A

Case study

on

COMMUNITY ACQUIRED PNEUMONIA

Submitted to:

Miss. Krystel Hope Bacacao

Clinical Instructor

Submitted by:

Miss. Leizl N. Mauricio

BSN level II Student
 TABLE OF CONTENT

I. INTRODUCTION
II. PHYSICAL ASSESSMENT
III. HISTORY OF PRESENT HISTORY
IV.ANATOMY AND PHYSIOLOGY
V. PATHOPHYSIOLOGY
VI.LABORATORY
VII.DRUGS STUDY
VIII.FOLLOW-UP
I. INTRODUCTION

Pneumonia is an inflammation of the lung parenchyma caused by

various microorganism, including bacteria, mycobacteria, mycoplasma, fungi,
parasites, and viruses. This is the common cause of death in the Philippines. It
ranked third among the causes of morbidity and fourth among the causes of death
in 2000. there was an increase in the morbidity trend of pneumonia from 1990-
1996. this may due to case findings and reporting with the intensification of the
program to control acute respiratory infection during his period morbidity trend
decreased slightly from 1997-2000. the number of cases remained igh at 892
cases per 100,000 populations in 2000. on the other hand, there is a decreasing
trend of mortality from pneumonia in the general populations from 1990-2000.

Pneumonia usually sudden onset death of chills, rapidly rising fever

(38.7- 45.5) and pleutic chest pain that is aggravated by deep breathing and
coughing .the patient is severely ill, with marked tachypnea accompanied by other
signs of respiratory distress, signs and symptoms of pneumonia may also
depends on a patients condition such as the following:

• People of 65 years old

• People with functional or anatomic asplenia
• Immunocompromised people at high risk for infections
• T.N
• 1months
• Boy
• Inayawan cebu city
• 052500
• Christian
• Mother: good reliability
• Dyspnea
• 3 day cough
 II. Physical assessment:

Eyes No motting of the eyelashes, no discharge, no strabismus.

Ears No deformity, no skin lesions or tags, no redness and swelling of

ear canal

Nose No deformity, septum at midline, no alar flaring, no sinus

tenderness.

Mouth Moist lips and pink

Neck (+)palpable occipital lympnode

Chest and (+)crackles, equal tactile, and vocal fremiti (+)wheezing r

lungs

Abdomen Soft, flat, symmetrical abdomen, no visible pulsation and peristalis,

no mass, no tenderness
X-ray examination.

AP and lateral views of the chest reveal hazy and streaky

densities seen in both lungs.
Trachea is in the midline. The superior mediastinum is not
widened.
Heart is not enlarged.
No evidenced of an enlarged paratracheal lympnode noted in
the lateral view.
The retrosternal and retrocardiac spaces are normal.
Both hemidiaphragms and costopheric sulci are sharp and
distinct.
The bony throax is unremarkable.

Impression:
Pneumonia on both lungs.
 (+) productive (-)
of cough. III. History of
fever

(+)difficulty
Present illness in
(+)
breathing. crackles
IV. Anatomy and physiology

The respiratory system

consist of the external nose, throat,
nasal cavity, the pharynx, the trachea,
the bronchi, and the lungs although air
frequently passes through the oral
cavity it is considered to be a part of
digestive system instead of the
respiratory system. The upper
respiratory tract refers to the external
nose, nasal cavity, pharynx and other
associated structures.

Nose
The nose consist of the
external nose and the nasal cavity. The
external nose is the visible structure
that forms a prominent feature of the
face. Most of the external nose is
composed of hyaline cartilage,
although the bridge of the external
nose consist of bones. The bone and
cartilage are covered by connective
tissue and skin.
 The trachea or windpipe is a membrane tube that
consist of connective tissue and smooth muscle, reinforced with 16-
20 shaped of pieces of cartilage. C-shape cartilage protect the
trachea and maintain an open passage way.
The right lung is larger than left lung and consist of
three lobes. In the right lung, the major fissure runs obliquely and
separates the lower lobe from the upper and middle lobes.
The pharynx cone shaped passageway leading from
the oral and nasal cavities in the head to esophagus and larynx.
Both serve respiratory and digestive functions.
The bronchus is a passageway of airway in the
respiratory system that conducts air into the lungs.
The left lung occupies a smaller volume than the
right.
The pleura is the cavity is the potential space between
the two pleurae (visceral-parietal) of the lungs . It is a serious
membrane which folds back onto itself to form a two-layered
membrane structure.
The bronchioles are the passageway by which air
passes through the nose or mouth to the alveoli (air sacs) of the
lungs in which the branches no longer contain cartilage or glands in
their submucosa.
The alveoli is an anatomical structure that has form of
a hollow cavity and is found in the lung parencyma (tissue inside the
lungs) the pulmonary a;veoli are the terminal ends of the respiratory
tree that outcrop from either alveolar sacs or alveolar ducts; both
are the sites of gas exchange.
V. Pathophysiology:
 VI. Laboratory:
Test Result Unit Normal values

