You are on page 1of 21

Republic of the Philippines ARELLANO UNIVERSITY College of Nursing Legarda Campus S.Y.



LAS PIAS GENERAL HOSPITAL Medical Ward February 2,3,9,10 Thursday Friday (2:00 pm- 10:00 pm) Submitted to: Mr. Jon Jon Martinez R.N.,M.A.N Clinical Instructor Submitted by: Lopez, Irish Michelle B BSN 3-1 / Group 3

I. INTRODUCTION Pneumonia is an inflammation of the lungs caused by an infection. It is also called Pneumonitis or Bronchopneumonia. Pneumonia can be a serious threat to our health. Although pneumonia is a special concern for older adults and those with chronic illnesses, it can also strike young, healthy people as well. It is a common illness that affects thousands of people each year in the Philippines, thus, it remains an important cause of morbidity and mortality in the country. There are many kinds of pneumonia that range in seriousness from mild to lifethreatening. In infectious pneumonia, bacteria, viruses, fungi or other organisms attack your lungs, leading to inflammation that makes it hard to breathe. Pneumonia can affect one or both lungs. In the young and healthy, early treatment with antibiotics can cure bacterial pneumonia. The drugs used to fight pneumonia are determined by the germ causing the pneumonia and the judgment of the doctor. Its best to do everything we can to prevent pneumonia, but if one do get sick, recognizing and treating the disease early offers the best chance for a full recovery. A case with a diagnosis of Pneumonia may catch ones attention, though the disease is just like an ordinary cough and fever, it can lead to death especially when no intervention or care is done. Since the case is 51 years of age an appropriate care has to be done to make the patients recovery faster. Treating patients with pneumonia is necessary to prevent its spread to others and make them as another victim of this illness.

II. GENERAL OBJECTIVES . To be able to come up with an understanding of the disease process and formulate a comprehensive nursing care plan using the specific objectives nursing process.

SPECIFIC OBJECTIVES 1. To review the anatomy and physiology of the disease. 2. To understand the pathophysiology of it. 3. To know the medical treatment such as the medications and laboratory works involved. 4. To know the importance of laboratory and diagnostic procedures. 5. To know the nursing management for the disease. 6. To practice nursing assessment during data gathering. 7. To prioritize identified health problems of the patient.

8. To formulate nursing process as a framework in making the nursing care plan. 9. To be able to acquire adequate knowledge on health education needed by the patient and relatives for the continuous care at home.

Reason: I am are presenting a case of Pneumonia to review the anatomy and physiology, the pathophysiology, and to know the medical treatment and nursing management of the disease.

III. THEORETICAL FRAMEWORK She stated in her nursing notes that nursing "is an act of utilizing the environment of the patient to assist him in his recovery" that it involves the nurse's initiative to configure environmental settings appropriate for the gradual restoration of the patient's health, and that external factors associated with the patient's surroundings affect life or biologic and physiologic processes, and his development. With regard to a nurses responsibilities of patient care, Nightingale defined a set of external factors in the patients environment that must be controlled:

Pure or fresh air Pure water Sufficient food supplies Efficient drainage Cleanliness Light (especially direct sunlight

The omission of any of these factors can retard, if not impede, the recovery process.Any deficiency in one or more of these factors could lead to impaired functioning of life processes or diminished health status. In addition to her theory she also emphasized the need for a calm, noisefree and warm environment for patients. She put forth that nurses should not only record the times of meals but also assess the effects of the diet on the patient.

IV. NURSING HISTORY A. General Data Name : Address : Age : Sex : Date of Birth: Nationality: Religion: Civil Status: Educational Attainment : Attending Physician: Source of emergency Contact Person Admission data: Date of Admission: Hospital: Chief Complaint: January 30, 2012 Las Pias General Hospital 1 day PTA pt. Complaint of right sided chest pain and dyspnea. Pneumonia t/c Effusion Mr. X 719 tramo st. Interior Mamuto 1 LPC 51 y/o Male March 3, 1961 Filipino Catholic Married High School Graduate Dr. Diosdado Agao Wife


B. History of Present Illness 2 weeks prior to confinement he has low grade fever and productive cough but he ignored it. He just take solmux for his cough. I day prior to admission the patient had a right sided chest pain and difficulty of breathing he brought him to the hospital with his wife and was admitted immediately.

