CASE STUDY (PNEUMONIA)

HISTORY OF PRESENT ILLNESS:

A 50-year-old female presents after admission to the general medical/surgical hospital ward with a chief complaint of shortness of breath on
exertion. She reports that she was seen for similar symptoms previously at her primary care physician’s office six months ago. At that time,
she was diagnosed with acute bronchitis and treated with bronchodilators, empiric antibiotics, and a short course oral steroid taper. This
management did not improve her symptoms, and she has gradually worsened over six months. She reports a 20-pound intentional weight loss
over the past year. She denies any sick contacts. A brief review of systems is negative for fever, night sweats, palpitations, chest pain, nausea,
vomiting, diarrhea, constipation, abdominal pain, neural sensation changes, muscular changes, and increased bruising or bleeding. She admits
a cough, shortness of breath, and shortness of breath on exertion.

Social History: Her tobacco use is 33 pack-years; however, she quit smoking shortly prior to the onset of symptoms, six months ago. She
denies alcohol and illicit drug use. She is married, in a monogamous relationship, and has three children aged 15 months to 5 years. She is
employed as clinical instructor. She has two pet cats. She loves to travel.
Allergies: No known medicine, food, or environmental allergies.
Past Medical History: Essential Hypertension
Past Surgical History: Appendectomy and CS
Medications: Lisinopril 10mg by mouth every day
Physical Exam:
Vitals: Temperature, 105. F; heart rate 108; respiratory rate, 26; blood pressure 130/86; BMI 26.
General: She is well appearing but anxious, a pleasant female lying on a hospital stretcher. She is conversing freely, with respiratory
distress causing her to stop mid-sentence.
Respiratory: She has diffuse rales and mild wheezing; tachypneic.
Cardiovascular: She has an irregular rate and rhythm with PSVT
Gastrointestinal: Bowel sounds X4. No bruits or pulsatile mass.

INITIAL EVALUATION:
Laboratory Studies: Initial work-up from the emergency department revealed pancytopenia with a platelet count of 74,000 per mm3;
hemoglobin, 8.3 g per and mild transaminase elevation, AST 90 and ALT 112. Blood cultures were drawn and currently negative for
bacterial growth or Gram staining.

ANNE DOMINIQUE S. LANUZO

BSN – 3A
I. PATIENT HISTORY

 GENERAL DATA

This is a case of Pneumonia of a 50-year-old female. The patient is admitted to the general medical/surgical hospital with a chief
complaint of shortness of breath on exertion.

 PRESENT HEALTH HISTORY

Prior to admission the patient has cough, shortness of breath, and shortness of breath on exertion.

 PAST HEALTH HISTORY

Six months ago, the patient reports that she was seen similar symptoms at her primary care physician’s office. At that time, she
was diagnosed with acute bronchitis and treated with bronchodilators, empiric antibiotics, and a short course oral steroid taper.
This management did not improve her symptoms, and she has gradually worsened over six months. She reports a 20-pound
intentional weight loss over the past year.

 PAST MEDICAL HISTORY

Essential Hypertension

 PAST SURGICAL HISTORY

Appendectomy and CS

 NUTRITIONAL HISTORY (ALLERGIES)

No known medicine, food, or environmental allergies.

 SOCIAL HISTORY

Her tobacco use is 33 pack-years; however, she quit smoking shortly prior to the onset of symptoms, six months ago. She denies
alcohol and illicit drug use. She is married, in a monogamous relationship, and has three children aged 15 months to 5 years. She
is employed as clinical instructor. She has two pet cats. She loves to travel.

ANNE DOMINIQUE S. LANUZO

BSN – 3A
PATIENT’S HEALTH ASSESSMENT

 GENERAL

She is well appearing but anxious, a pleasant female lying on a hospital stretcher. She is conversing freely, with respiratory distress
causing her to stop mid-sentence.

 RESPIRATORY

She has diffuse rales and mild wheezing; tachypneic.

 CARDIOVASCULAR

She has an irregular rate and rhythm with PSVT

 GASTROINTESTINAL

Bowel sounds X4. No bruits or pulsatile mass.

