Pneumonia

Medical Surgical Ward Submitted by: Group 3 Fatima Love Ariate Siena Marie Lundang Juan Paulo Manuel Tricia Kaye Micarsos Floriza Mondejar Anne Moralizon Jim Isaac Reyes Rona Grace Ulitin Mary Grace Umali

Introduction
Pneumonia is a form of acute respiratory infection that affects the lungs. The lungs are made up of small sacs called alveoli, which fill with air when a healthy person breathes. When an individual has pneumonia, the alveoli are filled with pus and fluid, which makes breathing painful and limits oxygen intake.Pneumonia is the single largest cause of death in children worldwide. Every year, it kills an estimated 1.4 million children under the age of five years, accounting for 18% of all deaths of children under five years old worldwide according to World Health Organization 2012. It is the 5th leading cause of mortality on the Philippines (2006) according Department of Health. Typical symptoms chest pain cough fever DOB Types of Pneumonia Community acquired: occurs outside of the hospital and other health care setting. Hospital acquired: some people catch pneumonia during a hospital stay for another illness higher risk if on a ventilator. Health care setting: other health care setting like nursing homes dialysis center, outpatients clinics. Bacterial: affect people who have weak immune system like old age, or malnutrition. Fungal: complications experienced by aids patients. Viral: common forms; flu virus, herpes simplex virus, rhino virus, adenovirus. Mycoplasma: possess of both bacteria and virus. Aspiration: occurs when inhaled foreign materials.

Objectives
This case presentation has the main goal of explaining the causes of Pneumonia and its different possible complications. It also emphasizes the proper nursing interventions that are applicable for this type of medical condition.

Rationale for choosing the case

This case was chosen by the group for the following reasons: To better understand the whole concept of Pneumonia and to identify the possible complications that may arise and affect the patient. To be able to enhance the groups knowledge regarding the proper nursing interventions needed in this particular medical condition.

Significance of the study

This study will greatly aid the students in broadening their knowledge regarding this particular medical condition and will promote the proper nursing interventions that are needed in this particular case.

Scope and Limitation

The study contains the following; a brief discussion of the condition and its causes, possible complications and proper treatment, a pathophysiology to better understand the connection of the condition to the persons over-all health, a nursing care plan that would present a nursing analysis and diagnosis about the condition, including a plan and intervention to assist in an enhance recovery.

Patients Profile
Patient name: Patient X Address: 75 M Leonor St. San Pablo City, Laguna Religion: Roman Catholic Nationality: Filipino Birthdate: March 2, 1930 Age: 82 years old Admitting Doctor: Dr. Tamucheen Galadari Attending Physician: Dr. Haydee Sarmiento Admission: August 1, 2012 Chief Complain: Cough and Difficulty of breathing

History of Present Illness

Dyspnea Upper GI bleeding Ischemic heart disease

Past Medical History

Hypertension 5th and 8th left rib fracture

Initial Vital Signs

August 1, 2012 Blood Pressure Pulse Rate Respiratory Rate Oxygen Saturation CBG 150/80 mmHg 107 bpm 32 cpm 92 % 108

Initial Intake and output:

Intake:580 Output:400

Gordons Functional Health Pattern

1. Health Perception / Health Management Patient is cooperative and is quick in compliance to medication regimen. Patient is aware of his condition and possible outcome. 2. Nutritional and Metabolic Pattern Patients main meal in the hospital was lugaw, gelatin, and crackers but at home he eats chicken, rice, fish and vegetables. Frequently skip meals 3. Elimination Pattern Patient has trouble in defecating and is positive for melena and has no problems upon urination. 4. Activity / Exercise Pattern Patient can walk before with assistance, but now is bed ridden. No activities and hobbies. 5. Sleep / Rest Pattern Patient gets adequate amount of sleep of 8 hours a day, but in the hospital, there was frequent disturbances due to close monitoring. 6. Cognitive and Perceptual Pattern Patient is conscious and coherent and is able to talk but with slurred speech. Hes aware of what is going on around him and is aware of the treatment being done to him. 7. Self-perception / Self-concept Pattern Patient knows that his disease is normal for his age. He is slightly depressed because he is unable to perform ADL by himself.

