Cap Grand Case Pre

PNEUMONIA
LUNGS
A Grand Case Presentation on Community Acquired Pneumonia
GENERAL
OBJECTIVES
After 2 hours of case presentation, the
student nurses will be able to gain
knowledge and understanding skills, and
attitude on how to handle clients with
pneumonia.
PNEUMONIA LUNGS | A Grand Case Presentation on Community Acquired Pneumonia | PHINMA UNIVERSITY OF ILOILO | DEPARTMENT OF NURSING
SPECIFIC OBJECTIVES
After 2 hours of case presentation, the student nurses must:
Knowledge:
• Achieve a complete understanding about pneumonia and it's real life
contexts
• Identify the causes and the signs and symptoms of pneumonia based
on the client's experiences.
• Understand how pneumonia started, its pathophysiology, and the
appropriate nursing care plan and treatment of the client's disease.
Skills:
• Know how to deal with clients with pneumonia.
• Formulates specific interventions for client's holistic recovery.
• Be equipped in implementing interventions for clients with
pneumonia.
Attitude:
• Actively listens during the case presentation.
• Follow the flow of instructions of the presentation.
• Participate in the entire activity.
PATIENT’S PERSONAL HISTORY
This presentation is about the case of Mrs. P.L.S., born on
April 15, 1936. She is 86 years old, female, married and
residing in Brgy. Taft North, Mandurriao, Iloilo City. She is a
mother of three. Two have jobs and the other one who is the
oldest of the three takes care of her. Due to environmental
exposure of her children on the outside or in their workplace,
Mrs. P.L.S. got sick and consulted to a doctor which was
suspected as COVID19.
HISTORY OF PRESENT ILLNESS
Three weeks prior patient experienced fever associated
with cough, sought consult with attending physician and
was managed as pneumonia and was prescribed
cefuroxime with relief. One week prior recurrence of
cough seek consult with attending physician and was
prescribed drug for cough. On the day of admission,
persistence of cough associated with loss of appetite
thus brought for admission.
PAST HEALTH PROBLEMS/STATUS
The patient has complete immunization.

She has a history of chickenpox however,
she has no known allergies. She has no
history of any accidents or falls. She had
a hospitalization before due to
hypertension.
FAMILY HISTORY OF ILLNESS
HYPERTENSION
CLINICAL INSPECTION
Date taken: February 27, 2023
Vital Signs:
T= 36.0 °C
PR = 114 bpm
O2 Sat = 93%
BP = 120/70 mmHg
RR = 10 bpm
Height: 152 cm.
Weight: 50 kg.
PHYSICAL ASSESSMENT
General Appearance:
Upon endorsement, an 86 year old female, married, lying in bed with
IVF D5 0.3 NaCl 500 ml x 30 cc/hr, with Foley Catheter, with oriented
verbal response, awake, and oriented to date, place, and person, well
kempt and light brown in skin color with vital signs taken as follows:
BP: 130/80, Temp: 36, RR: 14 bpm, PR: 78 bpm, and O2 Sat: 95%.
INTEGUMENTARY SYSTEM
Appearance:
Wrinkled skin due to aging,
and light brown in color.
Skin:
Cool and moist to touch.
Wound dressing:
None
Pressure ulcers:
None
NEURO-SENSORY SYSTEM
ASSESSMENT OF THE HEAD
• Symmetrically round
• No presence of rash and lesions
• No tenderness upon palpation
• Healthy scalp condition
• Hair is black and a little gray and blonde in color, not evenly
distributed
ASSESSMENT OF THE EYE
• Pupil equal, round, reactive to light and
accommodation
• Pupil size before light: 6mm
• Pupil size after light: 5mm
• Black in color
ASSESSMENT OF THE EARS
• Symmetrical in size and shape
• No presence of discharges
• Responsive to voice
• Unaided hearing
ASSESSMENT OF THE NOSE
• Same skin complexion with the face
• No presence of discharges
• No history of nasal flaring and swelling
• Symmetrical in shape
• With nasogastric tube intact
ASSESSMENT OF THE MOUTH
• Lips is moist and smooth
• Gums has no presence of redness, swelling, and lesions
• No teeth
• No dentures
• Response to gag reflex
ASSESSMENT OF THE NECK
Carotid Pulses: Left carotid artery has more thrill
and bruit than right.
RESPIRATORY SYSTEM
• Rhonchi sound heard upon auscultation on both lungs
• Uses accessory muscles when breathing
CARDIOVASCULAR SYSTEM/CIRCULATORY SYSTEM
• Skin/Mucous membrane: Pale
• Carotid Pulses: Left carotid artery has more thrill
and bruit than right.
• Capillary Refill: Normal less than 2 seconds
• Jugular neck veins: Not visible
• Edema: Absent
• Normal Lub-Dub Sound
GASTROINTESTINAL/
HEPATOBILIARY SYSTEM
ASSESSMENT OF THE ABDOMEN
• Flat and firm

