AKI CASE Nisha

KATHMANDU UNIVERSITY
LUMBINI MEDICAL COLLEGE AND TEACHING HOSPITAL
NURSING PROGRAMME
Parbhas-11, Tansen, Palpa
CASE STUDY REPORT ON:

“COMMUNITY AQUIRED PNEUMONIA WITH ACUTE
KIDNEY INJURY”
SUBMITTED TO: SUBMITTED BY:

Mrs. Chandra Kumari Garbuja Nisha Rana
Roll no. 22
Nursing Lecturer B .Sc.Nursing 2ndyear
LMCTH LMCTH
SUBMITTED ON: 5th June, 2019
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PREFACE
Case study is one of the best method of learning in which the students will be able to learn
and gain knowledge, skills easily about specific disease condition.
Learning is the process of acquiring new or modifying existing, knowledge, behaviors, skills,
values or preferences. Case study is one of the reliable methods for learning outcomes as it
gives emphasize to gain specific knowledge and related skill in certain duration of time.
According to the curriculum of Kathmandu University, students of B.Sc. Nursing 2nd year
has to select one case study during the geriatric posting in medicine ward. So, I have selected
a case of community acquired pneumonia (CAP) with acute kidney injury (AKI) to study in
detail.
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ACKNOWLEDGEMENT
First of all, I would like to express my gratitude to Kathmandu University for including a
case study and presentation on curriculum of B. Sc. Nursing 2nd year practicum. I would
like to express my deep gratitude to Lumbini Medical College and Teaching Hospital
(LMCTH) for providing the opportunity to carry out this case study for partial fulfillment of
the B.Sc.Nursing 2nd year practicum.
I would like to express my sincere gratitude to all expertise of different field and
department as well as different subjects who have contributed a lot to select the relevant
subject matter to develop this case study with pleasure and I am thankful to Mrs. Bandana
Pokharel, Assistant professor and Nursing programme coordinator; Ms. Sunita Rana,
Nursing lecturer and B.Sc. nursing 2ndyear co-coordinator; Mrs. Chandra Kumari Garbuja,
nursing lecturer, for their continuous supervision, suggestion, guidance, help and support
during my case study. I also like to thanks to all library staffs, administrative staff, ward
incharge and all staffs of medical ward.
I would like to express my gratitude to my case Mrs.Yam kala poudel and her family
members for their co-operation, support and help while taking the information. I would
like to convey special thanks to all my friends who helped me with their valuable
suggestions.
Ms. NishaRana
Roll no. 22
B.Sc.Nursing 2nd year
7th Batch, LMCTH
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UNIT- I
OBJECTIVES OF THE CASE STUDY
General objective
The general objective of the case study is to gain comprehensive knowledge about the
Community Acquired Pneumonia with Acute kidney injury.
Specific objective-
 To perform the comprehensive geriatric assessment.
 To take complete health history and physical examination of the patient with
Community Acquired Pneumonia with Acute Kidney Injury .
 To know about physiological, psychological and social changes occur in elderly
people.
 To provide the holistic care to the geriatric patient by using nursing theory.
 To identify the risk factors, pathophysiology and complications of the diseases
condition.
 To help in solving the problems of the patient and to reduce the stress of illness due to
hospitalization/
 To gain practical knowledge in real situation.
 To gain confidence in handling such case in future.
 To share the experience and knowledge to my friends, juniors and seniors.
Rationale for selection of case

- Community Acquired Pneumonia with Acute kidney Injury is one of the most common
respiratory diseases and kidney disease in increasing age.
- From the date of 2075/012/01 to 2076/02/ , patient admitted in medical ward, there were
diagnosed with as Acute Kidney Injury with Community Acquired Pneumonia
-I am interested to gain detail knowledge about the Community Acquired Pneumonia with
Acute kidney injury.
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Unit II
A. Health History (Date:2076-02-12)
Demographic Data:
Name : Yamkala saru poudel
Age/Sex : 80 years/female
Address : Humin-8, Palpa
Education : Illiterate
Occupation : Home Maker
Religion : Hinduism
Ethnicity : Brahmin
Marital status : Married
Inpatient ward
Ward : Medical ward
Bed number : 199
Inpatient number : 213187
Hospital number : 750205930
Date of admission : 2076-02-11
Date of discharge : 2076-02-16
Date of interview : 2076-02-14
Provisional diagnosis : Septic shock with Community Acquired Pneumonia
Final diagnosis : Community Acquired Pneumonia with Acute Kidney Injury
Consultant doctors : Dr. Tilchan pandey and his team
No of hospitalization days : 5 days
Informant : Patient and her son
B. CHIEF COMPLAINTS
I. At the time of admission (From ER on 2076/02/11)
 Shortness of breath for 5 years and aggravated since 3 days.
 Left side chest pain since 3 days
 Cough since 2 days
II. At present
 Fever (101.4 degree F)
 Mild swelling in both legs
 Headache since today’s morning
 Decreased appetite
 Disturbed sleep pattern
C. History of present illness
My patient named Mrs. Yamkala saru poudel was apparently well 5 years back then she
developed shortness of breath (SOB) which was insidious in onset, progresive in nature and
then initiated during time of exertion and now even at rest. Again shortness of breath was
aggravated since today morning around 8:45 am while working at home associated with
productive cough which was acute in onset with thick sputum, yellowish in colour and foul
smell was not present. And also no any diurnal and postural variation and the sputum not
mixed with blood.
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My patient also complaints of left side chest pain which was acute in onset, mild to moderate
in severity; aggravated on exertion, with non- radiating and no any relieving factors.
At present, she developed fever of (101.4 degree fahreheit ) which was continous type
without chills and rigor and relieved on medication (Thermadol 100ml IV stat) under
prescription. She also complaints of headache around the frontal area, decreased appetite, and
also disturbed sleep pattern and swelling of both legs.
With the above mentioned complaints, she came to Emergency department of LMCTH
around 10:30am. After primary survey, diagnostic investigations and symptomatic treatment
or IV medications (0.9%Nacl IIpint fast IV Stat, Nor-adrenaline 5mg per kg stat) was
administered with 5 liter oxygen via nasal cannula under doctor prescription. After the
diagnostic investigation and therapeutic management of patient she got admitted in the
critical ward of medical department of LMCTH and diagnosed as Septic shock related to
Community Acquired Pneumonia.
D. PAST HISTORY
1. Past medical history : She is the known case of chronic obstructive pulmonary
disease (COPD) since 5 years and under regular medication (i.e. Rotacapsule
SEROFLO x 250 mg via rotahaler x BD).
She had no history of DM, HTN, Heart diseases, Pulmonary Tuberculosis, Thyroid
disorder.
2. Past surgical history : Not significant
3. Past psychiatric history : Not significant
4. Special treatment : Not significant
E . Family history
 There are total 11 family members in the joint family.
 There is no any history of Hypertension, Diabetes Mellitus, pulmonary
tuberculosis, chronic obstructive pulmonary diseases and other illness in her family
members.
 She has a good and harmonious relationship with her family members.
A. List of family members with their health status
S.N Name of family Age\sex Education Occupation Relationship Health

status
.1. Yamkala poudel Illiterate Home Self CAP with
80yrs/Fe maker AKI
2. Dholraj poudel 82yrs/M Literate Farmer Husband Healthy
3. Khum bahadur 58yrs/M Masters Teacher Son Healthy

poudel level
4. Bimala kafle 53yrs/Fe Upto SLC Housewife Daughter-in- Healthy
law
5. Uttam poudel 49yrs/M Upto 11 Farmer Son Healthy
class
6. Suman poudel 37y/Fe Upto Bank Younger son Healthy
bacheloer member
2nd level
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7. Usha poudel 25y/ Fe Upto 12ve Student Grand- Healthy
class daughter
8. Sampada poudel 18yrs/ Fe 11th class Student Grand- Healthy
daughter
9. Sakxam poudel 12 yrs/M 6th class Student Grandson Healthy
10. Seema poudel 6yrs/Fe 2nd class Student Grand Healthy

daughte
11. Abhiney poudel 15month - - Grandson Healthy
/M
FAMILY TREE
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G. PERSONAL HISTORY
1. Immunization history : Unknown Immunization Status.

2. Allergies : No any allergies with pollen, food, drugs, cold etc.
3. Dietary pattern : Non vegetarian
- She takes meal 3–4 times a day.
- She takes curry, rice, vegetables and egg in meal.
- She prefer black tea in early morning and evening .
- No any dislike food.
4. Sleeping pattern
She used to sleeps 6 hours at night and also 1-2 hours at days time.
5. Elimination pattern
Bowel: She has normal bowel pattern
Bladder: She has normal bladder pattern
6. Habit
She has a history of cigarette smoking since 45 years back.
She used to take 17 pack a year; left 20 years back..
She also has history of taking local alcohol, half glass, regular, at night time since
30 years and left 5 years back.
Non - tobacco user.
No use of illicit drug.
She used to walks for half an hour in evening before and now she is unable to
move without support .
7. Leisure time activities

She likes to spend her leisure time by watching TV, listen radio and sitting without
doing any activities.
8. Menstrual History
Her menstrual was regular at that time
Her menarche start at the age of 13 years.
Her menopause : 48 years
No any other menstrual problem .
8. Obstetric history:
Number of live birth: 04
Absortion : None
Mode of delivery : Normal vaginal delivery
G. PSYCHOLOGICAL HISTORY
1. Family relationship
 She is the second head of family. She participates fully in family decision making.
 Support system : Her husband, son and daughter in law.
 Recent family crisis : none
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2. Occupational history
 She is a homemaker.
 There is no any stress related to occupation.
3.Cultural history
 She believes that health is a state of free from any disease.
 She believes that some illness is caused by itself in increasing age and sometimes by
itself due to carelessness.
 Client perception towards present illness : She tooks her present illness seriously.
 Clients health practice : She follow and prefer hospital rather than traditional healer.
They do not believe in superstitions and dhami- jhakri.
4.Socio economic history

 Family income : around 45 thousand from family.
 No. of earning member : 4 members
They are able to buy medication and do treatment.
 Support system : by her family members and adequate.
 Old age allowance :NRs.2000 per month
H. Spritual history
 She belief positively about human birth and death are natural process.
 She believe in god and goddess and worship everyday.
 She attends religious functions occassionaly.
I. Environmental History
 Type of house : cemented
 Number of room : 6 rooms
 Separate kitchen : yes
 Natural lightening : adequates
 Ventilation : adequate
 Types of fuel used in kitchen : firewood and LPG gas
 Source of drinking water : well
 Method of water purification : filtration
 Type of toilet used : water seal
 Type of drainage : closed type
 Type of waste disposal : both by burning and dumping
 Stagnant water in the surrounding areas :No
 Use of net in the doors and windows : No
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RISK ASSESSMENT:
1. Risk for infection related to continous oxygen supplement.

