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Community-acquired pneumonia (CAP) is a term used to describe one of several diseases in which individuals who have not recently been hospitalized develop an infection of the lungs (pneumonia). CAP is a common illness and can affect people of all ages. CAP occurs because the areas of the lung which absorb oxygen (alveoli) from the atmosphere become filled with fluid and cannot work effectively.

CAP occurs throughout the world and is a leading cause of illness and death. Causes of CAP include bacteria, viruses, fungi, and parasites. CAP can be diagnosed by symptoms and physical examination alone, though x-rays, examination of the sputum, and other tests are often used. Individuals with CAP sometimes require treatment in a hospital. 

SIGNS AND SYMPTOMS

difficulty in breathing, fever, chest pains, cough

TYPES OF CAP

Typical pneumonia usually is caused by bacteria such as Streptococcus pneumoniae. A

typical pneumonia usually is caused by the influenza virus, mycoplasma, chlamydia, legionella, adenovirus, or other unidentified microorganism.

The patient’s age is the main differentiating factor between typical and atypical pneumonia; young adults are more prone to atypical causes,5,6 and very young and older persons are more predisposed to typical causes.

CLINICAL PRESENTATION

Pneumonia is an inflammation or infection of the lungs that causes them to function abnormally.

Pneumonia can be classified as typical or atypical, although the clinical presentations are often similar.

Several symptoms commonly present in patients with pneumonia.

IntroductionIntroduction

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ETIOLOGY

Bacterial

Chlamydia species Haemophilus influenza Legionella species Moraxella catarrhalis Mycoplasma pneumonia Staphylococcus aureus Streptococcus pneumonia

Viral

Adenovirus Influenza A B Parainfluenza Respiratorysyncytial virus

Endemic fungi

Blastomycosis Coccidioidomycosis Histoplasmosis

EPIDEMIOLOGY

The epidemiology of CAP is unclear because few population-based statistics on the condition alone are available. The Centers for Disease Control and Prevention (CDC) combines pneumonia with influenza when collecting data on morbidity and mortality, although they do not combine them when collecting hospital discharge data. In 2001, influenza and pneumonia combined were the seventh leading causes of death in the United States,3,4 down from sixth in previous years, and represented an age-adjusted death rate of 21.8 per 100,000 patients.3 Death rates from CAP increase with the presence of comorbidity and increased age; the condition affects persons of any race or sex equally. The decrease in death rates from pneumonia and influenza are largely attributed to vaccines for vulnerable populations (e.g., older and immunocompromised persons).

RISK FACTORS

Age older than 65 years

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Human immunodeficiency virus or immunocompromised Recent antibiotic therapy or resistance to antibiotics Comorbidities Asthma Cerebrovascular disease Chronic obstructive pulmonary disease Chronic renal failure Congestive heart failure DiabetesLiver disease Neoplastic disease

INCIDENCE/PREVALENCE

The incidence of community-acquired pneumonia requiring hospitalization in the study counties in 1991 was 266.8 per 100,000 population; the overall case-fatality rate was 8.8%. Pneumonia incidence was higher among blacks than whites , was higher among males than females and increased with age

  

Patient’s ProfilePatient’s Profile

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Name : C.G.

Birth date : April. 15. 2011

Address : Umboy San Antonio Biñan Laguna

Age : 5 months

Gender : female

Religion : Catholic

Nationality : Filipino

Admitting diagnosis : Pneumonia

Final diagnosis : Community Acquired Pneumonia

Chief Complaint : Difficulty of Breathing

Attending Physician : Dra. A

Date of Admission : September, 12, 2011

Room Type : Pedia Ward

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HISTORY OF PRESENT ILLNESS

One week prior to admission, the patient’s mother stated that her daughter has a cough, fever and experience difficulty of breathing; she also noticed that her daughter’s lips are turning blue (cyanosis). They consulted at ONB-ER and was given antibiotic then admitted at pedia ward with Dra. Manalo Arzola as attending physician. The patient admitted last September 12, 2011 at around 5:00 pm.

PAST MEDICAL HISTORY

No past medical history, first time admitted at the hospital.

FAMILY HISTORY

(+) hypertension – paternal side

(+) asthma – maternal side

PERSONAL AND SOCIAL HISTORY

Patient’s mother stated that baby C.G is her 2nd child and has a twin which also experience having pneumonia before, she also stated that they live with her mother-in-law which have a rugby factory.

