A Medical Case Study of pneumonia

In Partial Fulfillment of
the Course Requirements in Medical Surgical Nursing

Submitted to the Faculty of

San Lorenzo Ruiz College
College of Nursing

Submitted by:
Suano, Dhebra Mia I.

Kilo Class 2018

March 2017
II. Objectives

Student Nurse-Centered

General Objectives:

After 3 days of giving holistic nursing care the student nurse-patient and

significant others interaction, the student nurse will be able to gain more knowledge, attitude

and skills in managing a patient with pneumonia.

Specific Objectives:

After 8 hours of student nurse-patient interaction, the student nurse will be able to:

1 define pneumonia

2 establish rapport and gain information in connection to reason why the

patient is admitted

3 make a thorough assessment about the patients personal history, family

background and lifestyle

4 enumerate clinical manifestation of pneumonia, manifested by the patient

5 state the causes of pneumonia

6 recall the anatomy and physiology of the organ affected by pneumonia

7 trace the pathophysiology of pneumonia

8 state the possible complications of pneumonia when not treated

9 develop a plan of care necessary in managing pneumonia

10 evaluate a feedback or patients reaction, state or condition after

implementation of the case

Patient-Centered

General Objectives:

After 3 days of student nurse-patient and significant others interaction, the

patient and significant others will be able to gain information for the management of

pneumonia.

Specific Objectives:

After 8 hours of giving holistic nursing care, the patient and significant others will be able to:

1 exhibit positive attitude and response towards the student nurse

2 identify the causes of disease condition

3 verbalize what he feels and opinion of the condition

4 cooperate in activities of daily living

5 gather information about the disease process of pneumonia

6 enhance a sense of independency in caring for himself

7 determine behaviors that improves the health condition

III. NURSING ASSESSMENT

1. Personal History

1.1 Patients Profile

Name: Barabad, Bienvinido Villar

Age: 64 y.o

Sex: male

Civil Status: married

Address : Brgy. Lake Danao, Ormoc City

Birthdate: September 12, 1952

Occupation: none

Date of Admission: February 21, 2017

Room No: MM8

Complaints: difficulty in breathing, fatigue, low level of consciousness, high

blood pressure

Diagnosis: pneumonia both lungs

Physician: Dr. Nelson Chu

Case No. 021798895

4.2 Pathophysiology of Disease

Pneumonia is an excess fluid in the lungs resulting from inflammatory process.

The inflammation is triggered by many organisms and by inhalation of irritating agents.
Infectious pneumonia are categorized as community- acquired pneumonia or hospital
acquired pneumonia, depending on where the client was exposed to the infectious
agent. The distinction is important because nosocomial pneumonia are more likely to be
resistant to antibiotics than the community-acquired pneumonia.
The inflammation occurs in the interstitial spaces, the alveoli, and often in the
bronchioles. The process begins when organism penetrate the airway mucosa and
multiply in the alveolar spaces. To do this, they must survive the lungs many defenses
against microbial invasion, including the inflammatory response. White blood cells
migrate to the area of infection, causing local capillary leak, edema, and exudate. The
fluids collection in and around the alveoli, and the alveolar walls thicken. Both events
reduce gas exchange and lead to hypoxemia. Red blood cells and fibrin also move into
the alveoli. The capillary leak spreads the infection extends into the pleural cavity,
empyema results.
The fibrin and edema of inflammation stiffen the lung, reducing compliance and
decreasing the vital capacity. Alveolar collapse further reduces the ability of the lungs to
oxygenate the blood moving through it. As a result, arterial oxygen tension falls, causing
hypoxemia.
Pneumonia may occur as lobar pneumonia with consolidation in a segment or an
entire lobe of the lung or as bronchopneumonia with diffusely scattered patches around
the bronchi. The extent of lung involvement after the organisms invades depends in a
persons whose immune system is compromised. Tissue necrosis results when
organism from an abscess that perforates the bronchi wall.
4.3 Pneumonia and its Effect on the Different organs

