CASE PRESENTATION:

PNUEMONIA
PRIMARY SURVEY (ABCDE APPROACH)

 Airway
 Airway obstruction
 Productive Cough with sputum (brown, blood stained)
 Breathing
 Rapid, shallow breathing
 Shortness of breath
 Dyspnea
 Respiratory rate of 22 bpm
 Nasal flaring
 Crackles, pleural friction rub
PRIMARY SURVEY (ABCDE APPROACH)

 Circulation
 Tachycardia (120 bpm)
 Pallor, flushed appearance, central cyanosis
 Blood pressure (130/90 mmHg)
 Disability
 LOC - Alert, voice responsive
 Lethargic
 Confusion
 Exposure
 Fever (38.9 C)
 Diaphoresis
SECONDARY SURVEY (AMPLE
APPROACH)

 Allergies
 Food allergies to chicken, seafood. Medication allergies: aspirin
 Medication
 Amoxicillin
 Penicillin
 Last Meal
 Rice and igado
 Soft drinks, san mig
 Event History
 Patient was at birthday party of his wife suddenly was feeling sharp stabbing pain at
chest, coughed blood, shortness of breath.
INTERVENTION: PRIMARY + DRUGS

1. Assess level of consciousness

2. Assess for airway obstruction, aspiration pneumonia
3. Place client on bed, semi fowlers
4. Assess the rate, rhythm, and depth of respiration, chest movement, and
use of accessory muscles.
5. Auscultate lung fields, noting areas of decreased or absent airflow and
adventitious breath sounds: crackles, wheezes.
6. Assess for oxygen saturation
7. Administer oxygen as prescribed
INTERVENTION: PRIMARY + DRUGS

1. Assess blood pressure, heartrate, capillary refill

2. Assess cough effectiveness and productivity
3. Observe the sputum color, viscosity, and odor. Report changes.
4. Suction if indicated.
5. Assess the patient’s hydration status.
INTERVENTION: SECONDARY + DRUGS

1. Elevate the head of the bed and change position frequently.

2. 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 the patient to do so often.
3. Suction as indicated: frequent coughing, adventitious breath sounds,
desaturation related to airway secretions.
4. Maintain adequate hydration by forcing fluids to at least 3000 mL/day
unless contraindicated. Offer warm, rather than cold, fluids.
5. Assist and monitor effects of nebulizer treatment and other respiratory
physiotherapy: incentive spirometer, IPPB, percussion, postural drainage.
Perform treatments between meals and limit fluids when appropriate.
INTERVENTION: SECONDARY + DRUGS

1.Encourage ambulation.
2.Use humidified oxygen or humidifier at the bedside.
3.Monitor serial chest x-rays, ABGs, and pulse oximetry readings
4.Assist with bronchoscopy and thoracentesis, if indicated.
5.Anticipate the need for supplemental oxygen or intubation if the
patient’s condition deteriorates.
6.Administer medications as prescribed
FDAR
NURSING CARE PLAN
TRIAGE
 LEVEL 2
Level 2 (emergent) requires an immediate nursing assessment and rapid treatment.
E - CART
 AED defibrillator
 Ambu bag with CPR mask
 Anaphylaxis kit (Epinephrine)
 Blood pressure cuff, stethoscope
 Thermometer, pulse oximeter
 CPR mask and non-rebreather oxygen face masks
 Disposal isolation equipment (PPEs): gown, mask, goggles, face shield
 Dressing supplies: medical tape, scissors, alcohol pads, gauze
 Exam gloves
 Hand sanitizer gel
 IV kits with angiocaths
 Nasal cannulas
 Oxygen mask
 Oxygen tank (FULL, in proper holding container), regulator, key
 Biohazard bags
 Small pad of paper and pen (for notes at the scene)/code blue sheet note
 Sterile gloves with sterile gauge
 Sterile water or normal saline (1000ml bags), sterile syringe, sterile needles
 Suction machine, suction catheter
 IV tubing
 Tourniquets
PATHOPHYSIOLOGY