STUDENT’S NAME: ARCAYAN, TRIXIE D.

BSN 3-A1

Name of the Patient: Feliciano Aranas Bugtay Age: 80

Chief Complaint/s: Cough and Dyspnea Diagnosis: Pneumonia

I. Brief Description of the Disease

A. Definition
Pneumonia is a lung infection that can range from mild to so severe that you
have to go to the hospital. It happens when an infection causes the air sacs in
your lungs (your doctor will call them alveoli) to fill with fluid or pus. That can make
it hard for you to breathe in enough oxygen to reach your bloodstream.

B. Risk factors (Based Upon Pathogen Type)

Being knowledgeable about the factors and circumstances that commonly
predispose people to pneumonia helps identify patients at high risk for the
disease (Bartlett, 2015).
Risk Factors for Infection with Penicillin-Resistant and Drug-Resistant Pneumococci
 Age >65 years
 1649
 Alcoholism
 Beta-lactam therapy (e.g., cephalosporins) in past 3 months
 Immunosuppressive disorders
 Multiple medical comorbidities
 Exposure to a child in a day care facility
Risk Factors for Infection with Enteric Gram-Negative Bacteria
 Residency in a long-term care facility
 Underlying cardiopulmonary disease
 Multiple medical comorbidities
 Recent antibiotic therapy
Risk Factors for Infection with Pseudomonas aeruginosa
 Structural lung disease (e.g., bronchiectasis)
 Corticosteroid therapy
 Broad-spectrum antibiotic therapy (>7 days in the past month)
 Malnutrition

C. Signs and Symptoms or Clinical Manifestation

Pneumonia varies in its signs and symptoms depending on the type, causal
organism, and presence of underlying disease. However, it is not possible to
diagnose a specific form or classification of pneumonia by clinical manifestations
alone. The patient with streptococcal (pneumococcal) pneumonia usually has a
sudden onset of chills, rapidly rising fever (38.5° 1657 to 40.5°C [101° to 105°F]), and
pleuritic chest pain that is aggravated by deep breathing and coughing. The
patient is severely ill, with marked tachypnea (25 to 45 breaths/min),
accompanied by other signs of respiratory distress (e.g., shortness of breath and
the use of accessory muscles in respiration) (Weinberger, Cockrill & Mandel, 2014).
A relative bradycardia (a pulse–temperature deficit in which the pulse is slower
than that expected for a given temperature) may suggest viral infection,
mycoplasma infection, or infection with a Legionella organism.
 Your symptoms can vary depending on what’s causing your pneumonia, your
age, and your overall health. They usually develop over several days.

Common pneumonia symptoms include:

 Chest pain when you breathe or cough

 Cough that produces phlegm or mucus
 Fatigue and loss of appetite
 Fever, sweating, and chills
 Nausea, vomiting, and diarrhea
 Shortness of breath
Along with these symptoms, older adults and people with weak immune systems
might be confused or have changes in mental awareness, or they might have a lower-
than-usual body temperature.

D. Management/Nursing Interventions
The major goals may include improved airway patency, increased activity
maintenance of proper fluid volume maintenance of adequate nutrition, an
understanding of the treatment protocol and preventive measures, and absence
of complications.
 IMPROVING AIRWAY PATENCY
Removing secretions is important because retained secretions interfere with gas
exchange and may slow recovery. The nurse encourages hydration (2 to 3 L/day),
because adequate hydration thins and loosens pulmonary secretions.
Humidification may be used to loosen secretions and improve ventilation.
 PROMOTING REST AND CONSERVING ENERGY
The nurse encourages the debilitated patient to rest and avoid overexertion and
possible exacerbation of symptoms. The patient should assume a comfortable
position to promote rest and breathing (e.g., semi-Fowler’s position) and should
change positions frequently to enhance secretion clearance and pulmonary
ventilation and perfusion.
 PROMOTING FLUID INTAKE
The respiratory rate of patients with pneumonia increases because of the
increased workload imposed by labored breathing and fever. An increased
respiratory rate leads to an increase in insensible fluid loss during exhalation and
can lead to dehydration. Therefore, unless contraindicated, increased fluid intake
(at least 2 L/day) is encouraged.
 MAINTAINING NUTRITION
Many patients with shortness of breath and fatigue have a decreased appetite
and consume only fluids. Fluids with electrolytes (commercially available drinks,
such as Gatorade) may help provide fluid, calories, and electrolytes.
 PROMOTING PATIENTS’ KNOWLEDGE
The patient and family are instructed about the cause of pneumonia,
management of symptoms, signs and symptoms that should be reported to the
primary provider or nurse, and the need for follow-up. The patient also needs
information about factors (both patient risk factors and external factors) that may
have contributed to the development of pneumonia and strategies to promote
recovery and prevent recurrence.
 MONITORING AND MANAGING POTENTIAL COMPLICATIONS
 .
 PROMOTING HOME, COMMUNITY-BASED, AND TRANSITIONAL CARE

