A Clinical Case Analysis Committee of the

College of Nursing and School of Midwifery

City University of Pasay
Pasadeňa St. F.B. Harrison Pasay City

Pneumonia

In partial fulfillment of the requirements in

NCM 112 Related Learning Experience

By:
BSN III – B Group 3
Espinosa, Adrianne Howell G.
Juvida, Clarissa
i. Introduction
Infectious diseases are caused by infectious organisms. Typically, bacteria, viruses, fungi, and worms/helminths are common
examples. Disease symptoms may not arise under normal conditions when the host’s immune system is fully working. An infectious
disease develops when the host immune system is weakened or the infectious pathogen overwhelms the immune system. Although
infectious diseases are present all around the world, the types of illnesses differ on climate, sanitation, and other environmental
factors. The consequences of infectious disease vary depending on the infectious agent and can range from mild inflammation to
life-threatening illness. And according to Mayoclinic.org (n.d.), some infectious diseases are contagious and can be spread from
person to person. Some of them are transmitted by insects or other animals. And you may get others by consuming contaminated
food or water or being exposed to organisms in the environment.
Coronavirus disease (COVID-19) is an infectious disease caused by the SARS-CoV-2 virus. Most people who get COVID-19 have mild
or moderate symptoms like coughing, a fever, and shortness of breath. But some who catch the new coronavirus get severe
pneumonia in both lungs. COVID-19 pneumonia is a serious illness that can be deadly. COVID-19 can cause lung complications such
as pneumonia and, in the most severe cases, acute respiratory distress syndrome (ARDS) and Sepsis, another possible complication
of COVID-19, can also cause lasting harm to the lungs and other organs. The pneumonia that COVID-19 causes tend to take hold in
both lungs. Air sacs in the lungs fill with fluid, limiting their ability to take in oxygen and causing shortness of breath, cough and other
symptoms.
Pneumonia is a common lung infection characterized by collection of pus and other fluids in the lung air sacs (alveoli). Lung air sacs
are structures that help in the exchange of oxygen and carbon dioxide. Collection of pus in them makes treating difficult. Pneumonia
can be caused by many kinds of microorganisms (germs) including bacteria, viruses, fungi or parasites.
Pneumonia is a form of acute respiratory infection that affects the lungs. The lungs are made up of small sacs called alveoli, which fill
with air when a healthy person breathes. When an individual has pneumonia, the alveoli are filled with pus and fluid, which makes
breathing painful and limits oxygen intake. Pneumonia is the single largest infectious cause of death in children worldwide.
Pneumonia killed 808 694 children under the age of 5 in 2017, accounting for 15% of all deaths of children under five years old.
Pneumonia affects children and families everywhere, but is most prevalent in South Asia and sub-Saharan Africa. Children can be
protected from pneumonia, it can be prevented with simple interventions, and treated with low-cost, low-tech medication and care,
(World Health Organization, August 2019).
The condition varies from mild to severe depending on the type of organism involved, age and the underlying health of the
individual. Pneumonia can be categorized as: communityacquired, hospital-acquired and pneumonia occurring in
Immunocompromised individuals (individuals with weakened immune system). Pneumonia is usually caused due to an infection with
a bacterium, virus, fungi or parasite. In adults it is mostly caused by bacteria whereas in children and infants it is commonly due to
viruses. Physical or chemical injury to the lungs can also result in the condition. Individuals who smoke, who are hospitalized and
have long-term illness such as asthma, heart disease, cancer, HIV/AIDS, lung diseases or diabetes are at a higher risk of developing
Pneumonia. Hospital Acquired Pneumonia is also common (Reproto, John Paul, 2019).
The Data from the 2019 Global Burden of Disease (GDB) study showed that Lower Respiratory Tract Infections (LRTIs) including
Pneumonia and Bronchiolitis affected 489 million people globally. Children of <5 years of age and adults of >70 years of age are the
populations most affected by Pneumonia. In 2016 GDB study, the global incidence of LRTI was 155.4 episodes per 1,000 adults of
>70 years of age and 107.7 episodes per 1,000 children of <5 years of age, (Vos, Theo et al., 2020).
The South American Andes region had the highest incidence of adults of >70 years of age with LRTIs (406.5 episodes per 1,000),
while South Asia had the greatest number of LRTI episodes amongst adults of >70 years of age. Incidence per global region was
171.1 per 1,000 people in Central Europe, Eastern Europe and Central Asia; 234.4 per 1,000 people in Latin America and the
Caribbean; 130.8 per 1,000 people in Southeast Asia, Eastern Asia and Oceania;
246.6 per 1,000 people in North Africa and the Middle East; and 229.3 per 1,000 people in Sub- Saharan Africa, (Troeger, Christopher
et al., 2018).

