Introduction

a. Background

Community-acquired pneumonia (CAP) is infectious pneumonia in a person who

has not recently been hospitalized. CAP is the most common type of pneumonia.
The most common causes of CAP vary depending on a person's age, but they
include Streptococcus pneumoniae, viruses, the atypical bacteria, and
Haemophilus influenzae. Overall, Streptococcus pneumoniae is the most
common cause of community-acquired pneumonia worldwide. Gram-negative
bacteria cause CAP in certain at-risk populations. CAP is the fourth most
common cause of death in the United Kingdom and the sixth in the United
States. The term "walking pneumonia" has been used to describe a type of
community-acquired pneumonia of less severity (because of the fact that the
sufferer can continue to "walk" rather than require hospitalization). Walking
pneumonia is usually caused by the atypical bacteria mycoplasma pneumonia.

Pneumonia is an inflammatory illness of the lung. Frequently, it is described as

lung parenchyma/alveolar inflammation and abnormal alveolar filling with fluid
(consolidation and exudation).

The alveoli are microscopic air-filled sacs in the lungs responsible for absorbing
oxygen. Pneumonia can result from a variety of causes, including infection with
bacteria, viruses, fungi, or parasites, and chemical or physical injury to the lungs.
Its cause may also be officially described as idiopathic—that is, unknown—when
infectious causes have been excluded.

Pneumonia is a common illness which occurs in all age groups, and is a leading
cause of death among the elderly and people who are chronically and terminally
ill. Additionally, it is the leading cause of death in children under five years old
worldwide. Vaccines to prevent certain types of pneumonia are available. The
prognosis depends on the type of pneumonia, the appropriate treatment, any
complications, and the person's underlying health.
Pneumonia can be caused by microorganisms, irritants and unknown causes.
When pneumonias are grouped this way, infectious causes are the most
common type.

The symptoms of infectious pneumonia are caused by the invasion of the lungs
by microorganisms and by the immune system's response to the infection.
Although more than one hundred strains of microorganism can cause
pneumonia, only a few are responsible for most cases. The most common
causes of pneumonia are viruses and bacteria. Less common causes of
infectious pneumonia are fungi and parasites.

Pneumonia is an inflammation of the lungs caused by an infection. It is also

called Pneumonitis or Bronchopneumonia. Pneumonia can be a serious threat to
our health. Although pneumonia is a special concern for older adults and those
with chronic illnesses, it can also strike young, healthy people as well. It is a
common illness that affects thousands of people each year in the Philippines,
thus, it remains an important cause of morbidity and mortality in the country.
There are many kinds of pneumonia that range in seriousness from mild to life-
threatening. In infectious pneumonia, bacteria, viruses, fungi or other organisms
attack your lungs, leading to inflammation that makes it hard to breathe.
Pneumonia can affect one or both lungs. In the young and healthy, early
treatment with antibiotics can cure bacterial pneumonia. The drugs used to fight
pneumonia are determined by the germ causing the pneumonia and the
judgment of the doctor. It’s best to do everything we can to prevent pneumonia,
but if one do get sick, recognizing and treating the disease early offers the best
chance for a full recovery.
A case with a diagnosis of Pneumonia may catch one’s attention, though the
disease is just like an ordinary cough and fever, it can lead to death especially
when no intervention or care is done. Since the case is a toddler, an appropriate
care has to be done to make the patient’s recovery faster. Treating patients with
pneumonia is necessary to prevent its spread to others and make them as
another victim of this illness.
To be able for me to present this case, I gathered the patient's medical history,
psychosocial history, the activities of daily living before and during his
hospitalization and medical management. The anatomy and physiology of the
affected part, nursing diagnosis and nursing management are also discussed for
better understanding of his condition and implement a necessary action to help
the patient recover.

b. General Objective

At the completion of this case, student/s will be able to:

> Determine the risk factors that precipitate the formation of pneumonia from the
patient which can be taken through his health history and his activities of daily
living before hospitalization.

> Formulate a nursing diagnosis regarding on his condition.

> Formulate nursing intervention to attain a good condition and alleviate the
existing problem.

> Promote teaching to patient’s self care to maintain good health and wellness.

c. Importance of the study

A case with a diagnosis of Pneumonia may catch one’s attention, though the
disease is just like an ordinary cough and fever, it can lead to death especially
when no intervention or care is done. An appropriate care has to be done to
make the patient’s recovery faster. Treating patients with pneumonia is
necessary to prevent its spread to others and make them as another victim of
this illness.
DATABASE
Client Profile

Name: Patient LAA

Age: 73 years old
Gender: Female
Race: Brown
Nationality: Filipino
Religion: Roman Catholic
City Address: 78 Brgy. M. Acevida, Sinoluan, Laguna
Marital Status: Widow
Occupation: Business woman

Diagnosis: CAP high risk; HCVD FC II; DM type 2

History

Chief Complaint:
D.O.B. - “Difficulty of breathing”
History of Present Illness:

Three days prior to consultation, she had a productive cough, moderate

grade fever with anorexia and vomiting, but due to complaint of difficulty of
breathing he was admitted for further monitoring.