C. Past Health History: No hospitalization / medical history No opearations / surginal history No accidents or injuries No allergies D. Social History: The patient does smoke, he smoked 1 pack per day. He lives with his wife and his only child daughter. He has no job he stayed at home all the time and watch television.

V. ANATOMY AND 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. Air that is breathed in is filled with oxygen and goes to the trachea, which branches off into one of two bronchi. Each bronchus enters a lung. There are two lungs, one on each side of the breastbone and protected by the ribs. Each lung is made up of lobes, or sections. There are three lobes in the right lung and two lobes in the left one. The lungs are cone shaped and made of elastic, spongy tissue. Within the lungs, the bronchi branch out into minute pathways that go through the lung tissue. The pathways are called bronchioles, and they end at microscopic air sacs called alveoli. The alveoli are surrounded by capillaries and provide oxygen for the blood in these vessels. The oxygenated blood is then pumped by the heart throughout the body. The alveoli also take in carbon dioxide, which is then exhaled from the body. Inhaling is due to contractions of the diaphragm and of muscles between the ribs. Exhaling results from relaxation of those muscles. Each lung is surrounded by a twolayered membrane, or the pleura, that under normal circumstances has a very, very small amount of fluid between the layers. The fluid allows the membranes to easily slide over each other during breathing.



Staphylococcus pneumoniae

Hygiene Environmental factor smoking

Organisms enter the respiratory tract through in inspiration and aspiration

Activation of defense mechanisn

Loss of effectiveness of defense mechanism

Penetrate the sterile lower respiratory tract (lungs)

Multiplies in alveoli

Release damaging toxins

Clinical Manifestations:
Difficulty of breating Chest pain Productive cough Fever


Activity of Daily Living 1. Nutrition

Before Hospitalization

During Hospitalization

Interpretation and Analysis The average adult drinks about 1500 ml per day with moderate activity and temperature, but needs 2500 ml. per day, an additional 1000 ml. (Fundamentals of Nursing, Kozier, pp. 1067-1068) An insufficient fluid intake reduces the amount of fluid in the chime, which enters the large intestine which in turn results in drier, harder feces. ( Fundamentals of Nursing, Kozier, pg. 1185)

Has a very good asks his wife to appetite; eats 2-3 buy him some cups of rice per food from outside meal the hospital Eats 3x/day and drinks sometimes even approximately eats biscuits for 500cc of snacks water/day Very fond of eating vegetables And as an alternative, they are fond of eating canned goods specially sardines if they dont have money drinks approximately 6 cups of water, 23 cups of sodas

2. Elimination

urinates without difficulty and experiences no pain when voiding urine is light amber in color, is aromatic, and adequate in amount voids 5-6x/day defecates once

urinates more frequently

Defecation, normal stool is semisolid in consistency. The amount and character of the stool is determined by the amount and kind of food ingested. (Fundamentals of

every morning without pain and difficulty stool is light brown to brown in color, semisolid in consistency, soft and tubular

Nursing, Phoebe Williams and Luz Tungpalan, pg. 321 Urination, Freshly voided urine is generally clear in appearance and pale to deep yellow. When formed, urine is sterile and aromatic. Urinating should not be painful and difficult.(Essentials of Human Anatomy and Physiology, Elaine Marieb, pg. 487-488) lying on bed most of the time cant perform ROM exercises because he experiences difficulty of breating Unable to perform ADL For exercise to be effective, it should be regular and sustained. Generally, exercising at least thrice a week is advised. (Fundamentals of Nursing, Kozier, pg. 104)

3. Exercise

sits on the chair most of the time while watching TV doesnt have time to exercise and considered walking around the village as an exercise

4. Hygiene

bathes once everyday, shampoos hair and cleanses body with soap and towel brushes teeth 2x a day gets fingernails cleaned and trimmed

never taken a full bath since he was hospitalized daily regimen includes using towel with soap to wipe clean the body parts hair hasnt been washed since first day of