8. Role-relationship Pattern Patient has good relationship with family and friends. He is not the bread winner of the family. 9. Sexuality / Reproductive Pattern He has no wife and children and is sexually inactive. 10. Coping / Stress Tolerance The patient avoids stress by watching TV and eating. Also talking to his family and conversing with friends. 11. Values / Belief Pattern Patient is a Roman Catholic, he values his family. Patients values and beliefs does not conflict with his medical treatment.

Physical Assessment

Head Eyes Ears Mouth Neck Chest Abdomen Arms Hands Genitalia Legs Feet

o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o

Normocephalic Thinning white hair Evenly distributed hair Asymmetrical blinking, strabismus, (-) PERLA, eye crust on both eyes Symmetrical Patent ear canal Good hearing acuity Absence of teeth Poor mouth hygiene Normal neck length Abnormal mass on right side Visible pulsation on right carotid artery Abnormal breathing pattern Arrhythmias upon auscultation No lumps upon palpitation (+) crackles on both lung fields Loose skin on abdomen Normal bowel sounds No abnormal mass upon palpitation (+) melena Loose flabby skin Muscle weakness fair skin tone Clubbing of nails Poor hand hygiene Uncut nails long (+) edema 3cm (+) diaper normal urinary function sexually inactive (+) distended veins on both legs abnormal skin color (freckles) Clubbing of nails abnormal bone structure on left toe abnormal skin tone (-) edema.

Anatomy and Physiology

Laboratory Examination
August 3, 2012 CBC RESULT WBC HGB 12.65 126 FLAGS + UNITS 10^3/uL g/L NORMAL RANGE 4 - 10 120 160 Interpretation
Increased in polycythemia vera,myelofibrosis and infection Decreased in various anemias, severe or prolonged hemorrhage and with excessive fluid intake Decreased in severe anemias, acute massive blood loss Risk for bleeding Increased with acute infection, trauma or surgery, leukemia, malignant disease, necrosis Decreased with aplastic anemia, immunodeficiency including AIDS Normal Increased with stress,use of some medication(ACTH, epinephrine,thyroxin)

HCT PLT NEUT% LYMPH% MONO% EO% BASO% RBC Indices RBC MCV MCH MCHC

0.36 74 0.82 0.05 0.12 0 0.01

+ 10^3/uL

0.37 0.47 150 - 450 0.5 0.7 0.2 0.4 0 0.14 0.01 0.03 0 0.01

3.78 79.40 29.90 37.70

10^6/uL fL Pg g/dL

2.5 5.5 81 - 99 27 - 31 33 - 37

Normal Decreased in microcytic anemia Normal Hereditary spherocytosis and immune hemolysis

August 10, 2012 ( 12:47nn)

CBC WBC HGB RESULT 8.28 113 FLAGS UNITS 10^3/uL g/L NORMAL RANGE 4 - 10 120 160 Interpretation
Normal Decreased in various anemias, severe or prolonged hemorrhage and with excessive fluid intake Decreased in severe anemias, acute massive blood loss Increased with acute infection, trauma or surgery, leukemia, malignant disease, necrosis Decreased with aplastic anemia, immunodeficiency including AIDS Normal Increased with stress,use of some medication(ACTH, epinephrine,thyroxin) Normal

HCT PLT NEU% LYMPH% MONO% EO% BASO% RBC Indices RBC MCV MCH MCHC

0.30 222.00 0.91 0.03 0.06 0 0

10^3/uL + -

0.37 0.47 150 - 450 0.5 0.7 0.2 0.4 0 0.14 0.01 0.03 0 0.01

4.42 80.50 28.50 35.40

10^6/uL fL Pg g/dL

2.5 5.5 81 - 99 27 - 31 33 - 37

Normal Decreased in microcytic anemia Normal Hereditary spherocytosis and immune hemolysis