II. Patient’s Signs and Symptoms or Clinical manifestations

 Cough
 Dyspnea
 Guarding Behavior
 ANATOMY AND PHYISOLOGY

Name of the Affected Organ

Lungs

Draw and label the affected organ

Function/s:

Your lungs’ main job is to get oxygen into your blood and remove carbon dioxide. This happens
during breathing. You breathe 12 to 20 times per minute when you are not sick. When you breathe
in, air travels down the back of your throat and passes through your voice box and into your
windpipe (trachea). Your trachea splits into two air passages (bronchial tubes). One bronchial
tube leads to the left lung, the other to the right lung. For the lungs to perform their best, the airways
need to be open as you breathe in and out. Swelling (inflammation) and mucus can make it
harder to move air through the airways, making it harder to breathe. This leads to shortness of
breath, difficulty breathing and feeling more tired than normal.

Reference/Source:

https://www.uptodate.com/contents/image?imageKey=PI%2F55943

https://my.clevelandclinic.org/health/diseases/4471-pneumonia
 Pneumonia

(Medical diagnosis)

Affected Organ
Lungs

Etiology/Causative Agent Risk factors:

Viruses and Bacteria most Bacteria enter the lungs (from the throat or nose,
Modifiable:
commonly (Streptococcus airborne, droplets, or blood).
Pneumoniae)  Smoking
 Alcoholism

Non-modifiable:
Bacteria may invade spaces between cells and
between alveoli.  Age (Patient is 80
years old)
 Immunocomprom
ised

The macrophages and neutrophils inactivate the bacteria. The neutrophils also
release cytokines

The neutrophils, bacteria and fluid fill the alveoli

S/Sx: _________________________________________________________________________

Cough Fatigue Dyspnea Fever Chest Pain

Reference/Source: file:///C:/Users/ADMIN/Downloads/pneumonia-6-638.webp
 LABORATORY/DIAGNOSTIC STUDIES

Date/Exam Patient’s Results Normal Values Significance/Interpretation

Hematology/Complete Blood Count Results shows an increase in WBC, which
RBC 5.14 x10/𝑚𝑚3 4.5-5.1x106 /𝑚𝑚3 indicates sign of infection and a low
WBC 15.3x103 /𝑚𝑚3 4.4-11.0x103 /𝑚𝑚3 platelet count may indicate bleeding.
Eosinophil 1.8% 0.0-7.0%
Basophil 2.6% 0.0-2.5% Others are in a normal range.
Neutrophil 54.6% 37.0-80%
Platelet 76x103 /𝑚𝑚3 150-450x103 /𝑚𝑚3
Hemoglobin 15.4 g/dl 12.3-15.3 g/dl
Hematocrit 47.1% 35.9-44.6%

Arterial Blood Gas Results shows pCO2 and HCO3 are below
pH 7.367 7.350-7.450 normal range while P02 is above the
pCO2 18.5 mmHg 35.0-45.0 mmHg normal arrange, analysis shows metabolic
pO2 115.0 mmHg 90.0-100.0 mmHg acidosis.
HCO3 10.8 mmHg 22.0-26.0 mmHg
BE (ecf) -15.00 mEq/L 2.0 mEq/L
O2 sat 99.0% >95.0 %