Bathing provides relaxation and comfort and it gives moat people a sense of well-being. Healthy feet are crucial in helping people stand and walk. Nails should

changes clothes everyday combs hair everyday

hospitalization nails are not cut but clean

be trimmed as needed. Proper oral hygiene includes daily brushing, flossing, and rinsing of teeth and care of dentures. Regular check-ups ensure the health of the teeth and gums. Normal grooming patterns includes daily brushing and combing of hairs. Nicotine causes many harmful physiologic effects and is a precursor of lung cancer and coronary artery diseases. Nicotine has a stimulating effect on the body and smokers often have more difficulty falling asleep than non smokers. Smokers are usually easily aroused and often describe themselves as light sleepers. The sleep wake cycle is very important to adults. The usually have an active lifestyle, and are thought to require 7 to 8 hours of sleep each night

5. Substance Use

He smoke 1 does not pack of smoke cigarettes cigarettes per since he was day hospitalized does drink does not drink alcoholic alcoholic beverages beverages sometimes does not use any does not use any forms of forms of recreational recreational drugs drugs

6. Sleep and Rest

usually sleeps at around 8 or 9 pm and wakes up at 7 to 7:30 am describes sleep as complete and stated feeling

the patient cant sleep easily due to difficulty of breathing wakes up for vital signs describes sleep as incomplete

7. Sexual Activity

relaxed after and feels tired waking up even after sleeps soundly waking up and describes Sleeps lightly sleep as deep and is easily wakes up in the awaken by middle of the disturbances in night to urinate the environment but can easily go back to sleep again does not nap during the afternoons or any time of the day besides night time inactive sex life inactive sex life primary form of primary form of affection is kiss affection is kiss on the forehead on the forehead

by may do well on less. This is a normal sleep pattern in the hospital ward, however, this resulted due to acute pain due to UTI.

At any time in life, physical, psychological and social problems may a profound effect on a persons expression of sexuality. This should be taken into account when it involves a persons health or the delivery of care. People who do not have active sex life still express sexuality in their clothes, grooming, activities and roles.

VIII. PHYSICAL ASSESSMENT Vital Signs: Tempereature: Pulse Rate Respiratory Rate: Blood Pressure: General Appearance

36.7c 89 bpm 25 cpm 120/80 mmHg Norms Actual Findings Interpretation and Analysis

1. Posture / Gait Erect posture, coordinated, smooth and steady gait 2. Skin Color Varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive A healthy adult should be well groomed. The hair is combed while the nails are trimmed. Light brown and even with freckles Normal

3. Personal Hygiene / Grooming

The client is well groomed and doesnt looks dirty. There is no presence of dirt at the tip of her nails, uncombed hair.

Deviation from normal, he has uncut nails because of hospitalization and he cant perform normal activities of daily living.

4. Verbal Behavior Speech should be clear, well paced and coherent. Language should seem appropriate for educational level. Facial expression and body movement should be appropriate with the mood and the answers to the questions

He speaks clearly and able to express her thought.


5. Non-Verbal Behavior

His facial expression is appropriate to the situation.


Body Parts


Actual Findings

Interpretation and Analysis

Scalp >> Color, appearance >> Lighter than the color of the face; negative to masses, lumps, lice and dandruff, nits and other depressions >> Negative for area of tenderness >> Lighter than the color of the face; >>presence of dandruff Normal Deviation from normal due to hospitalization

>> Areas of tenderness *Hair >> Color >>Evenness of growth over the scalp >>Thickness or thinness >>Texture and oiliness >>Presence of infections or infestations

>> no tenderness


>> Black >>Evenly distribution of hair

>> white and gray hair >>Hair is not evenly distributed

Normal for his age Deviation from normal due to aging Normal due to aging

>>Thick hair >>Thin hair >>Silky, resilient hair >>No infection or infestation >> Silky, resilient hair >>No infection or infestation

Normal Normal

*Nails >>Curvature and angle of the fingernail plate >>Fingernail and toenail texture >>Fingernail and toenail bed color >>Convex curvature; angle of nail plate about 160 degrees >>Smooth texture >>round nails, about 160 degree nail base >>thick, hard and smooth nails Normal >>Highly vascular and pink in lightskinned clients; darkskinned clients may have brown or black pigmentation in longitudinal streaks >>Intact epidermis >> pink nail bed Normal



>>Tissues surrounding the nails >>Blanch test

>>Intact; no hangnails


>>Prompt return of pink or usual color (generally less than four seconds)

>>Nail beds return to pink after 3 seconds.

