COMMUNITY ACQUIRED PNEUMONIA, HIGH RISK

A Care Study
Presented to
The Faculty of the College of Nursing
University of Cebu - Lapulapu and Mandaue
Mandaue City

In Partial Fulfillment
Of the Requirements in
Nursing Care Management 501201

By:

Abecia, Junheil Ryan B.

BSN-III A

November, 2009
 TABLE OF CONTENT

I. INTRODUCTION..........................................................................................................2

II. PATIENT PROFILE......................................................................................................3

III.HISTORY OF PRESENT ILLNESS............................................................................4

IV. PAST HEALTH HISTORY..........................................................................................5

V. CLIENT’S CLINICAL COURSE IN THE UNIT........................................................6

VI. FAMILY, PERSONAL, SOCIAL, AND ENVIRONMENTAL HISTORY................7

A. Family History......................................................................................................8

B. Heredo-Familial History........................................................................................9

C. Personal and Social History.................................................................................10

D. Environmental History........................................................................................11

VII. PHYSICAL ASSESSMENT AND NURSING REVIEW OF SYSTEMS...….......12

VIII.DEVELOPMENTAL DATA…………………………………………………....... 13

IX.ANATOMY, PHYSIOLOGY AND RELATED PATHOPHYSIOLOGY

A. Anatomy and Physiology of the Systems Involved............................................. 14

B. Conceptual Framework on Pneumonia............................................

C. Discussion of the Stages of Pneumonia................................................................15

D. Symptomatology..................................................................................................16

X.MEDICAL MANAGEMENT

A. Diagnostic Procedures…......................................................................................17

B. Treatment and Procedures………………

 C. Medication………………………........................................................................18

D. Diet…………………….......................................................................................19
XI. NURSING MANAGEMENT....................................................................................20

A. Actual Care Given..........................................................................................21

B. Problem Encountered During the Implementation of Nursing Care..............22

C. Restorative Measures Used............................................................................23

D. Evaluation.....................................................................................................24

E. Patient Teaching......................................................................................

XII. CONCLUSION AND RECOMMENDATION

XIII. IMPLICATION OF THE STUDY TO:

A. Nursing Education...............................................................................................25

B. Nursing Practice..................................................................................................26

C. Nursing Research................................................................................................27

APPENDICES

Appendix A: Permit Letter

Appendix B: NCP

Appendix C: Discharge Plan

Appendix D: Drug Study

Appendix E: IVF Study

BIBLIOGRAPHY
INTRODUCTION:

Pneumonia is an infection of one or both lungs which is usually caused by

bacteria, viruses, or fungi. Prior to the discovery of antibiotics, one-third of all people

who developed pneumonia subsequently died from the infection. Currently, over 3

million people develop pneumonia each year in the United States. Over a half a million of

these people are admitted to a hospital for treatment. Although most of these people

recover, approximately 5% will die from pneumonia. Pneumonia is the sixth leading

cause of death in the United States. Some cases of pneumonia are contracted by

breathing in small droplets that contain the organisms that can cause pneumonia. These

droplets get into the air when a person infected with these germs cough or sneezes. In

other cases, pneumonia is caused when bacteria or viruses that are normally present in the

mouth, throat, or nose inadvertently enter the lung. During sleep, it is quite common for

people to aspirate secretions from the mouth, throat, or nose. Normally, the body's reflex

response (coughing back up the secretions) and immune system will prevent the aspirated

organisms from causing pneumonia. However, if a person is in a weakened condition

from another illness, a severe pneumonia can develop. People with recent viral infections,

lung disease, heart disease, and swallowing problems, as well as alcoholics, drug users,

and those who have suffered a stroke or seizure are at higher risk for developing

pneumonia than the general population .Once organisms enter the lungs, they usually

settle in the air sacs of the lung where they rapidly grow in number. This area of the lung

then becomes filled with fluid and pus as the body attempts to fight off the infection.