A lot of the time, the body filters germs out of the air that we breathe. This keeps

the lungs from becoming infected. But germs from time to time obtain a method to enter

the lungs and lead to infections. This can be a lot more possible to happen when your

immune system weak. A germ is extremely sturdy. Your system fails to filter germs out

of the air that you breathe. Once the germs that bring about pneumonia achieve your

lungs, the lungs' air sacs (alveoli) come to be inflamed and fill up with fluid and pus. This

brings about the signs and symptoms of pneumonia, such as a cough, fever, chills, and

difficulty breathing.Once you have pneumonia, oxygen has problems reaching your

blood. If there is also little oxygen in your blood, the body cells can not function

adequately. Due to this and infection spreading through the body, pneumonia may

cause death. Pneumonia impacts your lungs in two approaches. Lobar pneumonia

impacts a section (lobe) of the lung. Bronchial pneumonia (or bronchopneumonia)

affects patches throughout both lungs. Persons at best risk for bacterial pneumonia

include things like men and women recovering from surgical treatment, men and women

with respiratory diseases or viral infections and individuals who have weakened immune

system.

In case your body's defenses are weakened-by illness, old age, malnutrition, or

impaired immunity-the pneumonia bacteria, which may reside in healthful throats, can

multiply and perform their way in to the lungs. The infection can rapidly spread through

the bloodstream and invade the whole body.

 PARTS DESCRIPTION
Pug or ski-jump in shape,
NOSE is the only external visible
part of the respiratory
system.
Is a muscular passageway
PHARYNX about 13 cm long that
(Throat) vaguely resembles a short
length of a red garden
hose.
Located inferior of the
LARYNX pharynx. It is forms by
eight rigid hyaline
cartilages and spoon-
shaped flap of elastic
cartilage, the epiglottis.
The walls of trachea is
TRACHEA fairly rigid because its
walls are reinforced with C
shaped rings of hyaline
cartilage.
Are fairly large organs.
LUNGS They occupy the entire
thoracic cavity except the
most central area which
houses the heart.
FUNCTION
During breathing, air
enters the nose by passing
through the nostrils r
external nares. the mucosa
moisten the air and traps
incoming bacteria and
other foreign debris.
Serves a common
passageway of food and
air.
Or the voice box, rotes air
and food into the proper
channels and plays a role
in speech.
The open parts of the rings
about the esophagus and
allow it to expand
anteriorly when we
swallow. The solid portion
support the trachea walls
and keep it patent in spite
of the pressure changes
that occur during
breathing.
The pleural membrane of
the lungs produces pleural
fluid , a slippery serous
secretions which allows
the lungs to glide easily
over the thorax wall during
breathing movements.
 The bronchi are two tubes
BRONCHI stemming off of the end of
the trachea. Each tube is
connected to a lung.
Alveoli are hollow,
ALVEOLI individual cavities that are
found within alveolar sacs.
The diaphragm is an
DIAPHRAGM important muscle of
respiration which is
situated beneath the
lungs.
Bibliography:
Books :
The bronchi connect the
wind pipe to the lungs,
allowing air from external
respiratory openings to
pass efficiently into the
lungs. Once in the lungs,
the bronchi begin to
branch out into secondary,
smaller bronchi, coined
tertiary bronchi.
Alveoli have extremely thin
walls, which allows the
exchange of oxygen and
carbon dioxide to take
place within the lungs.
There are estimated to be
three million alveoli in the
average lung.
The diaphragm
contracts to expand
the space inside the
thoracic cavity,
whilst moving a few
inches inferiorly into
the abdominal
cavity. Whilst this is
happening, the
intercostal muscles
also contract, which
moves the rip cage
up and out. The
contractions force
air into the lungs, by
creating a negative
pressure through
expansion.
Donna D. Ignatavicius, MS, RN, C and M. Linda orkman, PhD, RN, FAAN Medical-