Creatinine 2.00 mg/dl 0.51-0.95 mg/dl Normal

Blood Urea Nitrogen (BUN)
C-reactive protein (qCRP)
LDH (Serum lactate degydrogenase)
27.6 mg/dl 6.0-20.0 mg/dl Results shows BUN is above normal rang,
which indicates as a marker of Pneumonia,
The patients who have pneumonia are
usually dehydrated that results from
increase of BUN excretion from the
kidneys
>160 mg/dl <10 Elevated CRP values may also be found in
uncomplicated viral respiratory infections,
particularly those caused by influenza virus
and adenovirus.
1,560.09 U/L <480 An increase in serum lactate
dehydrogenase (LDH) activity is commonly
taken to support the presumptive
diagnosis of Pneumocystis carinii
pneumonia (PCP), although the LDH level
 may also be increased in other lung
infections and in a variety of
extrapulmonary disorders.
Procalcitonin 0.457 ng/mL <0.3 ng/mL= normal Possible Septic shock is a common
>0.3 ng/ml to <0.5 ng/ml= low complication of more severe pneumonia.
Risk of sepsis

Reference/Source: https://www.hilarispublisher.com/open-access/the-role-of-albumin-level-and-blood-urea-nitrogen-albumin-ratio-in-prediction-of-prognosis-of-
community-acquired-pneuomonia-2161-105X.1000159.pdf

https://www.hindawi.com/journals/jbm/2016/2198745/

https://pubmed.ncbi.nlm.nih.gov/7634877/

CT SACN/MRI/CHEST X-RAY/KUB RESULT:

Picture of X-ray is shown but no interpretation

 DRUG STUDY

Name of Mechanism of Indications Contraindications Side effects (by system) Nursing Responsibilities
the Drug Action
Ceftriaxone Ceftriaxone works Ceftriaxone is -Intravenous administration Local Reactions - pain, induration 1. Identify the patient and check
(Trizeto) by inhibiting the used for the of ceftriaxone solutions and tenderness was 1% overall. doctor’s order before administering.
mucopeptide treatment of the containing lidocaine. Phlebitis was reported in <1% after
Dosage: synthesis in the infections -Lidocaine contraindications if IV administration. The incidence of 2. Note reasons for therapy, physical
2 gm IV Drip bacterial cell (respiratory, skin, lidocaine solution used as warmth, tightness or induration was presentation, S&S of infection; list
q 24H ANST wall.10,11 The soft tissue, UTI, solvent with ceftriaxone 17% (3/17) after IM administration other agents trialed and obtain
beta-lactam ENT) caused by for intramuscular injection. of 350 mg/mL and 5% (1/20) after baseline cultures.
moiety of susceptible -Concomitant calcium- IM administration of 250 mg/mL.
ceftriaxone binds organisms.11 ceftriaxone administration: General Disorders And 2. Use care when transcribing orders
to Organisms that Administration Site Conditions - for administration and request
carboxypeptidases, are generally injection site pain (0.6%). clarification as needed.
endopeptidases, susceptible to Hypersensitivity - rash (1.7%). Less
and ceftriaxone frequently reported (<1%) were 3. If diarrhea develops, report any
transpeptidases in include S. pruritus, fever or chills. fevers. Monitor VS. I&O, stool, C&S,
the bacterial pneumoniae, S. Infections And Infestations - genital and electrolytes.
cytoplasmic pyogenes (group A fungal infection (0.1%).
membrane. These beta-hemolytic Hematologic - eosinophilia (6%),
enzymes are streptococci), thrombocytosis (5.1%) and
involved in cell- coagulase- leukopenia (2.1%). Less frequently
wall synthesis and negative reported (<1%) were anemia,
cell division. staphylococci, hemolytic anemia, neutropenia,
Binding of Some lymphopenia, thrombocytopenia
ceftriaxone to Enterobacter spp, and prolongation of the
these enzymes H. influenzae, N. prothrombin time.
causes the enzyme gonorrhoeae, P. Blood And Lymphatic Disorders -
to lose activity; mirabilis, E. coli, granulocytopenia (0.9%),
therefore, the Klebsiella spp, M. coagulopathy (0.4%).
bacteria produce catarrhalis, B. Gastrointestinal - diarrhea/loose
defective cell burgdorferi, and stools (2.7%). Less frequently
walls, causing cell some oral reported (<1%) were nausea or
death. anaerobes.1 vomiting, and dysgeusia. The onset
of pseudomembranous colitis
symptoms may occur during or after
antibacterial treatment (see
WARNINGS).
Hepatic - elevations of aspartate
aminotransferase (AST) (3.1%) or
alanine aminotransferase (ALT)
 (3.3%). Less frequently reported
(<1%) were elevations of alkaline
phosphatase and bilirubin.
Renal - elevations of the BUN
(1.2%). Less frequently reported
(<1%) were elevations of creatinine
and the presence of casts in the
urine.
Central Nervous System - headache
or dizziness were reported
occasionally (<1%).
Genitourinary - moniliasis or
vaginitis were reported occasionally
(<1%).
Miscellaneous - diaphoresis and
flushing were reported occasionally
(<1%).
Investigations - blood creatinine
increased (0.6%).