Most people who develop pneumonia initially have symptoms of a cold which are then
followed by a high fever (sometimes as high as 104 degrees Fahrenheit), shaking chills,

and a cough with sputum production. The sputum is usually discolored and sometimes

bloody. People with pneumonia may become short of breath. The only pain fibers in the

lung are on the surface of the lung, in the area known as the pleura. Chest pain may

develop if the outer pleural aspects of the lung are involved. This pain is usually sharp

and worsens when taking a deep breath, known as pleuritic pain.In other cases of

pneumonia, there can be a slow onset of symptoms. A worsening cough, headaches, and

muscle aches may be the only symptoms. In some people with pneumonia, coughing is

not a major symptom because the infection is located in areas of the lung away from the

larger airways. At times, the individual's skin color may change and become dusky or

purplish (a condition known as "cyanosis") due to their blood being poorly oxygenated.

Children and babies who develop pneumonia often do not have any specific signs of a

chest infection but develop a fever, appear quite ill, and can become lethargic. Elderly

people may also have few symptoms with pneumonia. So, I choose this kind of problem

for my care study because it has something to do to our body and aside from that it is

very common to our society today, and Even though, it is very common but it has very

virulent effect that may led to death,and I want them to know that it should not be

neglected to those people suffering from pneumonia in order to live life to fullest.
II. GENERAL DATA:

Name : Mr. FLI

Age : 74 years old

Address : Hinulawan, Toledo City

Sex : Male

Civil Status : Married

Occupation : Farmer

Citizenship : Filipino

Religion : Roman Catholic

Date of Admission : November 9,2009

Time of Admission : 4:15pm

Hospital Number : 090022559574

Attending Physician : Dr. Roy J. Entienza

Final Diagnosis : Community-Acquired Pneumonia,High Risk

III. Present Health History:

Patient was admitted last November 9,2009 because of dyspnea associated with cough

patient has episodes of severe dyspnea, hours prior to admission .the family decided to

admit the patient for therapeutic regimen.

IV. PAST HEALTH HISTORY:

According to his daughter , he was first admitted at Chong Hua Hospital last

September 12,2008 because of dyspnea and was diagnosed with Community Acquired

Pneumonia . And Mr. FLI is non-hypertensive and non-diabetic . He was diagnosed of

having PTB stage 4 because of smoking for 33 years. Patient experiences on and off

cough but afebrile. Dyspnea occurs often times, out patient Department consulted last

September 2008. 11 years ago Mr. FLI was diagnosed of pulmonary Tuberculosis. He

works on his kaingin under the heat of the sun then when he went home he did directly

taking a bath frequently. Then the area of his are not so clean and lot of the people

smoke. Mr. FLI start smoking when he was still 22 years old ,according to him he can

consume a 1 pack of cigarette in one day,then he only stop when he was diagnosed of

pulmonary tuberculosis last September 2008. According to him he did not expect of

having this kind of disease because he receive a complete immunization during

childhood. With the heredo-familial disease Mr. FLI have diabetec and hypertensive

family.
V. CLIENT CLINICAL COURSE IN THE UNIT:

Patient was admitted on November 9,2009 at Chong Hua Hopital due dyspnea

associated with cough patient has episodes of severe dyspnea with the following vital

signs: temperature of 37.7 degree Celsius, blood pressure of 120/70 mmHg, pulse rate of

84 beats per minute and respiratory rate of 24 cycle per minute.

On November 10, 2009, received patient lying on bed with intravenous fluid

of D5NM at 30 ggts/min at rignt armm, awake and responsive. . The physician ordered

full diet, vital signs monitoring every four hours and medication such as Zinnat

500mg/tab 1 tablet twice a day, Metronidazole 500mg/tab 1 tablet twice a day, Vitakay

1tablet twice a day.

On November 11, 2009, seen patient lying on bed febrile, conscious and

coherent with intravenous fluid of D5NM at 30 gtts/min.with the following vital signs:

temperature of 38.2 degree Celsius, pulse rate of 100 beats per minute, respiratory rate of

35 cycle per minute and blood pressure of 110/60 mmHg. Intake and output monitoring

done. Tepid Sponge done to lower the temperature within normal range.

On November 12, 2009, received patient sitting on her bed with intravenous

fluid of D5NM at 30 gtts/min. at right arm. Vital signs monitoring every 4 hours done.

