INTRODUCTION

A. Current trends about the disease condition

Pneumonia is an illness of the lungs and respiratory system in which the alveoli

(microscopic air-filled sacs of the lung responsible for absorbing oxygen from the

atmosphere) become inflamed and flooded with fluid. Pneumonia can result from a

variety of causes, including infection with bacteria, viruses, fungi, or parasites.

It is also called Pneumonitis or Bronchopneumonia. Although Pneumonitis is

actually a general term which refers to the inflammation of the lungs and Pneumonia is

one of the common Pneumonitis. While it is called Bronchopneumonia because

“broncho” indicate that of the lungs. Pneumonia is a serious infection that affects the air

sacs in the lungs, resulting to significant reduction in oxygenation. Because of this, the

oxygen will have difficulty reaching the blood. If there is too little oxygen in the blood,

body cells cannot work properly. As a result, infection will spread.

Pneumonia is a special concern to both extremes of age – the too old and the too

young, because it is during this time the individual is most at risk, for the too old, it is for

the reason that their immune system is degenerating, while for the too young it is

because their immune system is not yet fully developed. Although these extremes of

age are greatly at risk, Pneumonia can also affect healthy individuals, it is a common

illness that affects thousands of people in the Philippines each year. It remains as the

leading cause of morbidity in the country (according to the Department of Health).

Appropriate nursing care should be given to patients with Pneumonia. Health care

providers should remain vigilant with regards to dealing with this kind of disease.

Nurses, in cooperation with other members of the health care team should not only

focus on the curative aspect of the disease but to its preventive aspect as well. A patient

with pneumonia should be given appropriate care in order to hasten his/her recovery.

The focus should not only be in the patient himself but to the public as well for a person

with pneumonia could also infect other people around him/her.

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A major trial of a pneumococcal vaccine in South Africa has given children extra

protection against the deadly infection.

The World Health Organization (WHO), which helped run the testing program,

says that pneumonia, caused by pneumococcus bacteria, is the leading cause of death

in children worldwide. It claims approximately four million lives a year, predominantly in

less developed countries.

Although the lung congestion has many causes, the most common is

pneumococcus. The bacterium can also cause meningitis, ear infections and sinusitis.

The trial involved 40,000 children in Soweto, and found that the new vaccine

reduced the incidence of pneumonia by more than 20%.

In addition, the vaccine reduced the incidence of "invasive pneumococcal

disease" - where bacteria can be found in the bloodstream - by more than 80%. The

invasive form of the disease was reduced in incidence even in HIV-infected children.

Pneumococcal disease is one of the predatory illnesses most likely to kill HIV-

positive children in developing countries.

Researchers show a new type of vaccine can reduce the incidence of pneumonia

in children with and without human immunodeficiency virus (HIV). Acute respiratory

infections are a major cause of death in children under age 5. Additionally, pneumonia

is becoming increasingly resistant to antibiotics. Doctors from around the world are in

search of new methods to treat the illness. Researchers, conducted a study with nearly

40,000 children in South Africa. At 6 weeks, 10 weeks and 14 weeks of age, half of the

children received the 9-valent pneumococcal polysaccharide vaccine. All of the children

received the flu vaccine. The researchers found the pneumonia vaccine decreased the

rate of the particular strain of pneumonia in the vaccine, by 72 percent. It also reduced

the rate of confirmed cases by 17 percent. In an accompanying editorial, the authors

write, “The decrease in these two outcomes were remarkably similar in both U.S.

children and South African children. However, in South Africa about one third of the

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cases of invasive disease caused by serotypes included in the vaccine were associated

with meningitis, a much higher proportion than in the United States.” This vaccine,

according to the study investigators, may be useful in countries where HIV infection is a

significant cause of pneumonia. It also may reduce the risk of antibiotic resistance.

However researchers noted an increase in asthma in those who received the vaccine,

but that reason is not yet understood.

Another study showed particularly UT Southwestern Medical Center scientists

have revealed that a combination of corticosteroids with traditional antimicrobial therapy

may help people with pneumonia recover more quickly than with antibiotics alone.

Corticosteroids are often used to treat inflammation related to infectious diseases, such

as bacterial meningitis, but they have been rendered ineffective in case of other

infectious diseases. In a new study, scientists have shown that mice with a type of

severe bacterial pneumonia, when treated with steroids and antibiotics recovered faster.

The steroid treated mice had far less inflammation in their lungs than mice treated with

antibiotics alone. "Some people might think that if you give steroids, it would counteract

the effect of the antibiotic. But it turns out you need the antibiotic to kill the bug and the

steroid to make the inflammation in the lung from the infection get better. The steroids

don't kill the bugs, but they do help restore health," said Dr. Robert Hardy, associate

professor of internal medicine and pediatrics and the study's senior author. For the

study, the researchers gave a daily treatment of a placebo, an antibiotic, a steroid, or a

combination of the antibiotic and steroid to mice infected with the M pneumoniae

bacterium. The animals were then evaluated after one, three and six days of therapy. "It

turns out that the group that got both the antibiotic and the steroids did the best. The

inflammation in their lungs got significantly better," said Hardy . While antimicrobials

have been the primary therapy for M pneumoniae infection, many physicians have tried

adding steroids to the treatment regimen of patients with severe cases. But, Hardy said

that the problem is that those were individual case reports. "They never had a control

group, so it was impossible to tell what impact the addition of steroids had on recovery,"

he said. The new findings suggest that giving antibiotics with steroids can help

individuals with pneumonia get better faster. Also, the research suggests a potentially

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more effective therapy for someone in the midst of an asthma attack due to M

pneumoniae infection.

The student nurses chose Pneumonia for a case study because it is a

very interesting topic. It is one of the common problems in the country. It

remains the leading cause of morbidity in the Philippines as stated by the

department of Health. It is commonly mistaken as a common cough and cold

because it manifests almost the same signs and symptoms, for this reason,

people with this respiratory problem usually take it for granted. With this, the

student-nurses decided to choose the case of Pneumonia for their case

study.

OBJECTIVES

A. Student-Nurse Centered

After the completion of the case study, the researchers will be able

to:

General Objective:

Gain knowledge and deeper understanding of the disease

process itself, be able to provide the best nursing care for the

client, and impart health teachings regarding the client’s condition

in maintaining an optimum level of functioning.

Specific Objectives:

1. Interpret the current trends and statistics regarding the

disease condition;

2. Relate the present state of the client with his personal and

pertinent family history;

3. Analyze and interpret the different diagnostic and laboratory

procedures, its purpose and its essential relationship to

client’s disease condition;

4. Identify treatment modalities and its importance like drugs,

diet and exercise;

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5. Identify surgical management and its purpose that is

applicable with the disease condition;

6. Formulate nursing care plans based on the prioritized health

needs of the client;

7. Gain knowledge on the acquisition and progression of the

disease;

8. Impart knowledge on fellow students in providing care for

clients with the same illness.

B. Patient-Centered

After the completion of the study, the patient will be able to:

General Objective:

Acquire knowledge on the risk factors that have contributed to

the development of the disease, gain understanding of the disease

process and demonstrate compliance on the treatment management

rendered by the health care team.

Specific Objectives:

1. Gain knowledge about the disease;

2. Identify different interventions in his condition;

3. Gain knowledge on the importance of compliance to treatment

regimen;

4. Demonstrate compliance on the treatment management;

5. Identify different measures to prevent further aggravation of

condition;

6. Participate in his plan of care; and

7. Demonstrate independence on self-care and home

management upon discharge and during follow-up home visits.

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NURSING ASSESSMENT

PERSONAL DATA

Our patient is Ashleyto Montemayor, male, 2 years of age, residing in a barrio

somewhere in Pangasinan. He was born via normal delivery on April 09, 2007, on their

home by a midwife. He had 2 brothers and 2 sisters. He admitted to one of the hospital

in Pampanga last August 18, 2009

PERTINENT FAMILY HISTORY

Ashleyto Montemayor belongs to a family of 7, with two sisters, and two brothers.

All of them were born under Normal spontaneous delivery. The family belongs to a

nuclear family. The father’s job is a contractual carpenter and earns around 450 a day

while the mother is a plain housewife. Based on the father’s salary, they have

inadequate amount of money to spend on their daily living. According to our informant,

they live in a squatter’s area and they live near the road in which they are exposed in

pollution.

PERSONAL HISTORY

Ashleyto is 2 year old boy, a Roman Catholic and daughter of Mr. Montemayor and Mrs.

Montemayor who currently resides somewhere in Pangasinan and was born on April 09,

2007 in their house with the help of a midwife. He is the 2nd youngest among the five

children in the family and presently lives with her parents and siblings. (Such

informations are provided by Mrs. Montemayor).

HISTORY OF PAST ILLNESS

According to Mrs.Montemayor, her son didn’t acquire such illness before. He was

only affected by his sister’s colds and cough.

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HISTORY OF PRESENT ILLNESS

Ashleyto’s mother didn’t expect that her child was suffering from Bronchial

Pneumonia because at first, it was only cough and DOB. Days passed and Ashleyto’s

mother decided to bring her son to the hospital because Ashleyto started to vomit due to

hyperthermia.

As seen on the schematic diagram our patient’s father smoked and drunk alcohol

while his wife was pregnant with Ashleyto that is why Ashleyto’s immune system is

compromised. His sister had colds and cough before Ashleyto acquired the same

illness. Ashleyto’s unresolved colds and cough led to her difficulty of breathing, which

further led to pneumonia.

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PHYSICAL EXAMINATION

August 18, 2009(Day of admission)Patient Ashleyto upon admission: (lifted from the chart)

Flushed skin

(-) Edema

Vital Signs:

o Body temperature of 37.4 OC (febrile) (Normal=36.8OC)

o Heart rate of 135 bpm (tachycardia) (Normal=80-120bpm)

o Respiratory rate of 46 bpm (tachypnea) (Normal=25-40bpm)

August 19, 2009(1st day)

General appearance:

o conscious and coherent

o irritable

Vital Signs: (lifted from the chart)

o Body temperature of 37.9 OC (febrile) (Normal=36.8OC)

o Heart rate of 130 bpm (tachycardia) (Normal=80-120bpm)

o Respiratory rate of 48 bpm (tachypnea) (Normal=25-40bpm)

August 20, 2009 (2nd day)

General appearance:

o conscious and coherent

o irritable

Vital Signs:

o Body temperature of 37.6 OC (febrile) (Normal=36.8OC)

o Heart rate of 130 bpm (tachycardia) (Normal=80-120bpm)

o Respiratory rate of 46 bpm (tachypnea) (Normal=25-40bpm

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Head:

o No tenderness upon palpation

o No presence of lesions and scar

o symmetric facial features and movement

Skin:

o Fair complexion

o With good skin turgor

o (-) cyanosis

o No lesions or rashes noted

o Flushed skin

o Pale skin

Hair:

o Hair is evenly distributed

o Has short, black and dry hair

o No presence of dandruff and pediculosis upon inspection

Nails:

o Nails are clean and short

o Capillary refill 2-3 sec.

