COMMUNITY ACQUIRED PNEUMONIA

A Case Study Presented to The Clinical Instructors AUP College of Nursing Silang, Cavite

In Partial Fulfillment Of the Requirements in NMSN 325 Presented by:

Evans, Mochah M.

July 24, 2012

I.

DEFINITION

Pneumonia is the inflammation of the lung parenchyma caused by infection. The inflammation is triggered by many infectious organisms and irritating agent. Due to inflammation process, fluid accumulates in the lungs hindering gaseous exchange. Communityacquired pneumonia refers to pneumonia acquired outside of hospitals or extended-care facilities. (ignatavicius and workman 2010). The Philippines ranks among the top 10 countries with the most recorded pneumonia cases. About 9,000 Filipino children die from the disease every year. In 2007, there were 605,471 reported pneumonia cases. Children and babies who develop pneumonia often do not have any specific signs of a chest infection but develop a fever, appear quite ill, and can become lethargic. Elderly people may also have few symptoms with pneumonia Globally, 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 and elderly worldwide. Pneumonia affects children and families everywhere, but is most prevalent in South Asia and sub-Saharan Africa. Ignatavicius and Workmann stated that in the United States 2 to 5 million cases of pneumonia occur each year and its the seventh leading cause of death. The highest incidence among adult occur in older adult, nursing homes resident, hospitalized patent and those being mechanically ventilated (p659). The Centers for Diseases Control and Prevention (CDC) estimate that pneumococcus is the most common community-acquired pneumonia. (http://www.aahs.org/quality/quality_measures.php?cat=pneu).

II.

TYPES OF PNEUNONIA A. ACCODING TO SETTING OF ACQUISITION a. Community-acquired pneumonia

Community-acquired pneumonia (CAP) occurs either in the community setting or within first 48 hour of hospitalization or institutionalization. Hospitalization of this condition depends on the severity of pneumonia. Most people get CAP by breathing in germs (especially while sleeping) that live in the mouth, nose, or throat. CAP is the most common type of pneumonia. Most cases occur during the winter. (Bare B. & Smeltzer S.2008). b. Hospital-Acquired Pneumonia This is a type of pneumonia is acquired during hospital stay for another illness. Its also known as nosocomial pneumonia. Patients are at higher risk of getting HAP if they're on a ventilator (a machine that helps you breathe). The onset of this pneumonia symptoms starts more than 48 hours of hospitalization. HAP tends to be more severe compared to CAP because of existing infections. Also, hospitals tend to have more germs that are resistant to antibiotics (medicines used to treat pneumonia). (Bare B. & Smeltzer S.2008). c. Ventilator-associated pneumonia This type affect patients are intubated and mechanically ventilated. The endotracheal tube keeps the glottis open, so secretion can be aspired into the lungs. (Williams and hopper 2007) B. ACCORDING TO CAUSATIVE AGENT a. Aspiration Pneumonia

This refers to the consequences resulting from entry of endogenous or exogenous substances gaining access to the lower airways. The most common cause is infection from aspirated bacteria that normally resides at upper respiratory airways.(Williams & Wilkins, 2010). It can occur in community or hospital. The most common bacteria are Streptococcus pneumonia, hemophilia influenza, and staphylococcus aureus. Other causes may include, gastric content, chemical or irritating gases inhale food, drink, vomit, or saliva from your mouth into your lungs. This may happen if something disturbs your normal gag reflex, such as a brain injury, swallowing problem, or excessive use of alcohol or drugs. (Joyce M. Black 2009) b. Bacterial pneumonia : This type of pneumonia is caused by different types of bacteria. The most pneumonia inducing bacterium is Streptococcus pneumoniae. This pneumonia types generally affects people who have weakened immune system for reasons like old age, illness, malnutrition etc. (Lewis, et al 2008) c. Viral pneumonia : This Type of pneumonia can be caused by different types of viruses. The most common forms of viruses causing viral pneumonia are flu virus, parainfluenza virus, herpes simplex virus, rhinovirus, adenovirus, Hantavirus, cytomegalovirus and respiratory syncytial virus.(lemone &burke 2007) d. Fungal pneumonia : This is rare types of pneumonia. The fungus causing this type of pneumonia is Pneumocystis carinii. Its common among people with weak immune system or immunosuppressed. Often pneumocystis carinii pneumonia is described as a complication 4

experienced by patients with diseases that weaken the immune system such as AIDS, Cancer etc. (Leone &burke 2008) . e. Hypostatic pneumonia This type is related to patients who hypoventilate because of bed rest, immobility or shallow respiration. Secretions pools in dependent areas of the lungs and can lead to inflammation and infection (Williams and hopper 2007) f. Chemical pneumonia Inhalation of toxic chemicals can cause inflammation and tissue damage, which will lead to chemical pneumonia. (Williams and hopper 2007) g. Atypical Pneumonia (Walking Pneumonia) This refers to pneumonia that is mild enough so that you are not bedridden. The condition can be treated without hospitalization. It is caused by mycoplasma pneumonia Legionella pneumophila, mycoplasma pneumonia, and Chlamydophila pneumoniae It is known as atypical because its presentation and its course significantly differ from other bacterial pneumonia (lemone and Burke, 2008) C. ACCORDING TO THE PART IT AFFECT a. Lobar pneumonia As the name suggest, this types affect one or more lobes of the lungs. It can be anywhere in the lobe and may include both lobes. (Tampano, and Lewis, 2012) b. Bronchopneumonia or lobular pneumonia 5

This type affects the epithelial cells of distal airways and alveoli part of the lungs causing consolidations thereby decreasing gaseous exchange. (Tampano, and Lewis, 2012) c. Interstitial pneumonia This type is characterized by progressive scarring of both lungs. (Tampano, and Lewis, 2012) III. DEMOGRAPHIC PROFILE

Name: Rachel (not real name) Address: 391 Summitville Putatan municipality Sex: Female Civil status: widowed Academic attainment: unknown Birthdate: December 18, 1918 Nationality: Filipino Religion: Baptist Date of admission: June 29, 2012 Time of admission: 2:15 pm Admitting diagnosis: community acquired pneumonia t/c PTB Chief complaint: difficulty of breathing and fatigue 6

Admitting vital signs: Temperature 37.7 oC , Respiratory rate 32, Pulse rate 89, Blood pressure 90/110, Oxygen saturation 93% VI. FAMILY MEDICAL HISTORY

V.

