Case Study Pneumonia: August 25, 2020 BSN3 CSPC

History of Present Illness:

 A 50-year-old female presents after admission to the general medical/surgical hospital ward with a
chief complaint of shortness of breath on exertion. She reports that she was seen for similar
symptoms previously at her primary care physician’s office six months ago. At that time, she was
diagnosed with acute bronchitis and treated with bronchodilators, empiric antibiotics, and a short
course oral steroid taper. This management did not improve her symptoms, and she has gradually
worsened over six months. She reports a 20-pound intentional weight loss over the past year. She
denies any sick contacts. A brief review of systems is negative for fever, night sweats, palpitations,
chest pain, nausea, vomiting, diarrhea, constipation, abdominal pain, neural sensation changes,
muscular changes, and increased bruising or bleeding. She admits a cough, shortness of breath, and
shortness of breath on exertion.
Social History: Her tobacco use is 33 pack-years; however, she quit smoking shortly prior
to the onset of symptoms, six months ago. She denies alcohol and illicit drug use. She is married, in a
monogamous relationship, and has three children aged 15 months to 5 years. She is employed as
clinical instructor. She has two pet cats. She loves to travel.
Allergies: No known medicine, food, or environmental allergies.
Past Medical History: Essential  Hypertension
Past Surgical History: Apendectomy and CS
Medications: Lisinopril 10mg by mouth every day
Physical Exam:
Vitals: Temperature, 105. F; heart rate 108; respiratory rate, 26; blood pressure 130/86; BMI 26.
General: She is well appearing but anxious, a pleasant female lying on a hospital stretcher. She is
conversing freely, with respiratory distress causing her to stop mid-sentence.
Respiratory: She has diffuse rales and mild wheezing; tachypneic.
Cardiovascular: She has an irregular rate and rhythm with PSVT
Gastrointestinal: Bowel sounds X4. No bruits or pulsatile mass.

Initial Evaluation
Laboratory Studies: Initial work-up from the emergency department revealed pancytopenia with a
platelet count of 74,000 per mm3; hemoglobin, 8.3 g per and mild transaminase elevation, AST 90
and ALT 112. Blood cultures were drawn and currently negative for bacterial growth or Gram
staining.

ESTERNON, Ma. Mica Fatima A.

BSN-3A
A. Patient History
- A 50-year old female admitted to the general medical/surgical hospital with a chief
complains of shortness of breath on exertion.
- The pt., reports that she was seen for similar symptoms previously at her primary care
physician’s office six months ago.
- At that time, she was diagnosed with acute bronchitis and treated with bronchodilators,
empiric antibiotics, and a short course oral steroid taper.
- She reports a 20-pound intentional weight loss over the past year. She denies any sick
contacts.
- Social History: The patient consumed 33 pack-year of a tobacco
- Past Medical History: Hypertension
- Past Surgical History:  Appendectomy and CS
- Physical Exam: Vitals: Temperature, 105. F; heart rate 108; respiratory rate, 26; blood
pressure 130/86; BMI 26.
- Respiratory: She has diffuse rales and mild wheezing; tachypneic.
- Cardiovascular: She has an irregular rate and rhythm with PSVT
- Gastrointestinal: Bowel sounds X4. No bruits or pulsatile mass.

B. Anatomy of an affected organs

Pneumonia is an infection of the lungs that may

be caused by bacteria, viruses, or fungi. The
infection causes the lungs' air sacs (alveoli) to become inflamed and fill up with fluid or pus.
That can make it hard for the oxygen you breathe in to get into your bloodstream. The symptoms
of pneumonia can range from mild to severe, and include cough, fever, chills, and trouble
breathing.

ESTERNON, Ma. Mica Fatima A.

BSN-3A
- Many factors affect how serious a case of pneumonia is, such as the type of germ causing the
lung infection, the person’s age, and their overall health. The people most at risk are infants and
young children, adults 65 or older, and people who have other health problems.
- Pneumonia can be caused by a wide variety of bacteria, viruses and fungi in the air we breathe.
Identifying the cause of your pneumonia can be an important step in getting the proper treatment.

C. Pathophysiology

Bacteria enter the lungs (from the throat or nose, airborne droplets, or blood)

Bacteria may invade the spaces between cells and between alveoli.

The macrophages and neutrophils inactivate the bacteria. The neutrophil also releases
cytokines.

The neutrophils, bacteria, and fluid fill the alveoli.

Leading to the fever, chills and fatigue.

The causes general activation of the immune system.

Resulting in the consolidation seen on chest X-ray.

