Pneumonia is an inflammation or infection of the lungs most commonlycaused by a bacteria or virus.

Pneumonia can also be caused by inhaling vomitor other foreign substances. In all cases, the lungs' air
sacs fill with pus , mucous,and other liquids and cannot function properly. This means oxygen cannot
reachthe blood and the cells of the body.

Most pneumonias are caused by bacterial infections.The most commoninfectious cause of pneumonia in
the United States is the bacteria Streptococcuspneumoniae. Bacterial pneumonia can attack anyone. The
most common causeof bacterial pneumonia in adults is a bacteria called Streptococcus pneumoniaeor
Pneumococcus. Pneumococcal pneumonia occurs only in the lobar form.

An increasing number of viruses are being identified as the cause of respiratoryinfection. Half of all
pneumonias are believed to be of viral origin. Most viralpneumonias are patchy and the body usually
fights them off without help frommedications or other treatments.Pneumococcus can affect more than
the lungs. The bacteria can also causeserious infections of the covering of the brain (meningitis), the
bloodstream, andother parts of the body.

Community-acquired pneumonia

Develops in people with limited or no contact with medical institutions or settings. The most commonly
identified pathogensareStreptococcus pneumoniae, Haemophilus influenzae, and atypical organisms (ie,
Chlamydia pneumoniae,Mycoplasma pneumoniae, Legionella sp).

Symptoms and signs are

Fever,

Cough,

Pleuritic chest pain,

Dyspnea,

Tachypnea,

Andtachycardia.

Diagnosis is based on

clinical presentation and chest x-ray.

Treatment is with empirically chosen antibiotics.

Prognosis is excellent for relatively young or healthy patients, but many pneumonias, especially when
caused by S. pneumoniae or influenza virus, are fatal in older, sicker patients
Name: Patient J

Age: 74 years old

Sex: Female

Religion: Roman Catholic

Date Admitted: Nov. 17, 2017 at exactly 11:15 AM Admission

Diagnosis: COPD not in exacerbation

Final diagnosis: Community Acquired pneumonia (CAP) moderate Risk

Chief Complaint:

Difficulty of Breathing

General Data:

This is a case of a 74 year old female Filipino, presently residing in Adelina 3 Binan, Laguna who was
admitted in Perpetual Help Hospital on September 17, 2009.

Past history
No surgery or hospitalization ever before she had fever one month back

Present history
5 days prior to admission, patient had positive signs and symptoms of cough, yellowish phlegm,
persistent fever and back pain. Knowing that these signs and symptoms were just forms of little
discomforts, she self-medicated with paracetamol. However, she noticed no changes and experienced
difficulty of breathing so she sought medical consultation

Social history
According to the patient, she has no occupation already so she stays at home with his youngest
child and grandchildren. She walks around their compound to visit her neighbors. She cook
lugaw and feed her grandchildren. She always feeds and takes care of her favorite pets (dog and
cat).
Family history
According to the patient, She claimed that someone in her family member had pneumonia
before.

II. GORDONS 11 FUNCTIONAL PATTERN

1. Health Perception and Health Management Pattern
Prior to admission:
According to the patient, she sees himself as a weak person. She dont smoke but they use
firewood as their main equipment for cooking food When sick, their family use herbal
medicines such as oregano, guava, and ginger and they also use OTC drugs.
During Hospitalization:
She is awake, lying on bed, conscious and coherent. She depends his health
management to the nurses and doctors. She is concern about her condition and willing to get
better that is why she listens and does the health advices of the doctors and nurses. Patient rated
his health 7/10 when asked with 1 as the lowest and 10 as the highest.
2. Nutritional and Metabolic Pattern
Prior to admission:
According to the patient, he is fond of eating Green leafy foods. She eats fruits and
vegetable like Inabraw and pakbet. She rarely eats meat but usually eats fish. She has slightly
difficulty in swallowing d/t her condition. She always drinks ginger tea. She drinks 1-2 liter of
water a day
During Hospitalization:
According to the patient, she eats the food of the hospital but he eats minimally because
he has less than appetite than usual. Weight of 45 kg and height of 51 with a BMI- 20.5
(Normal).
When admitted, he is being infused with an IVF of PNSS in fast drip.
T-37 BP-90/60
RR-23
3. Elimination Pattern
Prior to admission:
According to the patient, she has sometimes having difficulty in urinating. Patient
usually urinates 250 ml with light yellow in color for 2 times a day. She usually moves his bowel
every morning with brown and formed stools and does not have difficulty in defecating.
During Hospitalization:

