COMMUNITY ACQUIRED PNEUMONIA

I. INTRODUCTION Pneumonia is an inflammation of the lung parenchyma caused by various microorganisms, including bacteria, mycobacteria, chlamydiae, mycoplasma, fungi, parasites, and viruses. This is the most common cause of death here in the Philippines. Several systems are used to classify pneumonia. Classically, pneumonia has been categorized into one of four categories: bacterial or typical, atypical, anaerobic/cavitary, and opportunistic. A more widely used classification scheme categorizes the major pneumonias as community-acquired pneumonia (CAP), hospital-acquired (nosocomial) pneumonia (HAP), pneumonia in the immunocompromised host, and aspiration pneumonia. Community-acquired pneumonia (CAP) occurs either in the community setting or within the first 48 hours after hospitalization or institutionalization. The causative agents for CAP that requires hospitalization are most frequently S. pneumoniae, H/ influenza, Legionella, Pseudomonas aeruginosa, and other gram-negative rods. Community-acquired pneumonia has 6 types namely: streptococcal pneumonia (pneumococcal) and the organism that responsible is streptococcus pneumoniae, haemophilus influenzae and the organism responsible is haemphilus influenzae, legionnaires disease and the organism responsible is legionella pneumophila, mycoplasma pneumoniae the organism responsible is mycoplasma pneumoniae, viral pneumonia and the responsible organism are influenza viruses types A, B adenovirus, parainfluenza, cytomegalovirus, coronavirus and last type is chlamydial pneumonia and the organism responsible is Chlamydia pneumoniae. Being knowledgeable about factors and circumstances that commonly predispose people to pneumonia helps identify patients at high risk for disease. Increasing numbers of patients who have compromised defenses against infections are susceptible to pneumonia. Some types of pneumonia, such as those caused by viral infections, occur in previously healthy people, often after a viral illness. Pneumonia occurs in patients with certain underlying disorders such as heart failure, diabetes, alcoholism, COPD, and AIDS. Pneumonia varies in its signs and symptoms depending on the casual organism and the presence of underlying disease. The patient with streptococcal (pneumococcal) pneumonia usually has a sudden onset of chills, rapidly rising fever (38.5 to 40.5C, and pleuritic chest pain that is aggravated by deep breathing and coughing. The patient is severely ill, with marked tachypnea (25-45bpm), accompanied by other signs of respiratory distress, Signs and Symptoms of pneumonia may also depend on a patients condition. Such as the fallowing: People 65 years of age and older

Immunocompetent people who are at increased risk for illness and death associated with pneumococcal disease because of chronic illness (eg, cardiovascular disease, pulmonary disease, diabetes mellitus, chronic liver disease) or disability People with functional or anatomic asplenia People living in environments or social settings in which the risk of disease is high Immunocompromised people at high risk for infection

Pneumonia in elderly patients may occur as a primary diagnosis or as a complication of a chronic disease process. Severe complications of pneumonia include hypotension and shock and respiratory failure (especially with gram negative bacteria in elderly patients) these complications are encountered chiefly in patients who have received no specific treatment or inadequate or delayed treatment. These complications are also encountered when the infecting organisms resistant to therapy, when a co-morbid disease complicates the pneumonia or when the patient is immunocomprmised. Patients may require endotracheal intubations and mechanical ventilation. Heart failure, cardiac dysrhythmias, pericarditis and myocarditis also are complications of pneumonia that may lead to shock. Respiratory failure is a sudden and life-threatening deterioration of the gas exchange function of the lung. It exists when the exchange of oxygen for carbon dioxide in the lungs cannot keep up with the rate of oxygen consumption and carbon dioxide production by the cells of the body. Acute respiratory failure is defined as the decrease in arterial oxygen tension (PaO2) to less than 50 mm Hg (hypoxemia) and increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with an arterial pH of less than 7.35. II. GENERAL DATA NAME: MRS.X AGE: 56 years old ADDRESS: Antipolo City BIRTHDATE: June 03, 1956 BIRTHPLACE: Catarman Samar CIVIL STATUS: Married RELIGION: Roman Catholic EDUCATIONAL ATTAINMENT: Elementary Level (grade 4) OCCUPATION: house wife CITIZENSHIP: Filipino SEX: Female CHIEF COMPLAINT: Cough, Dyspnea, Fever DIAGNOSIS: Community acquired pneumonia in acute respiratory failure III. HISTORY OF PRESENT ILLNESS

prior to admission, patient had cough productive of yellowish sputum associated with fever (undocumented) and occasional dyspnea especially on extreme condition tolerated. 1 day prior to admission, dyspnea at rest was noted associated with cyanosis of fingers. IV. PAST HEALTH HISTORY Mrs. X has Bronchial Asthma taking Seretide and Ventolin inhaler for treatment but is poorly compliant. She was taking vitamins. Family history of diabetes. Mrs. X used to smoke at about 20 packs per year and drinks alcohol occasionally. Months prior to admission weight loss was positive and occasional chest pains noted. V. NURSING REVIEW OF SYSTEM A. CENTRAL NERVOUS SYSTEM Patient experienced seldom headache, she takes pain reliever and take a complete bed rest to manage and relieve such disturbance. She also experience occasional uncoordinated movements. B. RESPIRATORY SYSTEM Patient experienced sore throat but was able to manage by eating ginger or taking herbal medicine. She claims that it was a proven to be effective on her because the soreness was relieved. She also claimed that she had seasonal rhinitis especially when she inhales dust and string odor and seldom, she have runny nose when the weather changes especially during cold days. She frequently experiences asthma attacks during cold days and is relieved by taking bronchodilators inhaler. Chest pain is also complained. Dyspnea bothers her during sleeping. C. ENDOCRINE She claimed that she has not experienced any signs of abnormalities. Neither has she experienced goiter nor tumor nor some other alterations related to the system involved. D. GASTROINTESTINAL SYSTEM The patient experienced thirst and hunger like any other normal person. She also experienced constipation and diarrhea. She experienced hyperacidity whenever meals are not taken on time. She claimed to have no allergies in any food and drugs. E. MUSCULOSKELETAL SYSTEM She experienced fatigue and muscle pains. She also claimed to have experienced back pain and joints but relieved by self-massaging, resting and taking pain reliever. The patient has an aged posture as observed.

