READINGS

DEFINITION

Pneumonia is an acute inflammatory process of the lung parenchyma with accompanying interstitial and alveolar fluid caused by aspiration, bacterial, viral, fungal, mycoplasma, or protozoan infections. Common organisms causing pneumonia are Staphylococcus aureus, Haemophilus influenza, and Staphylococcus pneumonaiae.

TYPES OF PNEUMONIA

Bacterial pneumonia

A pneumonia caused by various bacteria. The Streptococcus pneumoniae is the most common bacteria that causes bacterial pneumonia.

Usually occurs when the body is weakened in some way,such as illness, malnutrition, old age, or impaired immunity, and bacteria are able to work their way into the lungs.

Can affect all ages, but those at great risk include persons who abuse alcohol, persons who are deliberated, post-operative patients, persons with respiratory diseases.

Viral pneumonia

Caused by one of several viruses, including influenza, parainfluenza, adenovirus, rhinovirus, herpes simplexherpes simplex virus, respiratory syncytial virus, hantavirus, and cytomegalovirus.

Mycoplasma pneumonia

It is caused by mycoplasmas, the smallest free-living agents of disease in humankind, which have the characteristics of both bacteria or viruses, but which are not classified as either.

Often affects younger people and may be associated with symptoms outside of the lungs (such as anemia and rashes), and neurological syndromes (such as meningitis, myelitis, and encephalitis).

Aspiration pneumonia

An inflammation of the lungs and bronchial tubes caused by inhaling foreign material, usually food, drink, vomit, or secretions from the mouth into the lungs.

May progress to form a collection of pus in the lungs (lung abscess). Aspiration of foreign material (often the stomach contents) into the lung can be a result of disorders that affect normal swallowing, disorders of the esophagus (esophageal stricture, gastro-esophageal reflux), or decreased or absent gag reflex (in unconscious, or semi-conscious individuals).

Old age, dental problems, use of sedative drugs, anesthesia, coma, and excessive alcohol consumption are also causal or contributing factors.

Atypical pneumonia

Pneumonia caused by certain bacteria - namely, Legionella pneumophila, Mycoplasma pneumoniae, and Chlamydophila pneumonia.

Pneumonia due to Legionella, in particular, can be quite severe and lead to high mortality rates.

Atypical pneumonia due to Mycoplasma and Chlamydophila usually cause milder forms of pneumonia and are characterized by a more drawn out course of symptoms unlike other forms of pneumonia which can come on more quickly with more severe early symptoms.

Hospital-acquired pneumonia

An infection of the lungs contracted during a hospital stay. Tends to be more serious because defense mechanisms against infection are often

impaired during a hospital stay, and the kinds of infecting organisms are more dangerous than those generally encountered in the community.

Risk factors predisposing people to hospital-acquired pneumonia are alcoholism, older age, immunosuppression from medications or diseases, recent illness, and risk of aspiration.

Community-acquired pneumonia (CAP)

85% of cases of CAP are caused by the typical bacterial pathogens, namely, Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.

15% are caused by atypical pathogens, namely Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella species.

Unusual aerobic gram-negative bacilli (for example, Pseudomonas aeruginosa, Acinetobacter, Enterobacter) rarely cause CAP.

Pneumocystis carinii pneumonia

An infection of the lungs caused by the fungus Pneumocystis carinii.

INCIDENCE

WHO data suggest that there are 450 million cases of pneumonia each year and that it causes 3.9 million deaths. Pneumonia is the biggest cause of child deaths in the world, killing 1.8 million children under five years of age every year, more than 98% of which occur in 68 developing countries

In the Philippines, the incidence of Pneumonia was recorded as of 2009 at 1,521,912 as it was manifested by the records of the Department of Health.

The incidence of pneumonia during cold months in the Philippines (January-February) could increase. Reports on TV already indicated deaths in Baguio City, Benguet, Cagayan and even in Ilocos Norte.

RISK FACTORS/CAUSES

Chronic underlying diseasePneumonia is more likely to occur in people whose immune system is weakened

by an existing illness, such as the cancer, or AIDS, and in people with chronic conditions, such as sickle cell disease

, heart disease, diabetes, kidney disease, chronic bronchitis, chronic obstructive pulmonary disease (COPD), emphysema or cystic fibrosis

Severe acute illnessThe occurrence of pneumonia is also associated with certain illnesses such as flu

and asthma

Immune deficiency or suppressionPeople who have weak immune system are very prone to pneumonia, in such a

way that they are very vulnerable of being infected to the bacteria and viruses causing pneumonia. For instance, the infants, they are still on the stage of developing their fragile bodies, and that, making them to be very week to fights against bacteria causing such disease. Thus, this is also true to the elderly who have weak immune system due to old age.

SmokingFrequent exposure to cigarette smoke can affect the lungs in ways that make a

person more likely to develop pneumonia. The risk for pneumonia in smokers of more than a pack a day is three times that of nonsmokers. Those who are chronically exposed to cigarette smoke, which can injure airways and damage the cilia, are also at risk. Toxic fumes, industrial smoke, and other air pollutants may also damage cilia function, which is a defense again bacteria in the lungs.