Surgical Nursing Critical Thinking for Collaborative Care 5 th edition volume 1

Elaine N. Marieb, RN, PhD Essentials of Human Anatomy and Physiology 8th Edition

Barbara Kozier, MN,RN; Audrey Berma, PhD,RN, AOCN; Shirlee J. Snyder, EdD, RN;

and Glenora Erb, BSN,RN Fundamentals of Nursing Concepts, Process, and Practice

8th Edition Volume 1 and 2

Patricia A. Potter RN, MSN, PhD, FAAN And Anne Griffin Perry RN, EdD, FAAN

Fundamentals of Nursing 7th Edition Mosby Elsevier

Joyce M. Black and Jane Hokanson Hawks Medical-Surgical Nursing Clincal

Management for Positive Outcomes 8th Edition Volume 2 Saunders Elsvier

Marilynn E. Deonges, Mary Frances Moorhouse, Alice C. Murr Nursing Care Plan

Guidelines for Individualizing Clint Care Across the Life Span 8 th Edition

Walters Kluwer Nursing 2016 Drug Handbook

Mosbys Diagnostic and Laboratory Test Reference 8th Edition

Internet:

http://www.webmd.com/lung/tc/pneumonia-topic-overview
http://www.lung.org/lung-health-and-diseases/lung-disease-

lookup/pneumonia/symptoms-causes-and-risk.html?

referrer=https://www.google.com.ph/

http://www.wpro.who.int/philippines/typhoon_haiyan/media/Pneumonia.pdf?ua=1

1.2 Family and Individual, Social and Health history:

 His admitted due to thalamic bleed, his hypertension is hereditary. But

during his admission another condition was found out through conducting X-ray. He has

pneumonia in both lungs. According to the patients significant others hes been

coughing since he was still working and before his first admission last 2007. Based on

my assessment, his pneumonia have already developed a long time ago when he was

still working as a security guard in a factory in Ipil, Ormoc, City.

1.3 Level of Growth and Development

1.3.1 Normal development in older adult

Physical Development

As the person ages, a number of physical changes occur; some are

visible, some are not. In general, lean body mass is reduced, fat tissue increases, and
bone mass decreases. Extracellular fluid remains constant; however, intracellular fluid
decreases and leads to reduced total body weight. Thus, elders are at risk for
developing dehydration.

Therefore, alder adults engage in activities of daily living usually consider

themselves healthy, whereas those who have physical, emotional, or social impairments
that limit their activities perceived themselves as ill.

The body changes continuously with age, and specific effects on particular
older adults depend on health, lifestyle, stressors, and environmental conditions.

(Kozier and Erb) and (Potter.Perry)

Psychosocial Development
 The psychosocial changes occurring during aging involve life transition
and loss. He longer people live, the more transitions they have to cope with and more
losses they experience. Life transition, for which loss is the major component, including
retirement and the associated financial changes, changes in roles and relationship,
alteration in health and functional ability, changes older adult usually revolves around
the loss of relationship through death.

(Potter.Perry)

According to Erikson, 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. People who develop integrity accept ones one and
only life cycle. By contrast, people who despair often believe they have made poor
choices during life and wish they could live life over.

(Kozier and Erbs)

Cognitive Development

A common misconception about aging is that cognitive impairment are

widespread among older adults. Because of this misconception, older adults often fear

that they are, or soon will be, cognitively impaired. Younger adult assume that alder

adult are confused and no longer able to handle their affairs. Understand that

forgetfulness as an expected consequence of aging is a myth. Some structural and

physiological changes with in the brain associated with cognitive impairment, such as

reduction in the number of cells, deposition of lipofuscin and amyloid in cells, and

changes in neurotransmitter levels occur in this stage both with and without

impairments.
 The three common condition affecting cognition re delirium, dementia and

depression.

(Potter.Perry)

Moral Development

According to Kohlberg, moral development is completed in early adult

years. Kohlberg hypothesized that an older person at the preconventional level obeys
rules to avoid pain and is displeasure of others. Where older people may act to meet
anothers needs as well as their own. Elders at the conventional level follows societys
rules of conduct in response to the expectation of others.