And so with the intake and output of the patient. Administration of the said medication as

ordered.
 On November 13, 2009, physician ordered for discharge of the patient, vital

signs monitoring every four hours. The physician ordered take home medications such as

Cefuroxime ( Zinnat ) 500 mg/tab.PO 2x1 day x 3 days after breakfast and after dinner,

Metrinidazole ( Flagyl ) 500 mg/tab.PO 1 tablet twice a day x 4 more days after breakfast

and after dinner, Oneprazole ( Onepron ) 200 mg/cap.PO 1 capsule once a day x 5 days

before breakfast, and Multivatamins 1 tablet PO once a day after breakfast. Physical

assessment and a brief history about the case were done. Intake and output monitoring

done.

VI. FAMILY, PERSONAL, SOCIAL, AND ENVIRONMENTAL HISTORY

A. Table 1. Member of immediate family:

NAME AGE SEX POSITION IN THE EDUCATIONAL

FAMILY ATTAINMENT
1. Mrs. MFI - Female Grand mother Elementary
2. Mr. SI - Male Grand father -
3. Mrs. TI 90 Female Mother -
4. Mr. SFI 92 Male Father High school
5. Ms. ALI 75 Female Daughter High school
6. Ms. KLI 73 Female Daughter Elementary
7. PATIENT 70 Male Son Elementary

B. FAMILY GENOGRAM:
 GRANDMOTHER
GRANDFATHER

FATHER MOTHER

PATIENT SISTER SISTER

LEGEND:

= GRAND PARENTS

= PARENTS

= PRESENT
C. Personal and Social History

According to Ms. FS , daughter of the patient, the patient is very hardworking type of

person. Every morning he wakes up, he makes sure that before he goes out into his room

is already clean and well arranged and prepares all his things needed in kaingin. Then at

5:00 o’clock in the morning, he eats his breakfast and after that, patient does help his wife

to daily household chores before going to kaingin like pitching water. They take lunch at

12:00 o’clock in the afternoon. During Sunday and Saturday patient watch his kaingin for

pastime to checked his plants, but sometimes he will take a nap. Then after long day of

activities, they take supper at 7:00 o’clock in the evening.

The patient was able to maintain his status until now, Patient is a Roman Catholic

and speaks Visayan as the primary dialect. Eventually, he is depending on his daughter

financially. And he also used his kaingin as a source of food for his family.

D. Environmental History

The patient lives at Hinulawan, Toledo City,Cebu. They live in their own house and

lot. Their house is made of concrete materials as claimed by the mother of the patient.

They had their own water supply and uses mineral water for drinking. They throw their

garbage in the trash can at it is segregated and the garbage collector collects it everyday.

She claimed that their environment is quiet and peaceful but the only thing she doesn’t

like was there are mosquitoes outside their house, the place is surrounded of different

plants. The neighborhood around them is mainly consisting of relatives of the patient who
are friendly and helpful as verbalized by the significant others.

VII.PHYSICAL ASSESSMENT AND NURSING REVIEW OF SYSTEM:

Nursing Review of Systems Physical Assessment

Integumentary System:
Patient denied any abnormalities
HEENT:
Head:
Patient denied any abnormalities
Integumentary System:
Fair complexion; no presence of edema in the
extremities or any lesions noted. Skin is
smooth, and warm to touch. Has good skin
turgor.
HEENT:
Head:
Patient hair was evenly distributed. Hair was
dry and slight dandruff noted due to poor
hygiene. Hair is straight, long and black in
color.

Eyes:
“lubog-lubog ako pana-aw tungod sa
akong cataract sa left eye” claimed
by the patient
Eyes:
Eyes were symmetrical; pupils are black in
color. Eyes move symmetrically. The
conjunctiva was pinkish in color and no
secretions noted. Blinking reflex was normal.

Ears: Ears:
“Makadungog ra man ko dong” Ears are clean, minimal ear wax was noted. No
inflammation or lesions noted. Patient had
good sound acuity.