Past Medical History:

Client was diagnosed before at Philippine General Hospital, Laguna

of pneumonia. Client was confined for 3 weeks and later on continues the
medicines as prescribed by the doctor.

Family Medical History:

No hereditary disease can be attributed from her family. However, relatives from
his father side like uncle and cousins encountered illnesses such as
hypertension. Other than the latter, no hereditary diseases from both of his
parents are within the patient’s knowledge.

Social History:

As we know client runs a small business as a door-to-door sweets. Being

a business owner, client’s knows how to mingle and interact with her customers.
In consideration the client’s social environment are also good with her relatives
and neighbors.

Physical Assessment
 Body Part Method of Actual Findings Normal Interpretations
Assessment Findings

1. Head Inspection Hair color is gray Evenly Normal findings

with some black distributed hair,
Hair Palpation hair. Wavy hair. silky and no
infection.
Scalp No dandruff
Smooth skull
Face No lesions and contour, smooth
masses palpated and evenly toned
skin on face

2. Skin Inspection Pallor Varies from light Pallor in elderly,

to deep brown; skin loses its
Palpation Rough texture from ruddy pink elasticity and
and dry skin, to light pink. wrinkles due to
slow skin turgor. decreased
Secondary skin Moisture in skin collagen
lesions noted on folds and axillae. formation. Skin is
left arm and Skin springs also dry and flaky
masses palpated back to previous because
on different parts state when sebaceous
of his body. pinched. glands and sweat
glands are less
active.

3. Eyes Inspection Pupils are brown Pupil is black in Normal findings

in color, equal color, equal in
pupils, pale size, and round.
conjunctiva External eye
structures should
Grossly normal not manifest
visual activity edema nor is
sunken; Sclera
and Conjunctiva
should be white.
Normal visions
are 20/20.

4. Ears Inspection Symmetrical Symmetrical Normal findings

external pinae, external pinae
Palpation and gross
Symmetrical hearing, pinna
Gross hearing recoils after it is
folded.
5. Nose Inspection Brown in color, Pinkish mucosa, Sense of smell is
no discharge or absence of still perfect for his
Palpation any lesions; discharges age.

Able to breathe No lesions,

without symmetrical
restriction in both gross smelling
nares.

6. Mouth Inspection Pale lips, pinkish Uniform pink Normal findings

gums, no color lips, slight-
Palpation abrasions, pinkish gums, 32
swelling and teeth intact, no
ulceration. swelling, no
abrasions
ulceration.

7. Pharynx Inspection Midline pharynx Midline pharynx Normal findings

Palpation No tonsillitis Un-inflamed

noted tonsils

8. Neck Inspection Midline trachea Midline trachea Normal findings

Palpation Non-palpable Non-palpable

thyroids, no thyroids, no
swelling or discomforts and
masses, has equal
coordinated and muscle strength-
free range of free range of
motion and motions and
movements, with movements
some difficulty or without
discomfort, no discomfort.
nodules.

9. Chest and Inspection Irregular Regular Patient’s

Lungs breathing pattern breathing pattern breathing is
Palpation (Quiet rhythmic, altered due to his
auscultation and effortless present condition
respirations),
Vesicular and
bronchovesicular
breath sounds
 should be
audible.

10. Heart Auscultation No visible No visible Normal findings

pulsations noted. pulsations, lifts or
Normal Heart heaves, S1
Sounds (S1, S2) usually heard at
on four sites of all sites and
pericardium louder at apical
sites: aortic, area, S2 usually
pulmonic, heard at all sites
tricuspid, and and louder at
apical. base of heart.

11. Breast and Inspection Not Assessed Breast surface is Not Assessed
axilla generally even
with the chest
wall; smooth and
intact skin, no
inflammation, no
redness and
swelling.