F. GENITO-URINARY SYSTEM The patient experienced irregular menstruation at the age of 48 and a stoppage in menstruation at the age of 54 (Menopausal) She also claimed that her urination is normal as far as she can remember and urinates frequently depending on the amount of liquid she has taken in. B. PERSONAL AND SOCIAL HISTORY She was married at the age of 16. Her family used to reside at the island of Leyte where she and her husband worked as farmers. They had their children grown there and when she reached her 32 the family then decided to move their residence in Antipolo. As elders in provinces do, Mrs.X used to smoke native tobacco what they call tinustus. This was a habit of hers for quite a long time. Noticeably, As a mother she was bonded significantly to her youngest daughter who used to be her bedside person. As told by one of her daughters, her mother as a lola is really close to her grandchildren and feels in deep sadness whenever one of them leaves for work in far places. They also believe that sometimes the sorrow triggers her asthma attacks as well as other acute illfull conditions. C. ENVIRONMENTAL HISTORY As given by Mrs. X daughters. In the province they used to live in a farm house. The place is not well developed yet and is conducive for healthy living compared to their place in the city and for certain circumstances they moved. In the city, the family live in a 2 bedroom house. The place is slightly congested and is located near a squatters area. Space is inadequate for the number of family members. Smell and polluted air is their only choice to breath. Nearby canals were uncovered. Infestations were also confessed. They have their water supply in the community. They store water in drums and are covered. They dispose their garbage in two ways , burning and weekly collection. The bungalow house has a single bathroom with a water sealed toilet. Analytically, the family is living in a disease prone environment which might have caused her acquisition of her present illness. D. HEREDO-FAMILIAL HISTORY

Mrs. X was confirmed to be asthmatic. As told, the said condition is common to her side while on the other hand on her husbands they were known to be diabetic yet neither of the aforementioned conditions caused death to members of both sides of the family. VII. PHYSICAL ASSESSMENT General Observation: Patient appeared to be weak and not in good condition on the first time I saw her. She is conscious, coherent, and afebrile. She could hardly move her body and limited movement of extremities. She has an IV line of PNSS 1L @ 30gtts/min infusing well at her right hand. An oxygen is placed just behind the headboard of the bed Integumentary The patient has fair complexion, line spots noted, no lesions found, average skin turgor for aged person. She has a temperature of 36.7 degree Celsius and frequently sweats. Head and Face Head is symmetrical to the body. Free from lesions and swelling. Fair distribution of hair. White hairs are dominant. No lumps noted on the scalp, tenderness not complained, and no scaliness. Eyes The eyes are symmetrical, has normal accommodation and pink conjunctiva, free from swelling. Visual acuity not assessed but patient do not use eyeglasses. No complaints of tenderness, free of exudates, evenly distributed eyebrows, white to yellow sclera. Both pupils constrict and reactive to light. Ears The ears are symmetrical there were no swelling and discharges noted. Patient can hear clearly, no tenderness noted. Nose and Sinuses Nasogastric tube attached to the left nostril, midline to the face, no nasal flaring, inflammation and discharges noted. Mouth The lips are dry and teeth are incomplete. There is no swelling or lesions. The jaw is perfectly aligned. During the first contact with the patient, intubation was attached, no foul odor noted. Unable to assess inner mouth. Now, the intubation was removed and the patient can

now speak. The oral mucuosa, tongue, gums and uvula are pink, moist and without lesions. There were no inflammations in the tonsils. Neck The neck is symmetrical to the body. The patient could hardly move her neck in different directions during the first contact but now the patient can move it smoothly and without pain. Lymph nodes are in symmetric patterns and are not swollen. Carotid arteries are palpable and have no bruits. Thorax Difficulty in breathing noted, mechanical ventilator was attached to the patient during the first contact. Equal chest expansion, (+) rales, (+) occasional wheeze. Stomach The stomach has normal bowel sound and free from lesions and any swelling, no enlargement noted. Feeding through . Extremities Brachial and radial pulses are palpable. Skin is warm, pigmented and has average skin turgor. Bluish color on injection site due to poor circulation of the blood. Low resistance and slow/limited movement of both extremities.

Data of Mrs. X organized according to Gordons Functional Health Patterns: 1. Health perception/ Health management Patient had history of Pneumonia. Doctors prescribed her with medicines but the patient was not able to maintain it due to financial problem. She never complained about her condition though she experienced short of breathe and cough. Her family decided to admit her to a hospital when she cannot tolerate it anymore and when cyanosis was observed by the family member. 2. Nutrition/ Metabolic She loves to eat fruits as long as they have. She seldom eats meat. She eats vegetables once in a while. In the morning, she eats bread and ate breakfast and lunch (brunch) at around 11:00AM Few weeks before admission, she just want to eat porridge for her meal. 3. Elimination

Patient had normal elimination pattern but then, few days after her admission, she experienced constipation but had good urine output. Now, she defecates daily and maintains good urine output. 4. Activity/ Exercise Patient usually does sedentary activities at home, like eating, watching television, talking with some friends, and sometimes does sweeping. On first contact with the patient, seen patient lying on bed, weak, and with limited movements. 5. Cognitive/ Perceptual Patient needs to be oriented with the time and date though she is aware that she is currently admitted in the hospital. She is responsive (through gestures), coherent, and can relate to conversations. 6. Sleep/Rest Patterns Patient usually sleeps between 8:00PM 9:00PM and wakes up around 5:00AM. She had afternoon nap everyday. Now that she is admitted, she could hardly sleep because of her condition. She is also disturbed by her cough. 7. Self Perception/ Self Concept Though the patient looses weight, she doesnt look under weight at all. She is just weak because she is sick. She looks accommodating and friendly despite of her condition. 8. Role/ Relationship Patient lives in her own house with her daughter and two grandchildren. They have close family ties. She is open to them with her feelings. She is fond of talking. She spends most of her time at home with her family. 9. Sexuality/ Reproductive Health The patient has 3 children, one boy (deceased) and three girls. 10. Coping/ stress tolerance

The patient is open to her family about her problems. But then, with regards to her sickness, she never complained about it. She kept it to herself as long as she can tolerate it. 11. Values and beliefs Patient is a Roman Catholic but didnt go to church. She didnt join any religious community.

