OUR LADY OF FATIMA

UNIVERSITY
COLLEGE OF NURSING
VALENZUELA CAMPUS

Community Acquired Pneumonia

In Partial Fulfillment of requirements of NCM 107B RLE leading to the degree
of Science in Nursing

Presented to:
Mr. Fred Ruiz
Presented by:
Bungay, Maria Paula M.
Camba, Ma. Leizel M.
BSN 4Y 2-1
Group 1B
August 25, 2015

TABLE OF CONTENTS

I. Introduction
II. Objectives
III. Patients Profile
IV. Anatomy and Physiology
V. Pathophysiology
VI. Laboratory Examination Results
VII. Gordons Assessment
VIII. Nursing Care Plans
IX. Drug Study
X. Health Teachings

I. Introduction

III. Patients Profile

Name of Patient: Mrs. ME
Age: 44

Gender: Female

Birthday: not given

Birthplace: Navotas City
Address: Navotas City
Admitting Diagnosis: Community Acquired Pneumonia Moderate Risk, to
consider
Pulmonary Tuberculosis
Latest Diagnosis: Community Acquired Pneumonia Moderate Risk
Religion: Roman Catholic
Civil Status: Married
Nationality: Filipino
Language/Dialect Spoken: Tagalog
Date and Time of Admission: August 11, 2015 at 1:47 p.m.
History of Present Illness
3 weeks prior to admission, patient experienced cough with no phlegm
accompanied by difficulty of breathing and shortness of breath. There was no
associated fever, headache, colds, chest pain, low back pain, night sweats,
myalgia, arthralgia, nausea and vomiting. She consulted to a private
physician and was diagnosed to have Bronchial Asthma and was prescribed
with Terbutaline (Bricanyl) and Amoxicillin 500 mg for 7 days but offered no
relief.
1 week prior to admission, still with above signs and symptoms now
with whitish phlegm and upper back pain aggravated by coughing. She
consulted to another private physician and was diagnosed to have
Bronchiolitis and was given Co-amoxiclav 500mg for 7 days and Ambroxol tab
but still offered no relief.
Few hours prior admission, still with difficulty of breathing and
productive cough, consulted to a private hospital and was advised admission

but due to lack of room vacancy they opted to be transferred in the institution
with a diagnosis of Community Acquired Pneumonia Moderate Risk, to
consider Pulmonary Tuberculosis and patient was subsequently admitted.
HISTORY OF PAST ILLNESS
No information was obtained from the patient and the S.O. due to
unavailability.
Pre-operative Diagnosis
Community Acquired Pneumonia Moderate Risk, to consider Pulmonary
Tuberculosis
PHYSICAL ASSESSMENT
Physicians Physical Assessment done by the Resident on Duty (August
17, 2015, lifted from the patient's chart)
Height: 5'5
Weight: 68 kg
GCS: 15
Vital Signs as follows:
T: 36.5 C

PR: 144bpm

RR: 32pm

BP: 150/100 mmHg

SAO2: 97%

GENERAL SURVEY
Mrs. ME, Assessed/received patient lying on bed, sleeping, conscious with GCS 15.
With the following vital signs:
Temperature: 38.0 C
Heart rate: 148 bpm
Respiratory rate: 44 bpm
Blood Pressure: 140/100 mmHg
SAO2: 96%

Skin: Uniform in color, good skin turgor, pale, no edema, with skin rashes
Skull: Round, symmetrical, normocephalic, absence of nodules and masses
Face: Symmetrical, absence of nodules and masses

Eyes: Round and symmetrical, equally distributed eyelashes and eyebrows,

no discoloration on eyelids, eyelids close symmetrically, blinks
involuntarily, pale conjunctiva
Ears: Symmetrical with no discharges, auricles aligned with the outer
canthus of the eye
Nose: Symmetrical and straight, both nares are patent, no tenderness
Mouth: Dry and pale lips
Neck: With palpable modules on the left side of the neck, jugular veins
are not distended, neck muscles are equal in size
Chest/Lungs: Has symmetrical chest expansion, presence of rales on
both lung fields upon auscultation
Abdomen: Slightly globular in shape, with 18 bowel sounds per minute,
presence of resonance upon percussion
Extremities: Equal in size and length, absence of edema, both lower and
upper extremities move with coordination, with pale nailbeds
August 17, 2015
General Appearance: Patient is awake, coherent and conscious to time,
place and person. She is afebrile with vital signs taken and recorded as
follws:
VS: BP=140/90 mmhg; PR= 148 bpm; RR=44 bpm;T=37.6 C/axilla
Skin: Uniform in color, good skin turgor, pale, no edema, with skin rashes
Skull: Round, symmetrical, normocephalic, absence of nodules and masses
Face: Symmetrical, absence of nodules and masses
Eyes: Round and symmetrical, equally distributed eyelashes and eyebrows,
no discoloration on eyelids, eyelids close symmetrically, blinks
involuntarily, pale conjunctiva
Ears: Symmetrical with no discharges, auricles aligned with the outer
canthus of the eye
Nose: Symmetrical and straight, both nares are patent, no tenderness
Mouth: Dry and pale lips
Neck: With palpable modules on the left side of the neck, jugular veins
are not distended, neck muscles are equal in size

Chest/Lungs: Has symmetrical chest expansion, presence of rales on

both lung fields upon auscultation
Abdomen: Slightly globular in shape, with 15 bowel sounds per minute,
presence of resonance upon percussion
Extremities: Equal in size and length, absence of edema, both lower and
upper extremities move with coordination.

IV. Anatomy and Physiology

Respiratory System
The respiratory system functions to deliver the oxygen to the blood -the transport medium of the cardiovascular system -- and to remove oxygen
from the blood. The actual exchange of oxygen and carbon dioxide occurs in
the lungs.
The respiratory centers in the brain stem (pons and medulla) control
respiration's rhythm, rate, and depth. Primary controlling factors include 1)
the concentration of carbon dioxide in the blood (high CO2 concentrations
initiate deeper, more rapid breathing) and 2) air pressure within lung tissue.
Expansion of the lungs stimulates nerve receptors (vagus nerve X) to signal
the brain to "turn off" inspiration. When the lungs collapse, the receptors give
the "turn on" signal, termed the Hering-Breuer inspiratory reflex. Other
regulators are: 3) an increase in blood pressure, which slows down
respiration; 4) a drop in blood acidity, which stimulates respiration; and 5) a
sudden drop in blood pressure, which increases the rate and depth of
respiration. Voluntary controls -- "holding one's breath" -- can also affect
respiration, but not indefinitely. Carbon dioxide build-up soon forces an
automatic start-up.