Other rarely observed adverse

reactions (<0.1%) include abdominal
pain, agranulocytosis, allergic
pneumonitis, anaphylaxis,
basophilia, biliary lithiasis,
bronchospasm, colitis, dyspepsia,
epistaxis, flatulence, gallbladder
sludge, glycosuria, hematuria,
jaundice, leukocytosis,
lymphocytosis, monocytosis,
nephrolithiasis, palpitations, a
decrease in the prothrombin time,
renal precipitations, seizures, and
serum sickness.

Reference/Source: https://go.drugbank.com/drugs/DB01212 https://www.empr.com/drug/ceftriaxone/ https://www.rxlist.com/rocephin-drug.htm#side_effects

2008 NURSE’S DRUG HANDBOOK
 DRUG STUDY

Name of the Drug Mechanism of Indications Contraindications Side effects (by system) Nursing Responsibilities
Action
Azithromycin The mechanism of Treatment of the Hypersensitivity to Adverse reactions that 1. Identify the patient and check
(Zenith) action of following conditions azithromycin occurred with a doctor’s order before administering
azithromycin caused by organisms monohydrate, frequency of 1% or less
monohydrate is sensitive to erythromycin, any included the following: 2. Assess History: Hypersensitivity to
Dosage: based upon the azithromycin macrolide or ketolide azithromycin, erythromycin, or any
500 mg/cap, 1 cap suppression of monohydrate: Lower antibiotic and to any of Gastrointestinal: macrolide antibiotic; gonorrhea or
OD PO bacterial protein respiratory tract the excipients of Zenith. Dyspepsia, flatulence, syphilis, pseudomembranous colitis,
synthesis, that is it infections, including Pregnancy and lactation. mucositis, oral moniliasis, hepatic or renal impairment, lactation
binds to the bronchitis and mild to and gastritis. Physical: Site of infection; skin color,
ribosomal 50S sub- moderately severe lesions; orientation, GI output, bowel
unit and inhibits the community acquired Nervous system: sounds, liver evaluation; culture and
translocation of pneumonia. Headache, somnolence. sensitivity tests of infection, urinalysis,
peptides. Upper respiratory LFTs, renal function tests
tract infections, Allergic:
including sinusitis and Bronchospasm. 3. Culture site of infection before
pharyngitis/tonsilitis. therapy.
(Azithromycin Special senses:
monohydrate is not Taste perversion. 4. Administer on an empty stomach 1 hr
the substance of first before or 2–3 hr after meals. Food
choice for the affects the absorption of this drug.
treatment of
pharyngitis and 5. Prepare Zmax by adding 60 mL water
tonsilitis caused by to bottle, shake well.
Streptococcus
pyogenes. For this and 6. Counsel patients being treated for
for the prophylaxis of STDs about appropriate precautions and
acute rheumatic fever, additional therapy.
penicillin is the
treatment of first 7. Teach the patient to take the full
choice.) course prescribed. Do not take with
Inflammations of the antacids. Tablets and oral suspension
middle ear, skin and can be taken with or without food.
soft tissue infections,
uncomplicated
Chlamydia
 trachomatis, urethritis
and cervicitis.