August 10, 2012 (6 pm)

CBC WBC HGB RESULT 9.02 115 FLAGS UNITS 10^3/uL g/L NORMAL RANGE 4 - 10 120 160 Interpretation
Normal Decreased in various anemias, severe or prolonged hemorrhage and with excessive fluid intake Decreased in severe anemias, acute massive blood loss Increased with acute infection, trauma or surgery, leukemia, malignant disease, necrosis Decreased with aplastic anemia, immunodeficiency including AIDS Normal Normal Normal

HCT PLT NEU% LYMPH% MONO% EO% BASO% RBC Indices RBC MCV MCH MCHC

0.33 222.00 0.85 0.06 0.08 0.01 0

10^3/uL + -

0.37 0.47 150 - 450 0.5 0.7 0.2 0.4 0 0.14 0.01 0.03 0 0.01

4.11 79.80 29.70 37.20

10^6/uL fL Pg g/dL

2.5 5.5 81 - 99 27 - 31 33 - 37

Normal Decreased in microcytic anemia Normal Hereditary spherocytosis and immune hemolysis

Lipid Profile August 2, 2012 CHOL HDL TRI LDL GLUCOSE Result 137 52.5 88 66.9 94 Normal Value 0-200 40-60 0-150 0-100 70-105 Interpretation
Normal Normal Normal Normal Normal

August 3, 2012 INR Result 1.19 Normal Value 1.0 Interpretation There is increasing possibility of bleeding

% Activity Prothrombin Test APTT

60.9 14.2 sec 39.1 sec

9.8-12.7 26-37

Liver disease, Malabsorption, Vitamin K deficiency Liver disease, Malabsorption, Vitamin K deficiency

August 4, 2012 Potassium Conventional Potassium Result 3.2 low Normal Value 3.60-5 Interpretation Gastrointestinal losses, Diuretic administration Result 4.2 mmol/L Normal Value 3.5-5.1 Interpretation
Normal

Fecalysis Form
Character: soft Color: brown Occult blood: + (positive) Pus: none seen RBC: none seen Parasite or ova: neither ova nor parasite seen

Diagnostic Examination
Chest X-Ray Aug 1, 2012-Aug 5, 2012 Chest AP with obliquity Follow up study dated 08-05-12 compared with previous study dated 08-01-12 shows development of opacities in the right perihilar area and both lower lobes likely due to pneumonia. The bronchovascular markings are prominent with no definite active parenchymial infiltrates. The heart is enlarged The aorta is tortous and calcified at its knob. Diaphragm and sulci are intact. There are old healed fractures of the 5th-8th posterior ribs. Impression: -Cardiomegaly -Atheromatous Aorta -Old rib fractures, left

Pathophysiology
Predisposing factors: -Age -Gender -Race Exposure to a certain environment Precipitating Factors: -Alcoholism -Environment -Lifestyle

Staphylococcus Pneumoniea

Entry of Microorganism through nasal passages

Increase Neutrophils

Activation of Defense Mechanism

Loss effectiveness of the defense mechanism

Accumulation & Bacterial Replication in the Alveoli

Accommodation of Edematous Fluid

INFECTION/INFLAMMATION

Elevated White Blood Cells

Vasoconstriction

Cough and Crackles

Impaired Oxygen and Carbon Dioxide Exchange

DOB

Nursing Care Plan

Assessment Diagnosis
Subjective: Objective: - RR 30 - Use of accessor y muscles (nasal flaring) - (+) crackles on both lungs upon auscultat ion. - With nasal cannula at 2l/min - Po2 92% - Thick greenish secretion s with foul odor. Ineffective airway clearance related to increase production of secretions and increased viscosity.

Planning
After a series of nursing interventions patients Short term goal of 8hrs - Airway secretions will be lessened as evidenced by not using accessory muscles such as nasal flaring. Long term goal of 1week. - Airway secretions will be absent as evidenced by normal RR ranging from 1620, and absence of crackles upon auscultati on.