WBC count 6.48 x10^3/uL 5-10

RBC count L 2.62 x10^6/Ul 4.2-5-4
Hemoglobin L 8.06 g/dL 12.0-16.0
hematocrit L 23.7 % 37.0-16.0
Platelet count H 550.1 X10^3u/L 150-450

DIFRRENTIAL COUNT
Neutrophils (%) L 32.92 % 50-70
Lymphocytes (%) H 47.15 % 20-40
Monocytes(%) H 17.23 % 0-7
Eosinophils(%) 2.43 % 1-6
Basophils(%) 0.27 % 0-2

BLOOD INDICES
RDW-CV H 45.5 % 11.5-14.5
MCV 90.6 fL 80.0-99.0
MCH 30.8 Pg 27.0-31.0
MCHC 34 g/dl 33.0-37.0
NAME OF CLASSICATION/ Indication/ Side Nursing
DRUGS MECHANISM OF dosage contraindicatio effects/advers responsibilities
ACTION
n e reaction

CEFUROXI ANTIBIOTIC Pharyngitis,

Patients who CNS:  Determine the
ME tonsillitis,
have serious -seizures history of
second UTI, skin and
hypersensitivity (high doses) hypersensitivity
BRAND generation skin structure.
to drugs like -diarrhea reactions to
NAME: cephalosporin
penicillin. -cramps cephalosporin,
ZOLTAC that inhibits cell treatment of
-nausea penicillin, and
wall synthesis,. the following
-vomiting history of
infection
allergies before
promoting cause by
DERM: therapy.
osmotic susceptible
-rashes .
instability; usually organism.
basctericidal.
 Inspect the IM
Infant:
and IV injections
IV drip
sites frequently
OVON
for signs of
200mg 1* q8
phlebitis .
NST
 Monitor for
manifestation of
hypersensitivity.
NAME OF CLASSICATION/ Indication/ Side Nursing
DRUGS MECHANISM OF dosage Contraindicati effects/advers responsibilities
ACTION
on e reaction

AZITHROM Macrolide Treatment of

Patients who Mild to  Culture site of
YCIN lower
have serious moderate infections before
Used to treat a wide respiratory
variety of bacterial hypersensitivity nausea therapy.
infections
infections. It is a to azithromycin, Vomiting .
acute
macrolide-type crythromycin, or Abdominal pain
bactericidal
antibiotic. It works by any macrolide Diarrhea  Administer on an
stopping the growth exacerbation
antibiotic. Cramping empty stomach
of bacteria. This of COPD due
Jaundice 1hr before or 2-3
medication will not to
work for viral Angioedema hr after meals
haemophilus
infections (such as vertigo food affects the
influenza.
common cold) absorption of this
unnecessary use of drug
any antibiotic can Infant:
lead to its decreased IV drip OVON
 Take the full
effectiveness. 200mg 1* q8
course
NST
prescribed do not
take with
antacids tablet or
oral suspensions
can be taken with
or without food.
NAME OF CLASSICATION/ Indication/ Side Nursing
DRUGS MECHANISM OF dosage Contraindicati effects/advers responsibilities
ACTION
on e reaction

Generic Analgesic To relieve mild

Hypersensitivi Anemia  Assess patient
Name: (non-OPOID) to moderate
ty to fever or pain:
Paracetamol pain due to Jaundice type of pain
Paracetamol is things such as acetaminophe
a medicine that headache n or Hypogylce location,
intensity,
Brand Name: is commonly Muscle joint phenacitine mia durations,
biogesic used in children pain
and is available And period of
use with Liver temperature, and
alcohol. damage diaphoresis.
without Pains.
 Assess allergic
prescription. Rash reactions rash
The main use of
Urticaria urticaria if this
paracetamol are Infant:
occur drug may
for relief of pain IV drip OVON
have to be
and for reducing 200mg 1* q8
discontinue,
a fever. NST
 Teach patient to
recognize signs
of chronic over
dose, bleeding,
bruising, malaise,
fever, and sore
throat.
 Name of Classification/ Indication/ Side effects/
drug mechanism dosage Contraindication Adverse Nursing
Of action reaction Responsibilities

