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University of San Carlos Faculty-School of Health Care Professionals Cebu City

Presented to:

Bacatan, Louise Marie M. Banaag, Dale Wesley Branzuela, Maria Christine E. Cabrera, Sheina C. Cazar, Ma. Reina Carmel Ferolin, Alfe A.

Submitted By:

Mr. Waldo Ruben A. Reyes

Submitted to:

TABLE OF CONTENTS
I. Objectives II. Introduction III. 5-minute Assessment IV. Anatomy and Physiology V. Pathophysiology VI. Laboratory Results VII. Nursing Care Plan VIII. Drug Study IX. Discharge Teaching Plan

I.OBJECTIVES

General Objectives: After an hour of case presentation, the student nurse will be able to present the summary of the different aspect of the clients case in order to promote further consciousness and awareness of the condition for the promotion of health and prevention of further complications as equally significant to the clients wellness.

Specific Objectives: Present assessment to gather pertinent data about the client as deemed relevant to the case Present the major health problem of the client Present the anatomy and physiology Discuss the pathophysiology of the clients disease condition Present laboratory studies conducted therein Present other ideal laboratory studies and their implication to support the diagnosis of the disease Present the appropriate nursing diagnosis for the clients case Present a plan of care appropriate for the clients condition Provide health teachings regarding medications, exercise, treatments, hygiene, outpatient concerns, and diet necessary for the client to regain optimum level of functioning.

II. INTRODUCTION

Pneumonia is an inflammatory condition of the lung, especially of the alveoli (microscopic air sacs in the lungs) associated with fever, chest symptoms, and consolidation on a chest radiograph. While typically caused by an infection there are a number of non infectious causes. Infectious agents include: bacteria, viruses, fungi, and parasites.
Typical

symptoms include cough, chest pain, fever, and difficulty breathing. Diagnostic tools include x-rays and examination of the sputum. Vaccines to prevent certain types of pneumonia are available. Treatment depends on the underlying cause with presumed bacterial pneumonia being treated with antibiotics. Pneumonia can be classified in several ways. It is most commonly classified by where or how it was acquired (community-acquired, aspiration,healthcare-associated,hospitalacquired, and ventilator-associated pneumonia), but may also be classified by the area of lung affected (lobar pneumonia, bronchial pneumonia and acute interstitial pneumonia) or by the causative organism. Pneumonia in children may additionally be classified based on signs and symptoms into non severe, severe, and very severe. People with infectious pneumonia often have a productive cough, fever accompanied by shaking chills, shortness of breath, sharp or stabbing chest pain during deep breaths, confusion, and an increased respiratory rate. In the elderly confusion may be the most prominent symptom. The typical symptoms in children under five are fever, cough, and fast or difficult breathing. Fever however is not very specific as it occurs in many other common illnesses and may be absent in those with severe disease or malnutrition while a cough is frequently absent in those less than 2 months of age. More severe symptoms may include: central cyanosis, decreased drinking, convulsions, persistent vomiting, or a decreased level of consciousness. Some causes of pneumonia are associated with specific symptoms. Pneumonia caused by Legionella may occur with abdominal pain and diarrhea, while pneumonia caused by tuberculosis or Pneumocystis may cause only weight loss and night sweats. Physical examination may sometimes reveal low blood pressure, a high heart rate, or a low oxygen saturation. Struggling to breathe, confusion, and blue-tinged skin are signs of a medical emergency. Findings from physical examination of the lungs may be normal, but often show decreased expansion of the chest on the affected side. Harsher sounds from the larger airways transmitted through the inflamed lung are heard as bronchial breathing on auscultation with a stethoscope. Rales (or crackles) may be heard over the affected area during inspiration. Percussion may be dulled over the affected lung, and increased rather than decreased vocal resonance distinguishes pneumonia from a pleural effusion. Because some of these signs are subjective, physical examination alone is insufficient to diagnose or rule out pneumonia.