AspirationAspiration can cause a number of syndromes determined by the quantity and

nature of the aspirated material, the frequency of aspiration, and the host factors that predispose the patient to aspiration and modify the response. Aspiration of gastric acid causes chemical pneumonia (CP). Aspiration of bacteria from oral and pharyngeal areas causes bacterial pneumonia (BP).

Exposure to pulmonary pollutantsYour risk of developing some uncommon types of pneumonia may be increased if

you work in agriculture, in construction or around certain industrial chemicals or animals.

Exposure to air pollution or toxic fumes can also contribute to lung inflammation, which makes it harder for the lungs to clear themselves.Occupational exposure to toxic chemical fumes and/or smoke can weaken your lung’s defenses, predisposing you to pneumonia.

Cold climatesMany studies have provided evidence that mortality rates increase during periods

of cold weather. In general, total mortality is about 15% higher on an average winter day than on an average summer day (National Center for Health Statistics). The impact of cold on human well-being is highly variable. Not only is cold weather responsible for direct causes of death such as hypothermia, influenza, and pneumonia, it is also a factor in a number of indirect ways.

Age

If you're age 65 or older, particularly if you have other conditions that make you more prone to developing pneumonia, you're at increased risk of pneumonia. Very young children, whose immune systems aren't fully developed, also are at increased risk of pneumonia.

People who have recently had surgery or suffered a traumatic injury

They are less able to breathe deeply, cough, and get rid of mucous. People who have had surgery or who are immobilized from a traumatic injury have a higher risk of pneumonia because surgery or serious injuries may make coughing — which helps clear your lungs — more difficult, and lying flat can allow mucus to collect in your lungs, providing a breeding ground for bacteria.

Alcohol, Drug Abuse

Alcohol or drug abuse is strongly associated with pneumonia. These substances act as sedatives and can diminish the reflexes that trigger coughing and sneezing. Alcohol also interferes with the actions of macrophages, the white blood cells that destroy bacteria and other microbes. Intravenous drug abusers are at risk for pneumonia from infections that originate at the injection site and spread through the blood stream to the lungs.

Hospitalization in an intensive care unit. Pneumonia acquired in the hospital tends to be more serious than other types of

pneumonia. People who need mechanical ventilation are particularly at risk because the breathing tube bypasses the normal defenses of the upper respiratory tract, prevents

coughing, may allow the stomach's contents to back up into the esophagus where they can be inhaled (aspirated), and can harbor bacteria and other harmful organisms.

CLINICAL MANIFESTATIONS

Bacterial pneumonia

Shaking Chills Chattering teeth Severe chest pain High temperature Heavy perspiring Rapid pulse Rapid breathing Bluish color to lips and nail beds Confused mental state or delirium Cough that produces rust-colored or greenish mucus

Viral pneumonia

Low-grade fever (less than 102° F) Coughing up small amounts of mucus Tiredness Muscle aches Chills Clammy skin Headache Joint stiffness Nausea and vomiting Sore throat Sweating Shortness of breath

Mycoplasma pneumonia

Common symptoms include:

Chest pain Chills Cough (usually not dry and not bloody)

Excessive sweating Fever ( may be high) Headache Sore throat

Less frequently symptoms include:

Eye pain or soreness Muscle pain and joint stiffness Neck lump Rapid breathing Skin lesions or rash

Aspiration pneumonia

Bluish discoloration of the skin caused by lack of oxygen Chest pain Cough With foul-smelling phlegm (sputum) With sputum containing blood or pus With greenish sputum Fatigue Fever Shortness of breath Wheezing Other symptoms that can occur include: Breath odor Excessive sweating Difficulty of swallowing

Atypical pneumonia

Chills Confusion (especially with Legionella pneumonia) Cough Diarrhea (especially with Legionella pneumonia) Fever General ill feeling

Headache Loss of appetite Muscle stiffness and aching Rapid breathing Rash (especially with mycoplasma pneumonia) Shortness of breath

Hospital-acquired pneumonia

Cough that may produce mucus-like, greenish, or pus-like phlegm (sputum) Chills Easy fatigue Excessive sweating (rare) Fever General discomfort, uneasiness, or ill feeling (malaise) Headache Joint stiffness and pain (rare) Loss of appetite Muscle stiffness (rare) Nausea and vomiting Sharp or stabbing chest pain that gets worse with deep breathing or coughing Shortness of breath

Community-acquired pneumonia

problems breathing coughing that produces greenish or yellow sputum a high fever that may be accompanied with sweating, chills, and uncontrollable shaking sharp or stabbing chest pain rapid, shallow breathing that is often painful

Pneumocystis carinii pneumonia

Cough (often mild and dry) Fever Rapid breathing Shortness of breath especially with activity (exertion)

TREATMENT AND MANAGEMENT

Encourage bed rest. Encourage to increased fluid intake. Encouraged deep breathing. Position in semi-fowler’s position. Administer oxygen therapy as prescribed. Suction client as necessary via oropharyngeal or nasopharyngeal routes. Use a sterile suction catheter, and discard catheter after each insertion. Do not store suction catheters in any type of solution, including antibacterial solutions. Use sterile gloves for the suctioning procedure. Administer oxygen before, during, and after suctioning, as ordered. If using the same catheter, suction the major bronchi first before suctioning the mouth

and the nose to prevent contamination of the lungs. Vacuum pressures should not exceed 80-120 mmHg. Insert catheter during inhalation and apply intermittent vacuum while withdrawing

catheter. Insertion, suctioning, and removal of catheter should not exceed 10-15 seconds. Provide periods of rest. Instruct client how to use nebulizers or metered dose inhalers for aerosolization. Teach regarding antibiotic therapy (bacterial infections).