*Skull and Face >>Skull: size, shape, and symmetry

>>Rounded (normocephalic and symmetrical, with frontal, parietal, and occipital prominences); smooth skull contour >>Smooth uniform consistency; absence of nodules or masses >>Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds

>>Rounded shape, symmetrical


>>Skull: nodules or masses and depressions >>Facial features

>>Absence of nodules or masses


>> asymmetrical facial features

Deviation from normal due to aging

>>Eyes: edema and hollowness

>> head in central position


>>Symmetry of facial movements (facial nerve)

>>Deviation: periorbital edema; sunken eyes >>Symmetric facial movements

>>Eyes are hollow, no edema


*Eye structures and visual acuity >>Eyebrows >>Hair evenly distributed; skin intact >>Eyebrows symmetrically aligned; equal movement >>Equally distributed; curled slightly outward >>Skin intact; no discharge; no discoloration >>Lids close symmetrically >>Evenly distributed, symmetrical movement and alignment Normal

Normal >>Eyelashes >>Distributed evenly; shot lashes, curled outward >>Symmetrically closed, no discharge and discoloration Normal >> Blinking >>Approximately 15 to 20 involuntary blinks per minute; bilateral blinking >>When lids open, no visible sclera above corneas, and upper and lower borders of cornea are slightly covered >> Bilateral blinking, involuntary, at approximately 15 blinks/min



>> both eyes blink at the same time


>>Bulbar conjunctiva

>> Transparent Deviation from normal due to poor peripheral circulation and lack of sleep Normal

>>Palpebral conjunctiva

>> Pale conjunctiva

>>Lacrimal gland

>>Lacrimal sac and nasolacrimal duct >>Cornea

>>Transparent; capillaries sometimes evident >>Shiny, smooth, and pink or red

>> No edema or tenderness >> No edema



>> Iris are visible, transparent shiny >>Pupil: color, shape, symmetry of size, direct and consensual >>No edema or reaction to light tearing and accommodation >>Transparent, shiny, and smooth; details of the iris are visible >>Black in color; equal in size; normally 3-7 mm in diameter; round, smooth border, iris flat and round >>Illuminated pupil constricts (direct response) >>Nonilluminated pupil constricts (consensual response >>Pupil constrict when looking at near vision; pupils dilate when looking at far object; pupils converge when near object is moved toward the nose >>Eyes are coordinated, move in unison, with parallel alignment >>No edema or tenderness over lacrimal gland


>> Black in color, equal in size >> The pupil constricted when illuminated >> Pupil constricted when looking at near objects and pupils dilate when looking at far object

>>Extraocular Muscles (Oculomotor, Abducens, Trochlear Nerves)

>> unable to read newsprint

Deviation from normal due to deterioration of the optic nerves as a result of aging

>>Visual acuity >>>Near vision

>>>Able to read newsprint

*Mouth and Oropharynx >>Lips: symmetry of contour, color, and texture

>>Inner lips and buccal mucosa

>>Uniform pink color (darker, e.g. bluish hue, in Mediterranean groups and darkskinned clients) >>Soft, moist, smooth texture >>Symmetry of contour Ability to purse lips

>>Symmetrical, dry, Normal no swelling or lesions

>> Dry oral mucosa

>>Teeth and gums

>>Uniform, pink color (freckled brown pigmentation in darkskinned clients) >>Moist, smooth, soft, glistening, and elastic texture (drier oral >> pink gums mucosa in elderly due to decreased salivation) >>32 adult teeth >>Smooth, white, shiny tooth enamel >>Pink gums (bluish or dark patches in dark-skinned clients) >>Moist, firm texture to gums >>No retraction of gums (pulling away from the teeth)

Deviation from Normal due to poor peripheral circulation

Deviation from normal due to aging

>>Surface of the tongue

>> pink color on tongue borders >>No lesions >> Raised Papillae


>>Pink color (some brown pigmentation

>>Tongue movement (hypoglossal nerve)

on tongue borders in dark-skinned clients); moist; slightly rough; thin whitish coating >>Smooth, lateral margins; no lesions >>Raised papillae (taste buds) >>Moves freely; no tenderness