The respiratory system consists of two tracts: The upper respiratory

tract includes the nose (nasal cavity, sinuses), mouth, larynx, and trachea
(windpipe). The lower respiratory tract includes the lungs, bronchi, and
alveoli.
The two lungs, one on the right and one on the left, are the body's
major respiratory organs. Each lung is divided into upper and lower lobes,
although the upper lobe of the right lung contains a third subdivision known
as the right middle lobe. The right lung is larger and heavier than the left
lung, which is somewhat smaller in size because of the predominately leftside position of the heart.
A clear, thin, shiny coating the pleura envelops the lungs. The inner,
visceral layer of the pleura attaches to the lungs; the outer, parietal layer
attaches to the chest wall (thorax). Pleural fluid holds both layers in place, in
a manner similar to two microscope slides that are wet and stuck together.
The lungs are separated from each other by the mediastinum, an area that
contains the heart and its large vessels, the trachea (windpipe), esophagus,
thymus, and lymph nodes. The diaphragm, the muscle that contracts and
relaxes in breathing, separates the thoracic cavity from the abdominal cavity.

The chart of the respiratory system shows the intricate structures

needed for breathing. Breathing is the process by which oxygen in the air is
brought into the lungs and into close contact with the blood, which absorbs it
and carries it to all parts of the body. At the same time the blood gives up
waste matter (carbon dioxide), which is carried out of the lungs when air is

breathed out.
1. The SINUSES (frontal, maxillary, and sphenoidal) are hollow spaces in the
bones of the head. Small openings connect them to the nose. The functions
they serve include helping to regulate the temperature and humidity of air
breathed in, as well as to lighten the bone structure of the head and to give
resonance to the voice.
2. The NOSE (nasal cavity) is the preferred entrance for outside air into the
respiratory system. The hairs that line the wall are part of the air-cleaning
system.
3. Air also enter through the MOUTH (oral cavity), especially in people who
have a mouth-breathing habit or whose nasal passages may be temporarily
obstructed, as by a cold or during heavy exercise.
4. The ADENOIDS are lymph tissue at the top of the throat. When they
enlarge and interfere with breathing, they may be removed. The lymph
system, consisting of nodes (knots of cells) and connecting vessels, carries
fluid throughout the body. This system helps to resist body infection by
filtering

out

foreign

matter,

including

germs,

and

producing

cells

(lymphocytes) to fight them.

5. The TONSILS are lymph nodes in the wall of the throat (pharynx) that often
become infected. They are part of the germ-fighting system of the body.
6. The THROAT (pharynx) collects incoming air from the nose and mouth and
passes it downward to the windpipe (trachea).
7. The EPIGLOTTIS is a flap of tissue that guards the entrance to the windpipe
(trachea), closing when anything is swallowed that should go into the
esophagus and stomach.

8. The VOICE BOX (larynx) contains the vocal chords. It is the place where
moving air being breathed in and out creates voice sounds.

9. The ESOPHAGUS is the passage leading from the mouth and throat to the
stomach.
10. The WINDPIPE (trachea) is the passage leading from the throat (pharynx)
to the lungs.
11. The LYMPH NODES of the lungs are found against the walls of the
bronchial tubes and windpipe.
12. The RIBS are bones supporting and protecting the chest cavity. They
move to a limited degree, helping the lungs to expand and contract.
13. The windpipe divides into the two main BRONCHIAL TUBES, one for each
lung, which subdivide into each lobe of the lungs. These, in turn, subdivide
further.
14. The right lung is divided into three LOBES, or sections. Each lobe is like a
balloon filled with sponge-like tissue. Air moves in and out through one
opening -- a branch of the bronchial tube.
15. The left lung is divided into two LOBES.
16. The PLEURA are the two membranes, actually one continuous one folded
on itself, that surround each lobe of the lungs and separate the lungs from
the chest wall.
17. The bronchial tubes are lines with CILIA (like very small hairs) that have a
wave-like motion. This motion carried MUCUS (sticky phlegm or liquid)
upward and out into the throat, where it is either coughed up or swallowed.
The mucus catches and holds much of the dust, germs, and other unwanted
matte that has invaded the lungs. You get rid of this matter when you cough,
sneeze, clear your throat or swallow.
18. The DIAPHRAGM is the strong wall of muscle that separates the chest
cavity from the abdominal cavity. By moving downward, it creates suction in
the chest to draw in air and expand the lungs.
19. The smallest subdivisions of the bronchial tubes are called BRONCHIOLES,

at the ends of which are the air sacs or alveoli (plural of alveolus).

20. The ALVEOLI are the very small air sacs that are the destination of air
breathed in. The CAPILLARIES are blood vessels that are imbedded in the
walls of the alveoli. Blood passes through the capillaries, brought to them by
the PULMONARY ARTERY and taken away by the PULMONARY VEIN. While in
the capillaries the blood gives off carbon dioxide through the capillary wall
into the alveoli and takes up oxygen from the air in the alveoli.
Air Distribution
On inspiration, air enters the body through the nose and the mouth.
Nasal hairs and mucosa (mucus) filter out dust particles and bacteria and
warm and moisten the air. Less warming, filtering, and humidification occur
when air is inspired through the mouth.
Air travels down the throat, or pharynx, where two openings exist, one
into the esophagus for passage of food, and the other into the larynx (voice
box) and trachea (windpipe) for continued airflow. When food is swallowed,
the opening of the larynx (the epiglottis) automatically closes, preventing
food from being inhaled. When air is inspired, the walls of the esophagus are
collapsed, preventing air from entering the stomach. The larynx, which also
contain the vocal cords, is lined with mucus that further warms and
humidifies the air.
Air continues continues down the trachea, which branches into the
right and left bronchi. The main-stem bronchi divide into smaller bronchi,
then into even smaller tubes called bronchioles. The bronchial structures
contain hair-like, epithelial projections, called cilia that beat rythmically to
sweep debris out of the lungs toward the pharynx for expulsion. Once in the
bronchioles, the air is at body temperature, contains 100% humidity, and is
(hopefully) completely filtered.
Bronchioles end in air sacs called alveoli -- small, thin-walled
"balloons," arranged in clusters. When you breathe in, enlarging the chest

cavity, the "balloons" expand as air rushes in to fill the vacuum. When you
breathe out, the "balloons" relax and air moves out of the lungs. It is at the
alveoli that gas exchange occurs. Tiny blood vessels, capillaries, surround
each of the alveoli. On inspiration, the concentration of dissolved oxygen is
greater in the alveoli than in the capillaries. Oxygen, therefore, diffuses
across the alveolar walls into the blood plasma. In the reverse process,
carbon dioxide concentration is greater in the blood than the alveoli, so it
passes from the blood into the alveoli and is ultimately breathed out.