PREVENTION

Teach client to prevent pneumonia by: Avoiding large crowds during flu season and getting flu shots. Receiving pneumococcal vaccine if older and at risk of pneumonia. Washing hand thoroughly. Eating a nutritious diet Prevent aspiration of food, fluids or medications in at-risk clients, which can cause

aspiration pneumonia. Prevent contamination of aerosol inhalants. Prevent infection and mechanical trauma from oropharyngeal and nasopharyngeal

suctioning.

PHARMACOLOGICAL MANAGEMENT

Immunizations (pneumonia and influenza vaccine)- Vaccines can’t prevent all cases of infection. However, compared to people who

don’t get vaccinated, those who do and still get pneumonia tend to have: Milder cases of the infection Pneumonia that doesn’t last as long Fewer serious complications

Antibiotics (macrolides, ceftriaxone, levofloxacin)

CLASSIFICATION: Anti-infective agent

MECHANISM OF ACTION: Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins.

Bronchodilators (albuterol)

CLASSIFICATION: Sympathominetics

MECHANISM OF ACTION: Relaxes bronchial muscles by action on the beta2-receptors with little effect on the heart rate.

Corticosteroids (prednisone, methylprednisolone)

CLASSIFICATION: Adrenocorticosteroids

MECHANISM OF ACTION: Decreases inflammation by suppression of migration of polymorphonuclear leukocytes and reversal of increased capillary permeability; suppresses the immune system by reducing activity and volume of the lymphatic system.

Mucolytics/Expectorant ( guiafenesin)

CLASSIFICATION: Expectorants

MECHANISM OF ACTION: Thought to act an expectorant by irritating the gastric mucosa and stimulating respiratory tract secretions, thereby increasing respiratory fluid volumes and decreasing phlegm viscosity.

Antipyretics (acetaminophen, ibuprofen)

CLASSIFICATION: Non-narcotic analgesic

MECHANISM OF ACTION: Reduces fever by acting on the hypothalamus to cause vasodilation and sweating.

Nasal Decongestants ( pseudoephedrine)

CLASSIFICATION: Decongestant

MECHANISM OF ACTION: Directly stimulates alpha-adrenergic receptors of respiratory mucosa causing bronchial relaxation, increased heart rate and contractility.

DIAGNOSTIC PROCEDURES

CBC (Complete Blood Count)

- Also known as full blood count (FBC) or full blood exam (FBE) or blood panel, is a test requested by a doctor or other medical professional that gives information about the cells in a patient's blood.

- This procedure is done to the client to determine general health status and to screen for a variety of disorders and in order to determine whether there are evaluations in the blood components.

Chest X-ray

- Commonly used to detect abnormalities in the lungs, but can also detect abnormalities in the heart, aorta, and the bones of the thoracic area.

Sputum Culture

- A sputum culture is done to find and identify the microorganism causing an infection of the lower respiratory tract such as pneumonia

Blood Culture

- A test designed to detect if microorganisms such as bacteria and fungi are present in blood. A sample of blood obtained using sterile technique is placed in a culture media and incubated in a controlled environment for 1 to 7 days.

ABG’s (arterial Blood Gases) analysis

- Blood gas analysis, also called arterial blood gas (ABG) analysis, is a procedure to measure the partial pressure of oxygen (O2) and carbon dioxide (CO2) gases and the pH (hydrogen ion concentration) in arterial blood.

-Blood gas analysis is used to diagnose and evaluate respiratory diseases and conditions that influence how effectively the lungs deliver oxygen to and eliminate carbon dioxide from the blood.

PERTINENT DATA

NAME: Mr.Neumi

AGE: 48 years old

GENDER: Male

ADDRESS: Brgy. 17 Tabug Batac City

DATE OF BIRTH: September 27, 1960

BIRTHPLACE: Bacarra, Ilocos Norte

RELIGION: Roman Catholic

NATIONALITY: Filipino

WEIGHT: 87 kgs.

HEIGHT: 5’9”

HOSPITAL NUMBER: 19005

ADMITTING DATE AND TIME: August 14, 2010, 9:00 AM

ADMITTING DIAGNOSIS: Pneumonia

ADMITTING PHYSICIAN: Dr. Medeldorf M. Gaoat

ADMITTING HOSPITAL: Gaoat General Hospital

DISCHARGE DATE AND TIME: August 19, 2010, 2:00 PM

HEALTH HISTORY

FAMILY BACKGROUND

NAME AGE RELATIONSHIP EDUCATIONAL ATTAINMENT

OCCUPATION DISEASES

Alex Castro Sr.