• Non tender
• Auscultated, percussed and palpated in all quadrants
indicating normoactive bowel sounds
• Patent NGT
GENITO-URINARY SYSTEM
Patient has Foley catheter inserted, pale straw in
color, bladder trained 4 hours open, 4 hours close
REPRODUCTIVE SYSTEM
She complains of pain at the catheter site.
ENDOCRINE SYSTEM
Changes in weight and energy levels
decreased. She is sensitive to cold.
Mobility assisted with her
daughter. Capillary refill less
than 3 seconds. Upper and
lower extremities are light
MUSCULOSKE brown in color. Palpable
LETAL pulses when checked
SYSTEM simultaneously (brachial,
radial, dorsalis pedis,
popliteal)
LYMPHATIC SYSTEM
No tenderness and swelling upon palpation.
HEMATOPOEITIC SYSTEM
Elevated
white blood cells due to
pulmonary infection.
PSYCHOSOCIAL NURSING
ASSESSMENT
LIFESTYLE INFORMATION
Due to increasing age, she roams around
their backyard assisted with her daughter.
Then, in the afternoon, she do rosary and
prayer. On the evening, she prepares herself
going to bed to sleep and the cycle repeats.
ASSESSMENT
NORMAL COPING PATTERNS
Inability to walk independently. Shall be
assisted with folks. Mild wheelchair
exercises to prevent immobility.
ASSESSMENT
UNDERSTANDING OF PRESENT ILLNESS
The patient understands that her condition and
age will limit her to perform activities of daily living
(ADLs) such as going to the bathroom
independently, doing household chores etc.
ASSESSMENT
PERSONALITY STYLE
Her approach to student nurses depends on her
mood or feeling of discomfort. Participative in
collaborative activity such as vital signs taking and
pain verbalization.
ASSESSMENT
HISTORY OF PSYCHIATRIC DISORDER
No known psychiatric disorder. Attentive and

oriented to all aspects.
ASSESSMENT
RECENT LIFE CHANGES OR STRESSORS
Emotional stressors due to hospitalization.
ASSESSMENT
MAJOR ISSUES RAISED BY CURRENT ILLNESS
Prohibits her to do household chores.
CLINICAL HEMATOLOGY
DATE GATHERED: 04 MARCH 2023
Examination Result Unit Normal Values Significance

Hematocrit 0.35 0.38-0.47 Low
Red Blood Cells 3.95 10^12/L 4.00-5.50 Low
White Blood Cells 11.70 10^9/L 5.00-10.00 High
Segmenter 0.85 0.50-0.70 High
Lymphocyte 0.09 0.20-0.40 Low
URINALYSIS
Physical Property
Color Pale Straw
Transparency Slightly Hazy
Reaction(pH) Acidic
Specific Gravity 1.025
CHEST AP
• GASTRIC TUBE IS SEEN COURSIN OVER THE THORAX TO THE LEFT
UPPER HEMIABDOMEN WITH ITS TIP CUT OFF FROM VIEW
• IMPRESSION:
• -BILATERAL PNEUMONIA AND PLEURAL EFFUSSION, RELATIVELY
UNCHANGED.
• -PULMONARY CONGESTION
• -CARDIOMEGALY
• -ATHEROSCLEROTIC AORTA
• -THORACIC SPONDYLOSIS
OTHER LABORATORY RESULT
Examination Result Unit Normal Values Significance
Potassium 2.55 mmol/L 3.50-5.30 Low
pO2 185 mmHg 83-108 High
tCO2 30 mmol/L 19-24 High
HCO3 28.5 mmol/L 22-26 High
TEXTBOOK DISCUSSION
Definition
Community-Acquired Pneumonia, CAP, a common infectious disease,
occurs either in the community setting or within the first 48 hours after
hospitalization or institutionalization. The need for hospitalization for CAP
depends on the severity of the pneumonia.
Pneumonia can be classified into four types: community. acquired