Pneumonia can be due to micro organisms, irritants or unknown causes with infectious causes being the most common. Although more than one hundred strains of micro organism can cause pneumonia, only a few are responsible for most cases. The most common infectious causes are viruses and bacteria with less common being fungi and parasites. Mixed infections with both viruses and bacterial may occur in up to 45% of infections in children and 15% of infections in adults. The term pneumonia is sometimes more broadly applied to inflammation of the lung (for example caused by autoimmune disease, chemical burns or drug reactions), but this is more correctly referred to as pneumonitis. Pneumonia is typically diagnosed based on a combination of physical signs and achest X-ray. Confirming the underlying cause can be difficult however with no definitive test able to distinguish between bacterial and not bacterial aetiology. The World Health Organization has defined pneumonia in children clinical based on a either a cough or difficulty breathing and a rapid respiratory rate, chest indrawing, or a decreased level of consciousness. A rapid respiratory rate is defined as greater than 50 breaths per minute in children two month to one year of age or greater than 40 breaths per minute in children one to five years of age. In those under two months of age a respiratory rate of greater than 60 per minute can be used. In children an increased respiratory rate and lower chest indrawing are more sensitive than auscultation of chest crackles. Investigations are generally not needed in those with mild disease. In those requiring admission to hospital pulse oximetry, chest radiography, and blood tests including a complete blood count, serum electrolytes, C-reactive protein, and possibly liver function tests are recommended. Typically, oral antibiotics, rest, and fluids are sufficient for complete resolution. However, people who are having trouble breathing, with other medical problems, and the elderly may need greater care. If the symptoms get worse, the pneumonia does not improve with home treatment, or complications occur, then hospitalization may be recommended. Over the counter cough medicine has not been found to be helpful in pneumonia. Worldwide approximately 7-13% of cases in children result in hospitalization. Notifiable Diseases Reported Cases by Cause 2001 2008 Pneumonia 2001 652,585 2002 734,581 2003 674,386 2004 776,562 2005 690,566 2006 670,231 2007 605,471 2008 780,199

III. 5-MINUTE ASSESSMENT

BASELINE DATA Name: Visda, Oscar Tajo Age:65 Sex: Male Address: Kawit, Medellin, Cebu City Status: Married Occupation: Garbage Collector Religion: Catholic Date of birth: November 21, 1945 Place of birth: Daan, Bantayan island Admitting Diagnosis: Community-acquired Pneumonia; R/O Pulmonary Tuberculosis Final Diagnosis: Community-acquired Pneumonia

Assessment upon Admission Skin: warm, senile turgor Heent: pale palpebral conjunctiva Neck/lymph nodes: LAD Chest/lungs: +rales Cardiovascular: DHS Abdomen : flat non tender Musculoskeletal: 4/5 Extremities: - deformity edema Chef complaints: dyspnea, shortness of breath,fever HPI: one week PTA pt had on and off mod-high grade fever assoc. with chills no meds taken. A day PTA pt. had sudden onset of dyspnea he has brought to district hospital. Hereditary disease: Hypertension I Smoke:+ Alcohol:+
IV. ANATOMY AND PHYSIOLOGY

The Lungs The lungs are paired, cone-shaped organs which take up most of the space in our chests, along with the heart. Their role is to take oxygen into the body, which we need for our cells to live and function properly, and to help us get rid of carbon dioxide, which is a waste product. We each have two lungs, a left lung and a right lung. These are divided up into 'lobes', or big sections of tissue separated by 'fissures' or dividers. The right lung has three lobes but the left lung has only two, because the heart takes up some of the space in the left side of our chest. The lungs can also be divided up into even smaller portions, called 'bronchopulmonary segments'. These are pyramidal-shaped areas which are also separated from each other by membranes. There are about 10 of them in each lung. Each segment receives its own blood supply and air supply. Air enters your lungs through a system of pipes called the bronchi. These pipes start from the bottom of the trachea as the left and right bronchi and branch many times throughout the lungs, until they eventually form little thin-walled air sacs or bubbles, known as the alveoli. The alveoli are where the important work of gas exchange takes place between the air and your blood. Covering each alveolus is a whole network of little blood vessel called capillaries, which are very small branches of the pulmonary arteries. It is important that the air in the alveoli and the blood in the capillaries are very close together, so that oxygen and carbon dioxide can move (or diffuse) between them. So, when you breathe in, air comes down the trachea and through the bronchi into the alveoli. This fresh air has lots of oxygen in it, and some of this oxygen will travel across the walls of the alveoli into your bloodstream. Travelling in the opposite direction is carbon dioxide, which crosses from the blood in the capillaries into the air in the alveoli and is then breathed out. In this way, you bring in to your body the oxygen that you need to live, and get rid of the waste product carbon dioxide.

V. PATHOPHYSIOLOGY

LABS:

Results Hemoglobin Erythrocyte volume Leucocyte count Platelet count Segmenter Lymphocyte INTERPRETATION: 11.3 gms % 34 vol % 11800 cumm 200,000 cumm 74% 26

Normal value 14-16 gms % 42-50 vol % 5000-10000 cumm 150,000-400,000 cumm 36-66% 22-40

Low amount of hemoglobin in blood lowers the synthesis of erythropoietin, which is needed to stimulate the red bone marrow to produce red blood cell. The erythrocyte volume is lower than the normal value. It may be due to less oxygen that binds with the iron portion to form oxyhemoglobin. Leucocyte count is higher than the normal value since the patients body needs to combat pathogens by phagocytosis and immune response. Other components of the blood are within normal range.

VI. LABORATORY RESULTS

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