Father HPN

Amiliana Castro

Mother HPN, Ulcer

Patricia Valdez

62 Daughter College graduate Retired Teacher HPN, Arthritis

Felomena Sales

58 Daughter College graduate Clerk, Land Title Office

Osteoporosis

Saturnino Pacones

56 Son College graduate Retired Accountant

HPN

Elnora Castro

55 Daughter College graduate Housewife HPN, DM

Hepolito Castro

54 Son College graduate Seaman NONE

Sonia Castro

53 Daughter College graduate (Former) OFW NONE

Jesus Castro

49 Son College graduate Civil Engineer NONE

Alex Castro

48 Patient College graduate (Former) Seaman

Pneumonia, HPN

Napoleon Castro

47 Son College graduate Mechanical Engineer

Arthritis

Mercy David

45 Daughter College graduate OFW NONE

Henry Castro

44 Son College graduate Farmer, Driver Arthritis

Abelardo Castro

42 Son College graduate Architect NONE

A. FAMILY HEALTH HISTORY

Mr. Neumi belongs to an extended family. He is living with his parents-in-law and he is the head of the family.

Hypertension has been the prevailing disease in the family as well as arthritis, this may me cause credited as a manifestation of being in the old age bracket. With respect to hypertension, they resorted to neoblock 100mg OD while arthritis is being managed through liniments (i. e., efficascent) in which they apply it in the affected part.

From the interview with Mr. Neumi, it was found out that several diseases are being experienced in the family and they are predominant among them. They are as follows: cough, fever, stomachache and common colds.

As the most convenient and affordable remedy, they usually manage it through herbal medicines like oregano for cough and common colds. As for fever and stomachache, they manage it through self-prescription of OTC drugs like biogesic and diatabs, respectively. Increase in fluid intake is being observed when they are suffering from fever, cough or colds. The intake of vitamin C rich-foods and calamansi juice is of help to them to be relieved in their cough and colds.

With regards to childhood illnesses, members of the family had experienced mumps, chickenpox and measles. Mumps is being managed through “akot-akot”. For chicken pox, bed rest is being observed as well as exposing to burnt onions when lesions are healing. As for measles, they usually wear black long-sleeved shirts as prescribed by custom practice.

However, when all these remedies are not tenable, they seek for medical help in their respective Rural Health Unit. As for severe cases, they usually go to the Hospital for further consultation.

It was found out also that the elderly of the family are drinking liquor and indulge themselves also into smoking.

The family maintains healthy diet. They do not have allergy of any sort.

B. PAST HEALTH HISTORY

The facts which shall materialized to this study was derived from the interview with Mr. Neumi. He lamented that during his childhood days, he had experienced measles and mumps and these were treated through wearing black long-sleeved shirts and “akot-akot”, respectively.

As for illnesses, the common ones are cough, colds, fever and stomachache. Most of the time, Mr. Neumi resorts to OTC drugs like carbocysteine, Decolgen, Biogesic and Diatabs, respectively.

However,when things get worse and cannot be cured by self medication, Mr. Neumi seeks for medical assistance in the Hospital.

Mr. Neumi’s immunization,as to his records, he had only a shot of BCG, as to the others, he had not availed for one.

He was hospitalized once at Gaoat General Hospital because of slight physical injuries in which he acquired through a vehicular accident. He was given a shot of anti-tetanus of the said injuries. He was admitted as an OPD patient.

C. PRESENT HEALTH HISTORY

Before his hospitalization, Mr. Neumi had been experiencing cough and chest pain for two weeks. With that span of him, he had self-madication of carbocysteine and supplemented it with herbal medicine (oregano). After two weeks of such condition and that no effect has been noticed, he went to the hospital for consultation. Thereby, he was admitted by Dr. Medeldorf M. Gaoat in August 14, 2010 at 9:00 am with the admitting diagnosis of pneumonia.

D. LIFESTYLE AND RECREATIONAL ACTIVITIES

Mr. Neumi is a farmer and that he maintains a poultry as well.

He usually wakes up at 5AM and sleeps between 8 or 9 in the evening. He has his siesta time from 12 NN to 1:30PM.

He is having his bowel movement once every morning.Mr. Neumi started drinking alcohol since 1978. However, when he began to

experience chest pains lately, he seldom drinks alcohol.

With regards to managing his stress, he usually takes a rest in a hammock or watches the television.

As for his diet, Mr. Neumi maintains a healthy diet having fish or meat and vegetable in their menu. He drinks mineral water, however, sometimes, he drinks water from deep well.

E. PSYCHOLOGICAL DATA

Psychosocial Theory of Erik Erickson

According to Erik Erikson’s Theory of Psychosocial Development, our patient belong to the Early Childhood age bracket (18 months-3 years old), with a central task of Autonomy vs. Shame & Doubt.

Erickson’s envisions life as a sequence of levels of achievement. Each stage signals a task that must be achieved which viewed a series of crises. A successful resolution would indicate a support to the person’s ego while the failure to resolve the crises is damaging to the ego. Erikson believes that the greater the task achievement, the healthier the personality of the person while failure to achieve the task influences the person’s ability to achieve the next tasks.