2. Risk for pressure ulcer related to immobility.
3. Risk for fall injury related to blurred vision.
4. Risk for insect bite related to no use of door net
2] Physical Examination ( 2076/02/13) :

Vital signs of my patient:
 Temprerature : 101.4◦F
 Heart rate : 84 beats per minute, Regular
 Respiratory rate : 24 b/m, Regular
 Blood pressure : 90/60 mm of Hg
 Oxygen saturation (Spo2) : 94% in 3ltr O2 via nasal cannula.
Normal physiological changes in my patient.
 Hair is both mixture of black and white in colour.

 Presence of only molar teeth in upper and lower jaw.
 Decreased elasticity of skin.
 Wrinkling/Sagging of skin.
PHYSICAL EXAMMINATION:
S.N. Health history Yes No Physical examination (objective
(subjective data) data)
1] Problem related to head Hair –mixture of black and white

and face: color.
Headache Scalp –clean, no dandruff, no
Injury Lumps, no tenderness.
Puffiness of face Skull – normal in shape
Face –no swelling
Sinuses – no swelling , tenderness
and depression
2] Problem related to eye/ Eyelids – normal

vision : Eyeball- black in colour
Pain Cornea –transparent
Swelling Color of Sclera-slightly yellow
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Discharge conjunctiva is pale in color
Excessive tears Pupil size /symmetry- uniform in
Difficulty seeing at size and shape
night Reaction to light –reactive to
Others , specify light(when light approaches the eye
pupil constrict and when light is
removed it dilate)
Discharge –no discharge from eye
No any abnormalities in eyes as
evidenced by extra-ocular muscle,
convergence and comformation test.
3] Problem related to ear : Condition of external ear-both are

Pain normally located
Tinnitus Location-centrally located
Vertigo Drainage from ear-No discharge of
Dizziness pus, slightly wax present
Others Lumps or lesions- not present
Air conduction is greater than bone
conduction.
Hearing aids- not used
4] Problem related to nose Location –nose is centrally located

: Nasal deviation- not found
Injury Bleeding –absent
Bleeding / discharge Flaring of Nostrils -Normal
Blockage Any discharge –no discharge,
Smell present.
Condition of nasal mucosa- pinkish
in colour, no foreign bodies.
Inflammation – no inflammation
Nasal polyps- not found
5] Problems related to Lips –dry and cracked

mouth : Oral cavity –clean, no sores, oral
Sore on lips hygiene not maintained
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Sore on tongue Teeth – absence of teeth except
Gum bleeding molar teeth
Missing teeth/ dentures Tongue –papillae present,
Change in taste symmetrical in midline, no sores
Toothache Vocal cord, uvula and tonsils – not
enlarged and inflamed.
7] Throat and neck: Location – centrally located , no

Difficulty in tilting of head
swallowing Movement –full and smooth range of
Problems in tonsil movement , no stiffness or,
Neck rigidity tenderness
Jugular vein –not enlarged
Condition of thyroid – not enlarged
Lymph nodes-not enlarged, not
palpable
8] Problems related to Respiratory rate-24 breath / min

respiration : Depth of respiration –normal
Dyspnea Quality of respiration – wheezing
Cough sound is present
Hoarseness of voice Chest inspection – lateral diameter is
Cyanosis wider than antero-posterior diameter.
Others Sternum is located in midline.
Palpation:
No tenderness, lump or depression
along the ribs.
Even expansion on both sides of
chest.
Percussion :
Deep resonant sound was present
Auscultation –wheezing sound was
heard
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9] Heart and circulation : Pulse rate- 86beats/ min
Chest pain Blood pressure-140/80mmof hg
Numbness Peripheral pulse – all are present
Palpitation Capillary fill- 3 sec
Fever, chills Oedema :absent
Bleeding Varicosity- absent
tendencies Visible external jugular veins- absent
Others Systolic and diastolic murmur-absent
and normal lub dub sound is present.
Inspection:
10] Abdomen :
History of pain -Abdomen is in oval in shape and in
abdomen average size.
Distension -no scars
Indigestion -no abdominal distension
Nausea -no lumps or, depression and extra
vomiting mass
Auscultation:
-bowel sound was present.
-no scar, no abdominal distension
Palpitation:
-soft on palpation
-no abdominal mass
-no enlargement of spleen and liver
Percussion :
-dull and tympanic sound present in
all area of abdomen
11] Nutrition/ Hydration : Body built –normal looking

Anorexia Body weight – 64kg
Nausea /vomiting Height : 160cm
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Unusual thirst or BMI: 28.31 kg/m2
hunger Skin turgor/elasticity - normal
Diaphoresis Condition of buccal mucosa- intact
Non vegetarian
Special diet
Food dislikes
Ability to chew
Or swallow
Recent weight change
12] Elimination and Appearance of urine –normal in

reproduction : urine color i.e pale yellow
Painful micturation Appearance of stool- normal
Change in urine colour Enlargement of liver / spleen –absent
Urinary retention Mass in abdomen – not present
Frequency of urination Tenderness – not present
Incontinence of urine Bowel sounds-present(gurgles
Constipation sound)
Diarrhea Lesion / mass in rectal area – not
Presence of worms, present
mucosa, blood in stool Unexpected vaginal discharge –not
Discharge from vagina found
Bowel habits: regular / Mass per vagina – not present
irregular
13] Mobility: Motor strength or, mobility –normal

Difficulty with 5/5
ambulation Enlargement and stiffness of joint –
Muscle to cramps or absent
weakness Contractures- not present
Muscle pain Spinal deformity – not present
Back pain Range of motion –normal
Joint pain or swelling Edema- absent
Limited joint
movement
Ability to do activity of
daily living (ADLs)
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14] Comfort , sleep and rest Location of pain: no pain
: Difficulty in mobility independently
Pain Sleeping pattern: normal
Regular sleeping
pattern
15] Integumentary hygiene Colour of skin , textures , turgor-

: normal
Non –healing sores Pigmentation , lesion ,tumors- not
Change in mole /color found
Nail changes Skin inflammation – absent
Itching of skin Edema- absent
Regular bathing habits Abnormal nail conditions-not present
16] Reflexes Biceps reflex-present(+2)

Triceps reflex- present(+2)
Radiobrachialisrefles-present(+2)
Patellar reflex –present (+2)
Babinski reflex –negative
Finding of the physical examination
1. Problem related to eye and vision:
Slightly yellow sclera.
conjunctiva pale in coclor.
2. Problem related to mouth:
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Presence of dental carries
Missing teeth- upper 2 incision 2 permolar and 4 molar and lower 3 incision 2 cannie,
2 premolar and 3 molar
3. Problem related to respiration:
dyspnea, cough present
wheezing sound is present in left lower zone.
4. Problem related to mobility and comfort:
Difficulty in mobility independently
5.Nutrition/hydration: decreased elasticity
6.Problem related to Integumentary: wrinkled skin
A. DEVELOPMENT TASK
My patient Mrs. Yam kala poudel is 80years/female. So, According to Erik- Erikson theory
of psychosocial developmental task, she belongs to eighth stage of personality development
and her psychosocial crisis is Ego integrity Vs despair.
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According to book In my patient
1. Developing and discovering new She has developed and discovered new
satisfaction and a sense of unity and satisfaction and a sense of unity as her
building intimacy with spouse. children and grandchildren are staying with
her and has a very good and hormonius
relationship with her family members.
2. To maintain the body image and This is achieved as she has accepted
physical integrity. physiological changes in her body due to
aging.
3. Creating a pleasant and comfortable She has created a pleasant and comfortable
home, appropriate to values, interest, home and taught children and grandchildren
energy and resources. appropriate values, interests, energy and
resources.
4. To conduct the life review. This is achieved as she feels bad for taking
smoking cigarette and happy while she
reviews good things.
5. Preparing for the eventual death of She has accepted the god’s natural
parents unless they are already phenomenon of death.
decreased.
6. To accept the implication of She accept the household responsibilities