PAST MEDICAL HISTORY

Rachel past medical history was hard to retrieve since the watcher did not know. This is due to the patient age. Since the patient has advance age no one had exact information regarding to the Patient. But as much as the watcher could recall, Rachel has never been hospitalized. VI. HISTORY OF PRESENT ILLNESS

Seven (7) days prior to admission, the patient developed difficult of breathing together with productive cough which attacked more during the night time. Expectorate was greenish brown. This was associated with undocumented fever. She decided to seek medical attention at Alabang medical center where she was treated.(Pulmo-dual nebulization) and allowed to go home. Hours prior to admission, had difficult of breathing and severe cough, that prompted her to seek medical attention at Ospital ng Muntinlupa (and was subsequently admitted). VII. GORDONS PHYSICAL ASSESSMENT

a. Health Maintenance Perception Pattern Rachel has no history of smoking or drinking alcoholic beverages. She was active before this ailment. She used to walking around their compound with her grandchildren, this gave her happiness. Prior to admission, she complains of cough, which usually occurs during the night. No allergies on medications were documented. b. Nutritional Metabolic Pattern Before admission, Rachel was not under any special diet. She used to have 3 meals a day with good appetite. She was not taking any dietary supplements. During hospital confinement she had a decreased appetite and she was under soft diet. Her ability to swallow is not impaired. c. Elimination Pattern

Before hospitalization Rachel had 2 times bowel movement, but during hospitalization, under my care the patient she had no bowel elimination. Patient had urinary incontinence and she was wearing a diapers. Normally the diaper was changed once under my shift. d. Activity and Exercise Before hospitalization, the Patient was able to go to the comfort room with minimal assistance. As it was reported by the significance others, assistance was needed to accompany her to prevent injury and falls. Patient also did not need assistance during feeding. However, she needs assistance when walking far distances and when climbing the stairs. During hospitalization, the patient was fully dependent in all aspect of daily living. She is now immobilized which put her at risk of developing complications. e. Rest/Sleep Pattern Before Rachel used to sleep is 6-7 hours. She was normally sleep between 8- 9 PM and wakes up early at 6:00 in the morning. Prior to admission, her sleeping pattern was altered due to frequent episodes of coughing, which usually occurs during the night. During hospital stay her sleeping pattern was disturbed minimally. She started sleeping only for 5 hour but with some episodes of waking up by nurses and doctor. But it was tolerable. Also she complained of the environment, which looked strange to her. f. Cognitive-Perceptual Pattern Rachel has a problem with speech and hearing. She was alert but was not able to respond appropriately because of lack of teeth. Before admission, her usual complaints are cough and difficulty of breathing. She also had episodes of chest pain prior to admission. g. Role-Relationship Pattern

She was a widow for several years now. She seems to treasure the relationship she had. This is evidenced by the fact that she still has a wedding ring. It was reportedly that she normally says that by not throwing the ring its because she still loves her husband. She usually stays in their house with her grandchildren. h. Sexuality-Reproductive Pattern N/A i. Coping-stress Tolerance / Self-Perception / Self-Concept Pattern Rachel has to deal with loss when her husband died. She talks with her grandchildren during and that time to find comfort. j. Value-Belief Pattern Rachel is a passive member of Baptist church. She does not attend church services but she does her routine prayers. VIII. DEVELOPMENTAL TASKS Developmental task Integrity versus despair Theorist Erikson Status The developmental task at this time, according to Erikson, is ego integrity versus despair. People who attain ego integrity view life with a sense of wholeness and derive satisfaction from past accomplishments. They view death as an acceptable completion of life. For my patient, i had no chance to have her views about life due language incoherent. But from my assessment she seemed to take hospitalization as a

10

punishment in life. (Kozier and Erb, 2008, p. 416).

Genital Stage

Freud

Rachel is 93 years old, in which she can be categorized in the Genital Stage. In this stage, the client is expected to have her energy directed toward full sexual maturity and function and development of skills needed to cope with the dynamic environment. This implies that the patient should have the full independence and has the capability of making decisions for herself. The patient is unable to make sound judgment. She cannot perform tasks without assistance such as, going to the bathroom. There is also negative implication due to loss of spouse. At this age, they are supposed to support and encourage each other (Kozier and Erb, 2008)

Formal operation

Piaget

Use of rational thinking and reasoning is deductive and futuristic. The patient used to achieve this stage since the range of the age ids

11

from 11-15years old. She is not futuristic right now. She does not know what could possibly happen to her because she is not yet ready to accept the fact that the reality that she is sick. (Kozier and Erb, 2008, ).

Late maturity

Havighurst Robert Havighurst believed that learning is basic to life and that people continue to learn throughout life. He described growth and development as occurring during six stages, each associated with six to ten tasks to be learned. In relation with the patients age, she has to develop specific tasks, and one of which is adjusting to physical strength and health. Patient has been diagnosed with community-acquired pneumonia. This gives her hard time to adjust to hospital confinement. Other tasks include, adjusting to death of spouse, establishing an explicit affiliation with ones age group. (Kozier and Erb, 2008).