ii. Objectives

A. Cognitive

 Identify and explain the serious causes, factors and also the signs and symptoms of Pneumonia.
  To increase knowledge and awareness of Pneumonia by gathering enough information to serve as a guide for
nursing students.

B. Psychomotor

 Establishing specific and appropriate expected outcomes, planning, and implementing effective nursing
interventions, and evaluating patient outcome as a result of the overall assessment given.

 Demonstrate the pathophysiology of pneumonia.

C. Affective

 Increase your team's positive attitude like accept and listen to different ideas, point of view, and suggestions.

 To enhance skills and intellet in nursing process and management.

iii. Scope & Limitations

This case analysis was prepared by group 3 BSN 3-B as a requirement for the subject nursing care management 112 correlated
learning experience. This case analysis focuses on pneumonia moderate risk, its signs and symptoms, complications and effective
nursing interventions. In some manners, the sources were limited because the data is based on the given case scenario.
I. Personal Data

Name: Y.O

Address: Dasmarinas Cavite

Age: 55

Sex: Male

Civil Status: Married

Occupation: Truck driver

Religion: Roman Catholic

Birthday: January 15, 1967

Birthplace: Pangasinan

Attending Physician: Doctor Magbitang

Chief Complaint/Reason for Seeking Healthcare: Fever, Cough, Fatigue, Chills and difficulty in breathing

Medical Diagnosis: Pneumonia

Vital Signs during Assessment:

BP- 100/80

T-36.7 °C

PR-88 bpm

RR-25 bpm
II. Medical History
A. History of Present Illness
Y.O had a fever, chills, fatigue, and stomach aches on August 27, 2021. He initially observes and then takes over-the-counter (OTC)
medications such as Bioflu and Alaxan to treat his pain/discomfort. And he still did not feel well on September 2, with a fever and
cough. On September 03 at 5:00 p.m., he goes to Hospital with his son for a check-up. On September 09, he had difficulties in
breathing, and hospital staff provides him with oxygen. During the first week, he had an x-ray and all of the medicines he took had
no effect on his body. He also mentioned that he cannot remember if he completed his childhood immunization.
B. Past Medical History
Y.O verbalized that he experiences fever and a common cold due to weather conditions. he was in a self-accident on May 18, 2011
and he had minor injuries. He has no history of any medical surgeries. And there’s no information about his immunizations or
allergies.

C. Family Medical History

FATHER SIDE MOTHER SIDE
LEGEND

Living female

Living male

Deceased female
Deceased male
Point to patient

A&W= Alive & well

PN= Pneumonia

D. Social History
Y.O is a 54-year-old man who is married and has four children, two boys and two girls. He works as a tricycle driver. He consumes
alcohol on occasion, he does not smoke. And there is no history of any chronic diseases in their family.

E. Environmental History

F. Developmental History
Erik Erikson's Psychosocial Development Stage

Stage Age Normal findings Actual findings

Generativity vs. Age (40 to 65 years) Erik Erikson believed that if an adult .
Stagnation creates or nurtures things that will
outlast them, often by having
children or creating a positive change
that benefits other people. Success
leads to feelings of usefulness and
accomplishment (Generativity). while
failure results in shallow involvement
in the world (Stagnation).

Sigmund Freud’s Puberty to Death The onset of puberty causes

Psychosocial the libido to become active
Development once again. During the final
stage of psychosexual
development, the individual
Genital Stage develops a strong sexual
interest in the opposite sex.
This stage begins during
puberty but last
III. Patterns of Functioning – Altered System

Patterns of Before During Analysis/

Functioning Hospitalization Hospitalization Interpretation

IV. Physical Examination / Review of System

General Survey: The patient is conscious, well-oriented to time, place and to his present condition and it was clinically stable and
healthy, calm, and well-groomed; he speaks normally and cooperative in answering the questions.
Vital signs: BP- 100/80, T-36.7°C, PR-88 bpm, RR-25 bpm
Height: 5’5
Weight: 63 kg.