retirement. retirement to daughter in law.
7. Being able to lead or follow, She had never been involved in any
balancing work with other roles and occupation but has handed over her
preparing for retirement. responsibility to son and daughter in law.
8. Using leisure creativity with She used to take care of grandchildren and
satisfaction. spending time with her family.
9. To accept changes in the relationship She has good relationship with her
with grandchildren. grandchildren.
Conclusion : Since, she has completed all her developmental tasks, we can say that she has
fully developed her strength or ego identify as fulfilled; ego integrity.
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UNIT III
Anatomy and Physiology
Respiratory system
Respiratory system is consists of the upper respiratory tract (nose to larynx) and lower
respiratory tract ( trachea onwards). Together the two tracts are responsible for ventilation
(movement of air in and out of the airways). The upper tract, known as the upper airway,
warms and filters inspired air. So, that the lower respiratory tract (the lungs) can accomplish
gas exchange. Gas exchange involves, delivering oxygen to the tissue through the blood
stream and expelling waste gases, such as carbon dioxide during expiration.
 Conducting portion : transports air includes the nose, nasal cavity, pharynx, larynx,
trachea, and progressively smaller airways, from the primary bronchi to the terminal
bronchioles
 Respiratory portion :carries out gas exchange : composed of small airways called
respiratory bronchioles and alveolar ducts as well as air sacs called alveoli
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Respiratory system is made up of the organs involving :
Nose: The nose serves as a passage way for air to pass to and from the lungs. It fills
impurities and humidifies and warms the air as it is inhaled. Nose is composed of an external
and internal portion. The external portion protudes from the face and is supported by nasal
bones and cartilage.
The internal portion of the nose is hollow cavity separated into right and left nasal cavities by
a narrow vertical divider, the septum.
Air entering the nostrils is deflected upward to the roof of the nose, and it follow a circuitous
route before it reaches the nasopharynx.
Pharynx : The pharynx or throat is a tubelike structure that connects the nasal and oral
cavities to the larynx. It is divided into three regions: nasal, oral and laryngeal. The
nasopharynx is located posterior to the nose and above the soft plate. The laryangopharynx
extends from the hyoid bone to the cricoid cartilage. The epiglottis forms the entrance to the
larynx.The pharynx function as a passageway for the respiratory and digestive tracts.
Larynx : The larynx or voice organ, is a cartilagionus epithelium lined structure that
connects the pharynx and the trachea .The wall of the larynx is composed of nine pieces of
cartilage . Three occurs single( thyroid cartilage, epiglottis, cricoid cartilage), three occur in
pairs (arytenoid, cuneiform, corniculate cartilage ). Among them thyroid cartilage is a largest
which is called the adams apple. It is frequently referred to as the voice box. It consist of a 2
folds called vocal cords and opening between vocal cords is called glottis.
Trachea : It is also called windpipe. It is the membrano cartilaginous tube which extend
downwords as a continuation of larynx.
Orign : at the lower border of cricoid cartilage opposite to c6. It is 2 cm in adult male and 1.5
cm in female adult. It consists of incomplete C-shaped cartilaginous ring. Rings are 16-20 in
number. Trachea serves as the passage between the larynx and bronchi.
Bronchi and bronchioles :There are several division of the bronchi within each lobe of the
lung. Two bronchi are divided by trachea near center of chest, a right bronchus and a left
bronchus. 3 on right side and 2 on left side. Right bronchus is shorter, wider and has 10
segmental bronchi and has 8 segmental bronchi in left side. These bronchi are surrounded by
connective tissue that contain arteries, lymphatics and nerves. Respiratory bronchioles then
leads into the alveolar ducts and alveolar sacs then alveoli.
Alveoli : The lungs is made up of about 300 million alveoli, which are arranged in clusters of
15 to 20.
Lungs : The lungs are paired of spongy, airfilled, organs located on either side of the chest.
The trachea conducts inhaled air into the lungs through its tubular bronches, called bronchi.
The lungs are covered by a thin tissue layer called pleura. Thin layer of fluid acts as a
lubricant allowing the lungs to slip smoothly as they expand and contract with each other.
They extend from the root of the neck above to the diaphragm below and are against the ribs
both anteriorly and posteriorly.
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Pleura: The lungs and wall of the thorax are lined with a serous membrane called the pleura .
The visceral pleura covers the lung; the parietal pleura and the small amount of pleural fluid
between these two membranes serve to lubricate the thorax and lungs and permit smooth
motion of the lungs within the thoracic cavity with each breath.
Lungs are divided into 2 types :

1. Right lung
It is slightly larger than the left lung and is divided into three lobes by oblique and
horizontal fissures; i.e. the upper, middle and lower lobes.
2. Left lung
It is divided by a similar oblique fissure into two lobes i.e. the upper and the lower lobes.
PHYSIOLOGY OF RESPIRATORY SYSTEM

1. Oxygen is supplied to and carbondioxide is removed from the cell by way of
circulating blood enough the thin wall of capaillaries.
2. Oxygen diffuse from the capillary through the capillary wall to the interstitial fluid.
3. Oxygen is then transported to the tissue cells, where it is used by mitochondria for
cellular respiration.
4. The movement of the co2 occur by diffusion in opposite direction from cell to blood
this exchange of gas between cell and blood is called internal respiration.
5. After the tissue capillary exchange, blood enters the systemic venous circulation and
travels to pulmonary circulation and carried to lungs.
6. The oxygen concentration in the alveoli is more than in blood so by diffusion o2 is
transported to blood and co2 from blood to alveoli.
The exchange of gas between alveoli and blood is called external respiration and
again internal respiration takes between cell and blood.
DISEASE CONDITION
PNEUMONIA
Pneumonia is an inflammatory process of the lungs parenchyma or alveolar space involving
the terminal airways and alveoli of the lungs.
It causes consodilation of the lung tissues and fill the alveoli with serous fluids, mucous
and inflammatory cells in response to infections usually associated with a marked increase in
interstitial and alveolar fluids, commonly caused by microbial agents.
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Classification of pneumonia
 According to anatomy
 Lobar pneumonia
It is the form of pneumonia characterized by inflammatory exudate within the intra-
alveolar space resulting in consolidation that affects a large and continuous area of the
lobe of lung.
 Broncho pneumonia
It is the condition that cause inflammation of the lungs. Broncho pneumonia refers to
many patchy alveolar consolidation associated with bronchial and bronchiolar
inflammation often affecting both lower lobes. Many cases of bronchopneumonia are
caused by bacteria. Most types of pneumonia clear up within a week or two, although a
cough can linger for several weeks more. In sever case it may longer.
 Interstitial pneumonia
It is the form of lung diseases characterized by progressive scarring of both lungs. The
scarring is associated with interstitial lung diseases eventually affects your ability to
breathe and get enough oxygen into your bloodstream.
 Military pneumonia
Military pneumonia is a pneumonia that occurs in soldiers. Moisture from rain and
melting snow made it impossible for many soldiers to stay dry and allowed for spread of
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disease. wounded soldiers often may died from exposure to element. Unsanitary and
crowded conditions led to the proliferation of diseases and sickness such as typhoid and
pneumonia.
2. According to causative organism

 Bacteria
Bacterial infection is an inflammation of the lung due to bacterial infection. Different
types of bacteria can cause pneumonia. This types of pneumonia can occur in both lungs,
one lung, or one section of a lung and the most common cause is streptococcus
pneumoniae.
 Virus
Viral pneumonia is a infection of the lungs caused by a virus. The most common case is
influenza (flu), but you can also get viral pneumonia from common cold and other
viruses. These nasty germs usually stick to upper part of your respiratory system but the
trouble starts when they get down into your lungs.
 Fungi
Fungal pneumonia is a type of lung infection caused by fungi aspergillosis. Though
this condition is uncommon in most of the people those with compromised immune
system due to certain types of infection. Symptoms are similar to those experienced by
people with bacterial or viral pneumonia like cough, fever, chest pain, difficulty in
breathing.
3. According to exposure
Community Acquired Pneumonia
Community Acquired Pneumonia (CAP) is defined as a lower respiratory tract infection of
the lung parenchyma with onset in the community or during the first 2 days of
hospitalization. It is most prevalent during winter and spring. The need for hospitalization for
CAP depends on the severity of the pneumonia: Use of CURB 65 Criteria
Health Care Associated Pneumonia

Health care associated pneumonia includes any patients with a new onset pneumonia who
was hospitalized in an acute care hospital for 2 or more days within 90 days of the infections,
resided in a long term care facility, received recent intravenous antibiotic therapy,
chemotherapy, or wound care within the past 30 days of the current infections or attended a
hospital or hemodialysis clinic.
Hospital Acquired Pneumonia

Hospital acquired pneumonia or nosocomial pneumonia refers to a new episode of
pneumonia occurring at least 2 days after admission to hospital and not incubating at the time
of hospitalization. It is the second most common hospital acquired infection(HAI) and the
leading cause of HAI- associated death.
These respiratory infections occur when at least one of three conditions exists:
-Host defenses are impaired,
-Inoculum of organisms reaches the patient’s lower respiratory tract and overwhelms the
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host’s defenses,
-When a highly virulent organism is present
Ventilator Acquired Pneumonia

It refers to pneumonia that occurs more than 48-72 hours after endotracheal intubation.
Aspiration Pneumonia
Aspiration pneumonia refers to the sequelae occurring from abnormal entry of secreations or
substances into the lower airway. It usually follows aspiration of material from the mouth or
stomach into the trachea and subsequently the lungs. The persons who has aspiration
pneumonia usually has a history of loss of consciousness or an impaired cough or gag reflex.
It Increases the risk for subsequent bacterial pneumonia.
Community Acquired Pneumonia was present in my patient.
Community Acquired Pneumonia

It refers to the pneumonia (any of several lung diseases) contracted by a person with little
contact with health care system. It occurs either in the community setting or within the first
48 hours after hospitalization or institutionalization. The need of hospitalization for CAP
depends on the severity of the pneumonia use of CURB- 65
CURB-65 criteria
C - confusion ( disoriented to time, place and person)
U - urea > 7mmol/L
R - respiratory rate > 30 /min
BP – Systolic BP < 90mm of Hg or diastolic BP < 60 mm of hg
Age > than 65 years
The Causative agents for community acquired are: Streptococcus pneumonia, Haemophilus
influenza, Klebsiella pneumonia, Mycoplasma pneumonia, Chlamydia pneumonia,
Pseudomonas aeruginosa, Legionella and gram negative rods.
Epidemiology
The specific etiologic agent is identified in about 50% of cases. it is estimated that more than
915,000 episodes of CAP occur in adults 65 years of age and older each year in the united
states. ( Mandell, Wunderink, Anzueto, et al. 2007). Community acquired pneumonia is
common in worldwide and a major cause of death in all any group. More community
acquired pneumonia cases ocuur during winter than other time.
More common in male than in female and more common in black people than Caucasians. It
is the 6th leading cause of death worldwide. More than 3 million cases per year and 45000
deaths per year.
23
Risk factors
Book picture Patient picture
Age more than 65 Present
Chronic condition such as COPD Present
Smoking and alcohol Present
Decreased cough reflex Present
Immunocompromised status and organ -
transplanted patient.
Chemotherapy, radiation therapy, major -
surgeries.
Under mechanical ventilator and prolonged -
immobility
General anesthesia and sedated -
Nothing-by-mouth (NPO) status: -
placement of nasogastric, orogastric,
or endotracheal tube
Tracheal intubation, tracheotomy -
Etiology
Inhalation of smoke, toxic chemical, dust Smoke present
and gases.
Organism: Bacteria, virus, mycoplasm, -

protozoa
Aspiration of fluids/ foods/ vomit -
Pathophysiology
Entry of the organism to lungs through aspiration, inhalation, blood stream or direct spread of
surgery
Penetration to the lower respiratory tract by organism
Inflammation reaction in alveoli
Partial occulusion of the bronchi and alveoli decreased alveolar oxygen tension
(inadequate ventilation)
Interfere with diffusion of O2 and CO2
Ventilation perfusion mismatch