As oxygen diffuses into the plasma, hemoglobin in the red blood cell
picks up the oxygen, permitting more to flow into the plasma. The oxygencarrying capacity of hemoglobin allows the blood to carry over 70 times more
oxygen than if the oxygen were simply dissolved in the plasma alone.
Therefore, the total oxygen uptake depends on: 1) the difference in oxygen
concentration between the blood and alveoli, 2) the healthy functioning of
the alveoli, and 3) the rate of respiration.
Pulmonary Circulation
The pulmonary circulatory circuit describes the process whereby
oxygen and carbon dioxide are delivered to and from the lungs. Oxygen-poor
blood travels to the right atrium via the inferior and superior vena cavae,
then to the right ventricle. The right ventricle subsequently pumps the blood
into the pulmonary artery, which branches to the right and left lungs. The
pulmonary arteries subdivide until reaching the arteriole, then capillary
levels. After gas exchange, the capillaries recombine to form venules and

veins. Ultimately two right and two left pulmonary veins carry oxygen-rich
blood to the heart for distribution, via the aorta/systemic circuit, to the rest of
the body.

Lung Volumes/ Capacities

The air that the lungs can hold can be divided into smaller
designations called "volumes."
The amount of air a person breathes in and out at rest is called the
Tidal Volume (Vt about 500ml). During such breathing, a person could
actually take in more air or blow more out. The additional amount a person
could inhale, such as during maximum physical activity, is called the
Inspiratory Reserve Volume (IRV 3,000 ml). The additional amount a person
could exhale is called the Expiratory Reserve Volume (ERV 1,000 ml). The
Residual Volume (RV) is the amount of air that stays in the lung even after
maximum expiration.

Breathing is an active process - requiring the contraction of skeletal

muscles. The primary muscles of respiration include the external intercostal
muscles (located between the ribs) and the diaphragm (a sheet of muscle
located between the thoracic & abdominal cavities).
The external intercostals plus the diaphragm contract to bring about
inspiration:

Contraction of external intercostal muscles > elevation of ribs &

sternum > increased front- to-back dimension of thoracic cavity >
lowers air pressure in lungs > air moves into lungs

Contraction of diaphragm > diaphragm moves downward > increases

vertical dimension of thoracic cavity > lowers air pressure in lungs > air
moves into lungs:

To exhale:

relaxation of external intercostal muscles & diaphragm > return of

diaphragm, ribs, & sternum to resting position > restores thoracic cavity
to preinspiratory volume > increases pressure in lungs > air is exhaled

Intra-alveolar pressure during inspiration & expiration

As the external intercostals & diaphragm contract, the lungs expand.
The expansion of the lungs causes the pressure in the lungs (and alveoli) to
become slightly negative relative to atmospheric pressure. As a result, air
moves from an area of higher pressure (the air) to an area of lower pressure
(our lungs & alveoli). During expiration, the respiration muscles relax & lung
volume descreases. This causes pressure in the lungs (and alveoli) to become
slight positive relative to atmospheric pressure. As a result, air leaves the
lungs.

The walls of alveoli are coated with a thin film of water & this creates a
potential problem. Water molecules, including those on the alveolar walls, are
more attracted to each other than to air, and this attraction creates a force
called surface tension. This surface tension increases as water molecules
come closer together, which is what happens when we exhale & our alveoli
become smaller (like air leaving a balloon). Potentially, surface tension could
cause alveoli to collapse and, in addition, would make it more difficult to 'reexpand' the alveoli (when you inhaled). Both of these would represent serious
problems: if alveoli collapsed they'd contain no air & no oxygen to diffuse into
the blood &, if 're-expansion' was more difficult, inhalation would be very,
very difficult if not impossible. Fortunately, our alveoli do not collapse &
inhalation is relatively easy because the lungs produce a substance called
surfactant that reduces surface tension.

Role of Pulmonary Surfactant

Surfactant decreases surface tension, which increases pulmonary
compliance (reducing the effort needed to expand the lungs) and reduces
tendency for alveoli to collapse.

Partial Pressure
Partial pressure is the individual pressure exerted independently by a
particular gas within a mixture of gasses. The air we breath is a mixture of
gasses: primarily nitrogen, oxygen, & carbon dioxide. So, the air you blow
into a balloon creates pressure that causes the balloon to expand (& this
pressure is generated as all the molecules of nitrogen, oxygen, & carbon
dioxide move about & collide with the walls of the balloon). However, the
total pressure generated by the air is due in part to nitrogen, in part to
oxygen, & in part to carbon dioxide. That part of the total pressure generated
by oxygen is the 'partial pressure' of oxygen, while that generated by carbon
dioxide is the 'partial pressure' of carbon dioxide. A gas's partial pressure,
therefore, is a measure of how much of that gas is present (e.g., in the blood
or alveoli).

The partial pressure exerted by each gas in a mixture equals the total
pressure times the fractional composition of the gas in the mixture. So, given
that total atmospheric pressure (at sea level) is about 760 mm Hg and,
further, that air is about 21% oxygen, then the partial pressure of oxygen in

the air is 0.21 times 760 mm Hg or 160 mm Hg.