IX. A. ANATOMY AND PHYSIOLOGY OF THE RESPIRATORY SYSTEM The respiratory system consists of the external nose, the nasal cavity, the pharynx, the larynx, the trachea, the bronchi and the lungs. Although air frequently passes through the oral cavity, it is considered to be a part of the digestive system instead of the respiratory system. The upper respiratory tract refers to the external nose, nasal cavity, pharynx and other associated structures; the lower respiratory tract includes the larynx, trachea, bronchi and lungs. The terms are not official anatomical terms, however, and there are several alternative definitions. For example, one alternative places the larynx in the upper respiratory tract. NOSE The nose consists of the external nose and the nasal cavity. The external nose is the visible structure that forms a prominent feature of the face. Most of the external nose is composed of hyaline cartilage, although the bridge of the external nose consists of bone. The bone and cartilage are covered by connective tissue and skin.

The nasal cavity extends form the nares to the choane. The nares or nostrils are the external openings of the nose and the choane are the openings into the pharynx. The nasal septum is a partition dividing the right and left parts. The deviated nasal septum occurs when the septum bulges to one side or the other. The hard palate forms the floor of the nasal cavity, separating the nasal cavity from the oral cavity. Air can flow through the nasal cavity when the mouth is closed or when the oral cavity is full with food. Three prominent bony ridges called conchae are present on the lateral walls on each side of the nasal cavity. The conchae increase the surface area of the nasal cavity. Paranasal sinuses are air-filled spaces within bone. The maxillary, frontal, ethmoidal, and sphenoidal sinuses are named after the bones in which they are located. The paranasal sinuses open into the nasal cavity and are lined with a mucous membrane. They reduce the weight of the skull, produce mucus and influence the quality of voice by acting as resonating chambers.

The nasolacrimal ducts, which carry tears from the eyes, also open into the nasal cavity. Sensory receptors for the sense of smell are found in the superior part of the nasal cavity. Air enters the nasal cavity through the nares. Just inside the nares, the epithelial lining is composed of stratified sqaumous epithelium containing coarse hairs. The hairs traps some of the large particles of dust suspended in the air. The rest of the nasal cavity is lined with pseudostratified columnar epithelial cells containing cilia and many mucus producing goblet cells. Mucus produced by the goblet cells also traps debris in the air. The cilia sweep the mucus posteriorly to the pharynx, where it is swallowed. As air flows through the nasal cavities, it is humidified by moisture from the mucous epithelium and is warmed by blood flowing through the superficial capillary networks underlying the mucous epithelium. PHARYNX

The pharynx is the common passageway of both the respiratory and digestive systems. It receives air from the nasal cavity, food and water from the mouth. Inferiorly, the pharynx leads to the rest of the respiratory system through the opening into the larynx and to the digestive system through the esophagus. The pharynx can be divided into three regions: the nasopharynx, the oropharynx, and the laryngopahrynx. The nasopharynx is the superior part of the pharynx. It is located posterior to the choanae and superior to the soft palate, which is an incomplete muscle and connective tissue partition separating the nasopharnx from the oropharynx. The uvula is the posterior extension of the soft palate. The soft palate forms the floor of the nasopaharynx. The nasoharynx is lined with pseudostratiifed ciliated columnar epithelium that is continuous with the nasal cavity. The auditory tubes extend from the middle ears and open into the nasopharynx. The posterior part of the nasopharynx contains pharyngeal tonsils which aids in defending the body against infection. The soft palate is elevated during swallowing; this movement results to the closure of the nasopharynx which prevents food from passing from the oral cavity into the nasopharynx. The oropharynx extends fro the uvula to the epiglottis, and the oral cavity opens into the oropharynx. Thus food, drink and air all pass through the orpharynx. The oropharynx is lined with stratified squamous epithelium which protects against vibration. Two sets of tonsils, the palatine tonsils, are located near the opening between the mouth and the oropharynx. The lingual tonsil is located on the surface of the posterior part of the tongue. The laryngopharynx passes posterior to the larynx and extends from the tip of the epiglottis to the esophagus. Food and drinks pass through the laryngopharynx to the esophagus. A small amount of air is usually swallowed with the food and drink. Swallowing too much air can cause excess gas in the stomach and may result in belching. The laryngopharynx is lined with stratified squamous epithelium and ciliated columnar epithelium. LARYNX The larynx is located in the anterior throat, and it is continuous superiorly with the pharynx and inferiorly with the trachea. The larynx consists of an outer casing of nine cartilages that are connected to one another by muscles and ligaments. Three of the nine cartilages are unpaired and six of them form three pairs. The largest cartilage is the unpaired thyroid cartilage or Adams apple. The thyroid cartilage is attached superiorly to the hyoid bone. The most inferior cartilage of the larynx is the unpaired cricoid cartilage, which forms the base of the larynx on which the other cartilages rest. The thyroid and cricoid cartilages maintain an open passageway fro air movement. The third unpaired cartilage is the epiglottis. It differs from other cartilages in that it consists of elastic cartilage rather than hyaline cartilage. Its inferior margin is attached to the thyroid cartilage anteriorly, and the superior part of the epiglottis projects as a free flap toward the tongue. The epiglottis helps prevent swallowed materials from entering the larynx. As the larynx elevates during swallowing, the epiglottis tips posteriorly to cover the opening of the larynx.