24
Mixing of oxygenated and deoxygenated or poorly oxygenated blood
Arterial hypoxia
Shortness of breath cyanosis
Clinical manifestation
According to book In my patient
Rapid raising fever with chills Fever with chills

Cough with sputum productive Present
Pleuritic chest pain Present
Shortness of breath Present
Dyspnea Present
Crackle and wheezing sound over affected Present(wheezing sound)
area
Dullness over infected area in percussion Present
Headache, malaise, sweating Present (headache)
Decreased appetite Present
Hemoptysis (coughing with blood) -
Confusion -
Diagnostic investigations

1. History taking and Physical Done
examination
2. Chest X-ray. Done
3. Complete blood count Done (increased WBC count)
4. Blood culture Blood culture
5. Sputum culture and sensitivity test Done
6. Urine RE Done
7. ABG analysis Done
8. Bronchoscopy -
9. Gram staining and sensitivity test of -
sputum
25
Investigation done in my patient on 2076-02-11
Haematology report
Test Result Unit Ref. Range
Haemoglobin 11.7 gm/dl Male(14-18),female(12-16)
ESR 32 Mm/1s 0-20
WBC count 25,900 /cumm 4000-11000
Neutrophils 91 % 40-70
Lymphocytes 05 % 25-40
Eosinophils 02 % 1-6
Monocytes 02 % 2-6
Basophil 00
Total platelet count 2,38,000 /cumm 150000-450000
Biochemistry report
Test Result Unit Ref. Range
Random Blood 151 Mg/dl GOD-POD 60-140

Sugar
Blood urea 68.0 Mg/dl urease 15-45
Serum 3.2 Mg/dl JAFFEs/KI 0.5-1.4
Creatinine
Na+ 138 mEq/l Electrolyte 135-148
K+ 3.0 mEq/l Electrolyte 3.5-5.3
Urine and Stool test

Test Result
Urine R/E
Physical examination
Colour Slightly
Yellow
Appearance Clear
Chemical examination
Serology
Reaction Acidic
Albumin Nil report(2076-2-13)
Sugar Nil
Scrub typhus
Microscopic examination
( 2076-2-13)
Pus cells 2-3
Test
RBC Result Method
Nil
Scrub typhus
Epithelial cells Negative 2-4
OTHERS INVESTIGATIONS:
Urine c/s : No growth after 24 hours of incubation at 37degree centrigrade

Chest X-ray: (2076-02-11): presence of pulmonary infiltration
26
Sputum AFB I and AFB II : Negative report
Kalaazar ( K39) and Scrub typhus : Negative
Gene expert : Negative report
ABG Analysis (2076-02- 12):
PH: 7.42
PaCo2: 28.3 mmHg
PaO2: 80mmHg
HCo3:18mEq/L
Management and Treatment

 Medical management
1.Specific antibiotic therapy: it is widely Inj Tazolin 4.5gm IV TDS was given.
used in the treatment and prevention of Tab Doxycycline 100mg PO BD was given.
infection, either it kills or inhibit the growth
of bacteria.
Macrolides
• Clarithromycin 500 mg PO bid, or
• Azithromycin 500 mg PO OD,
then 250 mg QID or Doxycycline
100 mg PO BD
Fluoroquinolone
• Moxifloxacin 400 mg PO QID
• Gemifloxacin 320 mg PO QID
• levofloxacin 750 mg PO QID
• Tazolin 4.5gm IV TDS was given
Others:
• Amoxicillin 1 g TID ,
Amoxicillin/Clavulanate 2 g BD
• Ceftriaxone 1–2 g IV QID
2.Chest physiotherapy: it helps to remove the Chest physiotherapy was done.

obstructive, thick sticky secrection and helps
in ease breathing.
3.Suctioning: it helps to maintain and Not done as my patient was conscious.

establish gas exchange, adequate
oxygenation and alveolar ventilation.
27
4.Nebulization therapy: salbutamol, Provided with asthalin: ipravant: NS=1:1:2
ipratropium bromide and NS. 6 hourly.
5.Fluid intake/ hydration: to prevent or treat Fluid intake upto1500ml/day was provided.
dehydration and it also helps in release of
secrection.
6.Deep breathing and coughing exercise: it Taught and done

helps your breathing, clear your lungs and
lower risk of pneumonia
7.Humidification of air/ oxygenation: 3ltr 02 supplementation was provided via

nasal cannula as patient 02 was 83% in room
air
8.Analgesic to control pain Flexon was given
9.Mechanical ventilation -
 Surgical management
1. Lobectomy: surgicial removal of the lobe of -
the lungs. It is done to remove a portion of
diseased lung
2. Pneumonectomy: surgical removal of the entire -

lungs.
3. Thoracotomy: incision into the pleural space of -
chest.
4. Segmentectomy: surgical removal of the lungs -
5. Wedge resection: part of the lung is removed. -
 Nursing management
1. Humidification of air/ oxygen 3litre 02 was provided through nasal cannula.
2. Deep breathing and coughing exercise Taught and assist patient to perform this
‘deep breathing exercise.
3. Proper positioning Semi fowler’s position and changed patients
position every 2 hourly.
4. Promote fluid intake 2-3 liter per day Fluid intake 1500-2000ml was provided.
if not contraindicated.
5. Chest physiotherapy Provided
6. Maintain nutritional status IV fluid started and nutritious diet was
provided
7. Monitor and manage potential No any complication was monitored.
complication
28
8. Provide antibiotics Inj Tazolin 4.5gm IV TDS was given.
Tab Doxycycline 100mg PO/BD was given
9. Nebulization therapy Provided with asthalin: ipravant: NS=1:1:2, 6
hourly was provided
10. Promote rest Instruct patient to avoid high oxygen demand
activities
11. Provide education Health education was provided
-about proper administration of drug.
-Instruct breathing exercise.
-encourage gradual increased of
activities.
-instruct to take nutritious food
-Quitting smoking
-Avoidance of fatigue, stress
-need to follow up visit
 Complications
1. pleurisy: inflammation of the pleura -
(it is relatively common).
2. Pleural effusion: accumulation of -

excess amount of fluid in pleural
cavity.
3. Empyema: collection of pus in pleural -
cavity,usually associated with
pneumonia but may develop after
thoracic surgery.
4. Pneumothorax: occurs when air leaks -
into space between your lungs and
chest wall.
5. Acute respiratory distress syndrome -
6. Atelectasis (collapsed,airless alveoli ) -
of one or part of one lobe may occur.
7. Bacteremia(bacterial infection in the -

blood)
8. pericarditis:pericarditis results from -

spreadof the infecting organism from
an infected pleura or via
a hematogenous route to the
pericardium.
29
ACUTE KIDNEY INJURY
Acute kidney injury also referred to as acute renal failure ARF is defined as a rapid,
potentially reversible deterioration in function sufficient to result in accumulation of
nitrogenous waste in the body (URAEMIA) usually accomplished by a reduction in urine
volume :
 An increase in serum creatinine of _> 0.3 mg/dl within 48 hours.
 An increase in serum creatinine of _> 1.5times baseline, which is known or presumed
to have occurred within the prior seven days.
 Urine volume < 0.5mL/ Kg per hour for more than 6 hours.
Presently, the term acute renal failure AKI is often used in place of ARF. The conventially
used term ARF is often used in reference to the subset of patients with a need for acute
dialysis support.
RIFLE criteria are used to classify severity of acute kidney injury. The acronym RIFLE
stands for the increasing severity classes.
R : Risk
I : Injury
F : failure
L : Loss
E : End – stage kidney disease
The 3 severity grades are defined on the basis of changes in serum creatinine or urinary
output where the worst of each criteria is used. Also 2 outcomes criteria are defined by
duration of loss of kidney function, 4 weeks and 3 months, respectively.
Acute Kidney Injury is diagnosed if one of the following criteria meets:
 50% increase in baseline serum creatinine within 7 days.
 Urine output of less than 0.5 ml/kg/hour for at least 6 hour.
Phases of AKI
There are 4 phases including
1. Initial phase: common triggering events:
Significant blood loss, burns, fluid loss, diabete insipidus.
Renal blood flow 25% of normal
30
Tissue oxygenation 25% of normal
Urine output below 0.5 ml/kg/hour
2. Oliguria phase: urine output below 400 ml/day
Increased in blood urea nitrogen and creatinine levels
Electrolyte disturbances, acidosis and fluid overload (from kidney’s inability to

excrete water)
It takes 8 to 14 days or longer, depending on nature of AKI and dialysis initiation.
3. Diuretic phase: occurs when cause of AKI is corrected.
Renal tubules scarring and edema
Increase GFR
Daily urine output above 400ml but renal function may be still markedly abnormal.
Possible electrolyte depletion from excretion of more water and osmotic effects of
high BUN
It takes 7 to 14 days.
4. Recovery phase: decreased edema
Improvement of renal function.
Normalization of fluid and electrolyte balance
It takes 3-12 months.
B. Epidemiology
- Between 5% and 7% of all hospitalized patients develop AKI
- A greater prevalence of AKI is found in critically ill patients.
- Most affected population is 60-70 years old men due to surgery, diabetes, pneumonia,
cardiac failure.
Etiology

1. Pre renal AKI (55%)
 Hypovolemia: haemorrhage, Use of NSAIDs present
diuretics, vomiting, diarrhea,
NG suction, pancreatitis, burn,
sweating, massive bleeding.
 Impaired cardiac function: MI,
31
heart failure, dysrhythmias,
cardiogenic shock, cardiac
tamponade
 Vaso constriction:
hypercalcemia, NSAIDs ,
cocaine
 Vaso dilation: sepsis,
anaphylaxis, antihypertesive
drugs.
2. Intrarenal AKI (40%)

Prolonged renal ischemia: -
nephropathy,trauma, crush injuries,
burns.
Nephrotoxic agents: aminoglycoside,
antibiotics, diuretics, NSAIDs and
ACE inhibitors.
Acute pyelonephritis and
acuteglomerularnephritis.
3. Post renal AKI (5%) -