Reference/Source: https://www.mims.com/philippines/drug/info/zenith?type=full

https://www.rxlist.com/zithromax-side-effects-drug-center.htm#consumer

https://www.rnpedia.com/nursing-notes/pharmacology-drug-study-notes/azithromycin/
 NURSING CARE PLAN

Defining Nursing Scientific Analysis Goal of Care Nursing Interventions Rationale

Characteristics Diagnosis (short term)

Subjective Cues: Ineffective Ineffective Airway After 3-4 hours of Independent: Independent
(verbalization Airway Clearance is a appropriate nursing 1. Assess the rate, rhythm, and depth of 1. Tachypnea, shallow
from the Clearance common NANDA-I intervention, the respiration, chest movement, and use of respirations and asymmetric
patient) related to nursing diagnosis patient will be able accessory muscles. chest movement are
- Aspiration as for pneumonia to: frequently present because
evidenced by nursing care plans.  identify/demo of the discomfort of moving
Objective Cues: cough and This diagnosis is nstrate chest wall and/or fluid in the
(assessment dyspnea. related to behaviors to lung due to a compensatory
findings, excessive achieve response to airway
observations) secretions and airway obstruction. Altered
Vital Signs: ineffective cough clearance. breathing patterns may occur
or nonproductive  display/maint together with accessory
BP: 130/90 coughing. muscles to increase chest
ain patent
HR: 121 Inflammation and airway with excursion to facilitate
increased breath sounds effective breathing.
RR: 36 secretions in clearing;
pneumonia make it absence of
Temp: 36.7 difficult to dyspnea, 2. Assess cough effectiveness and productivity 2. Coughing is the most
maintain a patent cyanosis, as effective way to remove
O2 Sat: 75%
airway. evidenced by secretions. Pneumonia may
keeping a cause thick and tenacious
patent airway secretions in patients.
and
3. Auscultate lung fields, noting areas of 3. Decreased airflow occurs
effectively
clearing decreased or absent airflow and adventitious in areas with consolidated
secretions. breath sounds: crackles, wheezes. fluid. Bronchial breath
sounds can also occur in
these consolidated areas.
Crackles, rhonchi, and
wheezes are heard on
inspiration and/or expiration
due to fluid accumulation,
thick secretions, and airway
spasms and obstruction.
4. Assess the patient’s hydration status. 4. Airway clearance is
hindered with inadequate

5. Elevate the head of the bed, change position
frequently.
6. Teach and assist the patient with proper deep-
breathing exercises. Demonstrate proper
splinting of the chest and effective coughing
while in an upright position. Encourage patient to
do so often.
Dependent:
1. Administer medications, as indicated:
hydration and thickening of
secretions.
5. Doing so would lower the
diaphragm and promote
chest expansion, aeration of
lung segments, mobilization,
and expectoration of
secretion.
6. Deep breathing exercises
facilitates maximum
expansion of the lungs and
smaller airways, and
improves the productivity of
cough. Coughing is a reflex
and a natural self-cleaning
mechanism that assists the
cilia to maintain patent
airways. It is the most helpful
way to remove most
secretions. Splinting reduces
chest discomfort and an
upright position favors
deeper and more forceful
cough effort making it more
effective.
1. 1.1. Mucolytics increase or
liquefy respiratory secretions.
1.2. Expectorants increase
productive cough to clear the
airways. They liquefy lower
respiratory tract secretions
by reducing its viscosity.
1.3. Bronchodilators are
medications used to facilitate
respiration by dilating the
airways.
1.4. Analgesics are given to
improve cough effort by
 reducing discomfort, but
should be used cautiously
because they can decrease
cough effort and depress
respirations.

2. Monitor serial chest x-rays, ABGs, pulse 2. Follows progress and

oximetry readings. effects and extent of
pneumonia. Therapeutic
regimen and may facilitate
necessary alterations in
therapy. Oxygen saturation
should be maintained at 90%
or greater. Imbalances in
PaCO2 and PaO2 may
indicate respiratory fatigue.

Reference/Source: https://nurseslabs.com/pneumonia-nursing-care-plans/