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The six paired cartilages consist of three cartilages on either side of the posterior part of the larynx. The top cartilage on each side is the cuneiform cartilage, the middle cartilage is the corniculate cartilage, and the bottom cartilage is the arythenoid cartilage. The arythenoid cartilage articulates with the cricoid cartilage inferiorly. The paired cartilages form an attachment site for vocal folds. Two pairs of ligaments extend from the posterior surface of the thyroid cartilage to the paired cartilages. The superior pairs forms the vestibular folds, or false vocal cords, and the inferior forms the vocal folds, or true vocal folds. When the vestibular folds come together, they prevent air from leaving the lungs such as when a person holds his breath. Along with the epiglottis, the vestibular folds also prevent food and liquids from entering the larynx. The vocal cords are the primary source of voice production. Air moving past the vocal folds causes them to vibrate, producing sound. Muscles control the length and tension of the vocal folds. The force of the air moving past the vocal folds controls the loudness, and the tension of the vocal folds controls the pitch of the voice. An inflammation of the mucous epithelium of the vocal folds is called laryngitis. Swelling of the vocal folds during laryngitis inhibits voice production. TRACHEA The trachea or windpipe is a membranous tube that consists of connective tissues and smooth muscle, reinforced with 16-20 C-shaped pieces of cartilage. The adult trachea is about 1.4-1.6 centimeters in diameter and about 10-11 cm long. It begins immediately inferior to the cricoid cartilage, which is the most inferior cartilage of the larynx. The trachea projects through the mediastinum, and divides into the right and left primary bronchi at the level of the fifth thoracic vertebra. The esophagus lies immediately posterior to the trachea. C-shaped cartilages from the anterior and lateral sides of the trachea. The cartilages protect the trachea and maintain an open passageway for air. The posterior wall of the trachea has no cartilage and consists of a ligamentous membrane and smooth muscle. The smooth muscle can alter the diameter of the trachea. The trachea is lined with pseudostratified columnar epithelium, which contains numerous cilia and goblet cells. The cilia propel mucus produced by the goblets cells, as well foreign particles embedded in the mucus, out of the trachea, through the larynx, and into the pharynx, from which they are swallowed. Constant irritation of the trachea by constant smoke can cause the tracheal epithelium to change to stratified squamous epithelium. The stratified squamous epithelium has no cilia and therefore has no ability to clear the airway of mucus and debris. The accumulation provides a place for microorganisms to grow, resulting in respiratory infections. Constant irritation and inflammation of the respiratory passages stimulate the cough reflex, resulting in smokers cough. BRONCHI The trachea divides into the left and right main (primary) bronchi, each of which connects to a lung. The left main bronchus is more horizontal than the right main bronchus

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because it is displaced by the heart. Foreign objects that enter the trachea usually lodge in the right main bronchus, because it is more vertical than the left main bronchus and therefore more in line with the trachea. The main bronchi extend from the trachea to the lungs. Like the trachea, the main bronchi are lined with peudostratified ciliated columnar epithelium and are supported by C-shaped pieces of cartilage.

LUNGS The lungs are the principal organ of respiration, each lung is cone-shaped, with its base resting on the diaphragm and its apex extending superiorly to a point about 2.5 cm above the clavicle. The right lung has three lobes called the superior, middle, and inferior lobes. The left lung has two lobes called the superior and inferior lobes. The lobes of the lungs are separated by deep, prominent fissures on the surface of the lung. Each lobe is divided into bronchopulmunary segments separated from one another by connective tissue septa, but these separations are not visible as surface fissures. Individual diseased bronchopulmonary segments can be surgically removed leaving the rest of the lung relatively intact, because major blood vessels and bronchi do not cross the septa. There are 9 bronchopulmunary segments in the left lung and 10 in the right lung. The main bronchi branch many times to form the tracheobronchial tree. Each main bronchus divides into lobar bronchi as they enter their respective lungs. The lobar (secondary) bronchi, two in the left lung and three in the right lung, conduct air into each lobe. The lobar bronchi in turn give rise to segmental (tertiary) bronchi, which extend to the bronchopulmonary segments of the lungs. The bronchi continue to branch many times, finally giving rise to bronchioles. The bronchioles also subdivide numerous times to give rise to 12

terminal bronchioles, which then subdivide into respiratory bronchioles. Each respiratory bronchiole subdivides to form alveolar ducts, which are like long, branching hallways with many open doorways. The doorways open into alveoli, which are small air sacs. The alveoli become so numerous that the alveolar duct wall is little more than a succession of alveoli. The alveolar ducts end as two or three alveolar sacs, which are chambers connected to two or more alveoli. There are about 300 million alveoli in the lungs. As the air passageways of the lungs become smaller, the structure of their wall changes. The amount of cartilage decreases and the amount of smooth muscle increases, until at the terminal bronchioles, the walls have a prominent smooth muscle layer, but no cartilage. Relaxation and contraction of the smooth muscle with the bronchi and bronchioles can change the diameter of the air passageways. For example, during exercise the diameter can increase, thus increasing the volume of air moved. During an asthma attack, however, contraction of the smooth muscle in the terminal bronchioles can result in greatly reduced airflow. In severe cases, air movement can be so restricted that death results. As air passageways of the lungs become smaller, the lining of their walls also changes. The trachea and bronchi have pseudostratified ciliated columnar epithelium, the bronchioles have ciliated simple columnar epithelium and the terminal bronchioles have ciliated simple cuboidal epithelium. The ciliated epithelium of the air passageways functions as a mucus cilia escalator, which traps debris in the air and removes it from the respiratory system. As the passageways beyond the terminal bronchiole become smaller, their walls become thinner. The walls of the respiratory bronchioles are cuboidal epithelium and those of the alveolar ducts and alveoli are simple squamous epithelium.

