Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES

Tamag, Vigan City
2700 Ilocos Sur

College of Nursing
Website: www.unp.edu.ph Mail: unp_nursing@yahoo.com
CP #: 0917-714-8749, 0917-578-5986

___________________________________________

COMMUNITY-ACQUIRED PNEUMONIA

A Case Study

_____________________________________________

In Partial Fulfillment

of the Requirements of the course

NCM 103: Related Nursing Experience CL

Presented to:

Ms. Racel D. Abero, RN.

Clinical Instructor

Presented by:

Rabut, Clarinel R.

BSN III - C

This study source was downloaded by 100000881516420 from CourseHero.com on 03-02-2024 07:47:31 GMT -06:00

https://www.coursehero.com/file/117182036/CASE-STUDYdocx/
 TABLE OF CONTENTS

I.INTRODUCTION & OBJECTIVES..........................................................................................

II.PATIENT’S PROFILE ..............................................................................................................

III.HISTORY OF PAST AND PRESENT ILLNESS.......................................................................

IV.PEARSON ASSSSMENT .........................................................................................................

V.DIAGNOSTIC PROCEDURES ................................................................................................

VI.ANATOMY AND PHYSIOLOGY ............................................................................................

VII.PATHOPHYSIOLOGY .............................................................................................................

VIII.NURSING CARE PLAN...........................................................................................................

IX.DRUG STUDY..........................................................................................................................

X.DISCHARGE PLAN .................................................................................................................

XI.BIBLIOGHRAPHY ..................................................................................................................

This study source was downloaded by 100000881516420 from CourseHero.com on 03-02-2024 07:47:31 GMT -06:00

https://www.coursehero.com/file/117182036/CASE-STUDYdocx/
 CHAPTER I
INTRODUCTION

Pneumonia is an infection of the lower respiratory tract caused by bacteria, viruses, fungi,

protozoa, or parasites. It is the eighth leading cause of death in the United States. The incidence and

mortality of pneumonia are highest in the elderly. Risk factors for pneumonia include advanced age,

immunocompromise, underlying lung disease, alcoholism, altered consciousness, smoking,

endotracheal intubation, malnutrition, and immobilization. The causative microorganisms influence

the symptoms and signs with which the patient presents, how the pneumonia should be treated and the

prognosis.

Pneumonias can be classified into several ways. Pathologists originally classified them

according to the anatomic changes that were found in the lungs during autopsies. As more became

known about the microorganisms causing pneumonia, a microbiologic classification arose, and with

the advent of x-rays, radiological classification. Another important system of classification is the

combined clinical classification, which combines factors such as age, risk factors for certain

microorganism, the presence of underlying lung disease and underlying systemic disease, and whether

the person has recently been hospitalized.

Community-acquired pneumonia develops in people with limited or no contact with medical

institutions or settings. CAP tends to be caused by different microorganisms than those infections

acquired in the hospitals. The characteristics of the individual are important in determining which

etiologic microorganism is likely. For example, immunocompromised persons tend to be susceptible

to opportunistic infections that are uncommon in normal adults. In general, nosocomial infections and

those affecting immunocompromised individuals have higher mortality rate community-acquired

pneumonias.

The most common community-acquired pneumonia is caused by Streptococcus pneumoniae,

which has a relatively low mortality rate, although it is higher in the elderly. Mycoplasma pneumoniae

is a common cause of pneumonia in young people especially those living in group housing such as

This study source was downloaded by 100000881516420 from CourseHero.com on 03-02-2024 07:47:31 GMT -06:00

https://www.coursehero.com/file/117182036/CASE-STUDYdocx/
 dormitories and army barracks. Influenza is the most common viral community-acquired pneumonia

in adults. Legionella species, which also cause CAP, can contaminate cooling systems and water

supplies leading to outbreaks of disease. Signs and symptoms of CAP are fever, cough, dyspnea,

tachypnea and tachycardia. Diagnosis is based on clinical presentation and chest x-ray. Treatment is

with empirically chosen antibiotics. Prognosis is excellent for relatively young and healthy patients,

but many pneumonias, especially when caused by Streptococcus pneumoniae and influenza virus, are

fatal in older, sicker patients.

According to the World Health Report by the World Health Organization, lower respiratory

infections, which include community-acquired pneumonia, ranks ninth among the leading causes of

mortality on individuals aging 15 to 59 worldwide and ranks fourth on individuals aging 60 and over,

and that it is the leading killer of children worldwide.

CAP is one of the most common entities seen in Filipino adults. It is the most common

infectious disease prompting hospitalization and the first and fifth leading cause of morbidity and

mortality in the Philippines, respectively.

This study aims to provide the group a clear view of the pertinent facts surrounding

community-acquired pneumonia, which will lead them to become effective and efficient in the

nursing field.

This case is about patient A.R., 35-year-old female with the diagnosis of Community
Acquired Pneumonia. The patient was encountered with such condition on the 18 th of January of year
2020, and was admitted last January 22, 2020 at St. James Hospital, with a chief complaint of
difficulty in breathing and chest pain. This study was chosen to help us know the disease process of
Community acquired pneumonia, to orient ourselves for correct nursing interventions that could
render to the patient. This approach allows us to exercise our duties as a student nurse which is to
render care. We humbly present ourselves to present this case study and submit ourselves for further
corrections to broaden the scope of our knowledge and understanding.