Patient’s HistoryPatient’s History

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BODY PARTS NORMAL FINDINGS ACTUAL FINDINGS

Scalp size-varies somewhat

shape-symmetrical and round

-Absence of masses

-No Lesions

-symmetrical

Hair color-varies

amount and distribution

texture-fine to coarse, pliant

presence of parasites-none

-black

-normal

- fine to course

-with parasites

Face symmetry-symmetrical

facial features-features vary, symmetrical, centered head position

-symmetrical facial movement

-symmetrical

Eyes conjunctiva and sclera-bulbar and palpebral conjunctiva is pink with no discharge; sclera is white

cornea-transparent, smooth, moist

-pinkish and no discharge

-white sclera

Round, transparent, smooth and moist

Nose external nose

Physical AssessmentPhysical Assessment

VITAL SIGNS

Temperature Cardiac Rate Respiratory Rate

36 °C 125 bpm 51 cpm

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-skin appearance-color: same as face

-shape-symmetrical appearance

internal nose

-appearance-mucosa pink and moist with uniform color and no lesions

-color same as face

-with clear watery discharge

-not tender

-mucosa pink and moist

-no lesions

Mouth Open and close mouth for symmetry and alignment-lips and surrounding tissue relatively symmetrical in net position and with smiling

-proportional and symmetrical with the face

-no lesions, swelling, drooping

Lips color-

in white- pink

in dark-may have bluish hue or frecklelike pigmentation

consistency- moist, smooth with no lesions

-pink

-smooth, no lesions

Tongue symmetry and texture-moist symmetrical appearance; midline fissure present

movement-smooth

color-pink

-in central position

-moist

-moves freely

-no lesions or swelling

Ears size and shape- ears equal size and similar appearance

-equal

-similar in appearance

-same color as facial skin

Skin generalized color

light to dark brown

-light brown

-smooth, soft

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texture-smooth, soft

temperature and moisture-warm, dry

turgor-pinched skin returns immediately to original position

edema-no swelling, pitting, or edema

-warm

-pinched skin returns immediately to original position

-no edema and lesions

Neck appearance/movement-smooth, controlled movements; range of motion

flexion, extension, lateral abduction, rotation

-smooth no lesions

-no swelling

-can move in different direction

Thoracic and lung Inspection

Anterior and posterior thorax-

Intercostals spaces-even and relaxed

Chest symmetry-equal

Position of sternum-level with ribs

Position of trachea-midline

Respiration patterns/auscultate

-intercostal spaces even and relaxed

-symmetry equal

-sternum is level with the ribs

-shallow/labored breathing

-crackles heard upon auscultaion

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Abdomen Contour-rounded or flat

Symmetry-symmetrical

Surface motion-no movement or slight peristalsis visualized over aorta

-globular shape

-muscles used for labored inspiration

Palms Color-pink

creases

-pink

-(3)three

Finger nails Color-pink nail bed

Shape-round nail with 160 nail base

Texture-nail is round, hard, hard immobile in dark skin: may be thick

Condition of nail bed-smooth, firm, and pink

-pink

- round w/ 160° nail base

-long and dirty

-normal capillary refill

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Review of Review of Anatomy and Anatomy and PhysiologyPhysiology

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The Lungs constitute the largest organ in the respiratory system. They play an

important role in respiration, or the process of providing the body with oxygen and releasing carbon dioxide. The lungs expand and contract up to 20 times per minute taking in and disposing of those gases.Air that is breathed in is filled with oxygen and goes to the trachea, which branches off into one of two bronchi. Each bronchus enters a lung. There are two lungs, one on each side of the breastbone and protected by the ribs. Each lung is made up of lobes, or sections. There are three lobes in the right lung and two lobes in the left one. The lungs are cone shaped and made of elastic, spongy tissue. Within the lungs, the bronchi branch out into minute pathways that go through the lung tissue. The pathways are called bronchioles, and they end at microscopic air sacs called alveoli. The alveoli are surrounded by capillaries and provide oxygen for the blood in these vessels. The oxygenated blood is then pumped by the heart throughout the body. The alveoli also take in carbon dioxide, which is then exhaled from the body.Inhaling is due to contractions of the diaphragm and of muscles between the ribs. Exhaling results from relaxation of those muscles. Each lung is surrounded by a two-layered membrane, or the pleura, that under normal circumstances has a very, very small amount of fluid between the layers. The fluid allows the membranes to easily slide over each other during breathing.