12. Abdomen Inspection No rashes, No rashes, no Normal findings

masses and masses, no
Auscultation tenderness with tenderness, with
bowel sound that bowel sound that
Palpation carry on every persist for every
tympany. (tympany)
Percussion

13. Back and Inspection Equal size on Equal size on Less movements
extremities both sides of the both sides of the on the right lower
Palpation body, no body, no extremities due
contractures, to contractures, to to age.
tremors, firm tremors, firm
muscle tone, less muscle tone,
movements on smooth
the right lower coordinated
extremities, movements,
equal strength on equal strength on
each body side each body side

DIAGNOSTIC STUDIES
• Chest x-ray: Identifies structural distribution (e.g., lobar, bronchial); may
also reveal multiple abscesses/infiltrates, empyema (staphylococcus);
scattered or localized infiltration (bacterial); or diffuse/extensive nodular
infiltrates (more often viral). In mycoplasmal pneumonia, chest x-ray may
be clear.
• ABGs/pulse oximetry: Abnormalities may be present, depending on extent
of lung involvement and underlying lung disease.
• Gram stain/cultures: Sputum collection; needle aspiration of empyema,
pleural, and transtracheal or transthoracic fluids; lung biopsies and blood
cultures may be done to recover causative organism. More than one type
of organism may be present; common bacteria include Diplococcus
pneumoniae, Staphylococcus aureus, ahemolytic streptococcus,
Haemophilus influenzae; cytomegalovirus (CMV). Note: Sputum cultures
may not identify all offending organisms. Blood cultures may show
transient bacteremia.
• CBC: Leukocytosis usually present, although a low white blood cell (WBC)
count may be present in viral infection, immunosuppressed conditions
such as AIDS, and overwhelming bacterial pneumonia. Erythrocyte
sedimentation rate (ESR) is elevated.
• Electrolytes: Sodium and chloride levels may be low.

ANATOMY & PHYSIOLOGY

 A respiratory system functions to allow gas exchange. The gases that are exchanged, the
anatomy or structure of the exchange system and the precise physiological uses of the
exchanged gases vary depending on the organism. In humans and other mammals, for example,
the anatomical features of the respiratory system include airways, lungs, and the respiratory
muscles. Molecules of oxygen and carbon dioxide are passively exchanged, by diffusion,
between the gaseous external environment and the blood. This exchange process occurs in the
alveolar region of the lungs.

THE NOSE
 • Air enters through two openings, the external nares or nostrils.

• Just inside each nostril is an expanded vestibule containing coarse hairs.

• A midsagittal nasal septum divides the nasal cavity.

• The maxillary, nasal, frontal, ethmoid and sphenoid bones form the lateral and
superior walls of the nasal cavity.

• The hard and soft palate forms the floor of the cavity. (The posterior part of the
soft palate is the uvula)

• The external portion of the nose is composed of cartilage that forms the bridge
and the tip of the nose.

• The superior, middle and inferior nasal cochae are bony shelves that project
from the lateral walls of the nasal cavity.

• The spaces between the conchae are the meatuses.

• Posteriorly the internal nares open into the nasopharynx.

THE PHARYNX

• Is a chamber shared by the digestive and respiratory systems.

• It extends between the internal nares and the entrances to the larynx and
esophagus.

• A stratified squamous epithelium lines the pharynx.

The throat of pharynx is divided in three regions:

1. Upper naso-pharynx

2. Middle oropharynx

3. Lower laryngopharynx

THE NASOPHARYNX

• Lies superior to the soft palate

• Serves a passageway for airflow from nasal cavity

• It contains the pharyngeal tonsils (adenoids) in posterior wall, and the opening of
the eustaquian tubes (auditory tube)

THE OROPHARYNX
 • Extends front soft palate down to the epiglottis (base of the tongue)

• It contains the palatine and lingual tonsils.

THE LARYNGOPHARYNX

The narrow zone between the hyoid bone and the entrance to the esophagus.

THE LARYNX

• Joins the laryngopharynx with the trachea.

• It consist of cartilage

• It is called the voice box.

• The three main cartilage are: thyroid cartilage (Adams’s apple), epiglottis, and
the cricoid cartilage.

• Other cartilage is: arytenoids cartilage, corniculate cartilage and the cuneiform
cartilage.

• The epiglottis is a piece of elastic cartilages that falls over the opening
(GLOTTIS) during swallowing to prevent ingested food from entering the
respiratory tract.

• The corniculate cartilage are involve the opening and closing of the epiglottis, and
in the production of sounds

• Two pairs of folds span the glottal opening. The ventricular folds (false vocal
cords) are inelastic but the tension in the vocal cords can be adjusted by
voluntary muscle movements.

• During expiration air flowing through the larynx vibrates the vocal cords (true
vocal cords) and produces sound waves.

• Coughing and laryngeal spasms are protective reflex that protect the glottis and
trachea from objects and irritants.

THE TRACHEA
 • Extends from the level of the sixth cerebral vertebra, at the base of the larynx, to
the level of the fifth thoracic vertebra.

• is a tubular structure with 4.25 inch length and 1 inch in diameter.

• At its caudal limit the trachea divides to form primary bronchi.

• Lies anterior to the esophagus.

• Along the length of the trachea are 15-20 c-shapes in pieces of hyaline
cartilage (tracheal cartilages)

• The tracheal muscle holds the two sides of the c-shaped c

• Trachea is lined with pseudo stratified ciliated columnar epithelium.