This study source was downloaded by 100000881516420 from CourseHero.com on 03-02-2024 07:47:31 GMT -06:00

https://www.coursehero.com/file/117182036/CASE-STUDYdocx/
 PURPOSE AND OBJECTIVES

PURPOSE

At the end of the case presentation, the student will be able to expand not only the knowledge in the
disease process and clinical manifestations but also on how to provide essential intervention indicated
to the patient. By this, the student will be able to improve their knowledge, skills, and attitude in
giving appropriate nursing care for the patient.

OBJECTIVES

 To organize patient’s data for the establishment of good background information

 To analyze the family health history as well as the history of past and present illness for the

knowledge of what could be the predisposing factors that might contribute to the patient’s

illness

 To differentiate the definitions of the patient’s complete diagnosis for better understanding

 To describe the current condition of our patient through the PEARSON assessment

 To explain the anatomy and physiology of different organs involved

 To list several factors, signs and symptoms of cholelithiasis that are present or absent in the

patient

 To compose a flow chart showing the pathophysiology of CAP for a clear visualization of

how it affects a person

 To interpret the different results of the patient’s diagnostic exams together with comparisons

of normal values for the understanding of what changes during the disease

 To classify the different drugs used by the patient so that we can identify its functions and

purposes

 To create Nursing Care Plans applicable to the patient for the promotion of his well-being.

 To construct a discharge plan following the METHOD format

This study source was downloaded by 100000881516420 from CourseHero.com on 03-02-2024 07:47:31 GMT -06:00

https://www.coursehero.com/file/117182036/CASE-STUDYdocx/
 CHAPTER II

PATIENT’S PROFILE

Patient's code name: Mrs. A.G

Age: 35 years old

Sex: Female

Date of Birth: March 3, 1985

Occupation: Housewife

Educational Attainment: College Graduate

Civil Status: Married (living separately)

Nationality: Filipino

Address: Tamag, Vigan City, Ilocos Sur

Religion: Roman Catholic

Chief Complaint: Difficulty in breathing and chest pain

Date of Admission: January 22, 2020

Time: 2:00 pm

Admitting Diagnosis: Community-Acquired Pneumonia

Attending Physician: Dr. B

This study source was downloaded by 100000881516420 from CourseHero.com on 03-02-2024 07:47:31 GMT -06:00

https://www.coursehero.com/file/117182036/CASE-STUDYdocx/
 CHAPTER III

HISTORY OF PAST AND PRESENT ILLNESS

BIOGRAPHIC DATA:

This is the case of Mrs. A, a 35-year-old female, married and a resident of Tamag, Vigan City, Ilocos
Sur. She lives separately with her husband and was living alone. She was born on March 3, 1985 in
ISPH-GS, via normal delivery.

CHIEF COMPLAINTS:

Difficulty in breathing and chest pain.

HISTORY OF PAST ILLNESS:

Mrs. A rarely consults a physician in the past. She only visits clinics or hospitals whenever his

condition gets worse. She had been admitted before only once in ISPH-GS around 1990’s with a chief

complain of epistaxis. She stayed at the hospital for a day and a night. Also, in 2000’s, she had a

check-up at another hospital in Vigan City and was ordered to undergo chest x-ray and it was found

out that she had an accumulation of fluid in the lungs or pleural effusion. According to Mrs. A,

aspiration of the fluid was done after being diagnosed of such condition. Specific medications taken

cannot be recalled by Mrs. A but prescribed medications were taken for three months until the

condition was resolved. On mild fever and coughs, she usually does self-medication by taking

Medicol and Paracetamol. In some cases, she uses herbal plants like guava and oregano to relieve her

cough which are cheaper and always available. She has no history of diabetes mellitus, cancer or

hypertension and had not undergone any surgical procedures in thepast.

HISTORY OF PRESENT ILLNESS:

On January 22, 2020, the 35-year-old female patient, Mrs. A.G. was rushed in the emergency room
with a chief complaint of difficulty in breathing and chest pain. She has a history of coughing and
wheezing for the past three nights. It started with a dry cough, however, over the past couple of days,
patient expectorated some clear, and more recently, thicker rust-colored, mucous. Her vital signs show
a temperature of 36.7 degrees Celsius, PR: 88, RR: 26, BP: 160/100, SpO2: 94% on room air. Patient

This study source was downloaded by 100000881516420 from CourseHero.com on 03-02-2024 07:47:31 GMT -06:00

https://www.coursehero.com/file/117182036/CASE-STUDYdocx/
 was admitted and undergone ECG upon the arrival in the Hospital. Her admitting diagnosis is
Community Acquired Pneumonia.

This study source was downloaded by 100000881516420 from CourseHero.com on 03-02-2024 07:47:31 GMT -06:00

https://www.coursehero.com/file/117182036/CASE-STUDYdocx/
Powered by TCPDF (www.tcpdf.org)