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Nursing Department

MAJOR CONCEPT
MAJOR CONCEPT

EMERGENCY AND TRAUMA

DIAGNOSIS DIAGNOSIS
ASPIRATION PNEUMONIA

CASE SCENARIO

CASE SCENARIO
Patient E.A. is an 87-year-old female who was admitted last August 18 with a chief complaint of cough. Vital signs
are as follows: T – 36.1 °C P – 89 bmp RR – 18 bmp CR – 92 bmp BP–130/90mmHg.

Past Health Problem: Mrs. E.A has no notable Illness. She sometimes experiences cough, fever and cold. She is a
non-alcoholic and non-smoker.

HX OF
HISTORY PRESENT
OF PRESENT ILLNESS ILLNESS

Student Name: Dela Cruz, Jesfel B. Intensive Practicum Prof. Marilen F. Pacis RM, RN, MAN Prof Basilio L. Bermas Jr. RN, MAN, EdD
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Nursing Department
1 month prior to admission, the patient is (+) to CVA but it is undiagnosed. Mrs. E.A. is (-) to HPN and (-) DM.

1 week prior to admission, E.A. was noted to have cough associated with fever, undocumented. So, she sought consult with
AP given Co-amoxiclav with relief of symptoms.

Day of admission, folks decided to have patient admitted for general check – up.

FAMILY HISTORY
FAMILY HISTORY

Mrs. E.A. family is (+) in Hypertension.

Student Name: Dela Cruz, Jesfel B. Intensive Practicum Prof. Marilen F. Pacis RM, RN, MAN Prof Basilio L. Bermas Jr. RN, MAN, EdD
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Nursing Department

PATHOPHYSIOLOGY
PATHOPHYSIOLOGY & CONCEPT MAP & CONCEPT

**** DISEASE PROCESS AND/ OR HOW IT COMPLICATE THE INVOLVED SYSTEM. (MAY ADD ADDTL BOXES)

ASPIRATION PNEUMONIA PATHOPHYSIOLOGY:

Aspiration pneumonia is a type of pneumonia that might
occur if a person breathes something in instead of
swallowing it.
In normal healthy adults, the mucociliary mechanism and alveolar macrophages act as defenses in clearing micro aspirations from the oropharyngeal secretions. The pathological
process of aspiration pneumonia occurs when the normal defense mechanisms fail in a predisposed individual. The entry of fluid into the bronchi and alveolar space triggers an anti-
inflammatory reaction with the release of proinflammatory cytokines, tumor necrosis factor-alpha, and interleukins. Inoculation of organisms of common flora from the oropharynx and
esophagus results in the infectious process. Mendelson first studied the pathophysiology of aspiration pneumonitis by inducing gastric contents in the rabbit’s lung and comparing it to
0.1 N hydrochloric acid. Later studies conducted in rats using diluted hydrochloric acid demonstrated the biphasic response with the initial corrosive phase by acidic pH followed by a
neutrophil-mediated inflammatory response. Inoculation of normal oropharyngeal flora in the aspirate results in the infectious process and results in aspiration pneumonia. If the
bacterial load of aspirate is low normal host defenses will clear the secretions and prevent infection.

RISK FACTORS CLINICAL MANIFESTATIONS DISEASE PROCESS

Being less alert due to medicines, illness, Chest pain Liquid or object enters the respiratory system
surgery, or other reasons through inhalation of microorganism.

Old age  Fatigue Under the infection and immune response

inflammation process proceeded.

Trauma Shortness of breath Increase blood pressure then formation of heat

and redness to the site

Poor gag reflex in persons who are unconscious Swelling and pain emerges then led to loss of
or semi-conscious Wheezing tissue functions

Student Name: Dela Cruz, Jesfel B. Intensive Practicum Prof. Marilen F. Pacis RM, RN, MAN Prof Basilio L. Bermas Jr. RN, MAN, EdD
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Nursing Department

NURSING CARE MAP NURSING CARE MA

CASE DIAGNOSIS NURSING DIAGNOSIS
NURSING INTERVENTIONS

Ineffective airway clearance related to

- Monitor Vital signs every hour.
increased sputum production in as evidenced
by fatigue.
- Position patient in a moderated high position or semi fowler’s position.

- Instruct
NURSINGpatient or the folks regarding medications, DESIRED
ASSESSMENT OUTCOMES
side effects, and symptoms of adverse
reaction to report to the nurse or physician.

- Administer medication such as antibiotics and expectorants for productive cough as

Subjective:
ordered.
- -n/a
Instruct the patient or the family members to notify nurse if the patient is experiencing
shortness of breath or air hunger. Short term goal
Objective:
- After 8 hours of nursing intervention
the patient will be able to cough
- Inability to cough effectively.
effectively and clear secretions.
-T – 36.5 °C
Long term goal
COMMUNITY
NURSING RESOURCES
ALERTS
P – 83 bmp - After a week of nursing intervention
the patient will display patent airway
RR – 21 bmp with breath sounds clearing, absence
of dyspnea.
Refer
Watch
patient
out for
to support
blue lips,
groups,
tongue,
health
or
BP – 120/80 mmHg fingers,
promotion
difficulty
groups,
swallowing,
hospital,shortness
clinics, of
breath
emergency
and chest
hotlines.
pain.

Student Name: Dela Cruz, Jesfel B. Intensive Practicum Prof. Marilen F. Pacis RM, RN, MAN Prof Basilio L. Bermas Jr. RN, MAN, EdD