Synthesis of the Disease

1. Definition of the Disease
Community-

Acquired

Pneumonia

(CAP)

is

condition

caused

by

Streptococcus pneumoniae (also known as the pneumococcus) which has a

relatively low overall mortality rate, although it is higher in the elderly. Influenza
is the most common viral community-acquired pneumonia in adults. CommunityAcquired Pneumonia occurs either in the community setting or within the first 48
hours after hospitalization or institutionalization. The need of hospitalization for
CAP depends on the severity of pneumonia. (Adrews, Nadjm, Gant, et.al. 2003)
The causative agent for CAP that requires hospitalization are most
frequently S. Pneumoniae, H. Influenzae, Legionella, Pseudomonas aeruginosa
and other gram-negative rods. CAP is a common illness and can affect people of
al ages. It often causes problems like breathing, fever. Chest pain and cough.
CAP occurs because the areas of the lung which absorbed oxygen from the
atmosphere become filled with fluid and cannot work efficiently.
CAP occurs throughout the world and is the leading cause of illness and
death. CAP ranks as the fourth most common death in the United Kingdom and
sixth as the leading infectious cause of death when combined with influenza in
the United States. Overall, CAP mortality rate range from less than 1% to 9% for
those managed as out-patient, but increase to 50% for those requiring ICU
management ( Retrieved at www. Medscape.com/viewarticle/475218 accessed
on August 29, 2008 10:20 pm) The Global burden of the disease study publish by
the World Health Organization ranks pneumonia as the third leading cause of
mortality. Ass of 2002there were 3.8 million or 6.8% deaths out of the 6.1 billion
total estimated population (Brunner, 2008)
In the Philippines, pneumonia ranks as the 4 th leading cause of morbidity
and 3rd leading cause of mortality based on the latest health statistics report of
the Department of Health. The morbidity and mortality tred for pneumonia has
fallen from 96.7 deaths per 100,000 populations to 49 deaths per 100,000
populations. (Philippine Health Statistics, 2006)

1. Predisposing and Precipitating Factors

Predisposing / Non- modifiable factors
a) Age
Most common in people younger than 60 years of age without comorbidity and
in those 60 years and older among at risk factors for the development of CAP
b) Race
African- American has higher rates of Community Acquired pneumonia than
among whites.
c) Gender
CAP is most common among men than in women due to their lifestyle such as
smoking and drinking.
d) Seasonality
It is most prevalent during winter and spring, where Upper Respiratory Tract
infections are frequent.

a) Medical History and Treatments

Those

people

who

have

Bronchielectasis, Neutropenia,

illness
COPD

such
and

as

diabetes,
other

HIV

factors

infection,
involving

microorganisms.
Precipitating / Modifiable Factors
1. Lifestyle
CAP can occur with people who are smoking, 2 nd hand smokers and alcohol
abuse
2. Occupation

People who are expose in microorganisms especially in the community.

Laboratories,

Veterinarians

clinics

and

other

institution

involving

microorganisms.
3. Hygiene
Those that have a poor hygiene, improper hand washing, perineal care, and
preparing foods.
4. Poor Immune System
CAP could be common in children as well as n adults if they have poor
immune system or didnt acquire vaccination.

malnutrition can also

contribute to poor immune.

1. Signs and Symptoms

a) Pleuritic Chest pain that is aggravated by deep breathing and coughing.

Indicates of having pleural inflammation arising from parietal pleura, which is
richly supplied by

sensory nerve endings

b) Rapid Rising Fever (38.5 to 40.5 c)

Cause by release of endogenous pyrogens that reset the hypothalamus
thermostat
c) Sudden onset of chills
Due to invasion of microorganisms causing inflammatory process
d) Tachypnea, rapid pulse and bounding
It usually increase about 10 bpm for every degee acts as compensatory
echanism for

hyperthermia

a) Crackles
Due to lung congestion or consolidation
b) Wheezes
Due to accumulation of secretions the airway becomes narrowed

c) Dyspnea, cyanosis
Due to the interference in oxygen and carbon dioxide exchange that caused
hypoxem
d) Bacteremia
The invasion of microorganisms in the body
e) Cough
Brings up a greenish and yellowish mucous due to the bacterial invasion

1. Health Promotion and Prevention aspects of disease

Several ways to prevent infectious Community- Acquired Pneumonia like
smoking, it is important since it will not only helps to limit lung damage but also
because cigarette smoking interferes with many of the bodies natural defenses
against pneumonia.
Vaccination is also important in preventing pneumonia in children and
adults.

Vaccination

against

Haemophilus

Influenzae

and

Streptococcus

pneumoniae in the first year of life have greatly reduced their role in pneumonia
in children. These would also decreased incidence of these against infections in
adults because adults may acquire infections from children. Flu vaccine prevents
pneumonia and other problems cause by the influenza virus. Furthermore, health
care workers, nursing home residents and pregnant women should receive the
vaccine. A repeat vaccination may also be required after five to ten years, the
vaccines that confers immunity against pneumococus. It is also given to people
who most at risk like those the age of 65 with chronic heart, lung and liver
disease.
Aside from vaccines, deep-breathing exercise may also help in preventing
pneumonia especially if you are in the hospitalfor example, while recovering
from surgery. Drinking plenty of fluids does not suppress, because retained
secretions interfere with gas exchange and may slow recovery. Hydration of 2-3
L/day because adequate hydration thins and loosens pulmonary secretions.
Humidification may be used to loosen secretions and improve ventilation.

Lastly the best solution to prevent infections is proper hand washing and
sanitation. Always wash your hands frequently can prevent the spread of viral
respiratory illness, taking vitamins especially vitamin C will also be helpful in
reducing the risk for having CAP. Avoiding stress, avoid over exertion and
possible exacerbation of symptoms.
The solution to the problem is preventing the infections rather than curing
them. As the saying goes PREVENTION IS BETTER THAN CURE, these
preventive

measures

includes

avoid

uncooked

or

unwashed

fruits

and

vegetables in areas when sanitation is poor, good personal hygiene, wee

protective clothing and use insect repellent are some of the ways to prevent
pneumonia.