12

Post conventional: universal focus

Kohlberg

This theory specifically addresses moral development in children and adults. The morality of an individuals decision was not Kohlbergs concern; rather, he focused on the reasons an individual makes a decision. Rachael is in the Post conventional Level of Kohlbergs theory as she lives autonomously and defines moral values and principles that are distinct from personal identification with group values (Kozier and Erb, 2008, p. 359). At her age now she is impaired judgment due to advance in age.

IX.

PHYSICAL ASSESSMENT a. Vital signs

Date Time

6/29/2012 2.15 PM

7/2/2012 8:00 AM 12:00 PM

7/3/2012 8:00 AM

7/4/2012 8:00 AM 12:00 PM

T PB RR BP

38.0 89 33 90/110

37.2 86 26 110/70

36.7 86 32 100/70

36.9 84 28 110/70

37.2 80 26 120/80

37.4 82 28 110/70

13

b. Systemic assessment Systems Normal findings Actual patient findings - Well appearance, body Physical appearance symmetry, no obvious deformity. -Limbs should appear proportional. -Speech should be clear and understandable. - Breathing should be effortless, without cough or wheezing. -Patient should be willing to move all body parts freely. - Vital Signs: RR= 12-20 bpm PR= 60-100 bpm Temp 36.5C 37.2C BP= 90-130/60-90 A -Clean and well groomed - Client is well - Poor clothing may be an -Patient appears skinny and weak. -Limbs are thin with prominent blood vessels. -Speech was slurred. - Patient was unable to move. -Struggle while breathing - Vital Signs: RR= 32 PR= 89 Temp 37.4.C BP= 110/70 (7/4 2012) - An increase in RR is present in hyper metabolic and hypoxic states due to bacilli damaging the alveolar cell lining thus impairing the gas exchange which then results to an increase RR for the body to meet the bodys demands. (Weber and Kelly 2007) Significance

14

Neurological system

wearing appropriate clothing for age, and weather. -Smooth coordinated movements. -Expresses good feelings appropriate to situations -Expresses full and free flowing thoughts during interview -Aware of self, others, place and time -Correctly answers questions about current days activities; recalls significant past events

groomed and dressed appropriately. - Client is alert, and incoherent. -weak motor response - confused utter understandable words

indication of depression. - Cognitive impairment is caused by a number of syndromes such as dementia. - Elderly speech and motor function degenerate as they advance in age. The is caused due to decrease of nerve myelination (Weber and Kelly 2007)

Gastrointestinal -The contour of the system abdomen should be rounded or flat and symmetrical - No masses or nodules. - Uniform in color and

- No masses or nodules present. - Abdomen is unsymmetrical not uniform in color and pigmentation.

- decreased bowel sound signify signs of constipation or likelihood of developing constipation(Weber and Kelly 2007)

15

pigmentation. - Normal wt. 128-156 lbs. or 58-70kg.

- Bloated is observed. -decreased bowel movement

-Skin is uniform whitish Integumentary system pink or brown color, depending on the patient`s age. -Temperature should be

- Skin is dark brown and not uniform. - Hair white and evenly distributed.

- An increase in temperature may be caused by infection, trauma, sunburn, or windburn. - Skin crust is a serum/blood that has been dried in the surface of the skin. -.increased pigmentation is cause due to the decrease of melanin in the body(Waugh A. and grant A. 2008)

warm and equal bilaterally - Skin is warm to -Pitched-up skin returns immediately to original position -No swelling, pitting or edema -Hair varies from dark black to plonde based on the amount of melanin present and should be evenly distributed -The nails have pink cast in light-skinned individuals and are brown touch. -skin and nail bed pale, -pale conjunctiva -decreased skin turgor, -increased skin pigmentation, -thin and dry skin, -Capillary refill 4 seconds

16

in dark-skinned individuals with capillary refill returning to its normal within 2-3 seconds. Urinary system - The bladder should not be distended. -There should be no problem urinating, no presence of hematuria or dysuria. - Color should be amber yellow. - OU should not be 30cc/hr - Patients bladder is not distended. - Theres no hematuria, or dysuria when urinating. - OU is 100cc the whole shift. (total intake is 250cc) The urine output should be almost or equal to the input. If there is a deviation it may signify fluid accumulation(Weber and Kelly 2007)

-No vibrations or Circulatory system pulsations are palpated in aortic, pulmonic or tricuspid area -Rhythm should be regular - Radial pulse weak and apical pulse, strong and irregular. -Capillary refill is

- Pulmonary stenosis impedes blood flow form the right ventricle into the lungs, causing a bulge. - A systolic pulsation can result from the right

17

-Rate is 60-100 beats per minute -Radial pulse and apical pulse should be identical -Bilateral pulses strong and equal -Capillary refill within 2-3 seconds Respiratory system -The normal respiratory rate is 12-20 breaths per minute being regular and even in rhythm -The normal depth of respiration is nonexaggerated and effortless -Thorax rises and falls in unison in the respiratory cycle -Normal inhalation and exhalation is through the nose -light yellow or clear small amount of sputum

within 4 seconds.

ventricular enlargement secondary to an increased stroke volume. - A capillary refill within 3 seconds signifies a poor blood circulation.

- Productive cough without expectoration. - RR= 32 bpm - (+) Crackles heard upon auscultation in lower lobes of both lungs. - Difficulty breathing - Exaggerated respiration; use of accessory muscle when breathing.

-Bacteria or infection irritates the endothelium of the lungs which leads to excessive mucus production. -excessive mucus and some of the fluid accumulation caused fine crackles -difficulty of breathing is as a result of extended accumulation of fluid in the pleural space that reduces lungs compliance(Waugh A. and grant A. 2008)

18

which is odorless -Normal lung tissue produces a resonant sound -Symmetrical structure and development of muscles.