Urinary tract obstruction; calculi,
tumor, BPH, strictures, blood clots.
Risk factor
1. Hypertension -
Over time uncontrolled high BP can
cause arteries around kidney. These
damaged arteries are not able to
deliver enough blood to kidney tissue.
2. Congestive cardiac failure / septic Septic shock present.
shock. It is the significant risk factor
of kidney diseases.
3. Diabetes II (DM): a condition -
characterized by high blood glucose
or sugar level, this eventually leads
kidney failures.
4. Chronic infection -
It may develop complications and
early detection and treatment can
often keep AKI from getting worse.
Pathophysiology
Various etiologies
32
Damaged tubules cannot conserve sodium normally
Redistribute renal vascular supply by increasing the tone of both afferent and efferent
arterioles
The resulting ischemia may increase vasopression, cellular, swelling and inhibition of
prostaglandin synthesis and further stimulation of renin angiotensin system
Reduced blood flow decrease glomerular pressure, glomerular filtration rate, and tubular flow
Oliguria occurs.
Clinical manifestation
Peripheral edema Present
Weight gain present
Nausea, vomiting, diarrhea, anorexia Present( Nauses, vomiting, anorexia).
Fatigue Present
Shortness of breath Present
Anemia Present
Hyponatremia Present
Hypokalemia -
Mental status changes -
Oliguria -
Hypocalcemia -
Pruritis -
Diagnostic evaluation
1. History taking Done
2. Physical Examination Done
3. Blood test Done

Blood urea nitrogen( BUN)
Creatinine, Sodium, Potassium level.
4. Renal angiography -
5. Renal function test Done
6. Computed tomography Done
7. Complete blood count Done
8. Doppler scan -
9. Hyperkalemia Done
33
Medical management
1. Prerenal is treated by optimizing renal -

perfusion eg: fluid replacement in
dehydration
2. Intrarenal failure needs supportive

treatment with removal of causative
agent
3. Post renal failure is treated by reliving -

the obstruction.
4. If shock and infection present, treat -

them promptly
5. Maintain fluid and electrolyte balance Only Oral fluid was provided not IV
6. Correct acidosis with bicarbonate. -
7. Diuretic therapy: Furosemide and -

mannitol may be needed.
8. Correct haematologic abnormalities. Done
9. Electrographic monitoring Don e
10. Diet: avoid magnesium containing -

food eg: green vegetable, seeds, nuts
11. Prevent infection Done
12. Maintain nutritional status; high Done

calorie and low protein , sodium
13. Peritoneal dialysis may be necessary -
Nursing management

Monitor heart rate, BP and CVP Heart rate and BP monitored
Record accurate I/O charting I/O chart was strictly recorded
Assess skin, face, and dependent area for Edema is present in hand and sacrum region
edema and evaluate.
Monitor BUN, urine sodium and creatinine, BUN , Hb , sodium and creatinine level was
Hb level monitored
Administer and restrict fluid as indicated. Fluid was administered as indicated.
Carefully assess the complication No any complication of pericarditis, uremia,
pleural effusion
Monitor potassium, calcium and magnesium Monitored the level of potassium, calcium
34
level and magnesium
Observe ECG for changes in rhythm ECG was normal
Assess or review dietary plan Dietary pattern
Discuss haemodialysis or transplantation if Not done
needed in future.
Complication
Pericarditis, congestive heart failure, Hypertension present
hypertension
Anemia Present
Skin dry, itching Present
Decreased functioning of WBC -
Weakening of the bones and fractures -
Change in glucose metabolism -
Hepatitis B, hepatitis C, liver failure -
Seizure -
Electrolyte abnormalities including Present
hyperkalemia
Unit – IV
Drug Profile
During hospitalization
Drug name Generic name Dose Route Frequency Group

Injxone Ceftriaxone 2 gm IV OD Cephalosporin;
Antibiotics
Tab amlod Amlodipine 2.5 mg PO OD Calcium channel
blockers
Injhydrocort hydrocortisone 100 mg PO BD Anti inflammatory
Injlevoflox levofloxacin 500 mg IV OD Fluoroquinolones;
Antibiotics
Injvancomyci 500 mg IV BD Antibiotics
n
Syp lactulose Lactulose Laxative
Syp. Fortiplex Fortiplex–m 5 ml PO BD vitamin
Nebulization 1:1:2 SOS Bronchodilator
During discharge
Drug name Dose Route Duration

Tab levoflox 5oo mg PO 7 days
Tab amlod 2.5 mg PO continue
35
Tab pantop 40 mg PO 7 days
Sypfortiplex 5 ml PO Continue
Syp lactulose 15 ml PO Continue
1. Levofloxacin
Functional class: Anti-infective

Chemical class:Fluroquinolone
Mechanism of action
sInterferes with conversion of intermediate DNA fragments into high-molecular-weight DNA
in bacteria; DNA gyrase inhibitor.
Uses:
 Acute sinusitis, acute chronic bronchitis, community acquired pneumonia, skin infections,
complicated urinary tract infection, cellulitis, pelvic inflammatory disease
Contraindication: Hypersensitivity to quinolones
Available dosage: PO/IV 500mg or 750mg

Side effects:
 CNS: headache, dizziness, insomnia, anxiety, seizures, paraesthesia
 CV: chest pain, palpitations, vasodilation
 EENT: dry mouth, visual impairment
 GI: nausea, flatulence, vomiting, diarrhea, abdominal pain, hepatotoxicity
 GU: vaginitis
 INTEG: rash, pruritus, photosensitivity
 RESP: pneumonitis
Pharmacokinetics:
Metabolized in liver, excreted in urine unchanged, half life 6-8 hr, peak 1-3 hr
Nursing consideration:
 Assess signs and symptoms of infection: WBC >10,000/mm3, fever; renal function:
BUN/ Creatinine
 Increased fluid intake to 2L/day to prevent crystalluria.
 Evaluate therapeutic response: absence of signs and symptoms of infection.
 Teach patient/family:
- To report if vaginal itching, foul smelling stool pruritus, rash occurs
- To notify prescriber if diarrhea with blood or pus
- To complete full course of therapy
- To avoid hazardous activities
- To use frequent rinsing of mouth, sugarless candy or gum for dry mouth
2. Vancomycin
36
Functional class: Anti infective
Chemical class: Tricyclic glycopeptide
Mechanism of action: Inhibits bacterial cell wall synthesis, block glycopeptides.
Uses:
 Resistant staphylococcal infections, pseudo membranous colitis, endocarditis prophylaxis
for dental procedures, diptheroid endocarditis
Contraindication: Hypersensitivity, previous hearing loss
Available forms: Capsule 125, 250mg; Inj. 500mg, 1, 5, 10g
Side effects:
 CV: cardiac arrest, hypotension
 EENT: ototoxicity, permanent deafness, tinnitus
 GI: nausea, pseudo membranous colitis
 GU: nephrotoxicity, increased BUN, creatinine, albumin
 INTEG: chills, fever, rash, thrombophlebitis at inj. site, pruritus
 RESP: wheezing, dyspnea
Pharmacokinetics:
 PO: Absorption poor
 IV: Onset rapid, peak 1 hr, half life 4-8 hr, excreted in urine
 Assess infection; intake and output ratio: report hematuria, Oliguria; respiratory status.
 Increased intake of fluid to 2L/day to prevent nephrotoxicity.
 Evaluate therapeutic response: absence of fever, sore throat.
 Teach patient/ family:
- about all aspects of product therapy; to be taken in equal intervals, about the need to
complete entire course of medication to ensure organism death.
- To report sore throat, fever, fatigue; could indicate super infection.
3. Hydrocortisone
Functional class: Corticosteroid

Chemical class: Short acting glucocorticoid
Mechanism of action: Decreases inflammation by suppression of migration of

polymorphonuclear leukocytes, fibroblasts, reversal of increased capillary permeability and
lysosomal stabilization.
Uses: Severe inflammation, adrenal insufficiency, ulcerative colitis, collagen disorders

Contraindication: Children<2yr, psychosis, hypersensitivity, idiopathic thrombocytopenia,
fungal infections, AIDS, TB, recent MI
Available forms: Tabs 5, 10, 20mg; Inj. 25, 50mg/ml; enema 100mg/60ml
Side effects:
37
 CNS: depression, flushing, sweating, headache, mood changes
 CV: hypertension, tachycardia, edema
 EENT: fungal infections, increased intra ocular pressure, blurred vision
 GI: diarrhea, nausea, abdominal distention, increased appetite, pancreatitis, GI
hemorrhage
 INTEG: acne, poor wound healing, ecchymosis, petechiae
 MS: fractures, osteoporosis, weakness
Pharmacokinetics:
 Metabolized by liver, excreted in urine
 PO: peak 1-2 hr, duration 1- 1 ½ days
 IM/IV: onset 20 min, peak 4-8 hr, duration 1-1 ½ days
 Assess
- potassium, blood glucose, urine glucose while patient is receiving long term therapy.
- blood pressure, pulse; notify prescriber of chest pain.
- intake and output ratio; be alert for decreasing urinary output, increasing edema
- infection; increased temperature, WBC
- mental status: mood, affect, behavioral changes, aggression
- GI effects: nausea, vomiting, anorexia or appetite stimulation, abdominal pain, hiccups,
gastritis, pancreatitis.
 Evaluate therapeutic response: decreased inflammation, GI symptoms
- To immediately report abdominal pain, black tarry stools, because GI bleeding/
perforation can occur.
- Not to discontinue abruptly because adrenal crisis can result.
- That supplemental calcium/ vit. D may be needed if patient receiving long term therapy.
- To avoid OTC products; salicylates, alcohol in cough products unless directed by
prescriber.
- To avoid live- virus vaccines if using steroids long term.
4. Ceftriaxone
Functional class;broad spectrum antibiotic
Chemical class:cephalosporin
Mechanism of action
Inhibits bacterial cell wall synthesis ,rendering cell wall osmotically unstable ,leading to cell
death
Uses
Serious lower respiratory tract ,urinary tract ,skin gonococcal

,intraabdominalinfections.septicemia ,menigititis,bone,jointinfection,otitis media
38
Dosage and routes
 Adult :IM/IV 1-2 g/day ,max 2 g q12 hr

 Child :IM/IV 50-75mg/kg/day in equal doses q12hr
Uncomplicated gonorrhea
 Adult :250 mg IM as single dose