 BODY MASS INDEX

Patient is classified as overweight with a BMI of 26.

ANNE DOMINIQUE S. LANUZO

BSN – 3A
VITAL SIGNS

Normal Findings Actual Findings Interpretation

Elevated body temperature is a

sign that there is something
wrong with the body system
Temperature 36.5 – 37.5 oC 40.6 oC and the patient’s fever is due to
her present illness.

Cardiac rate is above normal.

The patient’s cardiac rate can
60 – 100 bpm 108 bpm
reflect exposure to stress and
Cardiac Rate
illness.

Increased respiratory rate. The

Respiratory Rate 12 – 20 bpm 26 bpm patient is experiencing
tachypnea.

Blood Pressure Pre-hypertension is a little

higher blood pressure than it
120/80 130/86 mmHg should be and means that the
patient can possibly develop
high blood pressure.

ANNE DOMINIQUE S. LANUZO

BSN – 3A
 II. ANATOMY OF THE AFFECTED ORGAN

The lungs are the major organs of

the respiratory system and are
responsible for performing gas
exchange. The lungs are paired
and separated into lobes; the left
lung consists of two lobes,
whereas the right lung consists of
three lobes. Blood circulation is
very important, as blood is
required to transport oxygen from
the lungs to other tissues
throughout the body. The
function of the pulmonary
circulation is to aid in gas
exchange. The pulmonary artery
provides deoxygenated blood to
the capillaries that form
respiratory membranes with the
alveoli, and the pulmonary veins
return newly oxygenated blood to
the heart for further transport
throughout the body. The lungs
are innervated by the
parasympathetic and sympathetic nervous systems, which coordinate the bronchodilation and bronchoconstriction of the airways. The
lungs are enclosed by the pleura, a membrane that is composed of visceral and parietal pleural layers. The space between these two
layers is called the pleural cavity. The mesothelial cells of the pleural membrane create pleural fluid, which serves as both a lubricant
(to reduce friction during breathing) and as an adhesive to adhere the lungs to the thoracic wall (to facilitate movement of the lungs
during ventilation).

ANNE DOMINIQUE S. LANUZO

BSN – 3A
III. PATHOPHYSIOLOGY

Predisposing Factors Etiology Precipitating Factors

Age Virulent Microorganisms Lifestyle

Sex Streptococcus Pneumoniae Environment

Microorganism enters the nose (nasal passage)

Passes to the pharynx, larynx, trachea

Microorganism enters and affects both airway and lung parenchyma

Airway Damage Lung Invasion

Infiltration of Bronchi Flattening of Eptithelial Cells

ANNE DOMINIQUE S. LANUZO

BSN – 3A
Infectious organism lodges Macrophages and Leukocytes
stimulation in bronchioles

Mucus and phlegm production

Alveolar wall collapse

COUGHING
Increase pyrogen in the body

FEVER
Necrosis of bronchial
tissues
Narrowing of air passage

Infiltration of pulmonary tissues

DIFFICULTY OF BREATHING

Overwhelming sepsis

DEATH

ANNE DOMINIQUE S. LANUZO

BSN – 3A
 IV. DIAGNOSTIC TEST

Result Normal Value Unit Remarks

Platelet Count 74,000 150,000 – 400,000 mcL L
Hemoglobin 8.3 (m)13.5 – 17.5 (f) 12.0 – 15.5 g/dL L
AST 90 5 – 40 u/l H
ALT 112 7 – 56 u/l H

Laboratory Studies:
Initial work-up from the emergency department revealed pancytopenia with a platelet count of 74,000 per mm3; hemoglobin, 8.3 g per and
mild transaminase elevation, AST 90 and ALT 112. Blood cultures were drawn and currently negative for bacterial growth or Gram
staining.