( Kozier and Erbs)

Spiritual Development

Elders can contemplate new religious and philosophical views and try to

understand ideas missed previously or interpreted differently. The older person may

derive the sense of worth by sharing experiences or views. In contrast, the older adult

who has not matured spiritually may feel impoverishment or despair as the drive of

economic and professional success lessens.

Many elders take their faith and religious practice very seriously, and

display a high level of spirituality. It would be mistake however, to assume that religious

increases with age. Todays elders grow up in a time when religion was much more

important than it is for younger people today. The participation of older adults in religious

organizations, therefore, is more likely to be a continuation of lifelong habits than a

correlate of aging. Involvement in religion often helps older adults to solve issues

related to the meaning of life, to adversity, or to good fortune.

( Kozier and Erbs)

1.3.2 The Ill Person at Particular Stage of Patient

People in this stage are more in developing an illness due to their physiological

changes. Their immune system and body defenses is low to fight against bacteria and

other organism. Leading causes of death in this age group include: falls, chronic

disease such as cancer, cyst and cardiovascular disease.

Illnesses and conditions experienced in older adults may affect their roles and

responsibility. Strained family relationships, retirement; modification in family activities,

increase health care task, increase financial stress; social isolation, medical concerns,

and grieving may all result from illness. The ill behavior of depression, describe them

as feeling sad and alone. Alteration in sleep patterns such as difficulty in sleeping,

insomnia, anxiety, feeling of social interest, headache, regardless of the amount of rest

and feeling of fatigue, low self-esteem and seek attention from the significant others.

Prior to admission, the patient was already experienced right sided hemiplegia,

due to his first admission last 2007.

2. Diagnostic Test

Name of Patient: Barabad, Bienvinido Villar Sex: Male Room #: MM8

Age: 64 y.o Physician: Dr. Nelson Chu

Chief complaint: difficulty in breathing, high blood pressure, fatigue

Date Taken: February 21, 2017

Diagnosis: Pneumonia in both lungs

HEMATOLOGY

Diagnostic Test Normal Patients Significance

Values Result

Hemoglobin Male:14.0- 10.6 Decreased: anemia - low

17.5 oxygen level in the blood.
Female:12.3- Decreased binding of oxygen
15.3 due to impaired respiratory
function specifically at the
alveoli

Hematocrit Male:41.5- 31.8 % Decreased: Anemia- low

50.4 packed red cell volume due to
Female:35.9- damaged alveoli and
44.6 decreased erythropoietin
production secondary to
decreased renal function (see
blood creatinine and uric acid
determination)
 RBC 4.50-5.90 4,25 Decreased: Anemia
(normocytic, normochromic
anemia) - low hemoglobin
content of the RBC due to
damaged alveoli.

WBC 4,000-11,000 17.5x10^3/L

Increased: due to bacterial
infection, the bodys
mechanism to combat infection.
(see differential count; elevated
neutrophil)

MCV 80-96 74.8 fl NORMAL

MCH 27.0-31.0 24 fl NORMAL

MCHC 32.0-36.0 32.1 fl NORMAL

Platelet Count 150,000- 272,000 NORMAL

450,000 10^3/L

Neutrophil 40-70 89.3 INCREASES : due to bacterial

infection in the lungs, the
bodys mechanism to combat
infection.
 Basophil 0-1 0.1 NORMAL

Eosinophil 1-5 1.1% NORMAL

Lymphocyte 20-40 5.8% NORMAL

Monocyte 0-8 3.7% NORMAL

BLOOD CHEMISTRY

NORMAL VALUES RESULT SIGNIFICANCE

Uric Acid 200- 240 umol/l 796.1 Increased : gout , High

levels of uric acid in the

blood can cause solid

crystals to form within

joints. Due to high blood

pressure cause damage

to the arteries leading to

the kidney that will cause

the kidney not to

effectively filter waste

from the blood.