LYMPHATIC SYSTEM

- WBC(5-10 X 10 9/L - Lymphocytes 0.250.35 - Monocytes 0.03-0.07 - Eosinophils 0.01-0.03 - Basophils 0-0.01 - Neutrophils 0.40-0.60

WBC-17.91

Elevation of white blood cell and lymph nodes are an

0.08

indication of infection in the lungs(Weber and Kelly

0.04

2007)

0.50

0.00

0.88 Musculoskeletal - Muscle equal in size - No tremor - No protrution of body prominence Muscle wasting all over the body. - Weak muscle strength. - protruding body Muscles may exhibit atrophy. Atrophy occurs as the cells in tissue shrink. The cause of this cell shrinking is unknown, but

19

prominent

may be due to reduced use, decreased workload, or reduced stimulation by nerves. (Weber and Kelly 2007)

X.

Diagnostic Test Results and Significance NORMAL VALUES RESULTS SIGNIFICANCE

NAME OF TEST

HEMATOLOGY WBC - Lymphocytes - Monocytes - Eosinophils - Basophils - Segments - Platelet count - Reticulocytes - MCV - MCH - MCHC - RBC 5-10x109/L 0.20-0.40 0.25-0.35 0.03-0.07 0.01-0.03 0-0.01 150-450 5-15x109/L 140-450/L 80.0-97 26.0-31.0 4.5-5.5x109/L 17.91 0.08 0.04 0.50 0.00 0.88 290 0.00 81 78.0 28.2 4.43 20

-elevated WBC indicates possible acute infection or inflammation or pneumonia, meningitis, or empysema. - Decreased MCV may indicate iron and thalassemia deficiency. -decreased RBC and hemoglobin indicates reduced tissue oxygenation.(Keogh J, 2010)

- Hemoglobin - Hematocrit

125-160g/L 0.38-0.50%

122 0.36

OXYGEN SATURATION

95% (Pagana, 2011)

93%

- This indicates that there is decreased oxygen concentration to the tissues due to lungs problem. (Pagana, 2011)

GRAM STAIN and culture

WBC 5-10x 10/L Epithelial cells:Tiny plemorphic

Presence of bacteria. Streptococcus pneumoniae 20-30/Lpf Gr(+) cocci in pairs in chains+++

- A Gram stain and culture of the material from an infected site are the most commonly performed microbiology tests used to identify the cause of an infection. This will allow appropriate antibiotic.(Keogh J, 2010)

It is used to differentiate bacterial species

(+) cocci in singles and pairs

X-ray

No nodules, no scarring, no lesions, no fluid in the spaces of the lungs

Cardiac shadow is enlarged with the chamber enlarged. Brocho-pulmonary marking appear prominent. Course

- Presence of nodules and lesion may predispose consolidation. The presence of fluid in the pleural spaces may indicate pleural effusion. Both situations decrease the lungs

21

reticular opacities seen in both lower lungs field associated with haziness. There is fibro hazed and calcified densities noted in the apices with biapical pleural thickness. Aorta is mildly dilated and tortious. Its knobs calcified, both sulci are blunted, severe dextroscoliosis n of the thoracic spine.

compliance.(Keogh J, 2010)

22

XI.

ANATOMY AND PHYSIOLOGY

The lungs are sponge like, elastic, cone-shaped organs located in the chest cavity in the chest. The lung itself is covered with a membrane called the visceral (or pulmonary) pleura. The visceral pleural is adjacent to the lining of the thoracic cavity which is called the parietal pleura. Between the two membranes is a thin, serous fluid which acts as a Lubricant reducing friction as the two membranes slide across one another when the lungs expand and contract with respiration. The surface tension of the Pleural fluid also couples the visceral and parietal pleura to one another, thus preventing the lungs from collapsing. Since the potential exists for a space between the two membranes, this area is called the pleural cavity or pleural space The apex (top) of each lung extends above the clavicle; the base (bottom) of each lung lies just above the diaphragm (major muscle for inspiration). McCance K.L. & Huether S.E. (2010). Gas exchange occurs in the lobule of the lungs. Each lobule is supplied by a branch of a terminal bronchiole, an arteriole, the pulmonary capillaries and a venule. Gas exchange takes place in the terminal respiratory bronchioles and the alveolar ducts and sacs, referred to as the respiratory zone. Blood enters the lobules through a pulmonary artery and exits through a pulmonary vein. Lymphatic structures surround the lobule and aid in the removal of plasma proteins and other particles from the interstitial spaces. (Waugh A. and grant A. 2008) Unlike the larger bronchi, the respiratory bronchioles are lined with simple epithelium rather than ciliated pseudo stratified epithelium. The respiratory bronchioles also lack the cartilaginous support of the larger airways. Instead, they are attached to the elastic sponge like tissue that contains the alveolar air spaces. The alveoli are the terminal air spaces of the respiratory tract and the primary site of gas exchange. Each alveolus is a small out pouching of respiratory bronchioles, alveolar ducts, and 23

alveolar sacs. The alveolar sacs are cup-shaped thin-walled structures that are separated from each other by thin alveolar septa. A single network of capillaries occupies most of the septa, so blood is exposed to alveolar air on both sides of the capillary. Unlike the bronchioles, which are tubes with their own separate walls, the alveoli are interconnecting spaces that have no separate walls. As a result of this arrangement, there is a continual mixing of air in the alveolar structures. Small holes in the alveolar walls, the pores of Kohn, also contribute to the mixing of air. The alveolar epithelium is composed of two types of cells: type I and type II alveolar cells. The alveoli also contain brush cells and macrophages. The brush cells, which are few in number, are thought to act as receptors that monitor the air quality of the lungs.( McCance K.L. & Huether S.E. (2010). The type I alveolar cells, also known as type I pneumocytes, are extremely thin squamous cells with a thin cytoplasm and flattened nucleus that occupy about 95% of the surface area of the alveoli. They are joined to one another and to other cells by occluding junctions. These junctions form an effective barrier between the air and the components of the alveolar wall. Type I alveolar cells are not capable of cell division. The type II alveolar cells, also called type II pneumocytes, are small cuboidal cells located at the corners of the alveoli. The type two cells synthesize pulmonary surfactant, a substance that decreases the surface tension in the alveoli and allows for greater ease of lung inflation. They are also the progenitor cells of type I cells. After lung injury, they proliferate and restore both type I and type II alveolar cells. Pulmonary surfactant is a complex mixture of phospholipids, neutral lipids and protein that is synthesized in the type II alveolar cells. The surfactant molecules produced by the type II alveolar cells reduce the surface tension at the air-epithelium interface and modulate the immune