Eyes and Vision:

o Both eyes are symmetrical

o Elicited blink reflex upon assessment

o Has pale conjunctiva

o Dark circles under the eyes

o Sclera appears white

o Pupils are equally round reactive to light and accommodation

Ears:

o Ears are at the level of the outer cantus of the eye

o They are symmetrical in size and shape

o No presence of lesions noted

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o No presence of discharges

o Pinna recoils after it is folded

Nose and sinuses:

o Presence of clear, watery discharges

o No lesions noted

o No presence of tenderness upon palpation

o With nasal flaring noted

Mouth:

o No lesions and tenderness noted

o Teeth are white and clean

o No presence of dental caries

Neck:

o Absence of masses

o No pain and swelling

o Trachea is on the middle of the neck

Thorax and Lungs:

o With symmetrical lung expansion

o Presence of wheezes on bilateral lung fields

o Respiratory rate is above normal (46bpm)

o Difficulty of breathing and shortness of breath

Abdomen:

o No tenderness upon palpation

o Absence of wounds, scar, and lesion upon inspection

o Absence of swelling or lump upon palpation

Extremities:

o No scar, lesion and wounds noted

o No deformities

o Absence of nodule and edema

Symmetrical in shape and size

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August 21, 2009 (3rd day)

General appearance:

o conscious and coherent

o irritable

Vital Signs:

o Body temperature of 36.7OC (febrile) (Normal=36.8OC)

o Heart rate of 121 bpm (tachycardia) (Normal=80-120bpm)

o Respiratory rate of 35 bpm (tachypnea) (Normal=25-40bpm

Head:

o No tenderness upon palpation

o No presence of lesions and scar

o symmetric facial features and movement

Skin:

o Fair complexion

o With good skin turgor

o (-) cyanosis

o No lesions or rashes noted

o Flushed skin

o Pale skin

Hair:

o Hair is evenly distributed

o Has short, black and dry hair

o No presence of dandruff and pediculosis upon inspection

Nails:

o Nails are clean and short

o Capillary refill 2-3 sec.

Eyes and Vision:

o Both eyes are symmetrical

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o Elicited blink reflex upon assessment

o Has pale conjunctiva

o Dark circles under the eyes

o Sclera appears white

o Pupils are equally round reactive to light and accommodation

Ears:

o Ears are at the level of the outer cantus of the eye

o They are symmetrical in size and shape

o No presence of lesions noted

o No presence of discharges

o Pinna recoils after it is folded

Nose and sinuses:

o Presence of clear, watery discharges

o No lesions noted

o No presence of tenderness upon palpation

o With nasal flaring noted

Mouth:

o No lesions and tenderness noted

o Teeth are white and clean

o No presence of dental caries

Neck:

o Absence of masses

o No pain and swelling

o Trachea is on the middle of the neck

Thorax and Lungs:

o With symmetrical lung expansion

o Presence of wheezes on bilateral lung fields

Abdomen:

o No tenderness upon palpation

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o Absence of wounds, scar, and lesion upon inspection

o Absence of swelling or lump upon palpation

Extremities:

o No scar, lesion and wounds noted

o No deformities

o Absence of nodule and edema

o Symmetrical in shape and size

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LABORATORY PROCEDURES

DIAGNOSTIC

PROCEDURE

DATE

ORDERED/

DATE

RESULTS

IN

INDICATION(S)/

PURPOSE(S)

RESULTS NORMAL

VALUES

ANALYSIS AND

INTERPRETATION OF

RESULTS

HEMATOLOGY

a) Hemoglobin

(hgb)

DO:

08-18-2009 It measures the

oxygen carrying

capacity of the blood

since hemoglobin is

the primary component

of the blood which

carries oxygen. Hgb

serves as a vehicle for

oxygen and carbon

dioxide transport.

Since asthma attacks

causes bronchospasm

which alters ventilation

150g/L M- 140-180 g/L Client’s hgb level is

within the normal range

of the standard hgb level

of the hospital.

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b. Hematocrit

(Hct)

c. White Blood Cell

(WBC)

and perfusion of the

lungs, therefore

oxygenation of the

blood may be affected.

To aid in the

calculation of

erythrocyte indices and

in the diagnosis of

anemia, polycythemia,

or abnormal states of

hydration.

To determine infection

or inflammation

caused by periods of

reversible spasms and

prolonged contraction

of the airway. To

determine the need for

further tests, such as

WBC differential or

bone marrow biopsy.

.43

14.8 9/L

M- 0.42-0.54

5-10 9/L

Client’s hct level is within

the normal range of

standard hct level of the

hospital.

Client’s WBC count is

above the normal range

of standard WBC count

of the hospital.

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d. Lymphocytes

e. Segmenters

To determine

lymphocyte blood

count. To assess and

monitor acquired

immunodeficiency

status. Since

lymphocytes play an

important role in the

immunity. They are the

one responsible for the

activities of the

immune system.

To measure the

neutrophil percentage

in the blood volume for

WBC differential count

.29

0.71

0.22-0.40

0.66-0.70

Client’s lymphocyte

blood count is within the

normal range of

standard WBC count of

the hospital.

An increased in the

number of segmenters

shows that the patient

has infection.

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NURSING RESPONSIBILITIES

Before:

Explain the purpose and procedure to the pt’s SO.

Restrict foods and fluids for 4-8 hours before test

During:

Pre medications are seldom given unless the client is extremely apprehensive or has nausea and vomiting

Mineral oil or conducive gel is applied to the skin surface at the site to be examined

The client’s position may vary from supine to oblique, prone, semi recumbent, and erect

Average time for procedure is 30 minutes

After:

Remove conducive gel applied on chest

Explain the ultrasound results to the client.

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ANATOMY AND PHYSIOLOGY

Respiratory System, in anatomy and physiology, organs that deliver oxygen to the

circulatory system for transport to all body cells. Oxygen is essential for cells, which use

this vital substance to liberate the energy needed for cellular activities. In addition to

supplying oxygen, the respiratory system aids in removing of carbon dioxide, preventing

the lethal buildup of this waste product in body tissues. Day-in and day-out, without the

prompt of conscious thought, the respiratory system carries out its life-sustaining

activities. If the respiratory system’s tasks are interrupted for more than a few minutes,

serious, irreversible damage to tissues occurs, followed by the failure of all body

systems, and ultimately, death.

While the intake of oxygen and removal of carbon dioxide are the primary

functions of the respiratory system, it plays other important roles in the body. The

respiratory system helps regulate the balance of acid and base in tissues, a process

crucial for the normal functioning of cells. It protects the body against disease-causing

organisms and toxic substances inhaled with air. The respiratory system also houses

the cells that detect smell, and assists in the production of sounds for speech.

The respiratory and circulatory systems work together to deliver oxygen to cells

and remove carbon dioxide in a two-phase process called respiration. The first phase of

respiration begins with breathing in, or inhalation. Inhalation brings air from outside the

body into the lungs. Oxygen in the air moves from the lungs through blood vessels to

the heart, which pumps the oxygen-rich blood to all parts of the body. Oxygen then

moves from the bloodstream into cells, which completes the first phase of respiration. In

the cells, oxygen is used in a separate energy-producing process called cellular

respiration, which produces carbon dioxide as a byproduct. The second phase of

respiration begins with the movement of carbon dioxide from the cells to the

bloodstream. The bloodstream carries carbon dioxide to the heart, which pumps the

carbon dioxide-laden blood to the lungs. In the lungs, breathing out, or exhalation,

removes carbon dioxide from the body, thus completing the respiration cycle.

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STRUCTURE

The organs of the respiratory system extend from the nose to the lungs and are

divided into the upper and lower respiratory tracts. The upper respiratory tract consists

of the nose and the pharynx, or throat. The lower respiratory tract includes the larynx, or

voice box; the trachea, or windpipe, which splits into two main branches called bronchi;

tiny branches of the bronchi called bronchioles; and the lungs, a pair of saclike, spongy

organs. The nose, pharynx, larynx, trachea, bronchi, and bronchioles conduct air to and

from the lungs. The lungs interact with the circulatory system to deliver oxygen and

remove carbon dioxide.

NASAL PASSAGES

Anatomy of the Nose

The uppermost

portion of the human

respiratory system, the nose

is a hollow air passage that

functions in breathing and in the sense of smell. The nasal cavity moistens and warms

incoming air, while small hairs and mucus filter out harmful particles and

microorganisms.

The flow of air from outside of the body to the lungs begins with the nose, which

is divided into the left and right nasal passages. The nasal passages are lined with a

membrane composed primarily of one layer of flat, closely packed cells called epithelial

cells. Each epithelial cell is densely fringed with thousands of microscopic cilia,

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fingerlike extensions of the cells. Interspersed among the epithelial cells are goblet

cells, specialized cells that produce mucus, a sticky, thick, moist fluid that coats the

epithelial cells and the cilia. Numerous tiny blood vessels called capillaries lie just under

the mucous membrane, near the surface of the nasal passages. While transporting air

to the pharynx, the nasal passages play two critical roles: they filter the air to remove

potentially disease-causing particles; and they moisten and warm the air to protect the

structures in the respiratory system.

Filtering prevents airborne bacteria, viruses, other potentially disease-causing

substances from entering the lungs, where they may cause infection. Filtering also

eliminates smog and dust particles, which may clog the narrow air passages in the

smallest bronchioles. Coarse hairs found just inside the nostrils of the nose trap

airborne particles as they are inhaled. The particles drop down onto the mucous

membrane lining the nasal passages. The cilia embedded in the mucous membrane

wave constantly, creating a current of mucus that propels the particles out of the nose

or downward to the pharynx. In the pharynx, the mucus is swallowed and passed to the

stomach, where the particles are destroyed by stomach acid. If more particles are in the

nasal passages than the cilia can handle, the particles build up on the mucus and

irritate the membrane beneath it. This irritation triggers a reflex that produces a sneeze

to get rid of the polluted air.

The nasal passages also moisten and warm air to prevent it from damaging the

delicate membranes of the lung. The mucous membranes of the nasal passages

release water vapor, which moistens the air as it passes over the membranes. As air

moves over the extensive capillaries in the nasal passages, it is warmed by the blood in

the capillaries. If the nose is blocked or “stuffy” due to a cold or allergies, a person is

forced to breathe through the mouth. This can be potentially harmful to the respiratory

system membranes, since the mouth does not filter, warm, or moisten air.

In addition to their role in the respiratory system, the nasal passages house cells

called olfactory receptors, which are involved in the sense of smell. When chemicals

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enter the nasal passages, they contact the olfactory receptors. This triggers the

receptors to send a signal to the brain, which creates the perception of smell.