Analysis/
Interpretation
Body Part Normal Findings Actual Findings
 Skin is uniform whitish pink or varies
Skin Normal
from light to deep brown color. Skin is brown and no skin lesions.
No skin lesions.

It is round.
It is round, no wounds or
No wounds or inflammation around the
HEAD inflammation around the head Normal
head

Rounded, (normocephalic and

symmetrical, with frontal, parietal, and
Skull
occipital prominences); smooth uniform
consistency; absence of nodules or
masses.
Black, evenly distribution of hair, silky
Hair and resilient hair and no infection or
infestation
Smooth texture with short and clean
Nails fingernails and toenails. The color is
uniform in a pink color. Intact epidermis.
-Eyeballs are symmetrical in size and
position.
-Uniform in color, black or brown.
Eyes - The vision is clear and able to identify
letter/read in the newsprints at a
distance of fourteen inches.
Rounded shape, symmetrical. Absence
Normal
of nodules or masses.
Black, evenly distribution of hair, silky
and resilient hair and it has a minimal
Normal
hair dandruff.
Thick, hard and smooth nails with
short and clean fingernails and
toenails. The color is uniform in a pink Normal
color and the tissues surrounding the
nails of the patients are intact.
Eyeballs are symmetrical in size and
position. The color is black. The vision
is clear and able to identify letter/read Normal
in the newsprints at a distance of
fourteen inches

Eyebrows -Hair is evenly distributed with skin -Evenly distributed with skin intact. Normal
intact. -Symmetrical aligned with equal
-Symmetrical aligned with equal movement
 movement
Equally distributed and curled slightly
Equally distributed and curled slightly Normal
Eyelashes upward.
outward.
Skin intact with no discharges and no Symmetrically closed, no discharge Normal
Eyelids
discoloration. Lids close symmetrically. and discoloration.
Symmetrical in size and no
Symmetrical in size and no
discolorations. No lesions or
Ears discolorations. No lesions or Normal
inflammation. Voice sounds audible
inflammation. Voice sounds audible and
and both ears can hear low sounds
both ears can hear low sounds very well.
very well.
-Symmetric and straight.
Symmetric
-Uniform in color.
and straight. Uniform in color. Normal
Nose and Sinuses No tenderness feels upon palpation. Can
No tenderness feels upon palpation.
breathe freely.
Can breathe freely.
The lips are uniform pink color. Soft, The lips are symmetrical, dry, no
moist, smooth texture. The teeth and swelling or lesions. Normal
Mouth
gums are uniform, the tongue moves Pink gums with clean teeth and no
freely, no tenderness tooth decayed. It moves freely.
The color is brown.
Uniform in color No lesions. No
No lesions. No inflammation around
inflammation around the
the
neck. No Normal
Throat and Neck neck. No
difficulties when head is moving and
difficulties when head is moving and
swallowing.
swallowing.

With normal breath sounds without presence of crackling sounds (rales) Abnormal
Respiratory
dyspnea.
It has a normal heart beat with
Cardiovascular Abnormal
It has a normal heart beats and sounds. presence of phlegm and increased of
mucus production.
Breast and Axilla Symmetrical in size. Symmetrical size and rounded in Normal
No lesions. shape. No lesions.
 No lumps. No lumps. The color is uniform
Symmetrical movements caused by
Symmetrical movements caused by
respiration.
respiration. Normal
Abdomen No scars. Uniform in color.
No scars. Uniform in color. No
No tenderness; relaxed abdomen with
tenderness and relaxed abdomen
smooth, consistent tension.
Symmetrical in size both sides of the
Symmetrical in size both sides of the
body and it has a good posture. No
Musculoskeletal body. No swelling. Joints move smoothly. Normal
swelling. Joints move smoothly.
Equal strength on each body side
Equal strength on each body side

Able to response, express oneself by Able to response, express oneself by

speech and concentrate as evidence by speech and concentrate as evidence Normal
Neurological
answering the questions appropriately. by answering the questions
appropriately.
V. Anatomy & Physiology

The lungs constitute the largest organ in the respiratory system. They play an important role in respiration, or the process of providing the body
with oxygen and releasing carbon dioxide.