V. Pathophysiology
Inhalation of microorganisms
Invasion of foreign bodies in the URT
Activation of the upper airway defense mechanism, cough reflex, mucociliary clearance and nasopharyngeal defense
Pathogens begin to colonize
Pathogens enter the lower

The body tries to remove

Release of
respiratory tract

pathogen that entered the

nasal
upper respiratory tract

discharges
Damage occurs to mucous membrane

Activation of the inflammatory process, release of chemical mediators

Histamine
Increase in
Stimulates goblet cells
Permeability
to increase mucus
production
Leaking of fluids and fluid

Bradykinin

Prostaglandin

Leukotriene
Vascular
Chemotaxis

Stimulate muscle spasm

that contributes to
bronchoconstriction

Migration of WBC to
the site of injury

Accumulation of mucus
accumulation of fluid in
secretions in the airway
sacs
contributing to the

shifting resulting to

Narrowing of airway
Release of pyrogens

the alveolar

narrowing of airway
accumulation of fluids

Stimulates the thermoregulatory

This

center of the body to reset

impairs gas

body temperature

resulting to

exchange
ventilationCrackles

Wheezes

Dyspnea/
Nasal flaring

perfusion mismatch
Fever
Tachypnea

Chest Pain
VI. Laboratory Examination Results

Pallor

VII. Gordons Assessment

VIII. Nursing Care Plans

Problem No. 1 Ineffective Airway Clearance
Assessme

Nursing

Scientific

nt

Diagnosis

Explanation

S=

Planning

Nursing

Rationale

Evaluation

Intervention

Ineffective

Community-

Short Term > Assess

> Abnormal

Short

Airway

Acquired

respiratory

breathing patterns

Term :

Clearance

Pneumonia is the

status: breath

may signal

O=Patient

related to

inflammation

sounds,

worsening of

Manifeste

retained

the

respiratory rate,

condition: flaring of

The patient

d the

secretions in

parenchyma

oxygen

nostrils indicate a

shall be

following :

the bronchi

when

saturation, note

significant decline in

able to

( increased

offending

abnormalities

respiratory status:

expectorate

thick

organism

such as dyspnea,

assessment

mucous as

>appears

mucous

reaches

the

presence of

establishes baseline

evidenced

weak

secretions)

alveoli

via

cyanosis, use of

and monitor

by

and lung

droplets or saliva

accessory

response to

productive

inflammatio

in whi8ch goblet

muscles, flaring

interventions

cough

>pale

n leading to

cells produces an

palpebral

accumulatio

outpouring

conjunctiva

n of mucous

into the alveoli.

of
lung
the

fluid

After

hours

of

Nursing
Intervention
s,

the

patient

will

expectorate
mucous

as

evidenced
by
productive
cough,
effective

of nostrils

effective
coughing
and

> rales on
both lung
lobes upon
chest
auscultatio
n

in the

The

organisms coughing

alveoli

multiply

in

the and

of
breathing

patient

the

presence

infection

spread.

is exercise

The

their

growth

and
function

leading

to

of breath

accumulation

of

mucus.
Disruption of the
mechanical

> nonproductive
cough

defenses

of

cough and ciliary

motility leads to
the

colonization

exercise

breath causes
anxiety and fear:

anxiety increases
Long

the demand for

Term :

oxygen

interference with
lung

> Being unstable to

calming presence:

damage the host

by

breathing

the patient needs a

organisms

massive
> shortness

and reassure

serous fluid and breathing

overwhelming
> difficulty

> Assess anxiety

> Place patient

After 2 days in high fowlers

> Maximize chest

Long Term

of

excursion and

Nursing position and

Intervention

support

s,

the overbed table as

patient

will needed.

subsequent
movement of air

maintain
airway
patency
evidenced
by
breath

as > Encourage
expectoration of

clear secretions and

assess the

> Thickened
secretions of Cap re

The patient
will
maintain
airway
patency as
evidenced
by clear
breath

of the lungs and sounds,

Patient
may
manifest
the
following :

>decreased
oxygen
saturation

accumulation

of absence

secretions in the dyspnea,

alveoli

>Abnormal
blood gases
(decreased
O2,
Increased

more likely to
occlude the airway:
making this
observation would
allow for

ineffective

implementation if

airway clearance

measures to thin

as evidence by

and loosen the

non-productive

secretions

cough

etc.

alveolar
consolidate,

>Tachypne
a

secretions

leading

exudates tend to
> Cyanosis

of and color of

and etc.

bronchi
to

viscosity amount

expectorate.

patient
coughing and
deep breathing

increasingly
difficult

> Assist the

> Mobilizes
secretions and
prevent atelectasis

to
> Increase fluid
intake
> Assists with
liquefying secretions
and enhancing
ability to clear

sounds,
absence of
dyspnea,
etc.

CO2)

airways
> Provide for

>
Restlessnes
s

periods of rest
and activity,
assisting

> Decrease demand

for oxygen

devices as
>
Orthopnea

> Flaring of
nostrils

needed

> Elevate head

of bed/ change of
position every 2
hours

> To maintain an
open airway and to
take advantage of
gravity decreasing
pressure on the
diaphragm and
enhancing drainage
of secretions.

> Assist

respiratory
therapist the
administration of
nebulizer

>This causes
bronchiodilation to
ease breathing

> Establish
intravenous
access as

> Ensures a route

ordered

for rapid- acting

medications

> Assess arterial

blood gases
(ABG)

>ABG provide data

for treatment
regarding the lungs
ability to oxygenate
tissues

> Provide
humidified

oxygen as

> Loosen secretions,

ordered to

making them easier

maintain O2

to expectorate

saturation >90%

coughing: improves
oxygenation

Problem No. 2 Impaired Gas Exchange

Assessment

S=
O=Patient
Manifested
the
following :

>difficulty of

Nursing

Scientific

Diagnosis

Explanation

Planning

Nursing

Rationale

Evaluatio

Intervention

Impaired

Community-

Short Term > Perform a

> Because airway

Short

Gas

Acquired

complete

inflammation and

Term :

Exchange

Pneumonia

is

respiratory

mucous

related to

defined

assessment ;

accumulation,

inflamed

lower respiratory After 8hours respiratory rate,

pneumonia can

lung tissue

tract infection of of

cause fluid in the

and

the

consolidati

parenchyma with s,

as

Nursing rhythm, chest

lungs Intervention

expansion, ease

the of breathing, use

lungs and increase

the work of

The
patient
shall be
relieved
from
dyspnea

breathing

on of

onset

in

the patient

mucous /

community

ffluid in

during thre first from

>nasal

specific

2days

flaring

lung lobes

hospitalization.

participating

preventing

Pneumonia

in breathing expectoration,

transfer of

occurs when the exercises,

perioral cyanosis,

>shortness

gases

offending

effective

tachypnea,

of breath/

across the

organism

coughing

dyspnea, pulse

exertional

alveolar

stimulate

and use of oximetry and

discomfort

capillary

inflammatory

oxygen

cellular

response

membrane

defense

or be

lip breathing,
mucous

as monitor

the evidenced

laboratory and

by absent of diagnostic

mechanism

presence of

the

crackles on

effectiveness

both lung

and

lobes upon

organisms

auscultation

penetrate
sterile,

relieved muscles, pursed

of dyspnea by breath sounds,

>with

lung

will of accessory

of nasal
lo9se flaring,

procedures such
as sputum

shortness of cultures,

allow breath, easy complete blood

to fatigability,
the etc.