PHARYNX

Air leaves the nasal passages and flows to the pharynx, a short, funnel-shaped

tube about 13 cm (5 in) long that transports air to the larynx. Like the nasal passages,

the pharynx is lined with a protective mucous membrane and ciliated cells that remove

impurities from the air. In addition to serving as an air passage, the pharynx houses the

tonsils, lymphatic tissues that contain white blood cells. The white blood cells attack any

disease-causing organisms that escape the hairs, cilia, and mucus of the nasal

passages and pharynx. The tonsils are strategically located to prevent these organisms

from moving further into the body. One tonsil, called the adenoids, is found high in the

rear wall of the pharynx. A pair of tonsils, the palatine tonsils, is located at the back of

the pharynx on either side of the tongue. Another pair, the lingual tonsils, is found deep

in the pharynx at the base of the tongue. In their battles with disease-causing

organisms, the tonsils sometimes become swollen with infection. When the adenoids

are swollen, they block the flow of air from the nasal passages to the pharynx, and a

person must breathe through the mouth.

LARYNX

Air moves from the pharynx to the larynx, a structure about 5 cm (2 in) long

located approximately in the middle of the neck. Several layers of cartilage, a tough and

flexible tissue, comprise most of the larynx. A protrusion in the cartilage called the

Adam’s apple sometimes enlarges in males during puberty, creating a prominent bulge

visible on the neck.

While the primary role of the larynx is to transport air to the trachea, it also serves

other functions. It plays a primary role in producing sound; it prevents food and fluid

from entering the air passage to cause choking; and its mucous membranes and cilia-

bearing cells help filter air. The cilia in the larynx waft airborne particles up toward the

pharynx to be swallowed.

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Food and fluids from the pharynx usually are prevented from entering the larynx

by the epiglottis, a thin, leaflike tissue. The “stem” of the leaf attaches to the front and

top of the larynx. When a person is breathing, the epiglottis is held in a vertical position,

like an open trap door. When a person swallows, however, a reflex causes the larynx

and the epiglottis to move toward each other, forming a protective seal, and food and

fluids are routed to the esophagus. If a person is eating or drinking too rapidly, or laughs

while swallowing, the swallowing reflex may not work, and food or fluid can enter the

larynx. Food, fluid, or other substances in the larynx initiate a cough reflex as the body

attempts to clear the larynx of the obstruction. If the cough reflex does not work, a

person can choke, a life-threatening situation. The Heimlich maneuver is a technique

used to clear a blocked larynx (see First Aid). A surgical procedure called a tracheotomy

is used to bypass the larynx and get air to the trachea in extreme cases of choking.

TRACHEA, BRONCHI, BRONCHIOLES

Air passes from the larynx into the trachea, a tube about 12 to 15 cm (about 5 to

6 in) long located just below the larynx. The trachea is formed of 15 to 20 C-shaped

rings of cartilage. The sturdy cartilage rings hold the trachea open, enabling air to pass

freely at all times. The open part of the C-shaped cartilage lies at the back of the

trachea, and the ends of the “C” are connected by muscle tissue.

The base of the trachea is located a little below where the neck meets the trunk

of the body. Here the trachea branches into two tubes, the left and right bronchi, which

deliver air to the left and right lungs, respectively. Within the lungs, the bronchi branch

into smaller tubes called bronchioles. The trachea, bronchi, and the first few bronchioles

contribute to the cleansing function of the respiratory system, for they, too, are lined with

mucous membranes and ciliated cells that move mucus upward to the pharynx.

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Human Lungs

In humans the lungs occupy a large portion of the chest cavity from the

collarbone down to the diaphragm. The right lung is divided into three sections, or lobes.

The left lung, with a cleft to accommodate the heart, has only two lobes. The two

branches of the trachea, called bronchi, subdivide within the lobes into smaller and

smaller air vessels known as bronchioles. Bronchioles terminate in alveoli, tiny air sacs

surrounded by capillaries. When the alveoli inflate with inhaled air, oxygen diffuses into

the blood in the capillaries to be pumped by the heart to the tissues of the body. At the

same time carbon dioxide diffuses out of the blood into the lungs, where it is exhaled.

The bronchioles divide many more times in the lungs to create an impressive tree

with smaller and smaller branches, some no larger than 0.5 mm (0.02 in) in diameter.

These branches dead-end into tiny air sacs called alveoli. The alveoli deliver oxygen to

the circulatory system and remove carbon dioxide. Interspersed among the alveoli are

numerous macrophages, large white blood cells that patrol the alveoli and remove

foreign substances that have not been filtered out earlier. The macrophages are the last

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line of defense of the respiratory system; their presence helps ensure that the alveoli

are protected from infection so that they can carry out their vital role.

Alveoli

A scanning electron micrograph reveals the tiny sacs known as alveoli within a

section of human lung tissue. Human beings have a thin layer of about 700 million

alveoli within their lungs. This layer is crucial in the process called respiration,

exchanging oxygen and carbon dioxide with the surrounding blood capillaries.

CNRI/Photo Researchers, Inc.

The alveoli number about 150 million per lung and comprise most of the lung

tissue. Alveoli resemble tiny, collapsed balloons with thin elastic walls that expand as air

flows into them and collapse when the air is exhaled. Alveoli are arranged in grapelike

clusters, and each cluster is surrounded by a dense hairnet of tiny, thin-walled

capillaries. The alveoli and capillaries are arranged in such a way that air in the wall of

the alveoli is only about 0.1 to 0.2 microns from the blood in the capillary. Since the

concentration of oxygen is much higher in the alveoli than in the capillaries, the oxygen

diffuses from the alveoli to the capillaries. The oxygen flows through the capillaries to

larger vessels, which carry the oxygenated blood to the heart, where it is pumped to the

rest of the body.

Carbon dioxide that has been dumped into the bloodstream as a waste product

from cells throughout the body flows through the bloodstream to the heart, and then to

the alveolar capillaries. The concentration of carbon dioxide in the capillaries is much

higher than in the alveoli, causing carbon dioxide to diffuse into the alveoli. Exhalation

forces the carbon dioxide back through the respiratory passages and then to the outside

of the body.

24 | P a g e

REGULATION

Diaphragm and Respiration

As the diaphragm contracts and moves downward, the pectoralis minor and

intercostal muscles pull the rib cage outward. The chest cavity expands, and air rushes

into the lungs through the trachea to fill the resulting vacuum. When the diaphragm

relaxes to its normal, upwardly curving position, the lungs contract, and

The flow of air in and out of the lungs is controlled by the nervous system, which

ensures that humans breathe in a regular pattern and at a regular rate. Breathing is

carried out day and night by an unconscious process. It begins with a cluster of nerve

cells in the brain stem called the respiratory center. These cells send simultaneous

signals to the diaphragm and rib muscles, the muscles involved in inhalation. The

diaphragm is a large, dome-shaped muscle that lies just under the lungs. When the

diaphragm is stimulated by a nervous impulse, it flattens. The downward movement of

the diaphragm expands the volume of the cavity that contains the lungs, the thoracic

cavity. When the rib muscles are stimulated, they also contract, pulling the rib cage up

and out like the handle of a pail. This movement also expands the thoracic cavity. The

increased volume of the thoracic cavity causes air to rush into the lungs. The nervous

stimulation is brief, and when it ceases, the diaphragm and rib muscles relax and

25 | P a g e

exhalation occurs. Under normal conditions, the respiratory center emits signals 12 to

20 times a minute, causing a person to take 12 to 20 breaths a minute. Newborns

breathe at a faster rate, about 30 to 50 breaths a minute.

The rhythm set by the respiratory center can be altered by conscious control. The

breathing pattern changes when a person sings or whistles, for example. A person also

can alter the breathing pattern by holding the breath. The cerebral cortex, the part of the

brain involved in thinking, can send signals to the diaphragm and rib muscles that

temporarily override the signals from the respiratory center. The ability to hold one’s

breath has survival value. If a person encounters noxious fumes, for example, it is

possible to avoid inhaling the fumes.

A person cannot hold the breath indefinitely, however. If exhalation does not

occur, carbon dioxide accumulates in the blood, which, in turn, causes the blood to

become more acidic. Increased acidity interferes with the action of enzymes, the

specialized proteins that participate in virtually all biochemical reaction in the body. To

prevent the blood from becoming too acidic, the blood is monitored by special receptors

called chemoreceptors, located in the brainstem and in the blood vessels of the neck. If

acid builds up in the blood, the chemoreceptors send nervous signals to the respiratory

center, which overrides the signals from the cerebral cortex and causes a person to

exhale and then resume breathing. These exhalations expel the carbon dioxide and

bring the blood acid level back to normal.

A person can exert some degree of control over the amount of air inhaled, with

some limitations. To prevent the lungs from bursting from overinflation, specialized cells

in the lungs called stretch receptors measure the volume of air in the lungs. When the

volume reaches an unsafe threshold, the stretch receptors send signals to the

respiratory center, which shuts down the muscles of inhalation and halts the intake of

air.

26 | P a g e

IMMUNITY

Immunology is the study of our protection from foreign macromolecules or

invading organisms and our responses to them. These invaders include viruses,

bacteria, protozoa or even larger parasites. In addition, we develop immune responses

against our own proteins (and other molecules) in autoimmunity and against our own

aberrant cells in tumor immunity (Tortora, et al., 2006).

Our first line of defense against foreign organisms are barrier tissues such as the

skin that stop the entry of organism into our bodies. If, however, these barrier layers are

penetrated, the body contains cells that respond rapidly to the presence of the invader.

These cells include macrophages and neutrophils that engulf foreign organisms and kill

them without the need for antibodies. Immediate challenge also comes from soluble

molecules that deprive the invading organism of essential nutrients (such as iron) and

from certain molecules that are found on the surfaces of epithelia, in secretions (such as

tears and saliva) and in the blood stream. This form of immunity is the innate or non-

specific immune system that is continually ready to respond to invasion.

A second line of defense is the specific or adaptive immune system which may

take days to respond to a primary invasion (that is infection by an organism that has not

hitherto been seen). In the specific immune system, we see the production of antibodies

(soluble proteins that bind to foreign antigens) and cell-mediated responses in which

specific cells recognize foreign pathogens and destroy them. In the case of viruses or

tumors, this response is also vital to the recognition and destruction of virally-infected or

tumorigenic cells. The response to a second round of infection is often more rapid than

to the primary infection because of the activation of memory B and T cells. We shall see

how cells of the immune system interact with one another by a variety of signal

molecules so that a coordinated response may be mounted. These signals may be

proteins such as lymphokines which are produced by cells of the lymphoid system,

cytokines and chemokines that are produced by other cells in an immune response,

and which stimulate cells of the immune system. The immune system is composed of

two major subdivisions, the innate or nonspecific immune system and the adaptive or

specific immune system. The innate immune system is our first line of defense against

invading organisms while the adaptive immune system acts as a second line of defense

27 | P a g e

and also affords protection against re-exposure to the same pathogen. Each of the

major subdivisions of the immune system has both cellular and humoral components by

which they carry out their protective function. In addition, the innate immune system

also has anatomical features that function as barriers to infection. Although these two

arms of the immune system have distinct functions, there is interplay between these

systems (i.e., components of the innate immune system influence the adaptive immune

system and vice versa).