24

functions of the lung. Recent research has revealed four types of surfactant, each with different molecular structure: surfactant proteins A (SP-A), B (SP-B), C (SP-C), and D (SP-D). SP-B and SP-C reduce the surface tension at the air-epithelium surface and increase lung compliance, which increases volume of air entering the lung and decreases the work of inhalation. SP-A and SP-D do not reduce surface tension, but contribute to host defenses that protect against pathogens that have entered the lung. Collectively, they opsonize pathogens, including bacteria and viruses, to facilitate phagocytosis by macrophages. They also regulate the production of inflammatory mediators evidence also suggests that SP-A and SP-D are directly bactericidal, meaning they can kill bacteria in the absence of immune system effector cells. (Ignatavicius D. & Workman M. L (2010). XII. Pathophysiology of the Disease Entity

Upper airway characteristics normally prevent potentially infectious particles from reaching the normally sterile lower respiratory tract. Pneumonia arises normally from present flora in a patient whose resistance has been altered, or it results from aspiration of flora present in the oropharynx. Another route of infection is through the inhalation of microorganisms that have been released into the air when an infected individual coughs, sneezes, or talks, or from aerosolized water, such as that from contaminated respiratory therapy equipment. (Joyce M. Black 2009) Pneumonia can also occur when bacteria are spread to the lungs in the blood from bacteremia that can result from infection elsewhere in the body or from intravenous drug abuse. Loss of the cough reflex, damage to the ciliated endothelium that lines the respiratory tract, or impaired immune defenses predispose to colonization and infection of the lower respiratory system. Bacterial adherence also plays a role in colonization of the lower airways. The epithelial cells of 25

the critically and chronically ill persons are more receptive to binding microorganisms that cause pneumonia. The initial step in the pathogenesis of streptococcus pneumoniae infection is the attachment and colonization of the organism to the airway passages. If a microorganism gets past the upper airway defense mechanisms, such as the cough reflex and mucociliary clearance, the next line of defense is the alveolar macrophage. This phagocyte is capable of removing most infectious agents without setting of significant inflammatory or immune responses. However, if the microorganism is virulent or present in large enough numbers, (1) it infects type II alveolar cells, which are responsible for the production of surfactant. Pulmonary surfactant is a complex mixture of phospholipids, neutral lipids, and proteins that is synthesized in the type II alveolar cells. The surfactant molecules produced by the type II alveolar cells reduces the surface tension at the air-epithelium interface and modulate the immune functions of the lungs. The reduced surface tension increases lung compliance, which increases volume of air entering the lung and decreases the work of inspiration. (lenone and burke 2008) The virulent number of organisms also triggers the organism to (2) release endotoxins, which stimulates the goblet cells of the epithelial lining to secrete mucus, and triggers the release of some chemical mediators, including the prostaglandins, histamine, and bradykinin. These chemical mediators increase the vascular permeability, and specifically with bradykinin attracts neutrophils. The pathologic process of staphylococcus aurius pneumonia can be divided into the four stages congestion, red hepatization, gray hepatization, and resolution. Lewis S.M. et al. (2005). Congestion occurs when the chemical mediators attract the white blood cells, especially the neutrophils, which cause the alveoli to be filled with a protein-rich edema fluid containing 26

numerous organisms and vasodilation. Marked capillary congestion follows, leading to massive outpouring of polymorphonuclear leukocytes, bacteria and other exudates. These exudates can extend into the pleural cavity and cause empyema. Empyema is the accumulation of purulent exudates in the pleural cavity. Exudates may also go to into the bloodstream, causing sepsis and septic shock.(Mccance K. and Huether E. 2010) The massive outpouring of the exudates causes a collection of fluid around the alveoli. The fluid leaks into pleural cavity. Red blood cells and fibrin migrate into the damaged alveoli trying to repair the destroyed portion. This gives the lung dry, dark-reddish appearance and it is called the red hepatization stage. Solidification of the lung (consolidation) also occurs during this stage.( Sharon L, Lewis et al 2012) Fibrin, a protein responsible for clotting, causes the lung to be stiff as if forms thread-like fibers. This causes lungs to decrease its compliance due to its incapability to expand completely. The amount of air inhaled also decreases, causing a shunt-type ventilation-perfusion mismatch. A decreased in arterial oxygenation can lead to hypoxemia. However, after two or more days depending on the success of the treatment, macrophages arrive at the site and ingestion of the debris occurs. Fibrin and epithelial cells repair the site. Because of fibrin deposition over the pleural surfaces and the presence of fibrin and leukocytes (neutrophils) in the consolidated alveoli, where phagocytosis is rapidly taking place, the lungs appear firm and gray color. This is the gray hepatization stage. With resolution, increasing number of macrophages appears in the alveolar spaces, the neutrophils degenerate and the exudates are gradually removed. The fibrin threads and the remaining bacteria are ingested by macrophages and removed by the lymphatic vessels or becomes a scar.( Lewis et al.. . 2011)