>> Moves freely


>> Smooth tongue base


>>Base of the tongue, floor of the mouth, and frenulum

>>Smooth tongue base with prominent base >>Smooth with no palpable nodules >>Swallowing ability, tongue movement, taste (posterior tongue (Barbara Kozier, et al., Fundamentals of Nursing Seventh Edition, page 614) >> Able to identify taste (Weber Handbook of Health Assessment, p. 101)

*Musculoskeletal system >>Muscles for size

>>Equal on both sides of the body No fasciculation or tremors

>>equal on both sides


Normal >> no tremors

>>Muscles for fasciculation or tremors >>Muscle tonicity >>Muscle

>>Normally firm >>Equal strength on

>> not firm >> equal strength

Deviation due to aging Normal


each body side >>No deformities >> equal in strength, Normal

>>Skeleton for normal structure and deformities >>Joints

>>No tenderness or swelling Normal >>Varies to some degree in accordance with persons genetic makeup and degree of physical activity >>No tenderness or swelling >> no tenderness or swelling

>>Full range of motion

IX. LABORATORY DIAGNOSIS URINALYSIS Macroscopic Color Transparency Reaction Specific gravity Protein Microscopic Sugar Pus cells Rbc Bacteria Fine granular cast Dark yellow Turbid 6.0 1.030 3+ Negative 50-100/HPF 2-5/HPF Many 0-2/LPF Clinical Chemistry Examination FBS Uric acid Result 5.49 596 Reference 3.3-6.1 mmol/L 149-458 mmol/L Analysis Normal Increased uric acid levels may indicate gout or impaired kidney function. Elevated BUN levels occurs in renal disease, reduced renal blood flow (due to dehydration), urinary tract obstruction, Elevated levels generally indicate renal disease that has seriously damaged 50% or more of the nephrons. Elevated levels may also indicate gigantism and acromegaly.

Uric nitrogen


2.5-7.5 mmol/L



M 71 115 mmol/L F 53 106 mmol/L

Total cholesterol Triglyceride Electrolytes Potassium Sodium

4.63 1.75 4.12 144.4

Up to 5.2 mmol/L Up to 1.74 mmol/L 3.5 5.5 mmol/L 135 145 mmol/L

Normal Normal Normal normal

Hematology Examination Hemoglobin Hematocrit Platelet RBC WBC Result 15.9 g/dl 0.48 318 5.26 30.10 Reference M-13.5 17.0 F-12.0 16.0 M-0.40 0.54 F-0.36 0.47 150 450 M-4.7 6.1 F-4.2-5.4 5-10 Analysis Normal Normal Normal Normal High numbers of WBCs (leukocytosis) may indicate: Infectious diseases Inflammatory disease (such as rheumatoid arthritis or allergy) Leukemia Severe emotional or physical stress Neutrophils increase in response to bacteria infection or inflammatory disease Normal




Lymphocytes Monocytes

7 3

25-40 3-8


Take the entire course of any prescribed medications. After a patients temperature returns to normal, medication must be continued according to the doctors instructions, otherwise the pneumonia may recur. Relapses can be far more serious than the first attack. Get plenty of rest. Adequate rest is important to maintain progress toward full recovery and to avoid relapse. Drink lots of fluids, especially water. Liquids will keep patient from becoming dehydrated and help loosen mucus in the lungs. Keep all of follow-up appointments. Even though the patient feels better, his lungs may still be infected. Its important to have the doctor monitor his progress. Encourage patient to wash his hands. The hands come in daily contact with germs that can cause pneumonia. These germs enter ones body when he touch his eyes or rub his nose. Washing hands thoroughly and often can help reduce the risk. Tell wife to avoid exposing the patient to an environment with too much pollution (e.g. smoke). Smoking damages ones lungs natural defenses against respiratory infections. Give supportive treatment. Proper diet and oxygen to increase oxygen in the blood when needed. Protect others from infection. Try to stay away from anyone with a compromised immune system. When that isnt possible, a person can help protect others by wearing a face mask and always coughing into a tissue.