The respiratory membrane of the lungs is where gas exchange between the air and blood takes place. It is mainly formed by the walls of the alveoli and surrounding capillaries but theres some contribution by the alveolar ducts and respiratory bronchioles. The respiratory membrane is very thin to facilitate the diffusion of gases. It consists of: 1. A thin fluid lining the alveolus

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2. The alveolar epithelium composed of a simple squamous epithelium 3. The basement membrane of the alveolar epithelium 4. A thin interstitial space 5. The basement membrane of the capillary epithelium 6. The capillary endothelium composed of a simple squamous epithelium The elastic fibers surrounding the alveoli allow them to expand during inspiration and recoil during expiration the lungs are very elastic, and when inflated, they are capable of expelling the air and returning to their original, uninflated state. Specialized secretory cells within the walls of the alveoli secrete a chemical called surfactant that reduces the tendency of alveoli to recoil. PLEURAL CAVITIES The lungs are contained within the thoracic cavity. In addition, each lung is surrounded by a separate pleural cavity. Each pleural cavity is lined with a serous membrane called the pleura. The pleuron consists of a parietal and visceral part. The parietal pleura, which lines the walls of the thorax, diaphragm, and mediastinum, is continuous with the visceral pleura, which covers the surface of the lung. The pleural cavity, between the parietal and visceral pleurae, is filled with a small volume of pleural fluid produced by the pleural membranes. The pleural fluid performs two functions: 1.) it acts as a lubricant, allowing the visceral pleurae to slide past each other as the lungs and thorax change shape during respiration, and 2.) it helps hold the pleural membranes together. The pleural fluid acts like a thin film of water between two sheets of glass (the visceral and parietal pleurae); the glass sheets can slide over each other easily, but it is difficult to separate them. B. NARRATIVE PATHOPHYSIOLOGY With the causative agent and patients predisposing condition, agents are acquired from a contaminated environment, thus providing the agents with a host conducive for proliferation. Agents are then again being transmitted through airborne droplets entering through the patients nasal and oral cavities. Bacteria typically enter the lung when airborne droplets are inhaled, but they can also reach the lung through the bloodstream when there is an infection in another part of the body. Many bacteria live in parts of the upper respiratory tract, such as the nose, mouth and sinuses, and can easily be inhales into the alveoli. Once inside the alveoli, bacteria may invade the spaces between cells and between alveoli through connecting pores. This invasion triggers the immune system to send neutrophils, which are type of defensive white blood cell to the lungs. The neutrophils engulf and kill the offending microorganisms and they also release cytokines, causing a general activation of the immune system. This leads to fever, chills and fatigue common in bacterial and fungal pneumonia. The neutrophils, bacteria and fluid from surrounding blood vessels fill the alveoli and interrupt normal oxygen transportation.

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Bacteria often travel from an infected lung into the bloodstream, causing serious or even fatal illness such as septic shock with low blood pressure and damage to multiple parts of the body including the brain, kidneys and heart. Bacteria can also travel to the area between the lungs and chest wall (Pleural Cavity) causing a complication called empyema. The most common causes of bacterial pneumonia are Streptococcus pneumonia often called pneumococcus, is the most common bacterial cause of pneumonia in all age groups except newborn infants. Another important Gram-positive cause of pneumonia is Staphylococcus aureus. Patients with CAP usually present with fever and a brief history of respiratory problems such as cough, dyspnea, tachypnea, sputum production, and pleuritic chest pain. Elderly patients may be less likely to present with standard symptoms of CAP (e.g., cough, fever) and may actually present with confusion and an altered mental status. Most patients with CAP will have a focal lung examination, with findings ranging from crackles to bronchial breath sounds (very loud, high-pitched sounds via stethoscope). One of its effects is systemic when the blood stream is supplied oxygen which would lead to hypoxemia. This matter triggers the medulla; the respiratory control center; to activate compensatory mechanisms resulting to tachypnea but because the problem lies with the gas exchange in the lung sites, no improvement in oxygen supply is made. The diaphragm which is one of the working muscle during this moment demanding and consuming large amount oxygen would ultimately be compromised. This causes damage to the muscles tissues impairing its normal functioning which would then result to respiratory failure. Acute Respiratory Failure is classified by blood gas abnormalities. Acute Respiratory Failure is further defined as ventilatory Failure, oxygenation Failure, or a combination of both ventilatory and oxygenation failure.

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Proliferation of Bacteria and viruses

Transmission
Airborne Droplets Nose, Mouth, Sinuses Tracheobronchial Tree Alveoli Immune System Inflammatory response Neutrophils (Cytokines) Capillary Leak, Edema, Exudates, Mucus
Risk Factors: Older adult No history of pneumococcal vaccination No History of having received the influenza vaccine in the previous year Chronic or other coexisting condition Recent history or exposure to viral or influenza infection History of Tobacco

Etiology: Streptococcus pneumonia Staphylococcus Aureus Haemophilus Influenza Legionella Pneumophila Mycoplasma Pneumoniae Chlamydia pneumoniae

Thickened Alveolar Walls

Systemic Respiration Chills Anorexia

Bloodstream

Fever

BP

Hypoxemia

Pleuritic Chest Pain

Shortness of Breath

Crackles & Wheezes

Cough

Sputum Production

Dull Percussion

Acute respiratory failure

Impaired respiratory muscles

O2 in the diaphragm

Tachypnea

Medullar Oblongata

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LABORATORY AND EXAMINATIONS Diagnostic Procedures X-Ray Conclusion 1. Chronic inflammation process in both lung fields 2. Modified silhouette 3. Atherosclerosis of the thoracic aorta 4. Calcified trachoebronchial tree 5. Generalized osteopenia/osteoporosis