Intervention
Independent - Further establish rapport. - Position patient semi fowlers position. - Encourage fluid intake unless contraindicate d - Perform chest tapping Suction patients secretions - Encourage patient to perform deep breathing exercise. - Health teaching (Proper deep breathing exercise, disease process, prevention of complications and control of the disease.) Dependent - 0xygen administration. -

Rationale Evaluation
Independent -To gain trust of patient. -For better lung expansion. -To liquefy secretions. After a series of nursing intervention patients.. short term goal of 8hours. - Airway secretions were lessen as evidenced by not using of accessory muscles. (Goal met) Long term goal 1 week. - airway secretions was absent as evidenced by lowered RR from 33 to 25, And absence of crackles.

-To loosen secretions. -To lessen secretions. -To facilitate clear airway. Brunner

-For management of disease.

Dependent -to improve clinical signs and symptoms, patient comfort and adequate oxygenation.

Administer prescribed medications. Collaborative - Coordinate with radiologist for chest x-ray - Coordinate with dietician for proper diet. - Collaborate with laboratory for laboratory results.

Brunner -to promote better wellness. Collaborative -

Assessment Diagnosi s
Subjective: Objective: - Pitting edema of 3 cm upon palpation . - v/s: BP: 130/90 PR: 64 RR: 30 O2: 92% - Poor skin turgor - Intake: 580 Output: 400 Excess fluid volume r/t water/sodiu m retention AEB skin indentation of 3 cm upon palpitation

Planning
After series of nursing intervention patient Short term goal of 8hrs - Excess fluid will be removed AEB increased urine output. Long term goal of 1week. - Patients fluid will be normalize d AEB absences of pitting edema and normal I & O

Intervention
Independent - Further establish rapport. - Record I & O.

Rationale
Independent -to gain trust of patient.

Evaluation

After a series of nursing intervention patients.. -to record for any Short term goal dehydration. of 8hrs. - Excess - Weigh daily -to check if fluid as save the each weight loss or removed day weight gain. by intake of 500 - Assess difficult - to know extent and areas for of the edema increased edema (face, urine foot,legs,hand output of s,arms) 720. - Turning of -to prevent bed (Partially patient every 2 sore and proper Met.) hours. circulation. Long term goal - Patient Health -for management fluid was teaching of disease. normaliz (disease ed by process absence prevention of of pitting complication edema and control.) after I & Dependent Dependent O and - Prescribe - to promote weighing. meds by better wellness (Goal physician Met.) - Restrict or - To maintain administer equilibrium fluid as on patients indicated body fluids. Collaborative - Collaborate with dietician for proper diets. - Collaborate with laboratory for laboratory results.

Assessment Diagnosis
Subjective: Objective: - (+) blood in stool AEB fecalysis - Hgb 115g/L - Pale skin - Black tarry stool - Weak in appearan ce - Blood type O+ Impaired gastrointestinal tissue perfusion r/t Excess gastric acid manifested by black tarry stool.

Planning
After a series of nursing intervention patient Short term goal of 8hrs. - Patients bleeding will prevented as evidenced by absence of black tarry stool Long term goal of 1 week - Good gastrointest inal perfusions. As evidenced by (-) blood in stool.

Intervention
Independent - Further establish rapport - Monitor I & O

Rationale Evaluation
Independent -to gain trust of patient. -to monitor for any dehydration. After a series of nursing intervention patient Short term goal of 8hrs. - Patient bleeding was lessen as evidenced by stool color consistenc y. (Goal Partially Met) Long term goal of 1 week - Patient gastrointes tinal perfusion was good as evidenced by. (-) blood in stool.

- To monitor any change in health status of the - Health Teaching patients. (Disease process, -for Prevention of management complication and of disease. control.) Dependent - Monitor meds prescribed by Dependent physician - to promote Collaborative better - Collaborative wellness with lab with laboratory result. - Collaborate with dietician for proper diet.

Monitor v/s and possible GI bleeding

Discharge Planning

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 the guardians to wash patients 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 guardians 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.