D. Diagnostic test
- Blood tests. Blood tests are used to confirm an infection and to try to identify the type of
organism causing the infection. However, precise identification isn't always possible.
- Chest X-ray. This helps your doctor diagnose pneumonia and determine the extent and
location of the infection. However, it can't tell your doctor what kind of germ is causing
the pneumonia.
- Pulse oximetry. This measures the oxygen level in your blood. Pneumonia can prevent
your lungs from moving enough oxygen into your bloodstream.
- test. A sample of fluid from your lungs (sputum) is taken after a deep cough and
analyzed to help pinpoint the cause of the infection.
Drug Mechanism Indications Contraindicatio Adverse Effect Nursing
of Action n Responsibility

ESTERNON, Ma. Mica Fatima A.

BSN-3A
 Assessment
LISINOPRIL -Probably - Lisinopril is -CNS: History: Allergy to
alters Hypertension; contraindicated in depression, lisinopril or
10mg by oral enalapril, impaired
chemical Congestive patients with dizziness, renal function,
every day
transmitters hyperkalemia, a fatigue, CHF, salt or
- Heart headache, volume depletion,
Classification:   in CNS, Failure
history of
paresthesia, lactation,
Antihypertensive, possibly by angioedema, renal
somnolence
pregnancy
ACE inhibitor interfering failure with prior -Physical: Skin
with ionic lisinopril use, color, lesions,
-CV: chest pain, turgor; T; P, BP,
pump bilateral renal hypotension, peripheral
mechanisms artery stenosis, orthostatic perfusion; mucous
in brain concomitant use membranes, bowel
hypotension sounds, liver
cells, and with aliskiren in evaluation;
may patients with -EENT: nasal urinalysis, LFTs,
complete diabetes mellitus, congestion renal function tests,
CBC and
with and during -GI: diarrhea, differential
sodium coadministration dysgeusia, Interventions
ions. with a neprilysin Implement aerobic
dyspepsia, exercise and
inhibitor or within nausea cardiac
Uses: 36 hours of taking conditioning
Lisinopril is one. -GU: impotence programs to
used to treat augment drug
high blood -Metabolic: therapy and
hyperkalemia maintain or
pressure. improve
Lowering - cardiovascular
pump function.
high blood Musculoskeletal: -Avoid physical
pressure muscle cramps therapy
helps interventions that
prevents - Respiratory: cause systemic
dry, persistent, vasodilation (large
strokes, whirlpool, Hubbard
tickling, non-
heart tank). Additive
productive effects of this drug
attacks, and
cough and the intervention
kidney may cause a
problems. It -Skin: rash dangerous fall in
blood pressure.
is also used -To minimize
to treat orthostatic
heart failure hypotension,
patient should
and to move slowly when
improve assuming a more
survival upright position.
after heart
attack.

NURSING CARE PLAN

NURSING
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
ESTERNON, Ma. Mica Fatima A.
BSN-3A
 DIAGNOSIS

a. Assess pt. a. To obtain

a. Subjective Ineffective - At the end of condition baseline data. -At the end of
Data: airway nursing care b. VS monitor and b. To monitor nursing care and
clearance r/t and recorded. the progress or interventions the
- cough shortness of patient:
- shortness of interventions, important.
breath the patient changes of VS.
breath on exertion -the pt is in a
- the pt. report that will be able to c. Auscultate c. To check for good condition
she decreased demonstrate: breath sounds and the presence
weight loss 20 -improved assess airways of adventitious -Maintain clear,
pounds over the breathing pattern. breath sounds. open airways as
past year. pattern. d. Assess the pt. to d. To evidenced by
- Maintaining a comfortable minimize normal breath
B. Objective clear, open position such as difficulty in sounds, normal
Data: airways as elevate the head of breathing.  rate and depth of
evidenced by the bed. respirations, and
-cough ability to
-shortness of normal breath e. Encourage deep e. To
sounds, breathing and maximize effectively cough
breath up secretions
-anxious normal rate proper coughing effort for
and depth of expectoration. after treatments
-the pt. has and deep breaths.
respiratory distress respirations, f. Encourage the f. Drinking
causing her to stop and ability to pt. to increase fluid extra fluids
mid-sentence effectively intake. can thin the
-diffuse rales cough up mucus and
-mild wheezing secretions helps the
-tachypneic after sinuses to
-Vital Signs: treatments and drain.
Temp -105.F;  deep breaths. g. Administer g. To control
HR -108; r medication as the risk of
RR- 26; doctor’s ordered. certain illness.
BP-130/86; 
BMI -26.

ESTERNON, Ma. Mica Fatima A.

BSN-3A