Nose: Nose:
“wala ra man ko’y gipamati dong” Symmetrical; no lesions and deformities; no
pain and tenderness; nasal septum is pinkish;
no colds

Mouth: Mouth:
“wala ra man koy gipamati nga lain Dry lip noted. Complete (upper and lower) set
dong” of chalky white teeth without dentures.
Toungue is pinkish and no lesions noted.

Neck: Neck:
“Wala ra man dong” No lymph nodes noted. Client able to move
freely his neck.
Respiratory System: Respiratory System:
“Makaginhawa ra man ko ug tarong No reports of pain during the inhalation and
dong” exhalation. Clear breathe sounds are present.

Cardiovascular System: Cardiovascular System:

“ Wala man ko’y gibati nga lain The patient has normal heart sounds and
dong” regular rhythm of 75 bpm; blood pressure was
140/90 mmHg.
Gastrointestinal System: Gastrointestinal System:
“Makalibang ra man ko day kausa sa Post surgical incision noted; few striae
usa ka adlaw” gravidarum are noted; normal abdominal
sounds and no masses are also
noted.

Urinary System: Urinary System:

“wala ra man ko’y gipamati nga lain Patient’s urine output was 710 cc during every
dong” shift. Urine color is yellow.

Neurologic System:

Patient was responsive and maintain eye-to-eye

contact when asked. Patient was conscious, awake and
oriented to time, place and person.

Cranial nerve assessment:

I. Olfactory

Patient was able to identify the scent

(green cross alcohol).

II. Optic

Can see clearly.

III. Oculomotor

Pupils are black in color and pupils

constricted when tested with penlight.

IV. Trochlear
 Ability to follow moving object.

V. Trigeminal

Reacted to different sensation, and able to

move jaw.

VI. Abducens

Able to follow eye movement, eyes can

open equally.

VII. Facial

Not performed

VIII. Vestibulocochlear

Can hear normally when spoken softly.

IX. Glossopharyngeal

Not performed

X. Vagus

Not performed

XI. Accessory

Able to move neck freely

XII. Hypoglossal

Not performed

Musculoskeletal System: Musculoskeletal System:

“wala jud ko ma feel sa akong right
nga tiil og kamot” verbalized by the
patient

Upper Extremities Upper Extremities

Patient denied abnormalities
Lower Extremities
Patient denied abnormalities
Reproductive System:
“wala raman ko'y gipamati dong”
Patient can moves her upper extremities. Good
muscle strength and tone noted. Reflexes were
normal.
Lower Extremities
Patient can move her lower extremities. Good
muscle strength and tone noted. Reflexes were
normal.
Reproductive System:
Breasts have no lesions, striae and masses
noted, red to brown vaginal secretions are
noted.

V. DEVELOPMENTAL DATA

Table 3. Erik Erikson Eight Stages of Psychosocial Development:

STAGE AGE DEVELOPMENTAL ERIKSON’S PATIENT’S
TASK RESOLUTION RESOLUTION
Infancy Birth to 1 Trust versus Infant Significant
year old Mistrust develops trust in Other of the
self, others, and patient claimed
the environment that Mr. FLI was
when caregivers on bottle feed
is responsive to until he was 8
basic needs and months And
provides gained trust
comfort; if from him.
needs not met,
infant becomes
uncooperative
and aggressive,
and shows a
decreased
interest in the
environment.

( Introduction to
Health Science
Technology )
Toddler 1 year old to Autonomy versus Toddler learn Significant
3 years old Shame/Doubt control while Other of the
mastering skills patient claimed
 such as feeding, that Mr. FLI was
toileting, and toilet trained but
dressing when still he needed
caregivers supervision
provide from the
reassurance but Parents.
avoid
overprotection;
if needs not met,
toddler feel
ashamed and
doubts own
abilities, which
leads to lack of
self confidence
in later stages.
( Introduction to
Health Science
Technology )
Preschool 3 years old Initiative versus Child begins to At this stage, he
Age to 6 years old Guilt initiate activities was sent to
in place of just school by her
imitating mother. Parent
activities; uses of Mr. FLI
imagination to remembered
play; learns that the patient
what is allowed really like to
to develop a play the whole
conscience; day.
caregivers must
allow child to be
responsible
while providing
reassurance; if
needs not to
met, child feels
guilty and thinks
everything he or
she does is
wrong, which
leads to a
hesitancy to cry
new task in later
stages.
 ( Introduction
to Health
Science
Technology )