pneumonia (CAP), health care- associated pneumonia (HCAP), hospital-
acquired pneumonia (HAP), and VAP. Pneumonia in older adult patients
may occur as a primary diagnosis or as a complication of a chronic disease.
Pulmonary infections in older adults frequently are difficult to treat and
result in a higher mortality rate than in younger people.
TEXT BOOK DISCUSSION
SIGNS AND SYMPTOMS
Textbook Manifested by the Patient
Cough +
Fever +
Chest Pain +
Sputum production +
Tachycardia +
Tachypnea +
Anorexia +
Weakness +
PATHOPHYSIOLOGY
PREDISPOSING FACTOR:
86 Y.O.
PRECIPITATING FACTOR:
ENVIRONMENTAL FACTOR
Pathogen enters the
respiratory tract through
inspiration/aspiration
Microbes propel into the

alveolar system
Adhere to alveolar
macrophages of cell wall
exposure and proliferates
Systemic Local
Increased inflammatory inflammatory Increased
WBC response releases response by Goblet cells
cytokines alveolar
epithelial cells
release Dyspnea
chemokines Mucus cough &
Disrupts
Fever and crackles
hypothalamic
Chills thermoregulation
Increase capillary Pleural
Airway
microvascular Effusion
occlusion
permeability
and
obstruction
Accumulation of neutrophils and plasma exudate Impaired O2 and CO2 regulation
Fluid-filled alveolar sacs
PNEUMONIA
PATHOPHYSIOLOGY
MANAGEMENT
NURSING MANAGEMENT
• To maintain nutrition:
• Fluids with electrolytes.
• To improve airway patency:
• Coughing exercises.
• Administer oxygen as prescribed.
• Monitor respiratory status.
• Position client in semi-Fowler position to facilitate breathing and lung expansion.
• Change client’s position frequently.
• Monitor pulse oximetry.
• Monitor and record color, consistency, and amount of sputum.
• Provide a balance of rest and activity, increasing activity gradually.
MANAGEMENT
MEDICAL MANAGEMENT
• The management of pneumonia centers is a step-by-step process that zeroes on the
treatment of the infection through identification of the causative agent.
• Administration of Methylprednisolone. management and treatment of asthma exacerbations
and as an anti-inflammatory and immunosuppressive agent.
• Administration of Ipratropium and Salbutamol Ipratropium and salbutamol belong to a group
of medicines known as bronchodilators or relievers (it is called a reliever medicine because it
quickly relieves your breathing problems).
• Administration of Piperacillin and tazobactam used to treat pneumonia and skin,
gynecological, and abdominal (stomach area) infections caused by bacteria. Piperacillin is in a
class of medications called penicillin antibiotics. It works by killing bacteria that cause
infection.
• Oxygen administration. Oxygen can be given if hypoxemia develops.
DRUG STUDY
NURSING CARE PLAN

Cap Grand Case Pre

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Cap Grand Case Pre

Uploaded by

Copyright:

Available Formats

PNEUMONIA

After 2 hours of case presentation, the student nurses must:

The patient has complete immunization.

FAMILY HISTORY OF ILLNESS

• Flat and firm

She complains of pain at the catheter site.

HISTORY OF PSYCHIATRIC DISORDER

No known psychiatric disorder. Attentive and

Emotional stressors due to hospitalization.

Prohibits her to do household chores.

Examination Result Unit Normal Values Significance

Color Pale Straw

Transparency Slightly Hazy

Specific Gravity 1.025

Potassium 2.55 mmol/L 3.50-5.30 Low

pO2 185 mmHg 83-108 High

tCO2 30 mmol/L 19-24 High

HCO3 28.5 mmol/L 22-26 High

Pneumonia can be classified into four types: community. acquired

Textbook Manifested by the Patient

Microbes propel into the

Fluid-filled alveolar sacs

You might also like