Although the innate and adaptive immune systems both function to protect

against invading organisms, they differ in a number of ways. The adaptive immune

system requires some time to react to an invading organism, whereas the innate

immune system includes defenses that, for the most part, are constitutively present and

ready to be mobilized upon infection. Second, the adaptive immune system is antigen

specific and reacts only with the organism that induced the response. In contrast, the

innate system is not antigen specific and reacts equally well to a variety of organisms.

Finally, the adaptive immune system demonstrates immunological memory. It

“remembers” that it has encountered an invading organism and reacts more rapidly on

subsequent exposure to the same organism. In contrast, the innate immune system

does not demonstrate immunological memory.

All cells of the immune system have their origin in the bone marrow and they

include myeloid (neutrophils, basophils, eosinpophils, macrophages and dendritic cells)

and lymphoid (B lymphocyte, T lymphocyte and Natural Killer) cells , which differentiate

along distinct pathways. The myeloid progenitor (stem) cell in the bone marrow gives

rise to erythrocytes, platelets, neutrophils, monocytes/macrophages and dendritic cells

whereas the lymphoid progenitor (stem) cell gives rise to the NK, T cells and B cells.

For T cell development the precursor T cells must migrate to the thymus where they

undergo differentiation into two distinct types of T cells, the CD4+ T helper cell and the

CD8+ pre-cytotoxic T cell. Two types of T helper cells are produced in the thymus the

TH1 cells, which help the CD8+ pre-cytotoxic cells to differentiate into cytotoxic T cells,

and TH2 cells, which help B cells, differentiate into plasma cells, which secrete

antibodies.

28 | P a g e

The main function of the immune system is self/non-self discrimination. This

ability to distinguish between self and non-self is necessary to protect the organism from

invading pathogens and to eliminate modified or altered cells (e.g. malignant cells).

Since pathogens may replicate intracellularly (viruses and some bacteria and parasites)

or extracellularly (most bacteria, fungi and parasites), different components of the

immune system have evolved to protect against these different types of pathogens. It is

important to remember that infection with an organism does not necessarily mean

diseases, since the immune system in most cases will be able to eliminate the infection

before disease occurs. Disease occurs only when the bolus of infection is high, when

the virulence of the invading organism is great or when immunity is compromised.

Although the immune system, for the most part, has beneficial effects, there can be

detrimental effects as well. During inflammation, which is the response to an invading

organism, there may be local discomfort and collateral damage to healthy tissue as a

result of the toxic products produced by the immune response. In addition, in some

cases the immune response can be directed toward self tissues resulting in

autoimmune disease.

NON-SPECIFIC IMMUNITY

The elements of the non-specific (innate) immune system include anatomical barriers,

secretory molecules and cellular components. Among the mechanical anatomical barriers are

the skin and internal epithelial layers, the movement of the intestines and the oscillation of

broncho-pulmonary cilia. Associated with these protective surfaces are chemical and biological

agents.

A. Anatomical barriers to infections

1. Mechanical factors

The epithelial surfaces form a physical barrier that is very impermeable to most infectious

agents thus, the skin acts as our first line of defense against invading organisms. The

desquamation of skin epithelium also helps remove bacteria and other infectious agents that

have adhered to the epithelial surfaces. Movement due to cilia or peristalsis helps to keep air

29 | P a g e

passages and the gastrointestinal tract free from microorganisms. The flushing action of tears

and saliva helps prevent infection of the eyes and mouth. The trapping effect of mucus that lines

the respiratory and gastrointestinal tract helps protect the lungs and digestive systems from

infection.

2. Chemical factors

Fatty acids in sweat inhibit the growth of bacteria. Lysozyme and phospholipase found in tears,

saliva and nasal secretions can breakdown the cell wall of bacteria and destabilize bacterial

membranes. The low pH of sweat and gastric secretions prevents growth of bacteria. Defensins

found in the lung and gastrointestinal tract have antimicrobial activity. Surfactants in the lung act

as opsonins (substances that promote phagocytosis of particles by phagocytic cells).

3. Biological factors

The normal flora of the skin and in the gastrointestinal tract can prevent the colonization

of pathogenic bacteria by secreting toxic substances or by competing with pathogenic bacteria

for nutrients or attachment to cell surfaces.

B. Humoral barriers to infection

The anatomical barriers are very effective in preventing colonization of tissues by

microorganisms. However, when there is damage to tissues the anatomical barriers are

breached and infection may occur. Once infectious agents have penetrated tissues, another

innate defense mechanism comes into play, namely acute inflammation. Humoral factors play

an important role in inflammation, which is characterized by edema and the recruitment of

phagocytic cells. These humoral factors are found in serum or they are formed at the site of

infection.

The complement system is the major humoral non-specific defense mechanism. Once

activated complement can lead to increased vascular permeability, recruitment of

phagocytic cells, and lysis and opsonization of bacteria. Coagulation system, depending

30 | P a g e

on the severity of the tissue injury, the coagulation system may or may not be activated.

Some products of the coagulation system can contribute to the non-specific defenses

because of their ability to increase vascular permeability and act as chemotactic agents

for phagocytic cells. In addition, some of the products of the coagulation system are

directly antimicrobial. For example, beta-lysin, a protein produced by platelets during

coagulation can lyse many Gram positive bacteria by acting as a cationic detergent.

Lactoferrin and transferrin binds with iron, an essential nutrient for bacteria, these

proteins limit bacterial growth. Interferons are proteins that can limit virus replication in

cells. Lysozyme breaks down the cell wall of bacteria. Interleukin-1 induces fever and

the production of acute phase proteins, some of which are antimicrobial because they

can opsonize bacteria.

 Cellular barriers to infection

Part of the inflammatory response is the recruitment of polymorphonuclear

eosinophiles and macrophages to sites of infection. These cells are the main line of

defense in the non-specific immune system.

Polymorphonuclear cells are recruited to the site of infection where they phagocytose

invading organisms and kill them intracellularly. In addition, PMNs contribute to collateral tissue

damage that occurs during inflammation.

Tissue macrophages and newly recruited monocytes, which differentiate into

macrophages, also function in phagocytosis and intracellular killing of microorganisms. In

addition, macrophages are capable of extracellular killing of infected or altered self target cells.

Furthermore, macrophages contribute to tissue repair and act as antigen-presenting cells, which

are required for the induction of specific immune responses.

Natural killer (NK) and lymphokine activated killer (LAK) cells can nonspecifically kill virus infected and tumor cells. These cells are not part of the inflammatory response but they are important in nonspecific immunity to viral infections and tumor surveillance. Eosinophils have proteins in granules that are effective in killing certain parasites.

31 | P a g e

PATIENT’S ILLNESS PATHOPHYSIOLOGY BOOK-BASED

32 | P a g e

NON-MODIFIABLE

Age Genetic Considerations

MODIFIABLE FACTORS

COMMUNITY ACQUIRED PNEUMONIA COMMON COLDS AND OTHER VIRAL INFECTIONS/ INFLUENZA

ABDOMINAL SURGERY IMMUNOSUPPRESSIVE

THERAPY SICKLE CELL DISEASE MALNUTRITION ASPIRATION

Invasion of bacteria or virus in the body

Presence of bacteria or virus on Lower Respiratory Tract

Expelling offending microorganism at Upper Respiratory Tract (mucus production, ciliary expulsion, inflammation, bronchial

constriction)

Pulmonary inflammatory response to the offending

microorganism

COUGH

CytokinesInflammatory

Response

Interleukin 1

Acts on the brain to increase

temperature

TNF-alpha

33 | P a g e

Increase WBC

Inflammatory response: Release of vasoactive substance

Release of endothelial binding of neutrophils &

macrophages

Bradykinin

Phagocytic effect on

microorganism

Emigration of neutrophils,

lymphocytes and macrophages into the

alveoli

Continuing Inflammation

Hyperthermia

VasoconstrictionAntigen-antibody

response on microorganism

Increase Mucus Production

Pulmonary Congestion

Abnormal Breath Sounds

DOB

Phagocytic effect on

microorganism

Nasal /Oral Secretions

Mechanism to expel foreign object in body

Presence of debris on

respiratory tract

consolidated exudates in alveoli

goes into enzymatic digestion

Pleuritic Chest Pain

HEMOPTYSIS

A. Synthesis of the disease

1) Definition of the disease (Book-based)

Pneumonia is an inflammatory condition of the interstitial lung tissue in which fluid and blood

cells escape into the alveoli. More than 3 million people in the United States are diagnosed each

year with pneumonia. The disease process begins with an infection in the alveolar spaces. As the

organism multiplies, the alveolar spaces fill with fluid, white blood cells, and cellular debris from

phagocytosis of the infectious agent. The infection spreads from the alveolus and can involve the

distal airways (bronchopneumonia), part of a lobe (lobular pneumonia), or an entire lung (lobar

pneumonia).

The infection is also classified as one of three types—primary, secondary , or aspiration

pneumonia. Primary results directly from inhalation or aspiration of a pathogen such as a bacteria or

virus; including pneumococcal and viral pneumonia. Secondary pneumonia may follow initial lung

damage from a noxious chemical or other insult (superinfection) or may result from hematogenous

spread of bacteria from a distant area. Aspiration pneumonia results from inhalation of foreighn

matter, such as vomitus or food particles, into the bronchi, which are common in patients receiving

nasogastric tube feedings, and impaired gag reflex, poor oral hygiene, or a decreased level of

consciousness.

Community-acquired pneumonia is caused by bacteria that are divided into two groups typical

and atypical. Organisms that cause typical pneumonia include Streptococcus pneumoniae

34 | P a g e

(pneumococcus) and Haemophilus and Staphylococcus species. Organisms that cause atypical

pneumonia include Legionella, Mycoplasma, and Chlamydia species.

The inflammatory process causes the lung tissue to stiffen, thus resulting in a decrease in the

work of breathing. The fluid-filled alveoli cause a physiological shunt, and venous blood passes

unventilated portions of lung tissue and returns to the left atrium unoxygenated. As the arterial

oxygen tension falls, the patient begins to exhibit the signs and symptoms of hypoxemia. In addition

to hypoxemia, pneumonia can lead to respiratory failure and septic shock. Infection may spread via

the bloodstream and cause endocarditis, pericarditis, meningitis, or bacteremia.