27

28

29

30

31

XIII. Nursing Care Plan Problem #1: Difficulty of breathing (July 2, 2012) Subjective Objectives Restlessness Tachpnea Difficulty vocalizing Pallor Pale nail beds Capillary refill: 4 seconds Irritability Positive crackles in both lower lobes upon auscultation Productive but non expectorated cough Use of accessory muscles RR-32 Bpm (N-12-20) CXR reveals: lung consolidation

Nursing diagnosis: Impaired gas exchange related to destruction of the lung tissues secondary to pneumonia Rationale: By the process of diffusion, the exchange of oxygen and carbon dioxide occurs in the alveolar-capillary membrane area. The relationship between air flow and blood flow affects the efficiency of gas exchange. Conditions that cause changes or collapse of the alveoli would be: impaired ventilation, presence of secretions, or altered oxygen carrying capacity of the blood from reduced hemoglobin. Gulanick/Myers, Nursing Care Plans 6th Edition 2007 (Pg.78) Nursing diagnosis: Ineffective airway clearance related to increased mucus production secondary to bacterial infection

32

Rationale: The inflammation and increased secretions seen with pneumonia patients make it difficult to maintain a patent airway. Joyce M. Black, Medical Surgical Nursing 8th Edition 2009. (Page 1599)

Nursing diagnosis: Ineffective Breathing Pattern related to accumulation of bacteria in the alveolus secondary to pneumonia

Rationale: streptococcus pneumoniae breaks down elastin in the connective tissue of the lungs resulting to alveolar walls destruction thereby many clients experience compensatory tachypnea because of an inability to meet metabolic demands. This occurs because affected alveoli cannot effectively exchange oxygen and carbon dioxide. Joyce M. Black, Medical Surgical Nursing 8th Edition 2009. (Page 1599) Expected outcomes NOC: Respiratory Status: Gas Exchange, Ventilation and Airway Patency, Short term: After 30 minutes of nursing interventions, the patient will be able to demonstrate ways to relieve from DOB like deep breathing and positioning herself in an upright position, Long term: After 8hours of nursing intervention, the patient will be able maintain airway patency. Nursing interventions: NIC: Respiratory Monitoring, Ventilation Assistance, and Airway Management Independent Assessed lung sounds, respiratory rate and effort use of accessory muscles

33

-Respiratory rate <12 or >24 may indicate an ineffective pattern or use of accessory muscles indicates distress.( Gulanick/Myers, 2007) -Diminished lung sounds indicate possible poor air movement and impaired gas exchange. ( Gulanick/Myers, 2007) -Crackles and wheezes may indicate excess secretions in airways. ( Gulanick/Myers, 2007) Elevated head of bed Upright positioning promotes lung expansion, mobilization and expectoration of secretions to keep the airway clear.. ( Gulanick/Myers, 2007) Provided opportunities for rest To reduce fatigue. ( Gulanick/Myers, 2007) Monitored amount, color and consistency of sputum Thick, purulent sputum indicates infection and should be reported to the physician. ( Gulanick/Myers, 2007) Encouraged small but frequent oral fluid intake Hydration decreases viscosity of secretions and aids expectoration. ( Gulanick/Myers, 2007)

Encouraged family members to feed client during rest periods. Rested patients may have less difficulty with swallowing. ( Gulanick/Myers, 2007) Determined best resting position for the patient e.g. patient propped on right side after feeding

34

Upper airway patency is facilitated by upright position and turning to right side decreases likelihood of drainage into trachea. ( Gulanick/Myers, 2007) Auscultated breath sounds for development of crackles Aspiration of small amounts can occur without coughing or sudden onset of respiratory distress, especially in patients with a decreased level of consciousness. ( Gulanick/Myers, 2007) Dependent Administered expectorants as ordered (fluimucil) Expectorants help liquefy secretions and trigger the cough reflex..( Gulanick/Myers, 2007) Monitored IVF of D5LR 1L x 16o (20-21 gtt/ml) Promotes hydration that able to enhance ability to do activities, .( Gulanick/Myers, 2007) Administered oxygen as ordered. Aid in correcting the hypoxemia that may occur secondary to diminished alveolar lung surface. ( Gulanick/Myers, 2007) Administered pneumonia drugs as ordered such as ampicillin 750mg IV every 2 hours and azithromycin 500mg IV every 4 hours.( Gulanick/Myers, 2007) Evaluation Goal met: Short term: After 30 minutes of nursing interventions, the patient demonstrated ways to relieve from DOB like deep breathing and positioning herself in an upright position, Goal partially met: 35

Long term Goal met: After 8hours of nursing intervention, the patient was be able to maintain airway patency but with some exerted effort while breathing. Problem #2 choking Subjective Objective Tachypnea 32bpm (N12-20) Difficulty of breathing Feeding while lying supine on bed Age(93) Nursing diagnosis: Risk for aspiration related to irregular patterns of breathing secondary to inflammatory response. Rationale: Patient who has persistent coughing is at risk of aspiration due to the food or liquid being ingested may go to the airway instead of the stomach. (Brunner & Suddarths Medical Surgical Nursing 10th edition 2008) Expected outcomes NOC: Aspiration Control Production of secretions(greenish brown) Watcher perform oral care as pt is on supine positions

36

Short term: After 30 minutes of nursing interventions, the patient will be able to demonstrate ways on preventing aspiration such as eating on an upright position, small and frequent feeding, and chewing food thoroughly. Long term After 8 hours of nursing intervention the patient will be free from any form of aspiration by abiding to the guidelines given Nursing interventions: NIC: Aspiration precautions Independent Encouraged family members to do oral care after meals This removes residual food that can be aspirated at a later time.( Gulanick/Myers, 2007) Kept head of bed elevated when feeding and for at least a half an hour afterward Maintaining a sitting position after meals may help decrease aspiration.( Gulanick/Myers, 2007) Monitored for choking during eating or drinking Choking indicates aspiration.( Gulanick/Myers, 2007) Encouraged the patient to chew thoroughly and eat slow during meals Well-masticated food is easier to swallow. (Gulanick/Myers, 2007) Evaluated swallowing ability by assessing for coughing, choking and after swallowing Coughing and choking are indicative of aspiration.( Gulanick/Myers, 2007) 37

