time Assessed:

Vital Signs:

Blood Pressure: 110/60

Temperature: 35.7 C

Pulse rate: 78bpm

Respiratory rate: 26 breaths/min

General appearance:

The patient is awake, lying on bed, conscious and coherent with an IVF of PNSS
and side drip of D5W with incorporation of aminophylline on the right arm.

V. 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.
VI. PATHOPHYSIOLOGY
Virulent Microorganism

Streptococcus Pneumoniae

Microorganism eneters the nose( nasal passages)

Passes through the larynx, pharynx, trachea

Microorganism enters and affects both airway and lung parenchyma

Airway damage Lung invasion

Infiltration of bronchi flattening of epithelial cells

Infectious organism lodges macrophages and leukocytes

Stimulation in bronchioles necrosis of bronchial tissues mucus and phlegm production

Alveolar collapse narrowing of air passage COUGHING

Productive/non-productive

Increase pyrogen in the body DIFFICULTY OF BREATHING

FEVER

Necrosis of pulmonary tissue

Overwhelming sepsis

DEATH
VII. Medical Management

VIII. Diagnostic Exam

Chest X-ray Result:

Impression: There are reticolunodular opacities on both lungfields with
upward traction of left hilus. There are dilated thick walled bronchi noted on both
lower lobes. Heart is not enlarged. Aortic knob is sclerotic other visualized
structures are unremarkable. Findings are suggestive of Extensive PTB, Bilateral
with cicatrical changes, left upper lobe.Bacteriologic correlation is suggested.

Clinical Chemistry Result:

Sodium: 124.9 mmol/L Normal: 135.0-148mmol/L

Hematology Result:
Hct: 0.29 Normal: 0.37-0.47

WBC: 23.5x10 Normal: 5.0-10.0x10

Segmenters: 0.87

Lymphocytes: 0.13

Urinalysis:
Color: Light Yellow

Transparency: Slightly Hazy

Reaction: (pH) 6.0

Protein: +1

Glucose: negative

Specific Gravity: 1.010

Pus cells: 3-4/HPF

RBC: 2-3/hpf
Crystals: A Urates: Many

Mucus threads: few

Cast: Fine Granular cast : 1-2/HPF

IX. Drug Study

Generic Name: Hydrocortisone Sodium succinate

Brand Name: Solu-Cortef

Classification: Corticosteroid, short acting

Dosage: 100mg IV, q 6 hours

Pharmacokinetics:
Metabolism: Hepatic; half life 80-120min.
Distribution: Crosses Placenta; enters breast milk
Excretion: Urine
Indications:
Replacement therapy in adrenal cortical insufficiency
Hypercalcemia; associated with cancer
Short term inflammatory disorders
Contraindications:
Infections, especially tuberculosis, fungal infections, amoebiasis, hepatitis B, liver
disease, liver cirrhosis, active or latent peptic ulcer.

Adverse Reaction:
Vertigo, headache, hypotension, shock, thin, fragile skin, petechiae, amenorrhea, muscle
weakness.

Nursing Considerations:
1. Give daily before 9AM to mimic normal peak diurnal corticosteroid levels and
minimize HPA suppression.

2. Space multiple dose evenly throughout the day.

3. Use minimal dose for minimal duration to minimize adverse effects.

4. Use alternate day maintenance therapy with short acting corticosteroids whenever
possible.
Generic Name: Acetylcysteine

Brand Name: Fluimucil

Classification: Mucolytic Agent

Dosage:

Pharmacokinetics:
Metabolism: Hepatic; half life 6.25 hr
Excretion: Urine (30%)
Indications:
Mucolytic Adjuvant therapy for abnormal, viscid, or inspissated mucus secretion in
acute and chronic bronchopulmonary disease (pneumonia,asthma,TB).
Contraindications:
Contraindicated with hypersensitivity to acetylcysteine; use caution and discontinue if
bronchospasm occurs.
Adverse Reaction:
Nausea, rhinorrhea, bronchospasm especially in asthmatics, stomatitis,and urticaria.

Nursing Considerations:
1. dilute with normal saline solution or sterile water for injection.

2. Administer the ff drugs separately because they are incompatible with

acetylcysteine: tetracyclines, hydrogen peroxide, trypsin.

3. Use water to remove residual drug solution on the patients face after administration
by face mask.

4. Inform patient that nebulization may produce an initial disagreeable odor, but will
soon disappear.
 X. NURSING CARE PLAN

Problem: Difficulty of breathing

Diagnosis: Ineffective Airway Clearance related to increased mucus production.

ASSESSMENT DIAGNOSIS SCIENTIFIC OBJECTIVES INTERVENTION RATIONALE EVALUATION

REASON
Subjective: Ineffective Increased Short term Independent: Goal half met.
airway mucus goal:
nagrereklamo clearance production is 1.Assessed 1.Tachypnea, After 4 hours of
nga yang si related to often caused After 3-4 hours rate/depth of shallow nursing
nanay na increase by an of intervention, respiration and respiration are intervention,
nahihirapan mucus underlying patient will chest movement. usually patient
siya huminga, production illness. If expectorate present. expectorated
dami din kasi mucus is the secretions secretion and
plema eh as effectively and 2.Lowers
most 2.Elevated head RR decreased
verbalized by RR will diaphragm,
prevalent of bed and from 26/min to
relative. decrease from promoting
symptom, it is changed position 22/min.
26 to normal chest
Objective: usually frequently. expansion,
caused by range of 16-
20/min. mobilization
*RR- 26 something and
simple like expectoration
allergies or of secretion.
*Dyspnea the common Long term
cold. Other
*(+)non- illnesses that goal:
productive result in
cough excessive After 3 days of
mucus intervention,
*Use of production patient will
accessory include maintain 3.Assisted patient 3.Deep
muscle pneumonia, patent airway with frequent breathing
flu and as evidenced deep breathing facilitates
bronchitis by normal RR. exercises. maximum
expansion of
the lungs and
smaller
airways.
4. Encouraged
increase in fluid 4.Fluids aid in
intake. mobilization
and
expectorations
of secretions

Collaborative:
5.Administered
mucolytics as 5.Aids in
indicated. mobilization of
secretion.
(Fluimucil)
6.Provided 6.Fluids are
supplemental required to
fluids. replace
insensible loss
(IVF: PNSS) and aids in
mobilization of
secretions.

7.Follows
7.Monitored progress and
chest Xray, ABG effects of
and pulse disease
oximetry results. process.