 Reduce dosage in severe renal impairement
Meningitis
 Adult and child ;IM/IV 100 mg/kg/day in equal doses q12 hr,max 4g/day
Available forms
Inj 250,500 mg 1,2,10 g
Side effects
CNS;headache ,dizziness,weakness,feverchills,seizures
CV;heartfailure,syncope
GI;nausea ,vomiting ,diarrhea.,bleeding abdominal pain
GU;proteinuria ,nephrotoxicity,renal failure
Resp ;dyspnea
Contraindication
Hypersensitivity to cephalosporin ,infants less than 1 month
Precautions
Pregnancy ,breast feeding ,children ,hypersensitivity to penicillins GI/renal disease
Nursing consideration
Assess
Sensitivity to penicillin other cephalosporin
Nephrotoxicity :increased BUN ,creatinine ,urine output
Electrolytes ;k, Na ,cl monthly if patient is on long term therapy
Bowel pattern daily ;if severe diarrhoeaoccurs
Bleeding :ecchymosis ,bleeding gums ,hematuria
39
5. Lactulose
Functional class: laxative

Chemical class: lactose synthetic derivative
Mechanism of action
Prevents absorption of ammonia in colon by acidifying stool; increases water, softens stool
Uses
 Chronic constipation
 Portal systemic encephalopathy in patients with hepatic disease
Contraindications
 Hypersensitivity
 Low- galactose diet
Dosage
Oral solution 10g/15Ml; Packets 10, 20 g; rectal solution10g/15mL
Side effects
 GI: Nausea, vomiting, anorexia, abdominal cramps, diarrhea, flatulence, distention
 META: Hypernatremia
Pharmacokinetics: Metabolized in colon, onset 1-2 days, peak unknown, duration unknown
Nursing considerations
Assess
 Stool: amount, color, consistency
 Cause of the constipation
 Blood, urine electrolytes if product used often; may cause diarrhea, hypokalemia,
hyponatremia
 Input and output ratio to identify fluid loss, replace any loss
Evaluate
 Therapeutic response; decreased constipation, decreased blood ammonia level, clearing of
mental state
Teach patient/ family
 Not to use laxatives for long term
 To dilute with water or fruit juice to counteract sweet taste
 To store in cool environment
 To take on an empty stomach for rapid action
6. Amlodipine
Functional class: Anti angina, Anti hypertensive, Calcium channel blocker

Chemical class:Dihydropyridine
40
Mechanism of action: Inhibits calcium ion influx across cell membrane during cardiac
depolarization; produces relaxation of coronary vascular smooth muscle, peripheral vascular
smooth muscle; dilates coronary vascular arteries; increases myocardial oxygen delivery in
patients with vasospastic angina.
Uses: Chronic stable angina pectoris, hypertension, variant angina
Contraindication: hypersensitivity, severe aortic stenosis, severe obstructive CAD
Available forms: Tab 2.5, 5, 10 mg
Side effects:
 CNS: headache, fatigue, dizziness, anxiety, depression, insomnia, paresthesia
 CV: peripheral edema, bradycardia, hypotension, palpitations, syncope, chest pain
 GI: nausea, vomiting, diarrhea, gastric upset, constipation, anorexia, dyspepsia, dysphagia
 GU: nocturia, polyuria, sexual difficulty
 INTEG: rash, pruritus, alopecia
 OTHER: flushing, muscle cramps, cough, weight gain, epistaxis
Pharmacokinetics: Peak 6-12 hr, half life 30-50 hr, metabolized by liver, excreted in urine
 Assess cardiac status, intake and output ratio.
 Evaluate therapeutic response: decreased anginal pain, decreased B/P, increased exercise
tolerance.
- To take drug as prescribed, not to double or skip dose.
- To comply in all area of medical regimen: diet, exercise, stress reduction, product
therapy, smoking cessation.
- To notify prescriber of irregular heartbeat; swelling of feet, face and hands; hypotension;
if chest pain does not improve
- To avoid large amount of grapefruit juice, alcohol
- To change position slowly to prevent orthostatic hypotension
UNIT V
Application of nursing theory
Problem solving theory by Faye Glenn Abdellah
I choose this theory as it is based on restoration and preventive measures for meeting total
client needs that is almost important in this case. It comprises of 21 topology of problems that
is either overt or covert and can be solved by direct or indirect means.
41
General introduction
Besides from being the first nurse and the first women to serve as a deputy surgeon general,
Faye Glenn Ablellah also made a name in the nursing profession with the formulation of her
“21 nursing problem theory
Her theory changed the focus of nursing from disease centered to patient centered and began
to include the care of families and the elderly in nursing care.
“ Nursing is based on an art and science that mould the attitudes, intellectual competencies
and technical skills of the individual nurse into the desire and ability to help people sick or
well cope with their health needs” – Abdellah.
Major assumptions, concepts and relationships:
She uses the term ‘she’ for nurses, ‘he’ for doctors and patients and refers to the object for
nursing as a patient rather than client or consumer.
She refers to nursing diagnosis during a time when nurses were taught that diagnosis was not
a nurse’s prerogative.
Assumptions were related to:
-Change and anticipated changes that affect nursing.

-The need of appreciate the interconnectedness of social enterprises and social problems.
-The impact of problems such as poverty, racism, pollution, education, and so forth on health
care delivery.
-Changing nursing education.
-Continuing education for professional nurses.Development of nursing leaders from under
reserved groups.
Abdellah and colleagues developed a list of 21 nursing problems. They also identified 10
steps to identify the client’s problem. 11 nursing skills to be used in developing a treatment
typology.
10 steps to identify the client’s problems:
42
Learn to know the patient.
Sort out relevant and significant data.
Make generalizations about available data in related to similar nursing problems presented by
other patients.
Identify the therapeutic plan.
Test generalization with the patient and make additional generalization.
Validate the patient’s conclusions about his nursing problems.
Continue to observe and evaluate the patient over a period of time to identify any attitudes
and clues affecting his behavior.
Explore the patient’s and families reaction to therapeutic plan and involve them in the plan.
Identifiy how the nurses feels about the patient’s nursing problems
Discuss and develop a comprehensive nursing care plan.
11 nursing skills:
Observation of health status.
Skills of communication
Application of knowledge.
Teaching of patients and families.
Planning and organization of work.

Use of resource materials.
Use of personnel resources.
Problem solving.
Direction of work of others.
Therapeutic use of the self.
Nursing procedure.
21 nursing problems:
Three major categories:
a.Physical, sociological and emotional needs of client.
b. Types of interpersonal relationship between nurse and patient.
c. Common elements of client care.
43
Basic to all patients:
To maintain good hygiene and physical comfort.

To promote optimal activity, exercise, rest and sleep.
To promote safety through the prevention of accidents, injury or other trauma and
through the prevention of the spread of infection.
To maintain good body mechanics and prevent and connect deformity.
Sustenal care needs:
To facilitate the maintenance of a supply of oxygen to all body cells.

To facilitate the maintenance of nutrition of all body cells.
To facilitate the maintenance of elimination.
To facilitate the maintenance of fluid and electrolyte balance.
To recognize the physiological responses of the body to disease conditions.
To facilitate the maintenance of regulatory mechanisms and functions.
To facilitate the maintenance of sensory functions.
Remedial care needs:
To identify and accept positive and negative expressions feeling and reactions.
To identify and accept the interrelatedness of emotions and organic illness.
To facilitate the maintenance of effective verbal communications.
To promote the development of productive interpersonal relationship.
To facilitate progress towards achievement of personal spiritual goals.
To create or maintain a therapeutic environment.
To facilitate awareness of self as an individual with varying physical, emotional and
development needs.
Restorative care needs:
To accept the optimum possible goals in the light of limitations, physical and
emotional.
To use community resources as an aid in resolving problem arising from illness.
To understand the role of social problems as influencing factors in the case of illness.
44
Ablellah’s theory and the four major concepts:
Nursing:
Nursing is a helping profession.

Nursing care is doing something to and for the person or providing information to the
person with the goals of meeting needs, increasing or restoring self help ability or
alleviating impairment.
Nursing is broadly grouped into the 21 problem areas to guide and promote use of
nursing judgment.
Nursing to be comprehensive service
.Person:
Abdellah describes people as having physical, emotional and sociological needs.
Patient is described as only justification for the existence of nursing.
Individuals (and family) and the recipient of nursing.
Health or achieving of it is the purpose of nursing service.
Health:
In patient- centered approaches to nursing, Abdellah describes health as a state

mutually exclusive of illness.
Although Abdellah doesn’t give a definition of health, she speaks of ‘total health
needs’ and ‘a healthy state of mind and body’ in her description of nursing as a
comprehensive service.
Society and environment:
“Society is included in planning for optimum health on local state, national and international
levels”. However, as she further delineated her ideas, the focus of nursing service is clearly
the individual.
The environment is the home or community from which patient comes.
Topology propose by Patient picture Nursing diagnosis