 Assessed patient`s ability to swallow and strength of cough reflex and evaluated amount of secretions Helps to determine the presence /effectiveness of protective mechanisms.( Gulanick/Myers, 2007) DEPENDENT Administered oxygen as ordered through cannula rate of 2-3l/min Aid in correcting the hypoxemia that may occur secondary to diminished alveolar lung surface.( Gulanick/Myers, 2007)

Evaluation Short term Goal met: After 30 minutes of nursing interventions, the patient will be able to demonstrated ways on preventing aspiration such as eating on an upright position, small and frequent feeding, and chewing food thoroughly Long term Goal met: After 8 hours of nursing intervention the patient was free from any form of aspiration by abiding to the guidelines given. Problem #3 decreased bowel moment Subjective Objective Hard stool No defecation for 2 days Hypoactive bowel sounds 2bowel sound per minute (N 520)

38

 Urine incontinence Bloated abdomen

Hard formed stool

Nursing diagnosis: constipation related to abdominal muscle weakness secondary to advance in age Rationale: Expected outcome NOC: Bowel movement Short term: After 30 min. of nursing intervention, the patient will be able to understand the importance to increase fluid intake so as help in softening the impacted or hard stool. Long term: After 2 days. Of nursing intervention, the patient will be able regain normal pattern of bowel functioning. Nursing interventions NIC: constipation management Independent Encourage activity and exercise within limit of individual ability To stimulate the contraction of the intestines.( Gulanick/Myers, 2007) Determine and Promote adequate fluid intake To promote passage of soft stool.( Gulanick/Myers, 2007) Encourage diet of balanced fiber, bulk and fiber supplements To improve the consistency of stool and facilitate passage through the colon.( Gulanick/Myers, 2007) Note the general dental or oral health issues To evaluate dietary intake.( Gulanick/Myers, 2007) 39

 Monitor input and out put To evaluate if the hydration of the patient.( Gulanick/Myers, 2007) Dependent Monitored IVF of D5LR 1L x 16 (20-21 gtt/ml) Promotes hydration that able to enhance ability to do activities, .( Gulanick/Myers, 2007) Evaluation Short term Goal met After 30 min. of nursing intervention, the patient was be able to understand the importance to increase fluid intake so as help in softening the impacted or hard stool Long term Goal partially met After 2 days. Of nursing intervention, the patient was be able regain normal pattern of bowel functioning but defecated 2 times.

Problem #4: loss of appetite (July 2, 2012) Subjective Objective Appear skinny bloated abdomen Difficulty of breathing loss of appetite (half a bowl of soup/ meal) Weight 35kgs. Generalized Muscle wasting

40

 Sunken Cheeks Generalized body weakness Inability to do ADLs: personal hygiene

NPO when dyspneaic Easy fatigability RBC: 4.43 X 1012/L Normal: 4-6 X 1012/L

Nursing diagnosis: Imbalanced nutrition less than body requirements related to increased metabolism utilization of energy 2o to infection Rationale: Any illness can affect a previously hearty appetite. Loss of appetite can cause unintentional weight loss. Expected outcomes NOC: nutritional status: food and fluid intake; nutrient intake Short term: After 30 min. of nursing intervention, the patient will be able to identify factors to gain weight such as eating well balanced food that are rich in Vitamin C, protein and carbohydrates. Long term: After 2 days of nursing intervention, the patient will be able to start eating well balanced diet such as fruits and vegetables rich in Vitamins and minerals. Nursing interventions NIC: Nutritional management; Nutrition therapy Independent: Noted age, body build, and strength and activity level. Helps determine nutritional needs. ( Gulanick/Myers, 2007) Documented actual weight and height of the patient. 41

Patients may be unaware of their actual weight and height or weight loss due to estimating weight.( Gulanick/Myers, 2007) Obtained nutritional history from his significant others in our assessment The patient`s perception of actual intake may differ.( Gulanick/Myers, 2007) Evaluated total daily food intake and obtained diary, patterns and times of eating To reveal possible causes of malnutrition.( Gulanick/Myers, 2007) Promoted adequate fluid intake ; limit fluids 1hr prior to meals to reduce possibility of early satiety.( Gulanick/Myers, 2007) Encouraged exercise Metabolism and utilization of nutrients are enhanced by activity.( Gulanick/Myers, 2007) Ensure that client receives small, frequent feedings, including a bedtime snack, rather than three larger meals. Large amounts of food may be objectionable, or even intolerable, to the client.( Gulanick/Myers, 2007) Encouraged client to eat foods rich in iron and vitamin B12 and C protein and carbohydrates. It is important to consume a balanced diet to provide body with the nutrients that it needs to fight tuberculosis. Vitamin C increases the solubility of iron. Vitamin B12 and folic acid are necessary for erythropoiesis. .( Gulanick/Myers, 2007)