The lungs expand and contract up to 20 times per minute taking in and disposing of those gases. The first line of defense includes the hair in the
nostrils, which serves as a filter for larger particles.

The epiglottis is a trap door of sorts, designed to prevent food and other swallowed substances from entering the larynx and then trachea.
Sneezing and coughing, both provoked by the presence of irritants within the respiratory system, help to clear such irritants from the respiratory
tract.

Mucous, produced throughout the respiratory system, also serves to trap dust and infectious organisms. Tiny hair-like projections (cilia) from
cells lining the respiratory tract beat constantly. moving debris, trapped by mucus, upwards and out of the respiratory tract. This mechanism of
protection is referred to as the mucociliary escalator.
VI. Pathophysiology
VII. Laboratory and Diagnostic Examination – Recent to past
HEMATOLOGY
LAB TEST RESULT REFERENCE REMARKS INDICATION
RANGE
 Hemoglobin 90.8 M (140-170/L) Low Possible signs of
mass count anemia
Leukocyte 6.0 x 10 9/L 5-10x10 9/L Normal Possible signs of
infection
Neutrophils 0.63 0.55-065 Normal Normal
Lymphocytes 0.35 0.25-0.35 Normal Normal
Eosinophils 0.02 0.02-0.04 Normal Normal
Platelet count 124,000/cc.mm 150,000- Low Possible signs of
350,5000/cc.mm infection

VIII. Medical and Surgical Interventions

Levofloxacin

- It used to treat bacterial infections in many different parts of the body. It is also used to treat anthrax infections after inhalation
exposure. It is to treat and prevent plague (including pneumonic and septicemic plague). Take once a day for 7 days PO, as prescribed by
the doctor.

There was no surgical intervention given to the patient.

IX. Drug Study
DRUG NAME CLASSIFICATION MECHANISM INDICATION CONTRAINDICATION ADVERSE NURSING
OF ACTION REACTION RESPONSIBILITIES

GENERIC Antibiotic(quinolo Inhibits  Acute  Hypersensitivi CNS: Seizures, BEFORE:

NAME: ne) bacterial DNA bacterial ty to drug, its dizziness,  Verify
Levofloxacin gyrase and sinusitis components, insomnia doctor’s
prevents DNA caused by or other order.
replication, strains of fluoroquinolo CV: chest pain,  Tell patient
transcription, streptococcus nes. palpitations, to take with
BRAND repair and pneumoniae, vasodilations or after
NAME: recombinatio Moraxella meals with
Novo- n in catarrhalis or GI: vomiting, full glass of
Lefloxacin susceptible Haemophilus nausea, water of
bacteria. influenza. abdominal pain, fruit juice to
 Community- diarrhea avoid GI
distress.
acquired-
MUSCULOSKE  Teach
ACTUAL pneumonia
LETAL: patient signs
DOSAGE,ROU  Uncomplicate Back pain, and
TE, d skin and tendon rupture symptoms
FREQUENCY: skin-structure of
500mg, PO,QD infections RESPIRATORY pneumonia
 Chronic : allergic and tell
bacterial pneumonitis patient to
prostatitis notify
SKIN: Rashes, prescriber if
erythema they occur.

DURING:
 Monitor
patient for
allergic and
skin
reactions.
 Monitor
patient for
CDAD,
which may
range in
severity
from mild
diarrhea to
fatal colitis.

AFTER:
  Tell patient
to take drug
as
prescribed,
even after
feeling
better.
 Advise
patient to
avoid
excessive
sunlight and
to wear
protective
clothing and
use
sunscreen
when
outside.
 Tell patient
to report
adverse
reactions
promptly.

X. Nursing Care Management

A. List of Nursing Diagnosis/Problem

 Cues Nursing Diagnosis Rationale

B. Nursing Care Plan (NCP)

Actual

Assesment Nursing planning intervention rationale evaluation

Diagnosis
subjective: Ineffective airway After 3 days of nursing Dependent: After 3 days of nursing
clearance - intervention patient will intervention patient was
“nahihirapan akong related to Demonstrate behaviors to  Encourage the  To reduce able to Demonstrate
huminga dahil sa increase mucus improve or maintain clear patient to do chest behaviors to improve or
production. airway. often coughing discomfort maintain clear airway.
plema” as verbalized
while in an and an upright
by the patient.
upright position position favors
and splint the deeper and
Objective: phlegm. more forceful
 Tachypnea cough effort
 facial making it
grimace more
 Cough effective.
 restlessness  To facilitate
 Teach patient the maximum
Deep breathing expansion of
Vital Signs taken: BP-
exercises. the lungs and
100/80 mmHg smaller
PR-88 bpm airways and
RR-25 bpm improve the
T-36.7°C productivity of
cough.