According to Erikson’s Developmental Theory, the primary developmental task of the stage adulthood is generativity, which is the concern of establishing and guiding the next generation.

 Infancy Birth – 18 months Trust vs. Mistrust

 Early Childhood 18 months – 3 years Autonomy vs. Shame & Doubt

 Late Childhood 3 – 5 years Initiative vs. Guilt

 School Age 6 – 12 years Industry vs. Inferiority

 Adolescence 12 – 20 years Identity vs. Role Confusion

 Young Adulthood 18 – 25 years Intimacy vs. Isolation

 Adulthood 25 – 65 years Generativity vs. Stagnation

 Maturity 65 years to death Integrity vs. Despair

TASK PROOF ANALYSIS

Love for others

Use leisure time creatively

PHYSICAL ASSESSMENT

The physical assessment was done last August 17, 2010 at 3:00 PM at Gaoat General Hospital, male ward.

General Appearance:

Our patient was walking along the corridor of the hospital without any gadget attached to him. Weak in appearance, afebrile and no complaint of difficulties in beathing. He is wearing a sando and a maong shorts.

Vital Signs August 17 August 18 August 19 August 20 August 21Body Temp. 36.1 0C 36.5 0C 37.1 0C 37.5 0C 37.3 0CPulse Rate 76bpm 72bpm 74bpm 70bpm 70bpmRespiratory Rate

22bpm 20bpm 23bpm 21bpm 22bpm

Blood Pressure

110/70mmHg 110/80mmHg 120/90mmHg 110/80mmHg 120/80mmHg

HEAD TO TOE ASSESSMENT

1. Hair

COLOR Black

TEXTURE AND MOISTURE Soft

DISTRIBUTION Equally distributed

THICKNESS AND THINNESS Fine

CONDITION OF THE SCALP No lice and dandruff noted

2. Head

CONDITION No mass palpated

CONFIGURATION Normocephalic

3. Eyes

CONDITION OF THE EYES With coordinated eye movement

COLOR OF THE SCLERA White in color

CONDITON OF THE CONJUNCTIVA Pink palpebral conjunctiva

REACTION TO LIGHT PERRLA (Pupil are Equally Round and Reactive to Light Accomodation)

VISUAL ABILITY Unable to read without eyeglasses

4. Ears

APPEARANCE Symmetrical in size and shape

ALLIGNMENT Both eyes are aligned to the outer canthus of the eyes

CONDITION OF THE EAR With cerumen impacted and no lesions noted

5. Nose

PATENCY OF THE NOSE No secretions

SYMMETRY With intact nasal septum and in midline position

CONDITION With flaring of the nares

6. Mouth

LIPS

MOISTURE Upper and lower lips are moist

COLOR Slightly black in color

CONDITION No lesions noted

TONGUE

MOISTURE Moist

COLOR Pinkish in color

TEETH

NUMBER OF TEETH incomplete set of teeth (15 upper, 16lower)

CONDITION with dental carries noted

GUMS

COLOR Pinkish in color

CONDITION No swollen gums

MUCOUS MEMBRANE

COLOR Pinkish in color

CONDITION Moist, intact mucous membrane

7. Neck

RANGE OF MOTION Able to move without difficulty

CONDITION No mass palpated

8. Chest

CONDITION With coarse crackles sound upon auscultation

9. Abdomen

SHAPE globular

BOWEL SOUND 5 clicks every quadrant (borborygmus)

Upper Extremities

RANGE OF MOTION With difficulty of moving of left wrist

CONDITION OF THE SKIN Presence of edema on left wrist

APPEARANCE With scar on the left deltoid

CONDITION OF THE FINGERNAILS Short and slightly dirty

COLOR OF NAILBED Pinkish

CAPILLIARY REFILL With normal capillary refill, at 2 seconds

Lower Extremities

RANGE OF MOTION Both leg has a good ROM able to extend and flex on normal ROM

CONDITION OF THE TOENAILS Slightly long and slightly dirty

COLOR OF THE NAILBED Pinkish

CAPILLIARY REFILL With normal capillary refill, at 2 seconds

10. Skin

COLOR Brown

TEMPERATURE Warm to touch

TEXTURE Slightly rough

ON GOING APPRAISAL

AUGUST 17, 2010

For the first day of appraisal, Mr. Neumi was seen lying on bed without an IV fluid attached. He is weak in appearance on DAT diet. He has a productive cough with minimal amount of secretions.

Vital Signs:

Body temp.-36.1 0C

PR-76bpm

RR-22bpm

BP: 110/70mmHg

AUGUST 18, 2010

Second day, he was seen sitting on bed. He is still weak in appearance with productive cough and a minimal amount of secretion. He is on a DAT diet.

Vital Signs:

Body temp.-36.5 0C

PR-72bpm

RR-20bpm

BP: 110/80mmHg

AUGUST 19, 2010

The patient was seen walking along the corridor of the hospital. Fair in appearance. Still, it has been observed with productive cough and a minimal amount of secretion. The doctor’s order is MGH.

Vital Signs:

Body temp.-37.1 0C

PR-74bpm

RR-23bpm

BP: 120/90mmHg

AUGUST 20, 2010 (home visit)

We visited our patient and he is watching television with his wife. Still, with cough and under medication.