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Non Modifiable Factors:

Age

Modifiable Factors: Environment Diet Bacteria and

Viruses

Entry of microorganism to nasal passages

Invasion of the respiratory system

Activation of immune response (mucus production)

Ineffective immune response results to

overwhelming infection

Invading lung parenchyma

cough

Release of endotoxins and exotoxins

Continues mucus production

Massive inflammation (pneumonia

fever

Altered gas exchange cyanosis

dyspnea

PathophysiologyPathophysiology

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NARRATIVE

Infectious organism enter the lung when airborne droplets are inhaled, but can also reach the lung through the bloodstream when there is an infection in another part of the body. Many bacteria live in parts of the upper respiratory tract, such as the nose, mouth and sinuses, and can easily be inhaled into the alveoli. Once inside, bacteria may invade the spaces between cells and between alveoli through connecting pores. This invasion triggers the immune system to send neutrophils, a type of defensive white blood cell, to the lungs. The neutrophils engulf and kill the offending organisms, and also release cytokines, causing a general activation of the immune system. This leads to the fever, chills, and fatigue common in bacterial and fungal pneumonia. The neutrophils, bacteria, and fluid from surrounding blood vessels fill the alveoli and interrupt normal oxygen transportation.

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MedicalMedical

ManagementManagement

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DATE PROGRESS NOTES

DOCTOR’S ORDER

RATIONALE NURSING CONSIDERATIONS

9/12/112:05 pm Wt : 5.3 kg Please admit

under the service of Dra. Arzola

Secure consent for admission

Monitor VS q 4 hrs

-Patients have different preferences and needs.

-To ensure that the patient’s mother understood and agreed on everything explained by the physician regarding to her baby’s condition.

-To document acute changes and trends over time and unexpected changes and values that deviate significantly from a patient’s normal values are brought to the attention of the patient’s primary health care provider. Also for monitoring hemodynamic, cardiac and ventilatory

-Familiarize the patient’s mother with the room and hospital facilities

-The nurse’s responsibility is to ensure that an informed consent has been obtained voluntarily from the patient’s mother by the physician. The signed consent form is placed in a prominent place on the patient’s chart.

-The nurse assessed individual client and determined that the client is medically stable or in a chronic condition and not fragile and that the vital sign measurement is considered routine for the client.

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NPO

IVF : D5 0.3 NaCl 500 cc, 39 > cc x 24 ° x a6.17 mcgtts/min

status.

-To prepare the patient for diagnostic procedure. It helps to prevent risks of aspiration. Aspiration pneumonia (where food particles can be regurgitated from the stomach into the lungs) is a life-threatening complication because it causes severe damage to the lungs requiring artificial ventilation and hospitalization.

- Replacement therapy particularly in extracellular fluid deficit accompanied by acidosis.

-Instruct the patient’s mother not to feed the baby.

- The nurse monitors IV infusions frequently to make sure that the fluid is flowing at the intended rate.

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Diagnostic tests:

CBC

UA

-Complete blood count is used to determine blood components and the response to inflammatory process and streptococcal infection.

-Urinalysis yields a large amount of information about possible disorders of the kidney and lower urinary tract, and systematic disorders that alter urine composition. Urinalysis data include color, specific gravity, pH, and the presence of protein, RBC’s,WBC’s, bacteria, Leukocyte, esterase, bilirubin, glucose, ketones, casts and crystals.

-Explain test procedure to the patient’s mother. Apply manual pressure over the puncture site and monitor for oozing of blood or hematoma formation. Follow up results.

- Instruct and demonstrate on the patient’s mother how to get the midstream urine. Follow up results. The nurse should be able to establish a base line as guide for deviations and monitoring for stability of these values.

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For CXR

Medications:

Cefuroxime 150mg IV q 8 ANST (-)

Paracetamol 60mg IV q 4° for fever T > 38.5 °C

Salbutamol ½ neb + 1 cc NSS q 390 cc x 3 dose

-It is used to rule out respiratory problems causes of referred pain. In some cases, chest abnormalities cause pain in the abdominal area.

-Cefuroxime is a cephalosporin antibiotic. It treats many kinds of infections such as cholecystitis.

-Paracetamol is a analgesics and Antipyretics drugs use to relieve fever and mild to moderate pain.

-Salbutamol is antiasthmatic drugs. It relieve bronchospasm in patient with

-Tell the patient that he must wear gown and must remove all metal object and jewelry from his neck and chest. Assist patient in assuming appropriate position. Reassure the patient that the amount of radiation exposure s minimal. Follow-up results.

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Moderate high back rest

02 at 1-2 LPM

Inform AP (attending physician)

Nebulize ĉ salbutamol q 6°

acute respiratory infection

-To provide patent, unobstructed airway , maximum lung excursion

-To prevent hypoxemia; to provide more oxygen to the body in order to promote health.