Diagnostic test performed to diagnose pneumonia include X-ray, sputum exam and culture,

complete blood count (CBC’s), Arterial blood gas (ABG), bronchoscopy and pulse oximetry. Chest X-

rays disclose infiltrates, confirming the diagnosis. Sputum specimen for Gram stain and culture and

sensitivity tests shows acute inflammatory cells. White blood cell count indicates leukocytosis in

bacterial pneumonia and a normal or low count in viral or mycoplasmal pneumonia. Blood cultures

reflect bacteremia and help to determine the causative organism. Arterial blood gas (ABG) levels

vary depending on the severity of pneumonia and underlying lung state. Bronchoscopy or

transtracheal aspiration allows the collection of material for culture. Pleural fluid culture may also be

obtained. Pulse oximetry may show a reduced level of arterial oxygen saturation.

Treatment for pneumonia is antimicrobial therapy based on the causative agent. Therapy

should be reevaluated early in the course of treatment. Supportive measures include humidified

oxygen therapy for hypoxia, bronchodilator therapy, antitussives, mechanical ventilation for

35 | P a g e

respiratory failure, a high-calorie diet and adequate fluid intake, bed rest, and an analgesic to relieve

pleuritic chest pain. A patient with severe pneumonia or mechanical ventilation may need positive

end expiratory pressure to maintain adequate oxygenation.

Without proper treatment, pneumonia can lead to life-threatening complications such as septic

shock, hypoxemia, and respiratory failure. The infection can also spread within the patient’s lungs,

causing empyema or lung abscess. It also may spread by way of the blood stream or by cross-

contamination to other parts of the body, causing bacteremia, endocarditis, pericarditis, or

meningitis (Kumar, et al., 2005).

2) Modifiable/ Non-modifiable Factors (Book based)

MODIFIABLE FACTORS

AGE

Children and young adults up to the age 30 are at risk for several forms of viral pneumonia,

including mycoplasma pneumonia, adenovirus pneumonia, rubeola pneumonia, and respiratory

syncytial virus pneumonia. Staphylococcal pneumonia tends to strike those who are debilitated or

who have a history of influenza or intravenous (IV) drug abuse. There are no known racial or ethnic

considerations (Kumar, et al., 2005).

36 | P a g e

GENETIC CONSIDERATIONS

Heritable immune responses could be protective or increase susceptibility (Kumar, et al.,

2005).

MODIFIABLE FACTORS

COMMUNITY ACQUIRED PNEUMONIA

This term is used to describe infections from organisms found in the community prior to

hospitalization, or diagnosed within 48 hours after admission to the hospital, or who has not resided

in a long-term care facility for 14 days or more before admission. The most common cause is

Streptococcus pneumonia (Black, et al., 2009).

COMMON COLDS AND OTHER VIRAL INFECTIONS

Common cold is a general term for coryza or inflammation of the respiratory mucous

membranes from the nasal mucosa to the nasal sinuses, throat, larynx, trachea and bronchi (Kumar,

et al., 2005).

INFLUENZA

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An acute contagious respiratory infection marked by fevers, chills, muscle aches, headache,

prostration, runny nose, watering eyes, cough, and sore throat caused by either influenza A, B or C

(Kumar, et al., 2005)

ABDOMINAL SURGERY

This deals with the manual and operative procedures form correction of deformities and

defects, repair of injuries, and diagnosis and cure of certain diseases in the abdominal region

(Kumar, et al., 2005).

IMMUNOSUPPRESSIVE THERAPY

Is the treatment with drugs such as cyclosporine or mycophenolate that impairs immune

responses such as in Pneumocystis carinii (Kumar, et al., 2005).

SICKLE CELL DISEASE

These are diseases characterized by an abnormal erythrocytes that are shaped like a sickle.

MALNUTRITION

These are any disease-promoting condition resulting from either an inadequate or excessive

exposure to nutrients caused by inadequate calorie consumption, intake of essential micronutrients,

improper absorption and distribution of foods within the body, overeating and intoxication by

nutrient excess (Kumar, et al., 2005).

38 | P a g e

ASPIRATION

Drawing in foreign bodies via the nose, throat or lungs on inspiration such as vomitus.

3) Signs and Symptoms with Rationale (Book-based)

FATIGUE

Frequent periods of dyspnea, which causes a person to have aversion to food, and the

infection, which causes an increase in the basal metabolic rate in order to sustain the immunologic

resistance, increases the demand for oxygen, which would be inadequate for a person who has

impaired gas exchange due to excessive lung consolidation of exudates in the lung alveoli, impairing

gas exchange (Black, et al., 2009).

CYANOSIS

Cyanosis is a blue, gray, slate or dark purple discoloration of the skin or mucous membranes

caused by deoxygenated or reduced hemoglobin in the blood due to impaired gas exchange brought

by the consolidation of the lungs (Black, et al., 2009).

TACHYPNEA

Tachypnea is an abnormally fast respiration brought about by increase in body temperature

and to compensate for low oxygen concentrations. Any inflammatory response such as fever

39 | P a g e

increases respiration to meet the increase in metabolic requirement to elicit inflammation or to

increase cellular resistance to an infection in cases such as pneumonia. Prolonged congestion of

exudates in the parenchyma may interfere with the gas exchange causing metabolic acidosis which

the body compensates by increasing respiration (Berman, et al., 2007)

PLEURITIC CHEST PAIN

Acute pain related to inflammatory or irritation of the parietal pleura when fibrinosuppurative

pleuritis is present, occurring during the early stages of consolidation that extends to the surface

pleural tissues (Kumar, et al., 2005).

COUGH

A forceful, sometimes violent expiratory effort preceded by a preliminary inspiration.

Pulmonary cough is often deep and may be hacking and irritating in the early stages of lung

infections; in later stages, it is frequent and productive (Venes, 2009).

NASAL SECRETIONS, SPUTUM PRODUCTION

Mucus expelled from the lung by coughing which may contain a variety of materials from the

respiratory tract, including in some instance cellular debris, mucus, blood, pus, caseous material,

and/ or microorganisms. Creamy yellow sputum suggests staphylococcal pneumonia, green sputum

40 | P a g e

suggests Pseudomonas organisms and currant jelly-like sputum indicates Klebsiella (clear sputum

means no infective causes) (Venes, 2009).

HEMOPTYSIS

Hemoptysis is the expectoration of blood that arises from the larynx, trachea, bronchi, or

lungs. This symptom may occur during the last stage of pneumonia, resolution, in which enzymes

are produced in the alveoli to dissolve consolidated exudates (Venes, 2009).

ABNORMAL BREATH SOUNDS

Breath sounds due to a disease process altering the airway or airflow dynamics. Alterations in

breath sounds may be due to vibration of solid structures, airflow through narrowed airways, and

abrupt changes in airway pressure. The following are common adventitious sounds found in

pneumonia cases:

Crackles/Rales

A discontinuous adventitious lung sound heard on auscultation of the chest, produced by air passing

over retained airway secretions or the sudden opening of collapsed airways, heard on inspiration or

expiration

41 | P a g e

Rhonchus

A low-pitched wheezing, snoring or squeaking sound heard during auscultation of the chest of a

person with partial airway obstruction caused by occlusion of respiratory passage by mucus or other

secretions in the airway (Venes, 2009).

HYPERTHERMIA

Hyperthermia or fever is an abnormal elevation in temperature above the usual range, usually one to

four degrees Celsius. Fever caused by infection is brought about by the release of cytokines such as IL-1,

interleukin 1, and TNF, tumor necrotizing factor, (called endogenous pyrogens) by stimulated leukocytes

that helps produce prostaglandins that act upon the hypothalamus to reset the temperature set point at a

higher level (Kumar, et al., 2005).

PATHOPHYSIOLOGY PATIENT CENTERED

42 | P a g e

NON-MODIFIABLE

Age Genetic Considerations

MODIFIABLE FACTORS

COMMUNITY ACQUIRED PNEUMONIA COMMON COLDS AND OTHER VIRAL INFECTIONS/ INFLUENZA

ABDOMINAL SURGERY IMMUNOSUPPRESSIVE

THERAPY SICKLE CELL DISEASE MALNUTRITION ASPIRATION

43 | P a g e

Invasion of bacteria or virus in the body

Presence of bacteria or virus on Lower Respiratory

Expelling offending microorganism at Upper Respiratory Tract (mucus production, ciliary expulsion, inflammation, bronchial

constriction)

Pulmonary inflammatory response to the offending

microorganism

COUGHAug 18-21

CytokinesInflammatory

Response

Interleukin 1

Acts on the brain to increase

temperatureInflammatory

response: Release of vasoactive substance

Release of endothelial binding of neutrophils &

macrophagesTNF-alpha

VasoconstrictionAntigen-antibody

response on microorganism

44 | P a g e

Increase WBCAug 19Bradykinin

Phagocytic effect on

microorganism

Emigration of neutrophils,

lymphocytes and macrophages into the

alveoli

HyperthermiaAug 18-20

Increase Mucus Production

Pulmonary Congestion

Abnormal Breath SoundsCrackles

Aug 18-20

DOBAug 18-20

Nasal /Oral SecretionsAug 18-20

Mechanism to expel foreign object in body

Presence of debris on

respiratory tract

b. Synthesis of the Disease (Patient-centered)

Upon admission in the hospital on August 18, 2009, Ashleyto showed

possible manifestations of an infection, having signs and symptoms of cough

with fever. During the medical history interview, the researchers were told

by the patient’s mother, Mrs. Montemayor that the patient was previously

hospitalized for difficulty of breathing and that his other siblings were also ill

and had recovered, having flu-like symptoms. Further physical assessment

by the health care team showed crackles, or rales, sounds, auscultated on

bilateral lung fields (BLF) with accompanying productive cough on August 18,

19, 20.

Diagnostic tests that can be performed to diagnose pneumonia include

X-ray, sputum exam and culture, complete blood count (CBC’s), and Arterial

blood gas (ABG). Bacillio’s chart did not contain any documentation on the

diagnostic tests made. If there was one performed, a chest X-rays would

show infiltrates, confirming the diagnosis. Sputum would also be taken,

cultured and examined to identify the exact microorganism responsible for

the infection.

Community-acquired pneumonia is caused by bacteria that are divided

into two groups typical and atypical. Organisms that cause typical

pneumonia include Streptococcus pneumoniae (pneumococcus) and

Haemophilus and Staphylococcus species. The treatment for community-

acquired pneumonia is antimicrobial therapy based on the causative agent.

Therapy should be reevaluated early in the course of treatment. Upon

admission, on August 19, 2009 Ashleyto was started with Cefuroxime an

endocarditis prophylaxis and a broad spectrum bactericidal against certain

bacteria that causes pneumonia, and Hydrocortisone.

Supportive measures used in the patient’s treatment include

bronchodilator therapy, antitussives, a high-calorie diet and adequate fluid

intake, bed rest, and an analgesic to relieve chest pain. Bronchodilator

therapy was started on August 18, 2009, using nebulization of salbutamol

(Ventolin).