Potassium 3.5-5.3 mmol/l 3.13 NORMAL

Creatinine 16.8-123.7 144.3 INCREASED: poor

kidney function.

Creatinine is elevated

due to the filtration

mechanism becomes

gradually damaged by

long-term raised blood

pressure.

Sodium 135-148 140.6 NORMAL

Albumin 35-50 37.1 NORMAL

3. Present Profile of Functional Health Pattern

Health Perception/Health Management

The patient is conscious but she doesnt know all about her

condition. He perceives health as absence of a disease. He manages to

keep healthy by eating healthy foods. When he got sick, he find alternative

ways for treatment. He was hospitalized last 2007 because of stroke, and

it resulted into hemi paralysis right side. Recently he was experiencing

stroke again. He arrived in the hospital with low level of consciousness,

slurred speech, stuporous and had blurred vision. Luckily he is now fine

and can hear, understand, see the object nearer to him, and answers all

the questions asked briefly.

Cognitive/Perceptual
The patient doesnt have a problems in vision, hearing, taste,

smelling and sense of touch. He is able to read and write. He is oriented

to time, place and he is responsive to verbal and physical stimuli. During

admission, the patients hearing ability is affected she cant sometimes

hear clearly even at short distance, he also cant see clearly even in short

distance. The patient was not able to read and write.

Nutritional and Metabolic
The patient eats three times a day and sometimes with snacks. He

usually eats rice, fish, vegetables and fruits. During admission, hes been

on NPO due o many laboratory examinations conducted. An IV line of

D5LR @ 20 gtts infusing well at his left arm

Elimination Pattern
 The patient usually voids 4-5 times a day and voids freely. The

patient voids normally before admission. During admission, the patients

voiding pattern was changed because he is being catheterized. He cannot

defecate everyday due to the effects of some drugs hes taking.

Sexuality and Reproduction

The patient is married and they have five daughters. The patient is

64 years old. His sexual life is not active and altered due to his condition

(hemi paralysis) aside from that hes been separated to his wife long time

ago and didnt get another chance to find someone and remarry again.

Activity and Exercise

The patient doesnt love to exercise because according to him, he doesnt

have time when he was still working as security guard. During his first

admission, his activity was totally changed. He cant move the right side of

his body and needs assistance in complying his daily activities.

Roles and Relationship

The patient was been separated with his wife. He is close with his children

and has no problem in relating with them, and conflicts were not

mentioned. He has five daughters and all of them got married already, and

he was living with the same roof with his one daughter. In their family,

they also discuss things concerning their health and able to express their

feelings freely.
IV. Nursing Intervention

I. Assess for:

Respiratory status including rate, depth, ease, shallow or irregular breathing,

dyspnea, use of accesory muscles, and diminished breath sounds, rhonchi or

crackles on auscultation - provides data baseline.

Changes in mental status, skin color, cyanosis - indicates possible decrease in

oxygenation.

Quality of cough and ability to raise secretions including consistency and

characteristics of sputum - removal of secretions prevents obstruction of airways

and stasis leading to further infection and consolidation of lungs; clearing airways

facilitates breathing.

II. Monitor, record, describe:

Respiratory rate, quality and breath sounds q2-q4 - indicates airway resistance,

air movement, severity of disease.

ABGs, oximeter reading - decreased oxygen levels result in hypoxemia.

III. Administer:

Oxygen therapy via cannula - maintain optimal oxygen level.