-Attending Physician will be sufficiently comprehensive to describe the clinical problem, pertinent history, and physical findings to enable continuity of care by others who may be involved in the patient’s care.

-Salbutamol is antiasthmatic

-Instruct the patient’s mother to elevate head of the bed and do not leave her daughter unattended.

- Instruct the patient’ smother on the method of administering oxygen safely.

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RR: 51 cpm(-) DOB

Reassessment c/o NOD

High back rest

CPR PRN

May have MF ĉ SAP

drugs. It relieve bronchospasm in patient with acute respiratory infection

-To evaluate patient’s condition and identify new patient problems needing different interventions according to a revised plan

-facilitate chest expansion to improve ventilation.

-To restore and maintain circulation and to provide oxygen if the petient has stopped breathing (respiratory arrest) 

-The patient is at a big risk of

-reassess the patient periodically, establish a plan of care based on the patient reassessment

-Instruct the patient’s mother to elevate head of the bed and do not leave her daughter unattended.

Have the patient be fed, head elevated

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9/13/119:35 am

4:30 pm

9/14/11 9:07 am

TF: D5 0.3 NaCl 500 cc x 16-17 mcgtts/min

IVF : D5 IMB 500 cc x 10 hrs

02 ĉ 4LPM thru funnel PRN

May feed ĉ SAP

throwing up and it getting into their lungs which can cause aspiration pneumonia

- Replacement therapy particularly in extracellular fluid deficit accompanied by acidosis.

- Replacement therapy particularly in extracellular fluid deficit accompanied by acidosis.

-To prevent hypoxemia; to provide more oxygen to the body in order to promote health.

-The patient is at a big risk of throwing up and it getting into their lungs which can cause

almost 90 degrees while feeding

- The nurse monitors IV infusions frequently to make sure that the fluid is flowing at the intended rate.

- The nurse monitors IV infusions frequently to make sure that the fluid is flowing at the intended rate.

- Instruct the patient’ smother on the method of administering oxygen safely.

-Have the patient be fed, head elevated almost 90 degrees while feeding.

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9/15/116:45 am

3:30 pm

IVF D5IMB 500 cc x 10°

TF: D5IMB 500 cc x 10°

Cefaclor drops 1ml TID x 5 days

Salbutamol neb ½ + 1cc NSS TID x 5 days TF: OPD after 1 week

aspiration pneumonia

- Replacement therapy particularly in extracellular fluid deficit accompanied by acidosis.

- Replacement therapy particularly in extracellular fluid deficit accompanied by acidosis.

-Cefaclor is a cephalosporin drugs. It used in the treatment of upper and lower respiratory infection

-Salbutamol is antiasthmatic drugs. It relieve bronchospasm in patient with acute respiratory infection

- The nurse monitors IV infusions frequently to make sure that the fluid is flowing at the intended rate.

- The nurse monitors IV infusions frequently to make sure that the fluid is flowing at the intended rate.

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Diagnostic Diagnostic ExamExam

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September 13,2011

Result Normal values Interpretation

Hemoglobin 115 110 – 140 gm / L

DECREASEDIndicates decreased oxygen level in the

blood/anemia

Hematocrit 0.36 0.37 – 0.47 NORMAL

RBC 4.1 4.5 – 5 x 1012 / L

DECREASEDIndicate hypoxemia or

decreased oxygen production

Total WBC 4.2 5 – 10 x 109 / LDECREASED

Indicates presence of infection

Platelet count 290 150 – 400 x 109 / L NORMAL

Differential count:

Segmenters 0.30 0.50 – 0.70 NORMAL

Eosinophil 0.70 0.20 – 0.80 NORMAL

hematologyhematology

urinalysisurinalysis

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September 13,2011

Results Normal Values InterpretationColor Yellow Yellow NORMALTransparency Slightly Hazy Clear to slightly hazy NORMALSpecific Garvity 1.015 1.015-1.025 NORMALPH Neutral 4.5-8.0 NORMALAlbumin Negative Negative NORMALSugar Negative Negative NORMALWBC 0-2/ HPF 0-2/ HPF NORMALRBC 0-1 / HPF 0-2/ HPF NORMALBacteria Negative Negative NORMALEpithelial cells Few Few

September 13,2011

Results Normal Values Interpretation

Consistency Mucoid formed ABNORMALIndicate presence of

bacterial infection

Color Green Yellow-brown ABNORMALIndicate diarrhea

Parasite seen Some found Negative ABNORMALIndicate diarrhea

Characteristics NORMAL

FecalysisFecalysis

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Drug Drug studystudy

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Nursing CareNursing Care PlanPlan