CBC WBC RBC HGB HCT MCV MCH MCHC Plt Neutrophil % Lymphocyte % Monocyte Eosinophil Basophil Neutrophil # Lymphocyte # 1.11 Monocyte Eusinophil Basophil RDW PDW MPV Ionized calcium Na K Result 6.28 5.45 16.5 50.6 92.8 30.3 32.6 193 72 1707 9.9 .2 .2 4.53 1.9-8 .62 .01 .01 14 9.8 9.5 .75 121.9 4.25 .16-1 0-.8 0-.2 11-16 9-14 7.2-11.1 1.09-1.33 135-148 3.5-5.0 reference 4.8-10.8 4.2-5.4 12-16 37-47 81.99 27-31 33-37 130-140 40-74 19-48 3.4-9 0-7 0-1.5 1.9-8 unit 10^3/ul 10^0/ul g/dl % fl pg g/dl 10^3/ul % % % % % 10^3/ul 10^3\ul 10^3/ul 10^3/ul 10^3/ul % % fl mmol/L mmol/L mmol/L 17

Temperature Thb FIO2 pH pCo2 PO2 HCO3 +CO2 SO2

36.6 15.0 21 7.287 68 54.5 31.8 33.9 84.4

C g/dl % 7.35-7.45 35-45 >80 95-98 mmHg mmHg mmHg mmHg %

U/A Physical Characteristics Color dark yellow Transparency sly cloudy pH 6.0 5-6 Sp-gray1.030 1.003-1.005 Chemical Characteristics Result Protein 100 Glucose Ketone Urobilinogen normal Leukocyte Bld Bilirubin Nitrite Vit C Microscopic RBC WBC Bacteria Mucus Hyaline cast Glucose Fasting Cholesterol Triglycerides 2 8 none 10 149 165 109 40

random

reference up to 2 *

unit mg/dl mg/dl mg/dl mg/dl WBC/ul mg/dl mg/dl mg/dl mg/dl

2-18 6.14 * * 60-110 150.0-240.0 45.0-150.0 mg/dl

/ul /ul /ul /ul mg/dl mg/dl

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VLDL LDL HDL Temperature FIO2 pCO2 pH PO2 HCO3 +CO2 BE SO2 Acid fast stain Specimen sputum

21.8 115.6 .0 27.6 36 14.2 21.0 7.335 60.4 238.1 33.7 3.8 99.8

.0-40.0 150.0 30.0-9.0

mg/dl mg/dl mg/dl C g/dl %

7.35-7.45 35-45 780 95-98

mmHg mmol/L mmol/L mmol/L %

Report: no acid fast bacilli seen

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NURSING CARE PLAN

Cues

Nursing Diagnos is Actual

Scientific Basis

Goal and Nursing Outcome Actions Criteria After 8 hours of nursing interventi on, clients airway is free of secretions as evidenced by eupnea and clear lung sounds after coughing or suctionin g. Specifical ly: 1. Client will maintain 2. Assess a stable cough breathing for . effectiv eness 2. and Clients producti mucus vity. will be thin and scant. To perform nursing care to help patient improved Airway Independent ; 1. Assess respirat ory moveme nts and use of accessor y muscles.

Rationale

Evaluation

S:Inuubo siya ng grabe.nahira pan din sya huminga As verbalized by the clients daughter.

A cough is a Ineffecti protective ve reflex that Airway cleanses Clearan the lower ce airways related by an to explosive increase expiration. d Inhaled O: sputum particles, 1.Received producti accumulat patient lying on as ed mucus, on bed, evidenc inflammat conscious, ed by ion or coherent cough. presence afebrile, of a tachypneic foreign and with body mechanical initiates ventilator the reflex support. by stimulatin 2. Change in g the respiratory irritant status. receptors in the 3. Patient airway. demonstrate The cough persistent consists of coughing inspiration and dyspnea , closure of glottis, 4. Abnormal and vocal lung sounds cord, contractio 5. With n of

Goal Partially met After 8 hours of nursing interventio n, clients airway was free of secretions as evidenced by eupnea and clear lung sounds after coughing or suctioning.

Use of accessory muscles to breathe indicates an abnormal increase in work of breathing. Patients may have ineffective cough due to fatigue or thick tenacious secretions. A sign of infection is Specificall y: discolored sputum. An odor may 1. Client maintaine be present. d a stable breathing. Hypoxemia may result from impaired gas exchange 2. Clients mucus was thin and scant.

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pulse oximeter attached T= 36.2 C - P= 81 bpm - R= MV - BP= 90/55 mmH g.

o

glottis, causing sudden, forceful expiration that removes the offending matter. The effectiven ess of the cough depends on the depth of the inspiration and the degree to which the airway narrow, increasing the velocity of the expiratory gas flow. Cough occurs frequently in healthy individual s. A persistent cough indicates presence of disorder or a

3. Clients breath sounds are clear.

3. Observe sputum color, amount, and odor and report significa nt changes.

from build up of secretions. ABGs provide data about carbon dioxide levels in the blood. These determine progression of disease process. Chest physiothera py includes the techniques of postural drainage and chest percussion to loosen and mobilize secretions in smaller airways that cannot be removed by coughing or suctioning. A nebulizer may be used to humidify the airway to thin secretions to facilitate their removal.

Depend ent: 1. Monitor pulse oximete r and ABGs.

2. Monitor chest xray reports.

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disease. An acute non productive cough often indicates bronchitis or viral pneumoni a. A persistent cough is commonly caused by a tumor, congestio n, or hypertensi ve airways. A cough that produces purulent sputum usually indicates infection, whereas a cough that produces non purulent sputum is non specific and merely indicates irritation.

Collaborati ve: 1. Consult the respirat ory therapist for chest physioth erapy and nebulize r treatme nts, as appropri ate and ordered.

Bronchosco py is done to obtain lavage samples for culture and sensitivity and to remove mucous plugs; thoracentesi s is done to drain associated pleural effusions. Intubation may be needed to facilitate deep suctioning efforts and to provide source for augmenting oxygenation . A variety of medications are available to treat specific problems.

2. Assist with broncho scopy and thoracen tesis, as

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appropri ate.