 Antitussives/expectorants (terpin hydrate, guaifenesin) - acts on bronchial cells to

increase fluid production and promote expectoration; guaifenesin reduces

surface tension of secretions; both relieve non-productive cough

Name of Patient: Barabad, Bienvinido Sex: Male

Age: 64years old Physician: Dr. Nelson Chu

Room #: MM8

Nursing Care Plan

Assessmen Nursing Scienti- Planning Interventions Rationale Evaluatio

t Diagnosis fic Basis n

Subjective: Ineffective Bacterial After 8 Measure to After 8
Nag lisod airway microorg hours of reduce
ug ginhawa clearance: anism giving difficulty in hours of
si papa
productive enter the holistic breathing:
maam, as 1.tachypnea, giving
verbalized cough airways nursing 1.assess rate shallow
by the related to care, the and depth of respiration are holistic
significant increase Inflammat patient will respiration and frequently
oher. sputum ion of be able to chest present. nursing
Objective: production the lung/s display movement
-deep secondary patent . care, the
breathing 2.to promote
to Air sacs airway
through chest patient
mouth. pneumonia filled breathe 2.elevate head expansion
-productive with pus sound of bed. therefore can was able
cough & other clearing. decrease
-harsh liquids difficulty in to display
breathe breathing.
sound Presence 3.suction patent
-HR: 104
of secretions as
-RR:28 cpm airway
obstructio indicated. 3.to clear
ns in the airway and breathe
airways 4.increased remove
 fluid intake as secretions sound
Inability prescribed
to 4.to liquify clearing.
mucos and it
breathe 5.administer
will be easy to
properly drugs as expectorate
ordered:
a.Salbutamol 5.
b.Exflem
a.Broncho-
dilator
b.Mucolytic

Assessmen Nursing Scientific Plan- Interventions Rationale Evaluation

t Diagnosis Basis ning

Subjective: Ineffective Cerebrov After 8 Measures to After 8
Sige rag cerebral ascular hours of prevent further hours of
katulog tissue accident giving deterioration: 1.deteriora- giving
akong papa perfusion is injury holistic 1.determine tion in holistic
maam, as related to or death nursing factors related neurological nursing
verbalized interruption to parts care, to individual signs and care, the
by the of blood of the the situation, symptoms or patient
significant flow brain patient cause forfailure to was able
other. secondary caused will be coma low improve may to display
Objective: to by an able to cerebral reflect low no further
-stuporous cerebrovas interrupti display perfusion. intracranial deteriorati
Facial cular on in the no adaptive on.
asymmetry accident. blood further capacity. So
-(-)Babinski supply to deterior that
reflex that area ation. treatment is
-GCS:6 causing geared
-pupil is disability toward
3cm dilated such as rehabilitation
-sensory paralysis 2.monitor and and
and or speech document preventing
language impairme neurological reoccurrence
Deficit nt. status .
-elevated frequently and 2.assess
V/S compare with trends in
-HR: 104 baseline. LOC and
bpm potential for
-RR: 28 increase ICP
cpm and is useful
-BP: in
180/100 determining
mmhg 3.close of CNS
monitoring of damage.
vital signs.
3.fluctuation
s in pressure
may occur
because of
cerebral
pressure or
4.evaluate injury in
pupils, noting vasomotor
the size and area of the
light reactivity. brain.
 4.pupil
reaction and
5.provide bed light
rest and reactivity are
restrain active useful in
activities determining
whether the
6.position with brainstem is
head slightly intact.
elevated.
5.continual
stimulation
can increase
ICP.

6.reduces
7.administer arterial
drugs as pressure by
ordered: promoting
a.Clomidine venous
b.Prevastatin drainage
may improve
cerebral
circulation
and
perfusion.

7.

a.antihyperte
nsives
b.antiepilipe
mics
2.2.4 Health Teaching Plan

Objectives Content Methodology Evaluation

General:
At the end of 8
hours of student
nurse,
client/patient and
significant others
interaction, the
client/patient and
significant others
will be able to gain
knowledge, skills, Specific:
and attitude in After 45 minutes of
caring for patient student nurse-patient
with Pneumonia. and significant others
Specific: interaction, the patient
After 45 minutes of and significant others
student nurse- was able to:
patient and
significant others -Pneumonia is an Lecture, visual
interaction, the inflammatory aids. 1. defined Pneumonia
patient and condition of the lung 4 mins.
significant others affecting primarily the
will be able to: microscopic air sacs
known as alveoli.
1. define Characterized
Pneumonia primarily by
inflammation or alveoli Discussion
filled with fluid or pus. and 2. enumerate the
questioning signs and symptoms
-signs and symptoms 12 minutes of Pneumonia
of Pneumonia
includes:
2. enumerate the -productive cough
signs and -night sweats
symptoms of -fast breathing
Pneumonia -high fever
-fast heartbeat
-chest pain when
coughing