Vital Signs:

Body temp.-37.5 0C

PR-70bpm

RR-21bpm

BP: 110/80mmHg

AUGUST 21, 2010 (home visit)

On the last day of appraisal, we had seen our patient watching television. With cough still.

Vital Signs:

Body temp.-37.3 0C

PR-70bpm

RR-22bpm

BP: 120/80mmHg

DATE August 17 August 18 August 19 August 20 August 21DIET DAT DAT DAT DAT DATWEAK IN APPEARANCE

X X X

MUCOSAL SECRETION

BODY TEMP. 36.10C 36.50C 37.10C 37.50C 37.30CPULSE RATE 76bpm 72bpm 74bpm 70bpm 70bpmRESPIRAORY RATE

22bpm 20bpm 23bpm 21bpm 22bpm

BLOOD PRESSURE

110/70mmHg 110/80mmHg 120/90mmHg 110/80mmHg 120/80mmHg

NURSING CARE PLAN

I.

Nursing Diagnosis:

Ineffective airway clearance related to exudates in the alveoli as manifested by dyspnea, cough, adventitious breath sounds such as crackles and wheezes and verbalization of “marigatan nak umanges”.

Nursing Inference:

The inflammatory response to infection causes tissue edema and exudates formation. In the lungs, the inflammatory response can narrow and potentially obstruct bronchial passages and alveoli. This may result to dyspnea, presence of adventitious breath sounds such as crackles (rales), wheezes, coughing amd it may also indicate hypoxia or decrease level of oxygen.

Nursing Goal:

After 30 min – 1 hour of rendering effective nursing intervention the patient’s airway clearance will be maintained as will be manifested by absence of dyspnea and verbalization of “haan nak marigatan nga umangesen”.

Nursing Intervention:

1. Re-assess respiratory status, including vital signs, breath sounds and skin color.Rationale : To validate data.

2. Place patient in fowler’s or high- fowler’s position and encourage frequent position changes.Rationale: To promote lung expansion.

3. Encourage the patient to have a deep breathing and coughing exercise.Rationale: To help clear airways.

4. Instruct the patient to increase his fluid intake for at least 2000ml/ day.Rationale: To help liquefy secretions.

5. Provide for rest periods.Rationale: Promoting a more effective breathing pattern.

6. Encourage patient to have chest physiotherapy.Rationale: To help ease breathing & liquefy secretions.

7. Administer prescribed medications as ordered such as bronchodilators.Rationale: To help maintain open airways.

Nursing Evaluation:

After 1 hour of rendering effective nursing intervention the patient’s airway was maintained as manifested by absence of dyspnea and verbalization of “haan nak uny marigatan umangesen”.

II.

Nursing Diagnosis:

Ineffective breathing pattern related to bronchial constriction as manifested by shortness of breathing, nasal flaring, RR , PR ,use of accessory muscle for breathing.

Nursing Inference:

Due to the narrowing and constriction of the airway there is obstruction in to the breathing pattern.

Nursing Goal:

After 20-45 min of rendering effective nursing intervention the patient will be able to improved his breathing pattern as manifested by normal RR, PR, absence of nasal flaring and does not use of accessory muscle when breathing.

Nursing Intervention:

1. Position patient to fowler’s position.

Rationale: For optimal lung expansion

2. Instruct patient to have enough rest.Rationale: To decrease oxygen demand

3. Instruct patient on how to perform DBCE.Rationale: Facilitates maximum expansion of the lungs leading to a more effective exchange of gases.

4. Administer oxygen inhalation.Rationale: To compensate the needed oxygen demand.

Nursing Evaluation:

After 20-45 min of rendering effective nursing intervention the patient has improved his breathing pattern as manifested by normal RR, PR, absence of nasal flaring and does not use of accessory muscle when breathing.

III.

Nursing Diagnosis:

Acute chest pain related to localized inflammation, persistent cough, aching, evidenced by reports of discomfort, expressive behavior, facial mask of pain (grimace) with a pain scale of 8/10.

Nursing Inference:

Unrelieved acute pain leads to debilitation ,diminished quality of life, and depression. Unrelieved acute postoperative pain leads to development of chronic pain syndromes and increasedcomplications.In fact, unrelieved pain can kill.

Nursing Goal:

After 3-4 hrs. of rendering effective and appropriate nursing intervention, the pain felt by the patient will be minimized or reduced. As will be manifested by absence of grimacing face, absence of expressive behavior, pain scale down to 6/10 and verbalization of “kaasi ni Apu Dios haan mt unay nasakiten”.

Nursing Intervention:

1. Perform pain assessment each time pain occurs.Rationale: to rule out worsening of underlying condition/development of complication.

2. Monitor v/s- usually altered in acute pain.3. Encourage verbalization of feeling about the pain.4. Provide comfort measures such as backrub, change of position.

Rationale: To provide nonpharmacological pain management5. Instruct or encourage use of relaxation exercises such as focused on breathing,

individualized tapes (ex. music).6. Note when pain occurs

Rationale: To medicate prophylactically as appropriate.7. Encourage adequate rest periods.

Rationale: to prevent fatigue.