SALBUTAMOL BRONCHODILATO To control and Hypersensitivity to -nervousness  Assess lung

RS prevent adrenergic amines -restlessness sounds, PR and
GENERIC reversible airway -tremor BP before drug
NAME: Relives nasal obstruction And to fluorocarbon -headache administration and
ALBUTEROL congestion and caused by -insomnia during peak of
reversible asthma or COPD -chest pain medication.
bronchospasm by -angina
relaxing the smooth INHALATION: -hypertension  Observe fore
muscle of the Used as quick -angina paradoxical spasm
bronchioles. relief agent for -hypokalemia and wit hold
acute -hyperglycemia medication and
Decrease the bronchospasm -nausea and notify physician if
intracellular calcium and prevention of vomiting condition occurs.
relaxes smooth exercise induced
muscle airways. bronchospasm.  Advise patient to
rinse mouth with
Infant: water after each
Z30 minutes inhalation to
now, then two minimize dry
or more dose. mouth.
(1,2,,3)
 NAME OF CLASSIFICATION/ME CONTRAINDIC SIDE NURSING
DRUGS CHANISM OF ACTION INDICATION/DOSAGE ATION EFFECTS/ADVERSE RESPONSIBILITIES
REACTION

RANITINE ANTI-ULCER It is a short team Hypersensit The child may  Instruct

treatment of ivity have some side patient not
BRAND active ulcers. effects like: to take new
NAME: medicine
ZANTAC *inhibits the Ranitidine is -headache w/o
action of treatment of -tiredness consulting.
histamine at the maintenance -loss of appetite
H2 receptor site therapy for -upset stomach  Advise
located primarily erosive -vomiting patient to
in gastric parietal esophagitis -diarrhea report onset
cells resulting in rash, fever,
inhibition of Prevention of stole, sore
gastric acid acid inactivation. throat, and
secretion confusions.
Infant:
*used to prevent IVTT q8h while  Instruct
damage to the on NPO patient to
stomach from take as
certain directed and
medicines and do not
diseases. increase
dose.
 NAME OF CLASSIFICATION/ME CONTRAINDIC SIDE NURSING
DRUGS CHANISM OF ACTION INDICATION/DOSAGE ATION EFFECTS/ADVERSE RESPONSIBILITIES
REACTION

Generic Pharmacologic: Treatment Allergies to Lethargy  Prior to

name: penicillin infection caused penicillin Hallucinations administrati
Ampicillin by susceptible cephalospor Seizures on skin test
Therapeutic: strains of in. Sore mouth is to be
Trade name: Antibiotic salmonella s. Furry tongue done to
principen typhosa E.coli Nausea determine
Bactericidal action haemophilus Vomiting signs and
against sensitive influenza protus diarrhea symptoms
organism , mirabilis neisseria of
inhibitors gonorrrkoese. hypersensiti
synthesis of vity.
bactericidal cell  Monitor
wall causing seizures
death. when giving
high doses.
 Do not miss
a dose
unless
ordered by
physician.
 NAME OF CLASSIFICATION/ME CONTRAINDIC SIDE NURSING
DRUGS CHANISM OF ACTION INDICATION/DOSAGE ATION EFFECTS/ADVERSE RESPONSIBILITIES
REACTION

Dextrose 3% This medication is Treatment for Hypersensit Redness or pain  Obtain

NACI-KCL an intravenous hyponatremia ivity at the injection baseline
(IV) solutions site. sodium and
Generic name used to supply Infant:: chloride
Dextrose water, calories D5 3% NACI Fever levels
sodium and electrolytes 25cc/hr Trouble breathing before
chloride (e.g sodium swelling starting
solutions chloride) to the therapy.
intravenous. body.  Monitor
other
It is also used as electrolytes
mixing solutions levels.
(difluent) for other  Assess
IV medications. patients fluid
status.
 Instruct
patients to
report
occurrence
of drug
induced
adverse
reactions.
 NAME OF CLASSIFICATION/ME CONTRAINDIC SIDE NURSING
DRUGS CHANISM OF ACTION INDICATION/DOSAGE ATION EFFECTS/ADVERSE RESPONSIBILITIES
REACTION

D5 IMB Hypertonic Slow Phlebitis  Do not

solutions administration to Peripheral administer
contains a high prevent overload edema unless
concentration of water intoxication Cellular solution is
solute relative to severe sodium dehydration clear and
another depletion. container is
solutions. undamaged.
 Cautions
must be
exercise in
the
administrati
on of
parenteral
fluids
especially
those
containing
sodium ions
to patient
receiving
conticotroph
in.