-slide show, 3. identify causes of

lecture Pneumonia
-the following causes 7 minutes
of pneumonia are:
-Bacteria
 -Virus
3. identify causes -Fungi
of Pneumonia - Parasite demonstration 4. demonstrate deep
and return breathing exercise
-procedure of deep demonstration and coughing
breathing exercise 22 minutes exercise.
and coughing
exercise.
4. demonstrate 1.explain rationale for
deep breathing the procedure.
exercise and 2.help client to sit
coughing exercise. straight up in bed or
on side of the bed
with knees slightly
flexed.
3.have client place his
hands palm down
around the sides of
clients lower ribs.
4.tell the client to
breathe in slowly
through nose until
chest expands and
abdomen rises visibly.
5.have client to hold a
sustained maximum
inspiration 3-5
seconds, then exhale
slowly through the
mouth.
6.insruct client to
 repeat the cycle 3
times.
7.after the third deep
breathe, have him 5.verbalized
inspire and hold deep understanding about
breathe briefly. Pneumonia.
8.have client expire
forcefully against the
close glottis and then
5.verbalized release the air
understanding abruptly while flexing
forward.
9.repeat cycles for 5
times every 30
minutes asa needed.

SOAPIE Charting

Name of Patient: Barabad, Bienvinido V. Sex: Male

Age: 64 years old Physician: Dr. Nelson Chu

SOAPIE # 1

S = Naglisod ug ginhawa akong papa maam, as verbalized by the patients significant

other.

O = Received patient lying on bed with an ongoing IVF D5LR 1 litter at 20 gtts./min
infusing well at the left arm. Deep breathing through his mouth was noted, productive
cough, and harsh breathe sound. With heart rate of 104 bpm and respiratory rate of 28
cpm.

A =Ineffective airway clearance: productive cough related to increase sputum production

secondary to Pneumonia.
P = After 8 hours of giving holistic nursing care, the patient will be able to display patent
airway with breathe sound clearing.

I = Assess rate and depth of respiration and chest movement. Elevating the head of bed
for lung expansion. Suction secretions as indicated to clear the airways. Administer
drugs as ordered such Salbutamol as bronchodilators and Exflem as mucolytic.

E = After 8 hours of giving holistic nursing care, the patient was able to display patent
airway with breathe sound clearing.

Evaluation and Recommendation

Prognosis:

The Philippines is one of the fifth teen countries that together account for 75% of

childhood pneumonia cases worldwide. In children aged under 5 years, pneumonia is

the leading cause of mortality with a mortality rate of 23.4 x100,000 population recorded

in 2009

Fortunately, with the discovery of many potent antibiotics, most cases of

pneumonia can be successfully treated. In fact, pneumonia can usually be treated with

oral antibiotics without the need for hospitalization. Many different specialists treat

pneumonia, most commonly primary-care physicians, including family practice,

pediatrics, and internal-medicine specialists. If some of the more serious manifestations

develop requiring hospitalization other specialists, like specialists in pulmonary medicine

(pulmonologists) and infectious diseases may be involved in the patient's care.

For patients who need hospitalization for pneumonia, the death rate is 10 - 25%.

If pneumonia develops in patients already hospitalized for other conditions, death rates

range from 50 - 70%, and are higher in women than in men.

The nurse emphasizes to the patient and family about the long term follow up

because of many complications that could happen in patient who have pneumonia.

Furthermore the nurse should remind the patient and the family as the regards of health

promotional activities and recommendation of health screening.