LABORATORIES AND DIAGNOSTIC PROCEDURE

Radiology report

X-ray No. : 17128

Examination requested: Chest PA

Hazy and streaky densities in both lungs bases are seen.

Pulmonary vascularity is within normal limits.

Heart is not enlarged.

Diaphragm is normal in position and contour.

Both costophrenic sula and visualized bones are intact.

Impression/s:

Pneumonia

Rosemarie Cabaccang- Marzan, MD, FPCR, FUSP

Radiologist- Sonologist

Chest x-ray is the most commonly performed diagnostic x-ray examination. A chest x-ray makes images of the heart, lungs, airways, blood vessels and the bones of the spine and chest.

An x-ray ( radiograph ) is a noninvasive medical test that helps physicians diagnose and treat medical conditions. Imaging with x-rays involves exposing a part of the body to a small dose of ionizing radiation to produce pictures of the inside of the body. X- rays are the oldest and most frequently used form of medical imaging.

A chest x –ray requires no special preparation.

You may be asked to remove some or all of your clothes and to wear a gown during the exam. You may also be asked to remove jewelry, dentures, eye glasses and any metal objects or clothing that might interfere with the x-ray images.

Women should always inform their physician and x-ray technologist if there is any possibility that they are pregnant. Many imaging tests are not performed during pregnancy so as not to expose the fetus to radiation. If an x-ray is necessary, precautions will be taken to minimize radiation exposure to the baby. Inform the health care provider if you are pregnant. Chest x-ray are generally avoided during the first six months of pregnancy. You must wear a hospital gown and remove all jewelry.

Purpose:

Chest x-ray is obtained to determine the extent and pattern of lung involvement. Fluid, infiltrates , consolidated lung tissue, and atelectasis ( areas of alveolar collapse) appear as densities on the film.

The chest x-ray is performed to evaluate the lungs, heart and chest wall.

A chest x-ray is typically the first imaging test used to help diagnose symptoms such as:

Shortness of breath A bad or persistent cough Chest pain or injury Fever.

Physicians use the examination to help diagnose or monitor treatment for conditions such as:

Pneumonia heart failure and other heart problems emphysema lung cancer

line and tube placement.

And other medical conditions ANALYSIS

ECG/ EKG

Date performed : August 13, 2010

Serial no: SCT8070813PA

Measurement Results:

QRS: 84ms

QT/ QTC : 396/ 396 ms

PR: 128 ms

P: 82 ms

RR/PP: 1014/ 1000ms

P/ QRS/T: 11/23/29 Deg

INTERPRETATION : Normal sinus rhythm

Normal ECG

The Electrocardiogram (ECG or EKG) is a noninvasive test that is used to reflect underlying heart conditions by measuring the electrical activity of the heart. By positioning leads (electrical sensing devices) on the body in standardized locations, information about many heart conditions can be learned by looking for characteristic patterns on the EKG.

EKG leads are attached to the body while the patient lies flat on a bed or table. Leads are attached to each extremity (four total) and to six pre-defined positions on the front of the chest. A small amount of gel is applied to the skin, which allows the electrical impulses of the heart to be more easily transmitted to the EKG leads. The leads are attached by small suction cups, Velcro straps, or by small adhesive patches attached loosely to the skin. The test takes about five minutes and is painless. In some instances, men may require the shaving of a small amount of chest hair to obtain optimal contact between the leads and the skin.

DRUG STUDY

Date Ordered: August 15, 2010

Generic name: Penicillin G Pottasium

Brand name: Pfizerpen

Dosage, Route, Frequency: 500mg/ IM/ OD

Classification: Antibacterial/ anti-infective

Mechanism of Action: Inhibits cell wall synthesis during bacterial multiplication

Desired Effect: To treat infection

Nursing Responsibilities:

1. Observe 10 R’s.2. Review orders and check for allergies or other penicillin and contraindicated.

Rationale: To prevent further complication.3. Inform patient that fever and increase WBC are most common reaction.

Rationale: so that the patient will not be alarm.4. Advice the patient to take the medicine on regular schedule as prescribed.

Rationale: adherence to antibiotic tx. Should be strictly followed to avoid resistant.5. Teach the patient to recognize s/sx of anaphylaxis. Tell him to contact emergency

medical service immediately if these occur.Rationale: To prevent further complication.

6. Discuss the side effect of the drug to the such as:Neurologic status, especially for seizures, decreasing LOC. -give quiet environment and bed rest.Diarrhea-Encourage the patient not to discontinue therapy w/o first consulting the health care provider. If diarrhea persist, monitor the pt. signs of dehydration-Add bulk to dietRash-Report a rash immediately and withhold additional doses pending approval by the health care provider.Nausea and vomiting-frequent small mealsDrowsiness and dizziness-caution the patient against driving or performing hazardous task until adjusted o the effect of the medication

Date odered: August 15, 2010

Generic name: Lidocaine Hydrochloride

Brand name: Lidocaine

Dosage, Route, and Frequency: .5cc/IM/OD

Classification: Antiarrhythmics

Mechanism of Action: A class IB antiarrhythmic that decreases depolarization, autmonaticity and excitability in the ventricles during the diastolic phase by direct action on the tissues especially the purkinje network.