count, arterial
blood gases, etc.

lower

respiratory tract,
> with non

where

> Obtain

breathing, resulting

by

in impaired gas

participati

exchange. These

ng in

assessment provide

breathing

data use for planning

exercise,

Interventions and
assessing progress.
Sputum cultures
identify the causative
organisms, arterial
blood gases
demonstrate
decreased oxygen
concentration, chest
x-ray will confirm the
presence of fluid in
the lungs or areas of
consolidation

effective
coughing
and use of
oxygen as
evidenced
by
absence of
nasal
flaring,
shortness
of breath,
easy
fatigability.
Etc.

productive

inflammation

Long

subjective data

cough

develops.

Term :

from the patient

Inflammation
occurs

due

or significant
to

other, including

> easy

colonization

of After 1 to 3 history of chronic

fatlgability

offending

days

organization

Nursing

of respiratory
disease and

wherein there is Intervention

> Patient
hooked to O2
therapy 2-3
LPM

the

release

of s,

the smoking

chemical

patient

mediators,

have

attraction

of improved

neutrophils,

will

accumulation

> Assist patient

of and

manifest

fibrinous

the

exudates,

following :

blood cells and of

turn
erythema
swelling,

information that can

determination other
factors that may
have contributed to
influence its
treatment

allows the diaphragm

lung

tissue

as

normal

arterial
edema blood gases,

to descend, resulting
>Take

Long
Term :

assist in

> Sitting upright

red oxygenation

trigger by

status contributes to

position

These would in evidenced

>abnormal
blood gases /
arterial ptt
( hypoxia,

to semi fowlers

adequate

macrophages.

patient respiratory

pneumonia or

an

ventilation

Patient may

history of

> knowledge of the

in easier breathing

temperature
every 4 hours
> Infectious
processes can cause

The
patient
shall have
an
improved
ventilation
and
adequate
oxygenatio
n of lung
tissue as
evidenced
by normal
arterial
blood
gases,
clear
Breathing
sounds,
absence of

increase CO2
)

and

stimulation patient

of nerve fibers,

will

have a clear

leading to pain. breath

>Diaphoresis

mucus absence

production
>Tachycardia

> abnormal
rate rhythm,
depth of
breathing

in purulent

attempt to dilute discharge

> Provide

of

measures
change linen or
clothing

temperature spikes,
linen and clothing
may become

offending

saturated with

organisms out of

perspiration

the

respiratory

tract.

Inflamed
> Helps thin and

alveolar

sacs

> Encourage

cannot exchange

adequate fluid

O2

intake to 2000

and

CO2

effectively
leading
hypoxia

> abnormal
capillary refill

>Following

amd wash away

fluid-filler

> abnormal
skin color
(pale, dusty)

temperature

comfort

Goblet cells will sounds,

increase

an increase body

liquefy secretions

cc/day
to

of

the

lung tissue and a

> Assess mucous

>Helps to detect

significant

amount, color

improving status of

ventilation-

consistency.

pneumonia, amount

purulent
discharges
, etc.

>Restlessnes
s

perfusion

should be decreasing

mismatch

and viscosity should

be thinning following
interventions; green,

>Confusion

brown or purulent
mucus indicate

>O2
saturation of
less than
90%

continued presence
of pneumonia

>Coughing and deep

>fever

breathing cause
alveoli to open and

>Encourage

O2

coughing and
deep breathing

loosen mucous to
help clear the
airways

with mucous
expectoration
>Loosen mucous

plugs thus increasing

are available for gas

> Provide chest

exchange

physiotherapy
postural
drainage, chest
percussion and
vibration
> To maintain
airway patency
> Elevate head
of bed
>Promotes optimal
chest expansion and
> Encourage

drainage of secretion

frequent position
changes
> Helps limit oxygen
needs/ consumption
> Encourage
adequate rest
and limit
activities to with
in patient

tolerance.
Promote calm
and restful
environment

> Administer

>Pneumonia

oxygen as

increased mucous

ordered

production and fluid

retention in lungs
which decreases
adequate gas
exchange;
supplemental oxygen
provides additional
oxygen for tissue
oxygenation

>Helps to stop the

proliferation of
microorganisms

>Administer
antibiotic as
ordered and
monitor for side
effects.

Ado

Problem No. 3 Ineffective Breathing Pattern

Assessment

Nursing

Scientific

Diagnosis

Explanation

Planning

Nursing
Intervention

Rationale

Evaluation

S=
O=Patient
Manifested
the
following :

>difficulty of
breathing

>shortness
of breath on
exertion,
paleness

Ineffective

Community-

Short Term > Assess

breathing

Acquired

pattern

disease

related to

involving

thick

inflammation

of After

tenacious

lung

It hours

secretions

typically

in the

when

Intervention

bronchi

microorganisams

s,

due to

enter

inflammati

normally

on of lung

lungs

tissue

nasopharynx and respiratory

is

a :

process

tissue.

cpm with
shallow,

Short

respiratory

abnormalities would

Term :

system by noting

indicate the studies

respiratory rate,

of the respiratory

4 depth chest

system and

The patient

progression of

shall have a

breath sounds,

disease; also

normal

arterial blood

establishes a

respiratory

baseline comparison

rate,

of expansion,

results Nursing

the gases, etc.

the patient shall

sterile have

from

produces
the
of

inflammation
the

alveoli

filed

with

depth of

> Assist Patient

in assuming a

of rhythm,
lung depth

Because

rate,

inflammation

rhythm,

the normal

parenchyma.
>RR of 38

> Any of this

reports

and
a

the shortness of
of breath
are

as

evidence by

fluid decrease RR

high- fowlers
position or
position of choice
such as leaning
forward or over
bed table

>maximizes

breathing

thoracic cavity

and relief

space, decreases

from

pressure from

shortness

diaphragm and

of breath as

abdominal organs

evidence by

and facilitates use of

decrease

accessory muscles

RR from 38
cpm to 16-

rapid

and mucus and from

breathing

oxygen

38

and cpm to 16-

carbon

dioxide 20 cpm

take place at a

supraclavicul

alveolar capillary

ar muscles

cellular

for

membrane level

respiration as

due to blood flow

well as

decreases

shoulder

(deceased

muscles

perfusion
blood

of

in

the

lungs)and
> non-

leukocytes

and

productive

fibrin consolidate

cough

in

the

affected

part of the lung

due

to

> with

decreased blood

presence of

flow there is a

rales on both

decreased supply

> Increase oral

fluids to 2000-

exchange cannot
>use of

>help to improve

20 cpm

hydration status and

decrease secretions.