7-3 3-11 11-7 Total

Intake
Oral 200 500 200 2000
IVF 700 100 300
Output
Urine 200 400 300 900
Stool 1 0 0

4. Activity Exercise Pattern

Prior to admission:
According to the patient, she has no occupation already so she stays at home with her
family. She walks around their compound to visit her neighbors. She also planting vegies in her
bakuran . During weekdays, she cook and feed her grandchildren. She always feeds and takes
care of his pets (dogs and cat). Thats the form of his exercise.
During Hospitalization:
According to the patient, she was just lying on bed, taking rest. Her strength and speed of
movement has decreased so she needs assistance in anything he does.
5. Sleep Rest Pattern
Prior to admission:
According to the patient, she can sleep for 8-9 hours per night and has a straight hours of
sleep but sometimes d/t her condition she sleep about 5-6 hours. She usually sleeps around 9PM
and wakes up at 5AM. she also takes a nap at 1 in the afternoon. She doesnt use any medication
to sleep. She usually sleeps in supine position.
During Hospitalization:
According to the patient, she sometimes have a good quality of sleep. She feels restless
and she has a body weakness. She tries to get some rest anytime of the day. During night time,
her sleep is usually interrupted due to her condition , administration of medication and any other
management.

6. Cognitive-Perceptual Pattern
Prior to admission:
The patient highest educational attainment was an elementary graduate. She is oriented to
person, time, and place. She slightly had difficulty in sight and he cant hear well. There is a
slightly problem with her sense taste and sense of smell. She breathes hardly. She can speak well
with Ilocano and Tagalog as his dialect.
During hospitalization:
The patient is oriented to people, time, and place, and also have an ability to understand
and follow directions sometimes. She has a difficulty in hearing but she answers my questions
clearly. There is a slightly problem with his sense of, taste, smell and touch especially her sight.
She is responsive and can speak well (Ilocano and Tagalog).
According to the patient, she is well supported by the family. she still plays the role of a
mother despite her condition by means of reminding important matters to her children.
9. Sexuality-Reproductive Pattern
Prior to admission:
According to the patient, She is married with 5 children alive. She has no history of any
disease affecting his genitals. She was got pregnant when shes 18 . She is not attracted with
other women. She is not sexually active. She said that she never used any contraceptives.
During Hospitalization:
According to the patient, She is not sexually active d/t his sickness.
10. Coping Stress Tolerance Pattern
Prior to admission:
According to the patient, she sometimes managed his stress by taking a nap or sleep but
his ultimate stress reliever is her grandchildren and planting veggies. When they have a problem
at home, they manage it by talking about it with the family and finds ways to resolve it together.
During Hospitalization:
 According to the patient, she feels restless so she always made a way to sleep. Her family
are one of the reasons why she desire to recover fast. she is able to accept situation by
cooperating with the medical advices and procedures.
11. Value-Belief Pattern
Prior to admission:
According to the patient, she was an Iglesia ni cristo who always go to church but d/t her
condition she rarely go there now. They believe in quack doctors and go there. They believe in
superstitious beliefs.
During Hospitalization:
According to the patient, She believes in God that he is able to make her feel better.

III. PHYSICAL ASSESSMENT

November 15, 2017 (8:00 am)

Patient: B
General Survey:
The patient is awake, lying on bed, conscious and coherent with an IVF of PNSS
and side drip of D5W with incorporation of aminophylline on the right arm.

Vital Signs:
Blood Pressure: 110/60
Temperature: 35.7 C
Pulse rate: 78bpm
Respiratory rate: 26 breaths/min
 Body Parts Methods Used Findings Interpretation
SKIN
Inspection Brown in color Normal
Skin turgor The skin go backs to Normal
its normal state after
Palpation pinching Normal
The skin is warm to
touch
HEAD
Scalp Inspection Round in shape Normal
Inspection No presence of Normal
dandruff, no lice
Palpation No nodules or Normal
Hair Inspection masses Normal
Black and more Normal
Palpation white Normal
long hair and
slightly thin
Hair is dry
EYES
Conjunctiva Inspection Symmetrical Normal
Transparent Normal
Pinkish in color Normal
Eyebrows Inspection Black in color Normal
Symmetrically Normal
aligned
Pupils Inspection using Normal
penlight Equally round and
react to light and
accommodation Normal
Eyelashes Inspection (4mm) Normal
Black in color
Equally distributed
Eyelids Inspection Normal
Normal
Skin intact
Iris Inspection Ability to blink Normal