Desired Effect: To decrease ventricular dysrhythmia

Nursing Responsibilities:

1. Observed 10 R’s2. Review and check allergies and contraindication

-to prevent futher complication3. Discuss the side effect of the drug to the patient such as:

Confusion, restlessness and light headedness

Rationale: Provide a calm environment as the patient need rest

Vomiting

Rationale: Frequent small mealsBlurred or Double vision

Rationale: Emphasize bed rest, caution the patient against driving or hazardous activities.

Date odered: August 15, 2010

Generic name: Streptomysin

Brand name: Streptomysin

Dosage, Route, and Frequency: 1 million/IM/OD

Classification: bactericidal antibiotic/ antituberculosis agent

Mechanism of Action: inhibits protein synthesis by binding directly of the 30s ribosomal subunit; bactericidal

Desired Effect: to treat infection

Nursing Responsibilities:

1. Observed 10 R’s2. Review and check allergies and contraindication

Rationale: to prevent further complication3. Advise the patient to the take the medicine on regular schedule as prescribed.

Rationale: adherence to antibiotic treatment should be strictly followed to avoid resistant

4. Discuss the side effect of the drug to the patient such as:

Headache

- emphasize bed rest to prevent injury

Nephrotoxicity

- monitor renal function carefully patients with reduced function should have reduced doses sense of fullness in ears

impair cognitive, motor and sensory function

- advise him to use caution when driving and performing other hazardous activities

Unusual bleeding or bruising

- prevent complication

Date Ordered: August 14, 2010

Generic name: Salbutamol

Brand name: Ventolin

Dosage, Route, and Frequency: 2 mg/PO/BID

Mechanism of Action: Binds to beta- adrenergic receptors in airway smooth muscle, leading to activation of adenyl cyclase and increased levels of cyclic aderosine monophosphate

Desired Effect: It causes bronchodilation thus facilitating comportable breathing

Nursing Responsibilities:

1. Observe 10 R’s2. Check doctors order and review directions for correct useof medication and inhaler( see

administration)Rationale: to avoid mistake and protect self from illegal action

3. Observed the 10 R’s of drug administrationRationale: to make treatmet regiment effective

4. Instruct the patient that salbutamol can cause dizziness/vertigoRationale: provide necessary precaution such as changing position slowly

Date Ordered: August 14, 2010

Generic name: Amoxicillin

Brand name: Amoxil

Classification: Antiinffective

Dosage, Route, and Frequency: 500mg PO TID

Mechanism of Action: Binds to bacterial cell wall, causing cell death

Desired Effect: It has bactericidal action: halting the bacterial infection

Nursing Responsibilities:

1. Observed 10 R’s2. Check allergies and contraindication

Rationale: to prevent further complication3. Determine previous hypersensitivity reactions to penicillins, cephalosporins and other

allergen prior to therapy Rationale: Person with a history of penicillin sensitivity may still have an allergic response.

4. Monitor patient for any signs of hypersensitivity to the drugs such as erythematous, maculopapular rash. Rationale: Report to physician immediately so he/she will prescribe another drug.

5. Document the result with regards to patient taking the drugRationale: For legal purposes.

Date Ordered: August 14, 2010

Generic name: Carbocisteine

Brand name: Carbocisteine

Classification: Expectorant

Dosage, Route, and Frequency: 500mg PO TID

Mechanism of Action: Increase the volume and reduces the viscosity of secretions in the tranchea and bronchi to facilitate secretion removal

Desired Effect: This is given to our patient to eliminate cough

Nursing Responsibilities:

1. Observed 10 R’s2. Review orders and check allergies and contraindication

Rationale: To prevent further complication3. Instruct the patient to drink plenty of fluids

Rationale: Optimal absorption of medicine4. Instruct the patient to eat food before taking the drug

Rationale: To prevent GI upset

GENERAL EVALUATION

Two weeks prior to admission, our patient, Mr. Neumi, had experienced chest pain and cough. During this span of time, he resorted to self-medication through Carbocysteine and medical plants like Oregano.

After two weeks of self medication, there was neither development nor signs as to the effect of the medications taken. He asked for medical assistance at Gaoat General Hospital on August 14, 2010 at 9:00 AM with a chief complaint of chest pain and cough. He was diagnosed by Dr. Medeldorf M. Gaoat.

During his confinement, due to his chief complaint of chest pain, he underwent Electrocardio Gram (ECG) procedure to reflect underlying heart condition. He as well underwent Chest X-Ray to determine the extent and pattern of lung involvement.

Medication were given Penicillin G. 1Mu IM/OD, Streptomysin 500mg 1/2IM/OD. Lidocaine .5cc IM/OD, Carbocysteine 500mg PO/TID, Salbutamol 2mg PO/BID, Amoxicillin 500mg PO/TID

From the X-Ray result, it was found out that there was hazy and streaky densities in both lung bases.

Our client was discharged on the 19th of August at 2:00 in the afternoon with take home medicines as follows: Cephalexin 500mg/PO/BID and Carbocysteine 500mg/PO/TID.

As a general evaluation, Mr. Neumi has regained strength.

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