3000 ml/day as
tolerated
Long

> mobilizes thick

Term :

> Provide chest

secretions, and

physiotherapy,

facilitates clearing

bronchial

of lung fields.

After 2 days tapping,

of

Nursing vibration, etc.

Long Term

Intervention
s,

the

patient shall >Assist with

be free from activities of daily
any

signs living as required

and
symptoms
of

hypoxia

as
evidenced

:
>patient with
pneumonia may lack
sufficient oxygen
reserves to perform
activites; even
eating may cause
severe dyspnea

The patient
shall be
free from
any signs
and
symptoms
of hypoxia
as
evidenced
by normal

lung lobe

of

oxygen

to by

normal

ABG, etc.

upon chest

other

auscultation

leading

easily

ineffective

> Teach patient

fatigability

breathing pattern

how to decrease

tissues ABG, etc.

> Knowing how to

to

shorthness of
breath by
Patient may

restructuring

manifest

activities

control shortness of
breath will help cope
and have optimal
functioning

the
following :

>severe
dyspnea

> Preventing spread

>Teach

of infection and

pulmonary

subsequent

hygiene;

hospitalization

prevention of
spread of
infection

> sitting up
leaning
forward,
hands on
knees

>Provide

>Provide some

humidified low

supplemental

flow of oxygen as

oxygen to improve

ordered

oxygenation and to
make secretions less
viscous

>Abnormal
blood gases

>Enhances

> abnormal
inspiratory
or/and
expiratory
ration

>Administer

expectoration of

bronchodilators

secretions of

and expectorants

previously
ineffective cough

> pursed lip

breathing

>Helps to prevent
or eradicate

> altered
chest
excursion

>hypoxia
(Confusion,

> Administer

infections to reduce

antibiotics as

secretions and to

ordered

end to inflammation

restlessness,
decreased
vital
capacity)

Problem No. 4 Hyperthermia

Assessmen

Nursing

Scientific

Diagnosis

Explanation

S=
O=Patient
Manifested
the
following :

>flushed
skin

Hyperther

CAP

is

mia

inflammation

warm to
touch

Nursing

Rationale

of :

core temperature

>To have a baseline

Short

data

Term :

lung

The

parenchyma due
to

offending After

organisms,

hours

inflammatory

Nursing

lung

be s,

stimulated

of or absence of

the body
of temperature

chemical

will

mediators

that decrease

increase

>Evaporation is
decreased by

sweating as body

environmental

attempts to

factors of high

the increase heat

patients

to

release

would

4 >Note presence

response Intervention

will

humidity and high

loss by

ambient

evaporation,

temperature as well

conduction,

as the body factors

diffusion

producing loss of
ability to sweat

from 38oC to

blood flow to the 37oC.

> increased
RR

lung
leading
erythema,

Evaluation

Intervention

the Short Term > Monitor body

the

leading
>skin is

Planning

tissues
to

>Promote heat loss

by radiation,

patients
body
temperatur
e shall have
decreased
from

38oC

to 37oC.

swelling,
>
Diaphoresis

and

pain,

increased

may
manifest
the
following :

conduction and

surface cooling

evaporation

body

by means of

temperature that

loose clothing;

would reset the

Patient

> promote

hypothalamus
which

is

the

cool

Long
Term :

body
temperature

of

cool/tepid

major center for

regulation

Long Term

environment/fan;
sponge bath

After

24

hours

of

Nursing

local icepack
especially in the
axilla and groin

Intervention
>Convulsion
s

s,

the

patient

will

maintain
>
Hypotension

normal body

>indicates need for

and symptoms of

prompt

hyperthermia

interventions

temperature
during
hospitalizati

>Fluid and
electrolyte
imbalance

> Review signs

ons and be
free
any

from

>Encourage the
patient to take
vitamin C in the
diet such as

> to increase
resistance

The patient
shall have
maintained
a normal
body
temperatur
e during
hospitalizati
ons and be
free from
any
complicatio
ns of
pneumonia.

complicatio
ns

citrus fruits, etc.

of

pneumonia.
>Discuss
importance of
adequate fluid
intake

> To prevent
dehydration

>Maintain bed
rest

>To reduce
>Provide highcalorie diet

>Provide
supplemental
oxygen

metabolic demands/
oxygen consumption

> to meet increased

metabolic demands

>To offset increased

>administer antipyretics as

oxygen demand and

consumption

ordered
>To control
shivering and
seizure

Problem No. 5 Activity Intolerance

Assessmen

Nursing

Scientific

Diagnosis

Explanation

S=
O=Patient
Manifested
the
following :

> appears
weak

> poor skin

turgor

Activity

The

Intolerance

pneumonia

related to

Nursing

Rationale

Evaluation

Intervention

of Short Term > Obtain

>Helps to determine

Short

is :

subjective data

the effects of

Term :

generally marked

from patient

pneumonia on the

increased

by

regarding normal

patients ability to

oxygen

dyspnea,

demand

shortness

with

breath and easy

activity and

fatigability

hypoxia

may

(lack of

inability

oxygen

perform activities able

supply with

of daily living.

fever,
and After

4 activities prior to

of hours
Nursing

that Intervention

lead

to s,

demand)

daily

thick

pneumonia;

able

to

monitor for

perform

to fatigue and

activities of

accumulation

be

is breathing,

perform

exhaustion.

>If increased
physical activity
causes shortness of
breath, activity
should be reduced

living

the without

The patient
shall

the labored

to patient

to

be active.

of onset of

oxygen
Due

>pale nail

onset

Planning

> Reduce level of

of shortness of activity as

tenacious breath such required in

until oxygenation is
adequate.

activities of
daily

living

without
shortness
of

breath

such
doing
personal
hygiene,

as

beds

mucous

in

alveoli

altering personal

gas
(
> easy
fatigability

the as

doing response to
shortness of

exchange hygiene,
oxygen

carbon

breath.

and etc.