Abdellah
45
II Basic to all patients:
1. To maintain good hygiene The patient has maintained -

and physical comfort good hygiene and physical
comfortable.
2. To promote optimal The patient complained of 1. altered sleep and

activity: exercise, rest and decrease sleeping pattern rest related to
respiratory problem
sleep and unable to perform
as evidenced by
activity independently difficulty in falling
asleep and verbal
complaints of not
feeling well-rested
2. Activity intolerance
related to impaired
respiratory function
as evidenced by
patient’s inability to
perform activities
independently
3. To promote safety through She was kept in safe Risk for infection related to
the prevention of accidents, environment. Side rails long term Foley;s catheter
injury or other trauma and were up and antibiotics insertion.
through the prevention of were provided to treat
the spread of infection. existing infection.
4. To maintain good body Patient is unable to -

mechanics and prevent and maintain Good body
correct deformity. mechanics .
II. Sustenal care needs
5. To facilitate the Patient was unable to Impaired gas

maintenance of a supply of maintain adequate oxygen exchange related to
ventilation
oxygen to all body supply to all body cells by
perfusion imbalance
46
herself so provided 4 litre as evidenced
02 via nasal cannula. bydyspnea.
6. To facilitate the Proper nutrition -

maintenance of nutrition of management has been done
all body cells
7. To facilitate the she had foley’s catheter Risk for

maintenance oF and input output was constipation related
to decrease dietary
elimination maintained but stool not
intake
passed since 4 days.
8. To facilitate the Fluid and electrolyte was -

maintenance of fluid and not balanced. She was
electrolyte balance suffered from
hyponatremia
III. Remedial care needs
9. To recognize the physical -

responses of body to
disease condition,
pathological, physiological
and compensatory
responses.
10. To facilitate the Regulatory mechanism was -

maintenance of regulatory maintained
mechanism and function
11. To facilitate the Her sensory function -

maintenance of sensory wasintact
function
12. To identify and accept she was anxious, shows

positive and negative negaitive attitude towards
expressions, feelings and his disease conditions.
reactions
47
13. To identify and accept the she suffers from itching in
interrelatedness of whole body so she
emotions and organic expressed her feeling via
illness verbalization.
14. To facilitate the Effective communication -

maintenance of effective and interpersonal
verbal and non-verbal relationship was
communication maintained
15. To promote the Interpersonal relationship -

development of productive has been maintained with
interpersonal relationship the patient
16. To facilitate progress Progress toward -

toward achievement of achievement of personal
personal spiritual goals spiritual goals
17. To create and or maintain Patient was able to -

therapeutic environment maintain therapeutic
environment
18. To facilitate awareness of She wasnot aware of -

self as an individual with various physical, emotional
the various physical, and developmental needs
emotional and
developmental needs
IV.Restorative care needs
19. To accept the optimum she has accepted the -

possible goals in the light optimum possible goals.
of limitation, physical and
emotional.
20. To use community She use community -

resources as an aid in resource in solving
resolving problems arising problem arising from
from illness illness.
21. To understand the role of she does not have social -
48
social problem as problems as influencing
influencing factors in the factors in case of illness.
care of illness
Nursing Diagnosis
Actual nursing diagnosis
 Impaired gas exchange related to ventilation perfusion imbalance as evidenced by

dyspnea.
 Activity intolerance related to impaired respiratory function as evidenced by

patient’s inability to perform activities independently
 Altered sleep and rest related to respiratory problem as evidenced by difficulty in

falling asleep and verbal complaints of not feeling well-rested
Potential nursing diagnosis
 Risk for constipation related to decrease dietary intake
 Risk for infection related to long term Foley;s catheter insertion.
Nursing care plan
5th nursing problem
1. To facilate the maintainence of a supply of oxygen to all body.
Assessment:
Overt(direct): on observation, patient has difficulty in breathing, decreased O2 saturation
Covert(indirect): patient said I have difficulty in breathing.
Nursing diagnosis:
Impaired gas exchange related to ventilation perfusion imbalance as evidenced by dyspnea.
49
Goal : patient’s breathing pattern will be ease within hospitalization days.
Planning
-ascultate lung and assessed respiratory rate, depth, o2 saturation of the patient.
-position the patient with head of bed elevated, in semi fowler’s position.
-encourage and assist with ambulation as per physician’s order.
-encourage slow deep breathing exercise, chest physiotherapy as indicated.
-provide 02 as prescribed by doctor.
-provide informal health teaching to the patient and visitors about deep breathing and
coughing, spirometry.
-administer medicine, bronchodilator as prescribed.
-provide suction if needed.
-reassess the condition of the patient.
Intervention with rationale
Lungs was auscultated and know the rate, depth and o2 saturation.
-patient was kept in semifowler’s position, it helps to increase the thoracic capacity and lung
expanxion.
-encouraged for ambulation, it helps to facilate lung expansion, stimulate breathing.
-encouraged for deep breathing and coughing exrecise it helps to promote deep inspiration
which increase oxygenation and prevent atelectasis.
-oxygen was provided in 4 l o2 and monitored effectiveness with pulse oximetry.
-informal health teaching was provided , it helps to aware patients and caregivers about it’s
important.
-bronchodilator was administered as prescribed, it helps to ease the breathing.
-reassessed the condition of the patient, it helps to evaluate the effectiveness of nursing
intervention.
Evaluation
My set goals was partially achieved as patient’s breathing pattern ease within hospitalization
in presence of 02.
50
2nd nursing problem
2. To promote optimal activity, exercise, rest, sleep
Assessment:
Overt(direct): on observation , patient is unable to walk and perform activities

independently.
Covert(indirect): patient said I was unable to perform daily activities independently.
Nursing diagnosis:
Activity intolerance related to impaired respiratory function as evidenced by patient’s

inability to perform activities independently.
Goal : patient will be able to perform her daily activities independently within hospitalization
days.
Planning
-assess the physical activity and mobility of the patient
-encourage and assist patient into a comfortable position.
-encourage patient for ambulation.
-counsel patient to rest and to avoid overexertion.
-Gradually increase the activity with active range of motion.
-provide emotional support to the patient regarding abilities.
-reassess the condition of the patient.
Intervention with rationale
-assessed the physical activity level and mobility, to obtain the baseline data for accurate
planning.
-keep the patient in comfortable position, it helps to ease the breathing.
-encouraged and assisted patient for ambulation.it enhance the mobility of patient.
-counselled patient to rest and to avoid overexertion, it reduce the exacerbation of the
symptoms.
-gradually increased activity with active range of motion,which prevent the overexertion.
51
-emotional support was provided to the patient, it helps to enhance the confidence level of the
patient.
-ressessed the condition of the patient, it helps to evaluate the effectiveness of nursing
intervention.
Evaluation: My set goals was partally achieved as patient was able to perform her daily
activity and walk dependently.
2nd nursing problem
3. To promote optimal activity, exercise, rest, sleep
Assessment:
overt(direct): on observation, patient looks tired, weak and restlessness
covert(indirect):patient said I was unable to sleep properly at night.
Nursing diagnosis: altered sleep and rest related to respiratory problem as evidenced by
difficulty in falling asleep and verbal complaints of not feeling well-rested.
Goal : patient will be able to maintain normal sleeping pattern within hospitalization days.
Planning
-assessed the patient’s sleeping pattern.
-plan daytime activities according to the patient’s interest.
-donot allow patient to sit idle.
-provide quiet and peaceful environment when patient is preparing for sleep.
-donot allow the patient to sleep for long time during day time.
-limit the number of visitors at bed time.
-talk to patient for a brief at bed time.
-reassess the sleeping pattern of the patient.
Nursing intervention with rationale
- Patients daily sleep was assessed by asking question, to find out baseline data and
accurate planning.
- Planned daytime activities according to patients interest, to improve sleep during
night.
- Not allowed them sit idle, negative thoughts may occurs about their condition.
- Quiet and peaceful environment was provided, it helps patient to sleep well.
52
- Not allowed patient to sleep during the day time, it may disturbed the sleeping
routine of night.
- At bed time, visitors are limited to sit with patient, it may disturbed sleep.
- Brief talked with patient at bed time, helps to reduce anxiety.
- Re-assessed the condition of patients, to evaluat the effectiveness of nursing
intervention.
Evaluation
My sets goals was partially achieved as she can able to sleep at night.
7th nursing problem
4. To facilitate the maintainance of elimination
Assessment
Overt (direct): On observation, patient had abdominal tightness.
Nursingdiagnosis:
Risk for constipation related to decrease dietary intake
Goals:
Patient states relief from discomfort of constipation my nursing intervention.
Planning
- Assess the general condition of patient.

- Encourage to eat fibre containing food.
- Encourage patient to take her favourite food.
- Assist and encourage for ambulation and exercise
- Encourage to avoid carbonated beverages.
- Administer medication as prescribed.
- Provide enema if needed.
- Re-assess the condition of patient.
Nursing intervention with rationae
- Assessed the general condition of patient, it helps to obtain baseline data and
accurate planning.
- Patient was encouraged to take fiber rich food, it helps to pass stool easily.
- Encouraged patient to take her favourite food like curd banana.
53
- Encouraged patient for ambulation and exercise, it helps to stimulate peristalsis
and helps to pass gas.
- Encouraged to avoid carbonated beverage, it may cause bloating.
- Laxative was provided, it helps soften stool and stimulate rectal mucosa.
- Re-assessed the condition of patient, to evaluate effectiveness of nursing
implementation.
Evaluation
My set goals was fully achived as patient was able to pass stool.
3rd nursing problem
5. To promote safety through the prevention of accidents, injury or other trauma

and through the prevention of spread of infection.
Assessment
Overt(direct): On observation , there is presence of Foleys catheter since 6 days and

WBC count was 15,200/ cumm
Nursing diagnosis
Risk for Infection related to Foleys catheter.
goal
The risk for urinary tract infection was prevented within hospitalization days.
Planning with rational

- Keep the drainage bag below the level of bladder and off the floor all times
which helps toprevent backflow of urine.
-Keep the catheter secured to patient’s thigh which helps to prevent from moving
of the catheter
-Empty the uro bag in every 2-4 hours as needed which helps to prevent the
accumulation of urine thus limiting the number of bacteria.
-Avoid tea ,coffe, to the patient which causes irritation to urinary system.
-Provide Foley’s catheter care under aseptic technique to prevent from infection.
54
-Monitor laboratory investigation including WBC count as increased WBC count
is a systemic response to infection.
-Frequently monitor the vital signs of the patients with focus on temperature as
increase in temperature is a systemic response to infection.
-Reassess the condition of patient which helps to evaluate the effectiveness of
nursing intervention.
Nursing implementation
-Drainage bag was kept below in level of bladder and off the floor at all times .
-The catheter was secured to patient’s thigh.
-The urobag was emptied in every 2-4 hours.
-Tea, coffee was avoided.
-Catheter care was provided by using betadine and normal saline.
-Laboratory WBC count was monitored i.e 15200/ cumm .
-The vital signs of the patient was frequently monitored and recorded.
-The condition of the patient was reassessed.
Evaluation
My set goal was fully achieved as there was no any sign of urinary tract infection during
the hospitalization days.
UNIT VI
Progress note
Admission day (2076-02-11)
Mrs yam kala poudel of 80 years female was admitted in medical ward from ER with
the diagnosis of Community Acquired Pneumonia with Acute Kidney Injury with
septic shock.
Vital signs were monitored and recorded as;
Temperature:100.8 degree F-maximum and 96.2 degree F-minimum
Pulse: 84beats per minute
Respiration: 26 breath per minute
Blood pressure : 90\60 mm of Hg
55
SPO2: 82 %in room air and 94% in 3 ltr o2 via nasal cannula.
Nursing intervention
1. Admission procedure were carried out.