45 | P a g e

c. Modifiable/ Non-modifiable Factors

MODIFIABLE FACTORS

AGE

Children and young adults up to the age 30 are at risk for several

forms of viral pneumonia, including mycoplasma pneumonia, adenovirus

pneumonia, rubeola pneumonia, and respiratory syncytial virus pneumonia.

Staphylococcal pneumonia tends to strike those who are debilitated or who

have a history of influenza or intravenous (IV) drug abuse. There are no

known racial or ethnic considerations (Kumar, et al., 2005).

MODIFIABLE FACTORS

MALNUTRITION

These are any disease-promoting condition resulting from either an

inadequate or excessive exposure to nutrients caused by inadequate calorie

consumption, intake of essential micronutrients, improper absorption and

distribution of foods within the body, overeating and intoxication by nutrient

excess (Kumar, et al., 2005).

COMMON COLDS AND OTHER VIRAL INFECTIONS

Common cold is a general term for coryza or inflammation of the

respiratory mucous membranes from the nasal mucosa to the nasal sinuses,

throat, larynx, trachea and bronchi (Kumar, et al., 2005).

NON-MODIFIABLE FACTORS

46 | P a g e

COMMUNITY-ACQUIRED PNEUMONIA

This term is used to describe infections from organisms found in the

community prior to hospitalization, or diagnosed within 48 hours after

admission to the hospital, or who has not resided in a long-term care facility

for 14 days or more before admission. The most common cause is

Streptococcus pneumonia (Black, et al., 2009).

d. Signs and symptoms

TACHYPNEA

Tachypnea is an abnormally fast respiration brought about by increase

in body temperature and to compensate for low oxygen concentrations. Any

inflammatory response such as fever increases respiration to meet the

increase in metabolic requirement to elicit inflammation or to increase

cellular resistance to an infection in cases such as pneumonia. Prolonged

congestion of exudates in the parenchyma may interfere with the gas

exchange causing metabolic acidosis which the body compensates by

increasing respiration (Berman, et al., 2007)

COUGH

A forceful, sometimes violent expiratory effort preceded by a

preliminary inspiration. Pulmonary cough is often deep and may be hacking

and irritating in the early stages of lung infections; in later stages, it is

frequent and productive (Venes, 2009).

NASAL SECRETIONS, SPUTUM PRODUCTION

Mucus expelled from the lung by coughing which may contain a variety

of materials from the respiratory tract, including in some instance cellular

debris, mucus, blood, pus, caseous material, and/ or microorganisms.

Creamy yellow sputum suggests staphylococcal pneumonia, green sputum

47 | P a g e

suggests Pseudomonas organisms and currant jelly-like sputum indicates

Klebsiella (clear sputum means no infective causes) (Venes, 2009).

ABNORMAL BREATH SOUNDS

Breath sounds due to a disease process altering the airway or airflow

dynamics. Alterations in breath sounds may be due to vibration of solid

structures, airflow through narrowed airways, and abrupt changes in airway

pressure. The following are common adventitious sounds found in

pneumonia cases:

Crackles

A discontinuous adventitious lung sound heard on auscultation of the

chest, produced by air passing over retained airway secretions or the sudden

opening of collapsed airways, heard on inspiration or expiration

HYPERTHERMIA

Hyperthermia or fever is an abnormal elevation in temperature above

the usual range, usually one to four degrees Celsius. Fever caused by

infection is brought about by the release of cytokines such as IL-1,

interleukin 1, and TNF, tumor necrotizing factor, (called endogenous

pyrogens) by stimulated leukocytes that helps produce prostaglandins that

act upon the hypothalamus to reset the temperature set point at a higher

level (Kumar, et al., 2005).

Health Promotion and Preventive Aspects of the Disease

Teach the patients the following to prevent pneumonia:

48 | P a g e

Urge bedridden and postoperative patients to perform deep-breathing and

coughing exercises frequently. Position such patients properly to promote full

aeration and drainage of secretion

Advise patients to avoid using antibiotics indiscriminately for minor infections.

Doing so could result in upper airway colonization with antibiotic-resistant

bacteria. If pneumonia develops, the organism that produce the pneumonia

may require treatment with more toxic antibiotics

Encourage the high-risk patient to ask his doctor about an annual flu

vaccination and the pneumococcal vaccination, which the patient would

receive only once.

Discuss ways to avoid spreading the infection to others. Remind the patient

to sneeze and cough into tissues and to dispose of the tissues in a waxed or

plastic bag. Advise him to wash his hands thoroughly after handling

contaminated tissues.

Patient teaching

Explain all procedures (especially intubation and suctioning) to the patient

and family members

Emphasize the importance of adequate rest to promote full recovery and

prevent a relapse. Explain that the physician will advise the patient when he

can resume full activity and return to work

Review the patient’s medication. Stress the need to take the entire course of

medication, even if he feels better, to prevent relapse

Teach the patient procedures to clear lung secretions, such as deep-

breathing and coughing exercises as well as home oxygen therapy. Explain

deep breathing and purse-lip breathing

Urge patient to drink 2 to 3 quart (2 to 3 L) of fluid a day to maintain adequate

hydration and keep mucus secretions thin for easier removal

Teach the patient and family about chest physiotherapy. Explain that postural

drainage, percussion and vibration help to mobilize and remove mucus from

the lungs

49 | P a g e

Urge the patient to avoid irritants that stimulate secretions, such as cigarette

smoke, dust, and significant environmental pollution. If necessary, refer him

to community programs or agencies that can help him stop smoking.

50 | P a g e

THE PATIENT AND HIS CARE

MEDICAL MANAGEMENT

a. IVF

MEDICAL

MANAGEMENT/

TREATMENT

DATE

ORDERED

GENERAL

DESCRIPTION

INDICATION/PURPOSE CLIENT’S RESPONSE

TO TREATMENT

D5IMB DO:

08-18-2009

Hypertonic solutions

greatly expand the

intracellular

compartment,

administer them by

IV pump and closely

monitor the patient

for circulatory

overload. Pull fluid

from intracellular

compartment.

For nutritional status and

electrolyte imbalance correction.

For prevention of edema

The patient did not

experience any

discomfort other than the

IV insertion and

medication

administration upon the

course of this IV therapy.

Noted no signs of edema

51 | P a g e

NURSING RESPONSIBILITIES:

Before:

Check doctor’s order first

Explain the procedure and the need for IV infusion

Prepare necessary materials needed

Check IVF as prescribed

During:

Check the IV label.

Check for patency of the IV tubing

Check if the IV infusion is infusing well

Maintain aseptic technique

Always check for the level of the IV.

Regulate and monitor flow rate as ordered

After:

Check for the presence of air in the tubing.

Monitor for evidence of local IV complication such as pain, swelling and treatments.

Adjust rate of flow of fluids appropriate to the needs as prescribed.

Document what has been done

52 | P a g e

Medical

Management

Date Ordered/

Performed/

Changed

General Description Indication(s) or

Purpose

Client’s Response to the

Treatment

Nebulization DO: 08-18-09 A nebulizer is a device used to

change liquid medication to an

aerosol particulate form. The

aerosolized medication is

extremely beneficial when

inhaled and deposited in the

lungs.

It is indicated for

proper ventilation of

air with the process of

bronchodilation.

The client’s secretion was

loosened as evidenced by

client was able to

expectorate

secretion/sputum

NURSING RESPONSIBILITIES:

Before:

o Verify the doctor’s order.

o Inform the patient’s SO about the procedure.

o Wash your hands prior to preparing each nebulizer treatment, and make sure the equipment is clean.

During:

o Hold the nebulizer in an upright position to prevent spoiling.

o Continue until the medicine is gone from the cup (about 5 minutes).

o Occasionally tapping the side of the nebulizer helps the solution drop to where it can be misted. Treatment is finished when

all the medication has been used from the container. The nebulizer will most likely begin sputtering when it is empty.

After:

o Document the time the procedure has done

53 | P a g e

b. Drugs

NAME OF DRUG

GENERIC NAME

BRAND NAME

DATE ORDERED

DATE

PERFORMED

DATE CHANGED

ROUTE OF ADMIN

DOSAGE AND

FREQUENCY OF

ADMIN

INDICATIONS OR

PURPOSES

(PT CENTERED)

CLIENT’S

RESPONSE

Cefuroxime

(Plerozef)

Salbutamol Neb

08-18-09

08-18-09

275mg IV q8

(-) ANST

Inhalation q8

For the treatment of

many different

types of bacterial

infections such as

bronchitis, sinusitis,

tonsillitis, ear

infections, skin

infections,

gonorrhea, and

urinary tract

infections.

Expectorant and

Bronchodilator

Reduces viscosity

the pt did not

encounter any side

effect of the drug

>the pt is able to

liquefy and cough

out secretions

54 | P a g e

Paracetamol

Hydrocortisone

Furosemide

08-18-09

08-19-09

08-20-09

115mg IV q4 PRN

for fever

110 mg IV now then

50 mg IV q8

10mg IV now then

OD x 2 doses

of secretions

prevent reversible

airway obstruction

Antipyretic

Treating severe

allergies, arthritis,

asthma, multiple

sclerosis, and skin

conditions. It works

by decreasing or

preventing tissues

from responding to

inflammation.

Treating fluid build-

up and swelling

caused by

congestive heart

failure, liver

cirrhosis, or kidney

The patient

temperature

decreased

the pt. did not experience any side effect of the drug.

the pt. did not manifest any side effects.

55 | P a g e

disease. It is also

used in combination

with other

medicines to treat

fluid build-up in the

lungs. 

NURSING RESPONSIBILITIES:

Cefuroxime, Hydrocortisone, Furosemide

Before:

Assess pt for s/sx of infection including characteristics of wounds, sputum, urine and stool.

Obtain C & S before beginning drug therapy to identify if correct tx has been initiated.

Identify urine output

Monitor bleeding and growth of infection.

During:

Give for 10 days to ensure organism death and prevent superinfection.

Give with food if needed for GI symptoms.

Give after C & S is completed.

After:

Teach pt’s SO to report sore throat, bruising, bleeding, and joint pain. It may indicate blood discarias.

Advise pt to contact prescriber if there is loose foul stool and furring of tongue occur.

Advise pt to notify prescriber if diarrhea with blood or pus occurs.

56 | P a g e

SALBUTAMOL

Before:

Explain to the patient and SO the reason why the drug was ordered.

Assess lung sounds, pulse and blood pressure before administration and during peak of medication. Note amount, color and

character of sputum produced.

Monitor pulmonary function tests before initiating therapy and periodically during therapy to determine effectiveness of

medication.

During:

Instruct the patient’ to Inhale this medication into the mouth and lungs using a special breathing device (nebulizer)

After:

Monitor the patient for any reactions.

Instruct patient’s SO to contact health care Professional immediately if shortness of breath is not relieved by medication or is

accompanied by diaphoresis, dizziness, palpitations or chest pain.