> Conserves energy

dioxide)

between

and reduces oxygen

the

demand patients

alveoli And

> Assist with

activities as
needed.

> nonproductive
cough

>shortness
of breath
during
activities

with pneumonia lack

enough oxygen
reserves to perform
activities

Long Term

independently.

>Pace activities

>It conserves

and encourage

energy.

The patient
shall states
that he is
comfortable
with
activity
performanc
e and
shortness
of breath is
improved
following

Long
Term :

After

24

hours

of

Nursing
Intervention
s,

the

patient
> RR of 38

etc.

states
he

periods of rest
and activity
during the day.
> Use the result to
indicate when the

that
is

activity may be
increased or

cpm, with

comfortable

shallow,

with activity

rapid

performanc

breathing

and

shortness of
breath

Patient
may
manifest
the
following :

> Monitor VS and

oxygen
saturation before
and after activity.

> Activities should

be increased
gradually, as

improved

tolerated, to avoid

following

over taxing the

cessation of

patient.

activity, and > Gradually

the patients increase activity
RR
to

returns as tolerated and

baseline share guidelines

within
>Inability to
perform
physical
activities

is

decreased.

minutes.

5 for progression
with patient.

> Physical activity

increases endurance
and stamina;
following
pneumonia, return
to normal activity

> Discuss with

the patients
> level I
functional

activities that
would be

may take time.

cessation of
activity,
and the
patients
RR returns
to baseline
within 5
minutes.

level
classificatio
n ( walk,
regular
phase, on
level
indefinitely;
one flight or
more but
more
shortness of
breath than
normal)

appropriate once
at home that
would be within
the patients
activity
tolerance.

> This indicate

intolerance to
activity and the
level of activity
should be
evaluated.

> Inform the

>labored
breathing

patient to stop
any activity that
produces

>physical
exhaustion

>oxygen
saturation
less than
90%

shortness of
breath.

> Encourage
intake of foods
high in iron and

> Iron has a role in

oxygen transport
and increases
energy level.

>To prevent injuries.


phy

good source of

>Improves

energy such as

oxygenation and

lean meat,

provides oxygen

legumes which

reserves to be used

are rich in

with increased

protein.

demand.

> Assist patient

to learn and
demonstrate
appropriate
safety measures.
> Have the
patient use
oxygen
immediately
prior to activity
in the acute
setting, as

ordered.

IX. Drug Study

X. Health Teachings
DISCHARGE PLANNING
Medications
Instruct patient to take all medications that were prescribed and
discuss the dosage, action, side effects, and contraindications of those
drug. Exact dosage is important as well as proper timing for the drug
to be effective.
o

Multivitamins; 1 tab OD

Ascorbic Acid 500 mg/tab; 1 tab OD

Cefuroxime 500 mg/tab; PO 3x for 5 days

Advise the patient of the side effects because it may be uncomfortable

to the patient.
Also, tell the patient to avoid taking medicines that is not prescribed by
the doctor or over-the-counter medication.
Remind the patient to report to the physician if adverse effects occur.
Advise client to supplement with multivitamins to provide
added nutrition.
Exercise/Environment
Teach the patient and his significant others to do passive and active Range of
Motion with slow progression in frequency.
Adequate rest periods must be given in between exercises to prevent straining.
Always bear in mind that one has to start on easy-to-do exercises first
and must rest frequently, building up strength is essential as one goes
on until hard exercises are tolerated.
Moderate exercises such as walking should be encouraged.
Maintain a quiet, pleasant environment, to promote relaxation.
Provide clean and comfortable environment
Avoid places that are stress provoking to facilitate fast recovery of the
patient.
Get plenty of rest.
Treatment
Tell patient to continue submitting self to diagnostic examination to
make sure that he is not having any complications.
Tell patient to follow advice of physician or any other health care
provider.
Health Teaching

 Encouragee patient to be more hygienic.

Indicating enough bed rest.
Impart to patient to have follow-up check-ups.
Avoid crowded or polluted areas.
Outpatient Referral
Remind for follow up check ups after 1 week.
Remind patient and family that frequent check-ups are important to
improve condition and maintain optimum balance of wellness.
Inform family to report for any abnormalities as soon as possible to
prevent further complications.
Diet
Advise patient to eat healthy food such as fruits and vegetables and
less intake of fatty food.
Advise patient to drink milk 3 times a day to provide calcium to her
body and have stronger bones.
Advise patient that alcoholic beverages should be discouraged.
Intake of vitamin supplements and other sources of minerals are
recommended.
Sources of fiber are to be added to the diet to aid indigestion.
Encourage patient to increased fluid intake.
Spiritual
Encourage significant other to contact family pastor to provide spiritual
guidance.
Participating in religious ceremonies together can be a form of family
bonding and can strengthen the family internally.
Ask the significant others to constantly remind patient that the disease
is not a form of punishment from God and that it is not the patients
fault for getting the disease in the first place.
Spiritual nursing actions to help clients meet their spiritual need
include:
Providing presence
Supporting religious practices
Assisting client with prayers
Referring client for spiritual counseling

RLE SUMMARY
As a student nurse, I have learned and gain new knowledge from this
case study. Doing a case study is not an easy task since it entails a lot of hard
work and understanding to come up with its content. But in the end, all
efforts and hard work are all worth it because of the values and learning I
have gained with my group mate.
Upon completing this case study, my group mate and I was able to
come up with several conclusions. Despite of the early description of the
condition, it is only in the recent times that Pneumonia was further
elaborated. Few researchers can be trace to have been presented in etiology
with touch of accuracy as many authors claim it to be of unknown cause. This
case study however, aims to give ideas, classifications with regards to the
origin, pathophysiology, clinical manifestations, diagnosis and treatment of
the disease.
In addition, I have also learned that to become a nurse it requires a
task to promote wellness to prevent diseases and help the patient.
Specifically, by giving appropriate health teachings. Which are to be taught
therapeutically and in a ways comprehensible to the patients including
rationale to enhance compliance. Through this way, we are able to make a
change and even save the lives of our patients. And seeing our patients get
better gives us sense of fulfillment and satisfaction. Which inspires me to be
more effective and efficient with the things I do to become a future nurse
someday.
Bungay, Maria Paula M.