Dependent Administered FeSO4 + Folic

42

This is a drug of choice for treating iron deficiency anemia and for preventing deficiency when iron needs cannot be met by diet alone.( Gulanick/Myers, 2007) Monitored IVF of D5LR 1L x 16 (20-21 gtt/ml) Promotes hydration that able to enhance ability to do activities, .( Gulanick/Myers, 2007) Consult with dietician for further assessment and recommendations regarding food preferences and nutritional support-dieticians have a greater understanding of the nutritional value of foods and may be helpful in assessing specific ethnic or cultural foods Evaluation Goal met Short term: After 30 min. of nursing intervention, the patient identified factors to gain weight such as eating well balanced food that are rich in Vitamin C, protein and carbohydrates. Goal not met Long term: After 2 days of nursing intervention, the patient did not start eating well balanced diet such as fruits and vegetables rich in Vitamins and minerals due to financial constraints. Problem #5: Body weakness (July 3, 2012) Subjective Objective Restlessness generalized body weakness loss of appetite RR 32 bpm 43 Needs support during ambulation Prolonged bed rest

 Assisted by significant others in performing ADLs: personal hygiene (grooming, eating, toileting) Poor appetite

RBC: 4.43 X 1012/L Normal: 4-6 X 1012/L Hgb: 122 normal 140-180 gm/L Hct: 0.36 normal 0.40- 0.54 gm/L

Nursing diagnosis: activity intolerance related to imbalanced oxygen supply and demand and decreased oxygen carrying capacity of the blood. Rationale: A person with insufficient nutrient and supply of oxygen also has insufficient physical or psychological energy to endure or perform desired physical activities. (Seaback, 2007). Expected outcome NOC: Activity tolerance; Short term: After 30 min. of nursing intervention, the patient will be able perform activities such assisted ROM exercises within capabilities. Long term: After 2 days of nursing intervention, the patient will be able to apply energy conserving techniques such as pursed lip breathing, using cups for liquids such as soups when eating, and adequate rest. Nursing interventions NIC: energy management Independent Obtained data regarding normal activities and limitations.

44

Determines the effects of fatigue have on normal functioning . (Seaback, 2007). Noted patients reports of weakness, fatigue and difficulty accomplishing tasks. Symptoms may contribute to intolerance of activity .( Gulanick/Myers, 2007) Planned care to carefully balance rest periods with activities to reduce fatigue. (Seaback, 2007). Assess the patients level of mobility It aids in defining what the patient is capable of which is necessary before setting realistic goals(Seaback, 2007). Assess nutritional status Adequate energy reserves are required for activity. (Seaback, 2007). Plan for progressive increase of activity level Both activity tolerance and health status may improve with progressive training. (Seaback, 2007). Assisted with ADLs as indicated; however, avoid doing for patients what they can do for themselves. Assisting the patient with ADLs allows for conservation of energy. (Seaback, 2007). Provided passive ROM exercises with the patient. ROM exercise helps in muscle strength. (Seaback, 2007). Instruct the client and family in the importance of maintaining proper nutrition and rest. This is for energy conservation and rehabilitation. (Seaback, 2007).

45

Evaluation Goal met Short term: After 30 min. of nursing intervention, the patient performed activities such assisted ROM exercises within capabilities. Long term: After 2 days of nursing intervention, the patient applied energy conserving techniques such as pursed lip breathing, using cups for liquids such as soups when eating, and adequate rest.

46

REFERENCES 1. Lemone, Priscilla and Burke, Karen. (2008.)Medical-Surgical Nursing: Critical Thinking in Client Care 4th Edition. Prentice Hall. 2. Christensen, B & Kockrow, E. (2011). Foundations and Adult Health Nursing. MosbyElsevier 3. Iannuzzi, M. (2009.)Medical-Surgical Nursing: Clinical Management for Positive Outcomes. Saunders-elsevier. 4. Monahan, F. et al. (2007.)Medical-Surgical Nursing: Health and Illness Perspectives 8th Edition. Mosby-Elsevier. 5. Kozier, B. & Erb, G.( 2007 )Fundamentals of Nursing: concepts, Process and Practice 8th Edition. Prentice Hall. 6. Palaski, A. and Suzanne E. Tatro. Luckmanns(2006.) Core Principles and Practice of Medical-Surgical Nursing. 7. Sparks, Sheila and Taylor, Cynthia.(2008.) Nursing Diagnosis Reference Manual 7th Edition. Lippincott Williams and Wilkins. 8. (http://www.aahs.org/quality/quality_measures.php?cat=pneu 9. Sharon L. L, Shannon D, Margret M.H, Linda B, Ian M.C. (2011) medical surgical nursing: assessment and management of clinical problems volume one, Philadelphia. W.B. Saunders Co. 10. Keogh J. (2010) Nursing laboratory and diagnostic test demystified. New York: MacGaw-hill companies, 11. Tampano C, Lewis M. (2011) Disease of human body: 5th ed. Philadelphia: F.A Davis company. 47

12. Linda S.& William D.( 2007) Understanding medical-surgical nursing: 3RD edit, Philadelphia. Devis company 13. Pagana K. D. & Pagana T. J. (2002). Mosbys Manual of Diagnostic and Laboratory Tests (2nd ed). Missouri: Mosbys Inc. 14. Weber J. & Kelley J. ( 2007). Health Assessment in Nursing (3rd ed.) 15. Lewis S.M. et al. (2005). Medical Surgical Nursing: Assessment and Management of Clinical Problems (6th ed).Missouri: Mosby Inc. 16. McCance K.L. & Huether S.E. (2010). Pathophysiology: The Biologic Basis for Disease in Adults & Children (4th ed). Missouri: Mosby Inc. 17. Ignatavicius D. & Workman M. L (2010). Medical Surgical Nursing:Critical Thinking for Collaborative Care (5th ed.). Philadelphia: W.B. Saunders Co. 18. Gulanick & Myers ( 2007). Nursing Care Plans: Nursing Diagnosis and Intervention (6th ed). Missouri: Mosby Inc. 19. Bare B.G. & Smeltzer S. C.(2008). Brunner & Suddaths Textbook of Medical-Surgical Nursing (11th ed). Philippines: Lippincott Williams & Wilkins.

48