Instruct patient to prime unit with 4 sprays before using and to discard canister after 2000 sprays. Actuators should not be

change among products.

Advise patient’s SO to use albuterol first if using other inhalation medications and allow 5 min. to elapse before administering

other inhalant medications unless otherwise directed.

Advise patient’s SO to rinse mouth with water after each inhalation dose to minimize dry mouth.

C. Diet

57 | P a g e

TYPES OF DIET

DATE ORDEREDDATE STARTEDDATE CHANGED

GENERAL DESCRIPTION

INDICATION(S)/ PURPOSE(S)

SPECIFIC FOODS TAKEN

CLIENT’S RESPONSE AND/ OR REACTION TO

DIET

Regular Diet

DO: 8/18/09 A regular diet is a

diet that includes

a variety of foods.

A healthy, regular

diet includes

fruits, vegetables,

whole grains and

fat-free or low-fat

dairy foods. It also

includes lean

meats, poultry,

fish, beans, eggs

and nuts. A

healthy regular

diet is low in

unhealthy fats,

salt and added

sugar.

The patient take

foods as tolerated to

maintain

nourishment or to

suffice the nutritional

demand of the

patient and thus

providing sufficient

energy. The patient’s

healthy regular diet

reduces his risk of

acquiring any other

complications of his

illness,

Rice, soups,

crackers,

meats, fruits.

The patient takes

food he usually

eat and thus

gaining more

energy as

evidence by

doing passive

range of motion.

58 | P a g e

Nursing Responsibilities

Prior:

Check for the doctors order

Assess client’s need

Before prepare the appropriate diet for the patient be sure that proper hand washing is maintained

During:

Give feedings with strict aspiration precaution

After:

Burped after each feedings

Place the child on side-lying position after each feedings

Monitor if the feeding is well-tolerated

Note and document any untoward reaction.

D. Activity/Exercise

*** no activity or exercise was ordered for the patient

59 | P a g e

B. NURSING MANAGEMENT

Proble

m

Numbe

r

Nursing Problems

1Ineffective airway clearance related to increased sputum production in

response to respiratory infection

2Impaired gas exchange related to collection of mucus in airways

3 Acute pain related to respiratory distress and coughing

4 Risk for altered nutrition less than body requirements

5 Hyperthermia

60 | P a g e

Nursing Management

a. Nursing Care Plans

Problem #1: Ineffective airway clearance related to increased sputum production in response to respiratory infection

Assessment Nursing Diagnosis

Scientific Explanation

Objectives Interventions Rationale Evaluation

S = Ө

O Pt. may manifest: Abnormal

breath sounds

Decreased breath sounds over affected areas

Cough Dyspnea,

orthopnea Change in

respiratory status

Cyanosis Wide-eyed, restlessness

Ineffective airway

clearance related to increased sputum

production in response to respiratory infection

Due to infected lungs a

substance and discharged are formed by a cell and tissues in

the lungs which indeed blocks the passage

way of oxygen, since oxygen cannot truly

pass and enter to it, this result for the patients to experience

difficulty of breathing and for him to have

ineffective airway

clearance for the reason of

Short term:

After 4 hours of nursing

interventions, the patient will

manifest behaviors to

improve airway

patency.

Long Term:

After 2-3 days of nursing

interventions the patient will

be able to maintain airway

patency.

1. Assess vital signs

2. Auscultate breath sounds

3. Assess respiratory movements and use of accessory muscles

4. Assist patient with coughing and deep breathing exercises.

- To have baseline date

- To note presence of adventitious breath sounds

- Use of accessory muscles to breathe indicates and abnormal increase in work of breathing

- To improve coughing

Short Term:

After 4 hours of nursing

interventions, the patient will

manifest behavior of improved

airway patency as evidenced

by able to cough out sputum.

Long Term:

Patient’s airway is free of secretions as evidenced

by eupnea and clear breath

61 | P a g e

Infiltrates on chest radiograph film

the present secretions. 5. Use

positioning

6. Maintain adequate hydration

7. Use nebulize

8. Institute suctioning as needed

9. Use naso-pharyngeal / oro- pharyngeal airway as needed

10.Monitor chest radiograph reports

11.Administer medication as prescribed (salbutamol, hydrocortisone

- To facilitate clearing secretions

- To aid in the mobilization of secretions

- Loosens secretions

- To remove sputum and mucous plugs

- To have patent airway through artificial means

- To monitor the severity of the disease

- To determine the progression of the disease process

sounds after coughing and

suctioning after 2-3 days.

62 | P a g e

Problem #2: Impaired gas exchange related to collection of mucus in airwaysAssessment Nursing

DiagnosisScientific

ExplanationObjectives Interventions Rationale Evaluation

S = Ө

OPt. may manifest: Dyspnea Cyanosis Tachypnea Air hunger Tachycardia Decreased

activity tolerance

Restlessness Disorientation

/ confusion

Impaired gas exchange related to

collection of mucus in airways

When a virus that causes

pneumonia reaches the lungs

when airborne droplets are

inhaled through the mouth and

nose. Once in the lungs, the virus

invades the cells lining the airways and alveoli. This invasion often leads to cell death, either

when the virus directly kills the cells, or through

a type of cell self-destruction. When the

immune system responds to the viral infection,

even more lung damage occurs

white blood cells,

Short term:

After 3 hours of nursing

interventions, the patient will participate in

treatment regimen within level of ability or situation.

Long Term:

After 3 days of nursing

interventions, the patient will

improve ventilation, adequate

oxygenation and will be able

to remove secretions in

the airway and

1. Monitor vital signs

2. Assess respirations: note quality, rate, pattern, depth, dyspnea on exertion, use of accessory muscles, position assumed for easy breathing

3. Assess skin color

4. Assess for changes in orientation and note increasing restlessness

- to have baseline data

- to note the severity of the disease

- to note the presence of cyanosis

- maybe a sign of hypoxia and hypercardia

- for the

Short Term:

The patient’s participation in

treatment regimen within level of ability or situation will be evident after

3 hours of nursing

interventions.

Long Term:

After 3 days of nursing

interventions, the patient will

improve ventilation, adequate

oxygenation and was able

to lessen secretions in the airway.

63 | P a g e

mainly lymphocytes,

activate a variety of chemical

cytokines which allow fluid to leak into the alveoli.

This combination of cell destruction

and fluid-filled alveoli interrupts

the normal transportation of oxygen into the

bloodstream which result for the patient to

have difficulty in breathing.

improve gas exchange. 5. Pace

activities to patient’s tolerance

6. Maintain oxygen administration device as ordered

7. To administer drugs as ordered (salbutamol, hydrocorti-sone)

patient not to consume much energy

- to have a patent airway

- to promote wellness and further complicatioons

64 | P a g e

Problem #3: Acute pain related to respiratory distress and coughingAssessment Nursing

DiagnosisScientific

ExplanationObjectives Interventions Rationale Evaluation

S = Ө

OPt. may manifest: complaints

of discomfort

withdrawal facial

grimaces irritability anxiety tachycardia increased

BP

Acute pain related to

respiratory distress and

coughing

A person may elicit chest pain

due to excessive

coughing or irritation of the lung tissue by the infection.

This infection is cause by the presence of secretions in the lungs that stocks up and due to person

inability to expectorate it,

it requires great force and energy for the

person to cough up and

spit out phlegm, in

order to clear out bronchial

passages.

After 1 day of nursing

interventions, the patient will be able relaxed

and comfortable

and will be able to verbalize reduction of

pain.

1. Assess complaints of discomfort: pain or discomfort with breathing, shortness of breath, muscle pains, pain with coughing.

2. Monitor nonverbal signs of discomfort

3. Administer appropriate medications to treat cough

4. Use cough suppressants and humidity

- to give appropriate intervention

- to the present condition

- for the patient to feel more comfortable

- for the patient to relieve pain

After 1 day fo nursing

interventions, patient will be relaxed, active

and exhibits alert and proper

mentation.

65 | P a g e

for dry, hacking cough

5. Administer analgesics as prescribed

6. Evaluate medication effectiveness

and expectorate phlegm easily

- to promote the patient’s wellness

- to note the effectiveness of the drug

66 | P a g e

Problem #4: Risk for altered nutrition less than body requirementsAssessment Nursing

DiagnosisScientific

ExplanationObjectives Interventions Rationale Evaluation

S pain

O long period

of NPO

Risk for altered nutrition less

than body requirements

An unexplained weight loss may be an

early sign of medical

disorder. Some weight loss may due to inadequate

caloric intake or failure to

increase caloric intake. Weight loss can also be

associated with the loss of

appetite of a person due of

having secretions like in the case of pneumonia.

This trigger the person to

decrease its interest to foods and

After 1-2 days of nursing

interventions, the patient will

be able to maintain optimal

nutritional status

1. Document patient’s actual weight

2. Obtain nutritional history and monitor present caloric intake

3. Maintain bed rest

4. Increase activity gradually as patient tolerates

- to have a baseline data

- to have a background about the patient’s illness that can affect her present condition

- for the patient not to consume much energy

- for the patient to have the exercise needed to promote wellness

After 1-2 days of nursing

interventions, the patient will

be able manifest and

maintain signs of optimal

nutrition status.

67 | P a g e

prefer not to eat indeed this may result to loss of body

weight for the required

nutrients that our body need

is not adequately supplied.

5. Provide high-protein / high – carbohydrate diet, and assist with meals as needed

6. Maintain oxygen delivery system

7. Administer vitamin supplements as prescribed

8. Administer enteral supplements and parenteral nutrition as prescirbed

- to give the patient adequate nutritional needs

- for patent airway

- to strengthen immune system

- to give the patient adequate nutritional need

68 | P a g e

Problem #5: Hyperthermia related to infectious process.Assessment Nursing

DiagnosisScientific

ExplanationObjectives Interventions Rationale Evaluation

S = Ө

OPt. may manifest: chills convulsions confusion Restlessness dizziness

Hyperthermia Temperature is an indication of

an inflammatory response that

indicates a probable

increase in the white blood

cells reflecting infection. The thermal center of the body is then triggered that results in the increases

in body temperature as its physiologic

response together with

the alterations of vital signs.

Short Term:

After 2-3 hours of nursing

interventions, the patient will

have a decrease in its temperature from 38.3 to

37.3.

Long Term:

After 3 days of nursing

interventions, the patient will

be able to maintain

normal core temperature.

1.Monitor vital signs

2.Provide TSB

3.Increase fluid intake

4.Monitored heart rate and rhythm

5.Assess underlying condition and temperature

6.Keep back dry

7.Remove excess

- to have a baseline data

- to release body heat

- to avoid dehydration

- to evaluate effects of hyperthermia

- to obtain comparative baseline data

- to provide comfort and aggravating the condition

- to decrease warm and

Short Term:

There will be a decrease in the

patient’s temperature from 38.3 to

37.3.

Long Term:

After 3 days of nursing

interventions, the patient will

be able to maintain

normal core temperature.