3. Anticipa te possible need for intubati on if patients conditio n deterior ates 4. Administer medications such as antibiotics and expectorant s for productive coughs. Administe r inhaled bronchodila tors and inhaled steroids, as prescribed, to open airway and decrease

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inflammatio n.

Nursing Care Plan Cues Nursing Diagnos is Potentia l Risk for aspiratio n r/t tube feedings and secretio ns. Scientific Basis Crackles indicate static pulmonary secretions that need to be mobilized. This also includes accumulatio n of saliva on the airways .When this obstructs the airway the pulmonary tissues beyond the collapses and massive atelectosis results. Pulmonary complicatio ns from NGT intubation occur because coughing Goal and Nursing Outcome Actions Criteria After 8 hours of nursing interventi on the patient will be able to maintain a patent airway To perform nursing care to prevent aspiration Independent : 1. Monitor level of consciousne ss. Rationale Evaluatio n goal met: After 8 hours of nursing interventi on the patient was able to maintain a patent airway. Specificall y the patient and s.o. was able to: 1. Feel relief of concerns about secretions. 2. Able to do basic suctioning procedure s. 3. Have a

S- Patient pointing her throat. -no verbalizati ons O- NGT inserted Mechani cal ventilator noted Suction machine at bedside. patient pointing on her neck.

A decreased level of consciousness is a prime factor for aspiration Decreased gastrointestinal mobility increases the risk of aspiration because foods and fluids accumulate in the stomach This decreases the risk of aspiration by promoting the drainage and secretions away from the airway. (Gulanick/Mayers: 2008 pp.19)

Specifica lly the patient and s.o. will be 2. able to: Auscultate bowel 1. Feel sounds to relief evaluate with bowel concerns motility and of assess for secretion abdominal s distention and 2. Will be firmness. able to do basic 3. Position suctionin patient in an g elevated

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and cleaning of the pharynx is impaired , because gas build up can irritate the phrenic nerve and because tubes may dislodged, retracting the distal and above the esophagogas tric sphincter places the patient of risk for aspiration

procedur es.

upper body or side Reduces orolying. pharyngeal 3. Have a secretions and secured reduces aspiration NGT rising. placemen 4. In t. Patients with A placed tube 4. Have artificial may erroneously no airways. deliver tube abnormal feeding into the breath Perform airway. sounds oral upon suctioning assessme as needed. nt. 5. In 5. Have patients normal with NGT breathing pattern. Check placement of tube On ineffective or before over inflated cuff feeding by can increase the color or risk for aspiration. aspirate or ((Gulanick/Mayers listening for :2008 bubbling pp.19) sounds upon air induction. Appropriate mixture of food as Collaborati well as balanced ve: meal provides nutrients needed. 6.Collabora te with respiratory therapist, as needed to determine To eliminate cuff secretions pressure(tub

secured NGT placement 4.Have no abnormal breathe sounds upon assessmen t 5. Have a normal breathing pattern.

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es) 7. Collaborate with the dietitians about having blenderized diet for the patient. Dependent: 8. Suction hourly as ordered by the physician. 9. Administer drugs in appropriate preparation as ordered by the physician. Drugs in tablet forms must be crushed during administration

Nursing Care Plan Cues Nursing Scientific Goal and Nursing Diagnos Basis Outcome Actions is Criteria In place After 8 hours To perform mechanic of nursing nursing care Rationale Evaluation

S: Patient Actual wrote on

Goal met

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a piece of paper gusto na ko mulakaw

Impaire d Physical Mobilit y related to O: restricti 1.Receiv ve ed patient devices lying on bed, consciou s, coherent afebrile, tachypnei c and with mechanic al ventilator support. 2. Pulse oximeter at right hand 3. IVF infused at right hand 4. Weak muscles

al devices are common to non ambulato ry patients but in cases where patients are able to walk, the devices would likely limit their activities provided that machines are easily altered by moveme nt examples would be casts, neck support and ventilator . (Microso ft Encarta 2007)

intervention the patient will be relieved from discomfort Specifically 1. Patient will be free of complications of immobility, as evidenced by intact skin, absence of thrombophleb itis, & normal bowel pattern.

2. Patient will perform exercises in bed 3 Encourage & facilitate 3. Patient will early move allowed ambulation body parts for & other exercise. ADLs when possible .

to help patient exercise in bed >Restricted movement 1. Assess affects the patients ability to ability to perform most perform ADLs . ADLs effectively and safely on a daily basis. >This provides 2 Assess baseline ability to measurement perform for the future ROM to all evaluation and joints. guides therapy.

After 8 hours of nursing intervention the patient was relieved from discomfort Specifically 1. Patient was free of complications of immobility, as evidenced by intact skin, absence of thrombophlebi tis, & normal bowel pattern.

2. Patient was >The sooner able to the patients perform becomes exercises in mobile, less bed chance that debilitation 3. Patient will occur. moved allowed body parts for >Patients may exercise. be reluctant to 4 Provide move or positive initiate new reinforcemen activity due to t during fear of falling. activity. A positive approach allows the learner to feel good about learning accomplishme nts. 5 Evaluate patients > Evaluating

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performance performance in doing helps in ADLs. improving once abilities & maximizing activities. Even patients who are temporarily immobile are at risk for effects of immobility such as skin breakdown, muscle weakness, thrombophlebi tis, constipation, pneumonia, & 6 Assess depression. patient or caregivers > Regular knowledge examination of of skin immobility (especially & its over bony complication prominences) . will allow for prevention or early recognition & treatment of pressure sores. 7 Assess skin integrity > Turning the patients optimizes circulation to all tissues & relieves 8 Assess pressure. elimination pattern. > Immobility

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promotes 9 Turn & constipation position the patient every > It helps in 2 hours or as evaluating needed. patients outcome from 10 Evaluate nursing the patient interventions. free of complication > It helps in s of determining immobility. factors that contributed to patients difficulty in 11 Assess moving patients difficulty in > To reduce walking. fatigue. 12 Encourage walking exercise interspersed with rest periods

> To enhance safety for client & SO/ caregivers.