2. Orientation about the ward, staff, drinking water, bathroom, meal time,
medication was given to the patient and visitors.
3. Consent was taken.
4. Vital signs were monitored and recorded 4 hourly.
5. Oxygen continued at 4l\min via nasal cannula.
6. Medication was done as per cardex.
7. All ordered investigation were sent including Hb, total WBC count, total
platelets, random blood sugar, serum creatinine, Na+, K+, blood urea.
8. Input/Output chart was maintained and recorded as:
Intake: 1200ml
Output: 1350ml
1st day (2076-01-03)
Patient is conscious and well orientation to time place and person.
Patients general condition is improving. Patient is in normal diet.
vital signs were monitored and recorded as
Temperature: 98.4 degree F-maximum and 96.6 degree F-minimum
Pulse: 80-max and 64-min
Respiration: 28 max and 18 min
Blood pressure: 150-120 max and 90-70 min
SPO2: 88 %in room air and 98% in 4 l o2 via nasal cannula
56
1. Morning care was given includes hair care, nail care, cannula care and oral care as
patient was in need of assistance to maintain personal hygiene.
2. Patients health history was obtain to know about detail information.
3. Chest x-ray and ECG was done.
4. Psychological support was provided.
5. Encouraged for deep breathing and coughing exercise.
6. Vital signs were monitored and recorded.
Intake: 1600ml
Output:1250ml
2nd day (2076-01-04)
Patient’s general condition is improving.
Vital signs were monitored as
Temperature: 98.6 degree F-maximum and 97 degree F-minimum
Respiration: 24- max and 18 min
SPO2: 87 %in room air and 97% in 4 l o2 via nasal cannula.
1. Assessed the condition of the patient for self care activities and found that she was
unable to do her activities herself.
2. Complete history was taken.
3. Psychological support was provided to the patient.
4. Ultrasonography was done.
6. Nebulization (asthalin: ipravent: NS) 1:1:2 was added 6 hrly.
7. Syrup lactulose, 30 ml PO HS was given.
8. Input and output chart was maintained and recorded as:
57
Intake:1300ml
Output: 1100ml
3rdday(2076-01-05)
Patient’s general condition is detorating. She is not oriented to time place and person.
1. Morning care was provided.

2. Vital signs were monitored 6 hourly.
3. Provide psychological support to the care givers as patient was not oriented.
4. Blood sample was sent for biochemestry and hematology investigation and
report collected.
5. Plan for head CT scan.
7. Ezivac enema was given
8. Input and output chart was maintained and recorded as :
Intake:1100ml
Output:1350ml
4thday(2075-09-25)
Patient’s general condition is improving. vital signs were monitored and recorded as
58

2. Physical examination was preformed.
3. Encouraged to take food frequently to maintain appetite.
4. Encouraged for ambulation.
5. Stool occult blood sample was sent.
6. ABG analysis was done.
7. I/O was monitored and charting was done.
Intake: 1200ml
Output:1250ml
5th day (2076-01-07)
Patient’s general condition is improving.
SPO2: 86%in room air and 97% in 2 l o2 via nasal cannula.

2. Vital signs were monitored 6 hourly.
4. Intake output chart was monitored.
Intake: 1150ml
59
Output:1100ml
6th day (2076-01-08) discharge day
Patient’s general conditionis improving and vital signs were monitored and recorded
as
SPO2: 86%in room air and 97% in 2 l o2 via nasal cannula.
1.All morning care was provided.
2.Vital signs were recorded 6 hourly.
3.Encourage for deep breathing and coughing exercise.
4. Discharge teaching was provided with follow up visit.
UNIT VII
Health teaching/discharge teaching
Discharge teaching is an intergral part of nursing process. It’s main objectives is to aware
the patient and family members about the factors of the particular disease condition,
management and prevention of illness. It also helps the family members and patient to clear
about their fear and doubts.
Discharge teaching was provided on

a. Rest and exercise : I provided the knowledge about the importance of rest and exercise
in our daily living. I advised her to do light exercise that helps in proper circulation in
our body and prevent from constipation, and also help to increase patient’s appetite and
also advice that to sleep wall 7-8 hours at night.
60
b. Diet: I provided knowledge to the patient about the importance of nutritious diet. I
encourage her to talk fresh fruits and green vegetables with fibre rich food on diet. I
adviced her to drink plenty of fluids.
c. Deep breathing and coughing exercise: I encouraged for deep breathing and coughing
exercise and explained the importance that it helps to loose secrection and helps to
expectorate and it also helps to reduce stress.
d. Medication: I adviced patient about the prescribed medicine, dose, time and its side
effects. I also advised her to report if any complication aries. And not to leave medicine
abruptly and not to take any other medication without prescription.
e.Avoid alcohol and smoking. I advice my patient to avoid alcohol and cigarette smoking as
well as caffeine which affect and alters the health
f.Personalhygiene:I advised her to maintain personal hygiene and taught about importance
of it to prevent from infection and further complications .
g.Follow up: I advised the patient and her family to visit medical OPD of LMCTH after 2
weeks for follow up as suggested by doctor. I advised them to bring their all reports and
documents with them.
UNIT VIII
ummarization
My patient named Mrs. GyanKumari Bhandari 83 yrs/female was admitted in medical

ward from emergency with the diagnosis of Community Acquired Pneumonia with Acute
Kidney Injury with anemia under evaluation. The patient came in emergency with the chief
complains of generalized body swelling and burning sensation over foot since 2 days,
shortness of breath since 1 day. After assessment,she was admitted in medical ward for
further intervention.
During 7 days of hospitalization, holistic nursing care was provided to the
patient along with medical and nursing management. I provided psychological support and
communicated with the patient and her family member about disease condition. When her
condition was improved in 7 days.she was discharged with the medication and follow up
61
advices after 2 weeks. Health teaching was also provided on various topics to the patient and
family member.
Learning of the case
Case study is an opportunity for all learners to gain in depth knowledge related to case. As, I
took case of Community Acquired Pneumonia with Acute Kidney Injury with anemia under
evaluation. I got chance to know detail knowledge regarding the diseases condition.
1. I learnt about the anatomy and physiology of Community Acquired Pneumonia

with Acute Kidney Injury.
2. I learnt to perform history taking and physical examination of patient with
Community Acquired Pneumonia with Acute Kidney Injury.
3. I learned how to deal with elderly people.
4. I learned about different physiological and psychological changes in the patient.
5. I got chance to provide comprehensive nursing care to the geriatric people based
on their needs.
6. I got chance to know about the required management and treatment procedure
forCommunity Acquired Pneumonia with Acute Kidney Injury.
7. I learnt in detail about the Community Acquired Pneumonia and Acute Kidney
Injury from different sources, books comparing to the patient in real situation.
8. I learned about the communication skills, teaching skill that is required for
handling those patient.
sUNIT IX
REFERENCE
I. Hinkle JL, Cheaver KH. Textbook of Medical- Surgical Nursing. 13thed. New Delhi:
Walters Kluwar Health; 2005.
II. Sharma M, Poudel R. Essential Textbook of Medical Surgical Nursing. 2nd ed.
Samikshya Publication; 2013.
III. Sharma M. Nursing concept and Principle. 2nded,Medhavi Publication.
IV. Tuitui R. Pocket book of drugs. 6thed, MakaluPublication House.
V. Masby’s ,Nursing drug reference. 25thed.Elsevier Publication.
VI. https://www.healthline . com> health>
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KATHMANDU UNIVERSITY

LUMBINI MEDICAL COLLEGE AND TEACHING HOSPITAL

CASE STUDY REPORT ON:

SUBMITTED TO: SUBMITTED BY:

SUBMITTED ON: 5th June, 2019

OBJECTIVES OF THE CASE STUDY

Rationale for selection of case

A. Health History (Date:2076-02-12)

C. History of present illness

A. List of family members with their health status

S.N Name of family Age\sex Education Occupation Relationship Health

3. Khum bahadur 58yrs/M Masters Teacher Son Healthy

10. Seema poudel 6yrs/Fe 2nd class Student Grand Healthy

1. Immunization history : Unknown Immunization Status.

7. Leisure time activities

4.Socio economic history

1. Risk for infection related to continous oxygen supplement.

2] Physical Examination ( 2076/02/13) :

Normal physiological changes in my patient.

 Hair is both mixture of black and white in colour.

1] Problem related to head Hair –mixture of black and white

2] Problem related to eye/ Eyelids – normal

3] Problem related to ear : Condition of external ear-both are

4] Problem related to nose Location –nose is centrally located

5] Problems related to Lips –dry and cracked

7] Throat and neck: Location – centrally located , no

8] Problems related to Respiratory rate-24 breath / min

11] Nutrition/ Hydration : Body built –normal looking

12] Elimination and Appearance of urine –normal in

13] Mobility: Motor strength or, mobility –normal

15] Integumentary hygiene Colour of skin , textures , turgor-

16] Reflexes Biceps reflex-present(+2)

Finding of the physical examination

1. Problem related to eye and vision:

Slightly yellow sclera.

conjunctiva pale in coclor.

2. Problem related to mouth:

3. Problem related to respiration:

dyspnea, cough present

wheezing sound is present in left lower zone.

4. Problem related to mobility and comfort:

Difficulty in mobility independently

5.Nutrition/hydration: decreased elasticity

6.Problem related to Integumentary: wrinkled skin

6. To accept the implication of She accept the household responsibilities

Anatomy and Physiology

Lungs are divided into 2 types :

PHYSIOLOGY OF RESPIRATORY SYSTEM

2. According to causative organism

Health Care Associated Pneumonia

Hospital Acquired Pneumonia

Ventilator Acquired Pneumonia

Community Acquired Pneumonia

Organism: Bacteria, virus, mycoplasm, -

Aspiration of fluids/ foods/ vomit -

Penetration to the lower respiratory tract by organism

Inflammation reaction in alveoli

Interfere with diffusion of O2 and CO2

Ventilation perfusion mismatch

Shortness of breath cyanosis

Rapid raising fever with chills Fever with chills

Book picture Patient picture

Random Blood 151 Mg/dl GOD-POD 60-140