69 | P a g e

clothing and covers

8.Promote adequate rest

9. Administer medications like analgesics and antipyretics as ordered.

increase evaporative cooling

- it reduces metabolic demands and consump-tion

- to lower the temperature to normal level

70 | P a g e

Date> August 20, 2009

PERFORMED BY NURSE ON DUTY (lifted from the chart)

ACTUAL SOAPIERSNursing Problem: Ineffective airway clearance related to increased

sputum production in response to respiratory infection

S> “Nagkasipon sa likod” as verbalized by the patient

O> Received patient on bed awake, conscious ongoing IVF of D5IMB 500ml

regulated at 40 mgtts/min infusing well at the right metacarpal arm.

Presence of rales upon auscultation with productive cough for 3 days. Vital

Signs as follows: Temperature: 37.6 degree Celsius; Pulse rate: 130 bpm;

Respiratory rate: 46 cpm.

A> Ineffective airway clearance related to increased sputum production in

response to respiratory infection

P> After 4 hours of Nursing Intervention the mother will verbalize

understanding of causes and therapeutic management regimen.

I> -Established rapport,

-Assessed the patient,

-Monitored VS,

-Maintained or bed rest,

-Encouraged to increase fluid intake of 2,000ml a day,

-Gave bronchodilators as ordered,

-Auscultated breath sounds and assessed air movements,

-TSB done, promoted surface cooling by assisting in changing clothes,

-promote comfort by fixing linens, and

-administered medicines as ordered.

E> Goal partially met as evidenced by the mother verbalizing understanding

of causes and therapeutic management regimen.

Date> July 21, 2009

71 | P a g e

PERFORMED BY NURSE ON DUTY (lifted from the chart):

Nursing Problem: for home management and home maintenance

S> Ø

O> Received patient flat on bed, conscious with an on going IVF of D5IMB # 5

330cc level with 30-31gtts/min infusing well on his right foot with rales on

BLF, productive cough, restlessness, irritable, VS are as follows: Temp: 36.7

Pulse rate: 121 bpm Respiratory rate:35 cpm

A>for home management and home maintenance

P>After 4 hours of Nursing Intervention the significant other will verbalized

understanding of health treatment regimen given.

I>

M- Gentamycin 0.8 BID x 5 days, Ventolin 1mg TID x 7 days

E- Deep breathing exercise and coughing exercise, Ambulation

T- Seek medical advice first prior to taking medicines

-instructed so to religiously give home medicines

H- Instructed so to increase fluid intake, instructed so to avoid contact of

patient with ill persons to decrease immune function, instructed to

keep back dry, provided adequate rest periods, to isolate patient

from the people who smoke to improve lung function

O- Instructed patient to return for follow up on August 28, 09 to monitor

client’s progress

D- Regular feeding

E> Goal met as evidenced by the SO’s understanding of health treatment

regimen given.

72 | P a g e

CLIENT’S DAILY PROGRESS

Days Admission

August 18, 2009

Day 1

August 19, 2009

Day 2

August 20, 2009

Day3

August 21, 2009

Nursing Problems

Ineffective airway clearance related to increased sputum production in response to respiratory infection

☺ ☺ ☺

Impaired gas exchange related to collection of mucus in airways ☺ ☺ ☺

Acute pain related to respiratory

distress and coughing ☺ ☺ ☺Risk for altered nutrition less than body

requirements ☺ ☺ ☺Hyperthermia ☺ ☺ ☺

Vital Signs

Temperature: 37.4 ‘C 37.9 ‘C 37.6 ‘C 36.7 ‘C

Pulse Rate” 135 bpm 130 bpm 130 bpm 121 bpm

Respiratory

Rate

46 cpm 48 cpm 48 cpm 35 cpm

73 | P a g e

Diagnostics and Laboratory

Procedure

Hematology

Hemoglobin √

Hematocrit √

White blood cells √

Segmenters √

Lymphocytes √

X- Ray √

Medical Management

D5 IMB √ √ √ √

Nebulizer √ √ √ √

Drugs

Cefuroxime √ √ √

Salbutamol Neb √ √ √ √

Paracetamol √ √ √

Hydrocortisone √ √

Furosemide √ √

Diet

regular diet √ √ √ √

74 | P a g e

2. DISCHARGE PLANNING

a. General Condition of Client upon Discharge

The patient upon discharge was restless, irritable and has productive cough. He

had his final assessment and vital signs were taken by the student nurse. VS are as

follows: Temp: 36.7°C axilla, Pulse rate: 121 bpm and Respiratory rate: 35 cpm.

b. METHOD

Medicatio

nsGentamycin 0.8 BID x 5 days, Ventolin 1mg syrup TID x 7 days

Exercise Deep breathing exercise and coughing exercise, Ambulation

Therapy Seek medical advice first prior to taking medicines

Instructed so to religiously give home medicines

Health

teachings

Instructed so to increase fluid intake with SAP, instructed

significant others to avoid contact of patient with ill persons with

decrease immune function;

to keep back dry;

provide adequate rest periods;

isolate patient from the people who smoke to improve lung

function

OPDInstructed patient to return for follow up on August 28, 09 to monitor

client’s progress

Diet Regular feedings

75 | P a g e

CONCLUSION

A. Nurse-centered

The researchers were able to gain knowledge and deeper understanding

of the disease process itself, improve their skills regarding the management

of the disease process and impart health teachings regarding the client’s

condition in maintaining an optimum level of functioning. Moreover, the

researchers were able to accomplish the following:

1. Interpreted the and deeply understand the disease condition;

2. Related the present state of the client with his personal and pertinent

family history;

3. Analyzed and interpret the different diagnostic and laboratory

procedures, its purpose and its essential relationship to client’s disease

condition;

4. Identified treatment modalities and its importance like drugs, diet and

exercise;

5. Identified surgical management and its purpose that is applicable with

the disease condition;

6. Formulated nursing care plans based on the prioritized health needs of

the client;

7. Gained knowledge on the acquisition and progression of the disease;

8. Imparted knowledge on fellow students in providing care for clients

with the same illness.

B. Patient-Centered

The client and the significant others were able to acquire knowledge on

the risk factors that have contributed to the development of the disease;

also, gain understanding of the disease process and demonstrate compliance

on the treatment management rendered by the health care team.

76 | P a g e

In relation to the patient’s condition, the proponents were also able to

accomplish these tasks:

1. Gained knowledge about the disease of the patient;

2. Identified different interventions in his condition;

3. Gained knowledge on the importance of compliance to treatment

regimen;

4. Demonstrated compliance on the treatment management;

5. Identified different measures to prevent further aggravation of

condition;

6. Participated in his plan of care; and

7. Demonstrated independence on self-care and home management upon

discharge and during follow-up home visits.

The student nurses therefore concluded that low socio-economic status

and nutritional deficiency greatly affect the individual’s susceptibility against

the occurrence of diseases. They also include the different risk factors that

contribute to the occurrence of pneumonia such as: the environment,

improper sanitation, deficient knowledge and understanding regarding the

disease, its cause, mode of transmission, prevention and treatment, and the

patient’s susceptibility to the disease. Furthermore, the student nurses

conclude that:

The environment plays a vital role in the health of a person.

The viruses and bacteria that cause pneumonia are contagious and are

usually found in fluid from the mouth or nose of an infected person.

Illness can spread when an infected person coughs or sneezes on a

person, by sharing drinking glasses and eating utensils, and when a

person touches the used tissues or handkerchiefs of an infected

person.

Risk for infection will always be blamed to the decrease in the primary

defenses as well as with the virulence of a microorganism.

77 | P a g e

Recommendations

With this, the student nurses would like to give the following

recommendations:

For the Nurses:

Adequate research of the disease condition must should be acquired

regarding the so that proper treatment and prevention can be

implemented, without costing the patient time and money. Nurses

must stress the need for good prenatal care and emphasize on

parents, the value of regular check-ups and follow-up care. Proper

infection control especially strict hand washing should be

implemented in the hospital because it is the most effective

method in controlling the spread of infection from staff to patient

and staff to other immune-suppressed.

For the hospital:

Sterility or cleanliness of hospital equipment should be maintained.

Seminars about infection control should be conducted with hospital

staff to be knowledgeable in the prevention of infection from spreading

the disease. Maintain and supply of resources, especially sufficient

and accurate diagnostic laboratory tests.

Parents:

If your child's doctor has prescribed antibiotics for bacterial

pneumonia, give the medicine on schedule for as long as the doctor

78 | P a g e

directs. This will help your child recover faster and will decrease the

chance that infection will spread to other household members. For

instance, if the antibiotic is required by the doctor to be given for 7

days, strictly follow the said time, do not stop even if the child no

longer experiences the signs and symptoms. Don't force a child who's

not feeling well to eat, but encourage your child to drink fluids,

especially if fever is present. Ask your child's doctor before you use a

medicine to treat your child's cough because cough suppressants stop

the lungs from clearing mucus, which may not be helpful in some types

of pneumonia. If your child has chest pain, try a heating pad or warm

compress on the chest area. Take your child's temperature at least

once each morning and each evening, and call the doctor if it goes

above 102 degrees Fahrenheit (38.9 degrees Celsius) in an older infant

or child, or above 100.4 degrees Fahrenheit (38 degrees Celsius) in an

infant under 6 months of age. Check your child's lips and fingernails to

make sure that they are rosy and pink, not bluish or gray, which is a

sign that your child's lungs are not getting enough oxygen. Isolate the

sick child from the healthy children so as to prevent the transmission

of the disease.

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BIBLIOGRAPHY

Davis's DRUG GUIDE for Nurses / ed. Deglin Judith Hopper and Vallerand April Hazard. - [s.l.] : F. A. Davis Co., 2009.

Kozier & Erb's Fundamentals of Nursing [Book] / auth. Berman Audrey [et al.]. - [s.l.] : Pearson Education South Asia PTE. LTD., 2007. - 8th Edition : Vol. I : II.

Medical-Surgical Nursing: Clinical Management for Positive Outcomes [Book] / auth. Black Joyce and Hawks Jane Hokanson. - Singapore : Saunders Elsevier, 2009. - Eight : Vol. II.

Microbiology: An Introduction [Book] / auth. Tortora Gerard J., Funke Berdell R. and Case Christine L.. - California : Pearson Education, Inc, 2006. - 9th Edition.

Pathophysiology [Book] / auth. Lippincott Williams & Wilkins. - Ambler, PA : Lippincott Williams & Wilkins, 2007.

Robbins and Cotran Pathologic Basis of Disease [Book] / auth. Kumar Vinay, Abbas Abul K. and Fausto Nelson. - China : Elsevier Saunders, 2005. - Seventh Edition. - 0-8089-2302-1.

Taber's Medical Dictionary 21/e / ed. Venes Donald. - [s.l.] : F.A. Davis Company, 2009. - 21st.

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