13 Involve client/ SO in care, > To reduce assisting risk of falls them to learn ways of managing deficits. 14 Instruct client/ SO in safety measures as individually. (eg. maintaining > It helps in determining patients outcome to be effective or not.

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safe travel pathway, proper lightning.

DRUG STUDY Generic Name: Hydrocortisone Sodium succinate Brand Name: Solu-Cortef Classification: Corticosteroid, short acting Dosage: 100mg IV, q 6 hours Pharmacokinetics: Metabolism: Hepatic; half life 80-120min. Distribution: Crosses Placenta; enters breast milk Excretion: Urine Indications: Replacement therapy in adrenal cortical insufficiency Hypercalcemia; associated with cancer Short term inflammatory disorders Contraindications: Infections, especially tuberculosis, fungal infections, amoebiasis, hepatitis B, liver disease, liver cirrhosis, active or latent peptic ulcer. Adverse Reaction: Vertigo, headache, hypotension, shock, thin, fragile skin, petechiae, amenorrhea, muscle weakness. Nursing Considerations: 1. Give daily before 9AM to mimic normal peak diurnal corticosteroid levels and minimize HPA suppression. 2. Space multiple dose evenly throughout the day. 3. Use minimal dose for minimal duration to minimize adverse effects. 4. Use alternate day maintenance therapy with short acting corticosteroids whenever possible. Generic Name: Acetylcysteine Brand Name: Fluimucil Classification: Mucolytic Agent Dosage: Pharmacokinetics: Metabolism: Hepatic; half life 6.25 hr Excretion: Urine (30%)

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Indications: Mucolytic Adjuvant therapy for abnormal, viscid, or inspissated mucus secretion in acute and chronic bronchopulmonary disease (pneumonia,asthma,TB). Contraindications: Contraindicated with hypersensitivity to acetylcysteine; use caution and discontinue if bronchospasm occurs. Adverse Reaction: Nausea, rhinorrhea, bronchospasm especially in asthmatics, stomatitis,and urticaria. Nursing Considerations: 1. dilute with normal saline solution or sterile water for injection. 2. Administer the ff drugs separately because they are incompatible with acetylcysteine: tetracyclines, hydrogen peroxide, trypsin. 3. Use water to remove residual drug solution on the patients face after administration by face mask. 4. Inform patient that nebulization may produce an initial disagreeable odor, but will soon disappear.

DISCHARGE PLAN

M MEDICATION TO TAKE Instruct and explain to the patient that the medication is very important to continue depending on the duration that the doctor ordered for the total recovery of the patient.

E EXERCISE Encourage and instruct the patient to do proper breathing exercise.

T TREATMENTS Advice the patient to relax in order to recover in his present condition. Instruct the patient to minimize the exposure to an open environment such as dusty and smoky area, which airborne microorganism is present that can be a high risk factor that may cause severity of his condition.

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H HEALTH TEACHING Encourage and explain to the patient that it is important to maintain proper hygiene to prevent further infection. Instruct the patient to take a bath every day and explain that bathing early in the morning is not a factor or cause of having pneumonia. Instruct to increase fluid intake of the patient.

O OUT PATIENT FOLLOW UP Regular consultation to the physician can be factor for recovery and to assess and monitor the patients condition.

D DIET Diet as tolerated, meaning, the patient can eat everything until he can. Diet plays a big role in fast recovery so that, instruct the patient to take nutritious food such as green leafy vegetables and fruits.

Evaluation It was evident that the patient has enough motivation to counter act the illness and bring her self back to normal condition. The patient has a big chance of being cured as her actions manifests. The intensive care of her daughters and grandchildren did help the patient a lot in maintaining a better condition even with the presence of illness. I observed from her that she is coping up from stress. The patient thus needs more guidance in her lifestyle so as not to acquire the same disease again. A clean environment conducive for health also is essential for her to prolong healthy status. E. Patient Teaching The main focus of the health teaching is basically to supply adequate knowledge about the patients condition, for urgent restoration of her condition and for promotion of healthy living in accordance to avoid the disease. Explanations were provided to patient and about the importance of taking medications on Time scheduled. The family were also taught on following proper drug identification, dosage and frequency as indicated by the physician. Discussion was made about the importance of clean environment and its basic characteristics. An elaboration on the importance of proper 32

compliance of treatment regimen was made and also about doing proper personal hygiene. Following scheduled check ups were instructed so as to its schedule. To promote the said teaching its importance were told. About the patients diet, it was instructed to have a high fiber vitamin rich foods to eat, enumeration of specific items were provided. Conclusion The patients asthmatic condition is considered to be a risk factor plus that of the aggravating factors which might have contributed to the severity of the illness. Community environment did not trigger the development of the said disease instead it primarily aided the severe effect of the illness to the host thus compromising her in different aspect. Learning these, may be essential to keep ones self away from possible development of the disease. Therefore knowledge, discipline, and self/environment care should be there, utilized and benefited. B. Recommendations As this study proceeds, few lessons were learned and things discovered. One of the basic is education and awareness. For this, I strong suggest to strengthen and intensively increase the provision of basic health education as well as imparting it to the different sectors starting from the most basic unit of the community. This knowledge campaign would surely help the eradication of unawareness and promotion of health motives. XIII. IMPLICATION OF THE STUDY As part of a nurses responsibility to have a holistic character as in knowledge, skills and attitude; doing the said research is a way of exercising a student to develop or enhance the aforementioned. Vitally important to be competitive enough in the said field, this focus would cause a permanent retention of a charged experience useful in initiating action for future cases. This has several implications can be credited to this research. One of which is an update to the possible mutation of a new strain of a causative agent or a manifestation of new signs and symptoms uncommon to the disease condition. Records of the disease condition are also a help to those who want to study or predict the progress of the disease condition so as to be applied to patients having a comparable illness.

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Having this knowledge would be essential such that prevention of compromising patients health in a terminal stage can be initiated.

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