Laboratory Interpretation:
Diagnostic test revealed that there is a decreased platelet count and decreased hemoglobin level. The body needs all of these blood cells
to carry oxygen throughout the body and to allow blood to form clots. The result shown that the patient is suffering from pancytopenia
which causes the respiratory distress. Increased aspartate aminotransferase (AST) and alanine aminotransferase (ALT) may mean that
there is some types of liver damage. These enzymes are normally predominantly contained within liver cells and to a lesser degree in
the muscle cells. If the liver is injured or damaged, the liver cells spill these enzymes into the blood, raising the AST and ALT enzyme
blood levels and signaling liver disease. Thus, the exact levels of these enzymes cannot be used to determine the degree of liver disease
or predict the future prognosis of liver function.

ANNE DOMINIQUE S. LANUZO

BSN – 3A
 V. MEDICATIONS

MECHANISM OF ADVERSE SPECIAL

DRUG CLASSIFICATION INDICATIONS DOSAGES CONTRAINDICATION
ACTION REACTION PRECAUTION

Lisinopril ACE Mild to Adult: PO As Description: Lisinopril Hypersensitivity to Volume depletion and Hepatic cirrhosis,
Inhibitors/Direct moderate HTN. tab containing competitively inhibits sulphonamide drugs. electrolyte imbalance severe heart failure,
Renin Inhibitors / lisinopril ACE from converting (eg hyperkalaemia); oedema, renal
Diuretics (mg)/hydrochlor angiotensin I to Patients with anuria, dry mouth, thirst; impairment (including
othiazide (mg): angiotensin II resulting aortic stenosis or lethargy, drowsiness; haemodialysis
10/12.5, in increased plasma hyperkalaemia. muscle pain, cramps; patients), unilateral
20/12.5. renin activity and hypotension; renal artery stenosis,
Usual: 1 tab reduced aldosterone History of hypersensitivity hepatic impairment,
once daily, up secretion, causing angioneurotic reactions eg, rashes, diabetes, gout,
to 2 tab once reduced BP and sodium oedema related to use photosensitivity, hyperuricaemia, left
daily if needed. and water retention. of ACE inhibitors. thrombocytopenia, ventricular
Hydrochlorothiazide jaundice, pancreatitis; hypertrophy and/or
increases renal excretion Hereditary or fatigue; weakness; ventricular ectopics
of sodium and chloride idiopathic may precipitate an (extrasystoles),
and reduces cardiac load. angioedema. attack of gout electrolyte
The two drugs exert (hyperuricaemia); disturbances (e.g.
additive effects in Lactation. impotence, hyperkalaemia),
hypertension. hyperglycaemia; collagen vascular
anorexia, gastric disease, valvular
Onset: Lisinopril: 1 hr; irritation, nausea, stenosis, renovascular
hydrochlorothiazide: vomiting, constipation, hypertension,
diuresis: approx 2 hr. diarrhoea; sialadenitis; hypercholesterolemia.
dizziness; Before, during or
Duration: Lisinopril: 24 hypercalcaemia; immediately after
hr; hydrochlorothiazide: headache; cough; anaesthesia; surgery.
6-12 hr. chest pain; Assess renal function
angioneurotic oedema; before initiation.
Pharmacokinetics: occasional increase in Patients with
liver enzymes and hypertension should
serum bilirubin; renal be stabilised on
function deterioration; individual components
alopecia; before starting
oliguria/anuria; combination. Therapy
should not be started

ANNE DOMINIQUE S. LANUZO

BSN – 3A
Absorption: Lisinopril: urticaria, pruritis; after MI if systolic
Well absorbed, diaphoresis. blood pressure <100
unaffected by food; peak Potentially Fatal: mmHg. Hypotension
effect: approx 6 hr. Seizures; cholestatic may occur after initial
Hydrochlorothiazide: jaundice; neutropenia dose in patients who
approx 50-80%; peak and agranulocytosis are hypovolaemic
effect: 4-6 hr. (with or without and/or salt depleted
myeloid hyperplasia); (diuretic should be
Distribution: Plasma acute renal failure, discontinued for 2-3
protein binding: oliguria; progressive days and then
lisinopril: 25%; azotemia; haemolytic lisinopril initiated
hydrochlorothiazide: anaemia; angioedema alone). Discontinue
68%. Distribution of associated with before carrying
hydrochlorothiazide: 3.6- laryngeal oedema. parathyroid function
7.8 L/kg. test.