 Fluids help
maintain
 Encourage the
hydration and
patient to
increase ciliary
maintain
action to
3000ml fluids a
remove
day.
secretions and
reduce
viscosity.

 to take
advantage of
 Teach patient
gravity
how to elevate
head of bed and
decreasing
Change position pressure on
every 2 hours the
diaphragm
and
enhancing
drainage of
ventilation to
different
lung
segments.
 Encourage the
patient to use  Increasing
humidified the humidity
oxygen or will decrease
humidifier at the the viscosity
bedside. of secretions.
 Dependent: Clean the
 Administer humidifier
Levofloxacin as before use to
ordered by avoid
physician.
bacterial
growth.
Potential/ris

assesment Nursing diagnosis planning intervention Rationale evaluation

Objective: Risk for infection After 5 days of Independent: Independent: After 5 days of
 Tachypnea nursing intervention  Assess and  Vital signs monitoring nursing intervention
 facial patient will document vital provides the nurse patient was able to
grimace Verbalize ease in signs, noting for with immediate Verbalize knowledge
 Cough respiration and changes in information about on ways of how to
 restlessness knowledge on ways temperature, the general status of prevent or reduce risk
of how to prevent or respiratory effort the patient. Increases of infection.
Vital Signs taken: reduce risk of and complaints of in temperature may
BP- 100/80 mmHg infection. pain. indicate the presence
PR-88 bpm of infection.
RR-25 bpm
T-36.7°C  to prevent spread of
infection. It will be
beneficial to
 Teach patient
encourage the
proper
practice of
handwashing and
handwashing by
its importance to
showing them how to
prevent infection.
do it.

 resting helps the

patient to build and
 Encourage the
maintain his natural
patient to rest.
defenses and
resistance to
infections. It also
helps to promote
faster healing.
 Most cases of complicated
infections and drug-resistant
 Ensure that the strains of infections are
patient caused by patients who are
understands and not able to adhere to the
adheres to the prescribed length of therapy
antibiotic therapies. and proper dosage.

Dependent:

 Administer
Levofloxacin as
ordered by
physician.
Wellness rediness

Assesment Diagnosis Planning intervention rationale Evaluation

Subjective: readiness for  after 6 hours of Independent:  after 3 hours of
“wala po akong enhanced health teaching  Review patient’s  to document status, health teaching
pneumonia Immunization patient will knowledge plan for boosters, patient was
vaccine’ as stated Status Identify and regarding and/or discuss able to Identify
by the patient. adopt behaviors pneumonia appropriate and adopt
on how to vaccination. intervals for follow- behaviors on
prevent up. how to prevent
pneumonia by pneumonia by
Objectives: getting  To tract getting
vaccinated.  Discuss appropriate vaccinated.
time intervals for
VitalSigns: pneumonia
Bp:100/80mmHg vaccination.
Pr: 88 bpm  Teach patient the  To make the patient
benefits of aware and informed
Rr: 25 bpm
pneumonia
 T: 36.7°C vaccination, route about possible
of administration, effects after
expected side vaccination.
effects, and
potential adverse
reactions.

 Address patients
concerns about  to clarify plans and
pneumonia deal with
vaccinations misconceptions or
myths.
Collaborative:
Collaborative:
 Refer to near BRGY
health care  To get free and
providers to get convenient
vaccinated. vaccination.

Note: Minimum of 3 identified problems per classification (actual, potential/risk, wellness)

References:
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, prioritized interventions,
and rationales. Philadelphia: F.A. Davis.

Carpenito, L. (2016). Handbook of Nursing Diagnosis (15th ed.).

Herdman, T., & Kamitsuru, S. (2018). NANDA International, Inc. nursing diagnoses (11th ed.).
Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L., & Harding, M.M. (2017).