Light brown in color

EXTERNAL EARS Inspection Symmetrical Normal
Same color with Normal
face Normal
Without lesions Normal
The upper point of
attachment is
INTERNAL EARS Palpation levelled to the outer Normal
Inspection using cantus D/t poor hygiene
penlight Pinna recoil
Discharges are seen
NOSE Inspection Same color as the Normal
face
Peeling of the skin
MOUTH
Lips Inspection Dark lips D/t history of
smoking
Teeth Inspection With one dental D/t poor oral
carry hygiene
No dentures Normal
Tongue
Inspection Pink in color Normal
Moist Normal
Moves freely Normal

Gums Inspection Dark brown in color D/t history of

smoking
CHEEKS Inspection Symmetrical Normal

NECK
Inspection Distended jugular D/t past history of
Inspection vein goiter and
Presence of scar cardiomyopathy
Thyroid Palpation D/t hyperthyroidism
Mass palpated
CHEST
Thorax Inspection Symmetrical Normal
Auscultation No presence of Normal
crackles
Abdomen Inspection Normal
Palpation No lesions Normal
Apical Pules Auscultation No pain during D/t dysrhythmia and
using a Doppler palpation lack of O2 supply of
the heart
 Abnormal heart
rhythm

UPPER
EXTREMITIES Inspection Moves freely Normal
Shoulder Symmetric to both Normal
right and left

Inspection Moves freely Normal

Arms Right and left arm Normal
are symmetrical Normal
No lesions
Inspection
Hands Symmetrical to both Normal
left and right
Inspection No presence of Normal
Fingernails edema D/t poor oxygenation
Clubbing fingernails

Pulse Capillary bed Cannot distinguish D/t poor oxygenation

refill
Palpation Weak and thready D/t poor oxygenation
radial pulse
Pulse rate: 84

NECK
Inspection Distended jugular D/t past history of
Inspection vein goiter and
Presence of scar cardiomyopathy
Thyroid Palpation D/t hyperthyroidism
Mass palpated
CHEST
Thorax Inspection Symmetrical Normal
Auscultation No presence of Normal
crackles
Abdomen Inspection Normal
Palpation No lesions Normal
Apical Pules Auscultation No pain during
using a Doppler palpation
 Abnormal heart D/t dysrhythmia and
rhythm lack of O2 supply of
the heart

UPPER
EXTREMITIES Inspection Moves freely Normal
Shoulder Symmetric to both Normal
right and left

Inspection Moves freely Normal

Arms Right and left arm Normal
are symmetrical Normal
No lesions
Inspection
Hands Symmetrical to both Normal
left and right
Inspection No presence of Normal
Fingernails edema D/t poor oxygenation
Clubbing fingernails

Pulse Capillary bed Cannot distinguish D/t poor oxygenation

refill
Palpation Weak and thready D/t poor oxygenation
radial pulse
Pulse rate: 84

LOWER
EXTREMITIES Inspection Hairy Normal
Legs Symmetrical to both Normal
left and right
Able to flexed and Normal
extend
No presence of Normal
Palpation edema
No pain during Normal
palpation
Feet Inspection No mass or lumps Normal
Palpation No presence of Normal
edema
Short nails Normal
Presence of Edema D/t fluid volume
Grade 1 Edema excess
Normal
 No pain during
palpation

ANATOMY AND PHYSIOLOGY

The Lungs

The lungs are paired, cone-shaped organs which take up most of the space inour chests, along with
the heart. Their role is to take oxygen into the body, whichwe 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 lungand a right lung. These are divided up into 'lobes', or big sections of tissueseparated by 'fissures'
or dividers. The right lung has three lobes but the left lunghas 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 bymembranes. There are about
10 of them in each lung. Each segment receives itsown blood supply and air supply.Air enters your lungs
through a system of pipes called the bronchi. These pipesstart from the bottom of the trachea as the left
and right bronchi and branch manytimes throughout the lungs, until they eventually form little thin-
walled air sacs or bubbles, known as thealveoli. The alveoli are where the important work of
gasexchange takes place between the air and your blood. Covering each alveolus isa whole network of
littleblood vesselcalledcapillaries, which are very small
branches of thepulmonary arteries. It is important that the air in the alveoli andthe blood in the
capillaries are very close together, so that oxygen and carbondioxide can move (or diffuse) between
them. So, when you breathe in, air comesdown the trachea and through the bronchi into the alveoli. This
fresh air has lotsof oxygen in it, and some of this oxygen will travel across the walls of the
alveoliinto 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 isthen breathed out. In this way, you bring in to
your body the oxygen that youneed to live, and get rid of the waste product carbon dioxide