• The trachea branches within the mediastum, forming the left and right bronchi.

(Extra pulmonary bronchi)

• Each bronchus enters a lung at groove, The Hilus.

• Each bronchus branches into increasingly smaller passageway to conduct air

into the lungs.

• The primary bronchi branch into as many secondary bronchi

(Intrapulmonary bronchi)

• The smallest passageway is the bronchioles.

THE LUNGS

• is pair of cone shaped organs lining in the pleural cavity.

• The apex is the conical top of each lung, and the broad inferior portion is the
base.

• Each lung has a hilus, a medical slits as the bronchial tubes, vascularization,
lymphatic, and nerves reach the lungs.

• Each lining is divided into lobes by deep fissures.

• Right lungs have three lobes and left lungs have two lobes.

• Left lung is divided by oblique fissure into superior and inferior lobes.

• Right lung is divided into three lobes (superior, middle and inferior)

• Superior and middle lobes are separated by a Horizontal fissure and

• The Oblique fissure separates Inferior and Middle lobes.

THE PLEURAL CAVITIES

• The thoracic cavity is bounded by the ribcage and the muscular diaphragm.

• The mediastinum divides the region into TWO PLEURAL CAVITIES.

• The pleural cavity is lined with a serous membrane, THE PLEURA.

• Parietal pleura line the thoracic wall, diaphragm, and mediastinum.

• Visceral pleura cover the surfaces of the lungs.

• The alveolar walls are made of simple squamous pulmonary epithelium.

• Scattered among epithelium are surfactant cells that secretes oil coating to
prevent

The alveoli from sticking together after exhalation

• Also the alveolar walls are macrophages that phagocytes debris or potential
pathogens.

• Pulmonary capillaries cover the exterior of the alveoli.

PATHOPHYSIOLOGY OF PNEUMONIA
 Predisposing Factors Etiology Precipitating Factors:

Age Virulent microorganism Lifestyle

Sex Streptococcus Pneumoniae Environment

Microorganism enters the nose (nasal passages)

Passes to the Pharynx, Larynx, Trachea

Microorganism enters and

affects both airway and lung parenchyma

Airway Damage Lung Invasion

Infiltration of Bronchi Flattening of epithelial cells

Infectious organisms lodges in bronchioles macrophages and leukocytes stimulation

Alveolar wall collapse necrosis of bronchial tissue mucus and phlegm production

narrowing of air passages

Increase pyrogen in the body COUGHING

(PRODUCTIVE OR
NON- PRODUCTIVE)
Necrosis of pulmonary tissue
FEVER

DIFFICULTY IN
Overwhelming sepsis BREATHING

DEATH
DISCHARGE PLANNING

Medications: Take the entire course of any prescribed medications.

Medication must be continued according to the doctor’s
instructions, otherwise the pneumonia may recur. Relapses can be far more
serious than the first attack.

Exercise: Get plenty of rest. Adequate rest is important to maintain progress

towards full recovery and to avoid relapse.

Treatment: Give supportive treatment. Proper diet and oxygen to increase

oxygen in the blood when needed.

Health Teaching: Drink lots of fluids, especially water. Liquids will keep
patient from becoming dehydrated and help loosen mucus in the lungs.

Encourage the guardians to wash patient’s hands. The hands come in daily
contact with germs that can cause pneumonia. These germs enter one’s body
when he touch his eyes or rub his nose. Washing hands thoroughly and often
can help reduce the risk.

Tell guardians to avoid exposing the patient to an environment with too much
pollution (e.g. smoke). Smoking damages one’s lungs’ natural defenses
against respiratory infections.

Protect others from infection. Try to stay away from anyone with a
compromised immune system. When that isn’t possible, a person can help
protect others by wearing a face mask and always coughing into a tissue.

Oxygenation and OPD follow-up: Keep all of follow-up appointments. Even

though the patient feels better, his lungs may still be infected. It’s important to
have the doctor monitor his progress.
Diet: Maintain low salt and low sugar diet and obtain foods high in fiber.
Maintain healthy lifestyle.

Spiritual and sexual teaching: Keep close contact in spiritual members of

the church, strengthened faith and belief in God. Beliefs and practices are
associated with all aspects of a person’s life.
References

Medical-Surgical Nursing Clinical Management for Positive Outcomes by

Joyce M. Black and Jane Hokanson Hawks 8th Edition Volume 1 & 2

Fundamentals of Nursing The Art and Science of Nursing Care by Taylor,

Lillis and LeMone 5th Edition

Nursing 2008 Drug Handbook by Wolters Kluwer | Lipincott Williams & Wilkins

PDR Nurse’s Drug Handbook by George R. Spratto & Adrienne L. Woods

http://www.wikipedia.org/

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