Metabolism: Lisinopril:
Not significantly
metabolised.
Hydrochlorothiazide:
Not metabolised.

Excretion: Half-life
elimination: lisinopril:
11-12 hr;
hydrochlorothiazide: 5.6-
14.8 hr. Excretion:
lisinopril Mainly via
urine as unchanged drug
(lisinopril and
hydrochlorothiazide).

ANNE DOMINIQUE S. LANUZO

BSN – 3A
 VI. NURSING CARE PLAN

NURSING
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Subjective: Ineffective breathing SHORT TERM:  Assess and record  It is important to take SHORT TERM:
 The patient pattern related to respiratory rate and action when there is
complaining of infection/inflammatory After 4 hours of depth at least every 4 After 4 hours of
an alteration in the
shortness of breath at process as evidenced nursing intervention, hours. nursing intervention,
pattern of breathing to
rest and on exertion. by cough, shortness of the patient will be the patient is able to:
detect early signs of
 Reports of tobacco breath on exertion, able to: respiratory  Maintained an
use for 33 pack/years mild wheezing, and compromise. effective breathing
and quit smoking tachypnea.  Maintain an pattern, as
shortly prior effective breathing  Assess ABG levels,  This monitors evidenced by
to the onset of pattern, as according to facility oxygenation and relaxed breathing
symptoms, six evidenced by policy. ventilation status. at normal rate and
months ago. relaxed breathing depth and absence
at normal rate and  Observe for breathing  Unusual breathing of dyspnea.
Objective: depth and absence patterns. patterns may imply an  Established a
 Cough of dyspnea. underlying disease respiratory rate
 Mild Wheezing process or that remains within
 Tachypnea  Establish a dysfunction. normal limits.
 Observed to be well respiratory rate that
appearing but anxious remains within  Auscultate breath  This is to detect
 Result of normal limits. sounds at least every decreased or LONG TERM:
electrocardiogram four (4) hours. adventitious breath
that shows irregular sounds. After 1 – 2 days of
rate and rhythm with LONG TERM: nursing intervention,
Paroxysmal  Assess for use of  Work of breathing the patient is able to:
supraventricular After 1 – 2 days of accessory muscle. increases greatly as
tachycardia (PSVT) nursing intervention, lung compliance
the patient will be decreases.
able to:

ANNE DOMINIQUE S. LANUZO

BSN – 3A
 Apply techniques  Monitor for  Paradoxical  Applied
that would improve diaphragmatic muscle movement of the techniques that
breathing pattern. fatigue or weakness abdomen (an inward would improve
(paradoxical motion). versus outward breathing pattern.
 Verbalize movement during
awareness of inspiration) is  Verbalized
causative factors. indicative of awareness of
respiratory muscle causative factors.
 Initiate needed fatigue and weakness.
lifestyle changes.  Initiated the
 Observe for  These signs signify an needed lifestyle
retractions or flaring increase in respiratory changes.
of nostrils. effort.

 Place patient with  A sitting position

proper body permits maximum
alignment for lung excursion and
maximum breathing chest expansion.
pattern.

 Encourage sustained  It promotes deep

deep breaths and inspiration, which
educate patient or increases oxygenation
significant other and prevents
proper breathing and atelectasis. Controlled
coughing. breathing methods
may also aid slow
respirations in
patients who are
tachypneic.
Prolonged expiration
prevents air trapping.

ANNE DOMINIQUE S. LANUZO

BSN – 3A
 Encourage frequent  Extra activity can
rest periods and teach worsen shortness of
patient to pace breath. Ensure the
activity. patient rests between
strenuous activities.

 Encourage small  This prevents

frequent meals. crowding of the
diaphragm.

 Avail a fan in the  Moving air can

room. decrease feelings of
air hunger.

ANNE DOMINIQUE S. LANUZO

BSN – 3A