School-Age 6 years old Industry versus School-aged Parent of the

to 12 years inferiority becomes patient claimed
old productive by that Mr. FLI was
mastering honor student
learning and from Grade 1-4.
obtaining She likes to
success; child joined
learns to deal extracurriculum
with academics, activities.
group activities,
and friends
when others
show
acceptance of
action and
praise success;
if needs not met,
child develops a
since of
inferiority and
incompetence,
which hinders
future
relationships
and the ability
to deal with life
events.
Adolescence 12 years old Identity versus Role Adolescents Patient claimed
to 18 years Confusion searches for self that he was
old –identity by attracted with
making choices his opposite sex
about and able to
occupation, mingle with his
sexual peer group
orientation, Patient said that
lifestyle, and at this stage he
adult role; relies was able to join
on peer group curricular
 for support and activities in
reassurance to school.
create a self –
image separate
from parents; if
needs not met,
adolescent
experiences role
confusion and
loss of self-
belief.
(Introduction
to Health
Science
Technology )
Young 19 years old Intimacy versus Young adult Patient claimed
Adulthood to 40 years Isolation learns to make a that he had his
old personal girlfriend who
commitment to becomes his
others and share wife.
life events with
others; if self- Patient got
identity is married at the
lacking, adult age of 27 and
may fear became father
relationships with their 1st
and isolate self baby at the age
from others. of 29.

( Introduction to
Health Science
Technology )
Middle 30-65 years Generativity versus
Adulthood old Stagnation middle-age is
when we tend to
be occupied
with creative
and meaningful
work and with
issues
surrounding our
family.
 The significant
task is to
perpetuate
culture and
transmit values
of the culture
through the
family (taming
the kids) and
working to
establish a
stable
environment.
Strength comes
through care of
others and
production of
something that
contributes to
the betterment
of society

Late 65 above Integrity versus late adults can

Adulthood until death Despair often look back
on our lives
with happiness
and are content,
feeling fulfilled
with a deep
sense that life
has meaning and
we've made a
contribution to
life
IX. ANATOMY AND PHYSIOLOGY OF THE SYSTEM INVOLVED AND

RELATED PATHOPHYSIOLOGY
A. Anatomy and Physiology of the Lungs:
Structure of the Human Respiratory System

Nasal passages:
Air entering from the nostrils is led to the nasal passages. The nasal cavity that is
located behind the nose comprises the nasal passages that form an important part of the
respiratory system in human beings. The nasal cavity is responsible for conditioning the
air that is received by the nose. The process of conditioning involves warming or cooling
the air received by the nose, removing dust particles from it and also moistening it, before
it enters the pharynx.

Pharynx:
It is located behind the nasal cavity and above the larynx. It is also a part of the
digestive system of the human body. Food as well as air passes through the pharynx.

Larynx:
It is associated with the production of sound. It consists of two pairs of membranes.
Air causes the vocal cords to vibrate, thus producing sound. The larynx is situated in the
neck of mammals and plays a vital role in the protection of the trachea.

Trachea:
The term refers to the airway through which respiratory air travels. The rings of
cartilage within its walls keep the trachea open.
Bronchi:
The trachea divided into two main bronchi. The bronchi extend into the lungs
spreading in a tree-like manner as bronchial tubes. The bronchial tubes subdivide and
with each subdivision, their walls get thinner. This dividing of the bronchi into thin-
walled tubes results in the formation of bronchioles. The bronchioles terminate in small
air chambers, each of which contains cavities known as alveoli. Alveoli have thin walls,
which form the respiratory surface. The exchange of gases between the blood and the air
takes place through these walls.
Bronchioles or Bronchioli :
are the first airway branches that no longer contain cartilage . They are branches of the
bronchi. The bronchioles terminate by entering the circular sacs called alveoli.
Alveoli:
is an anatomical structure that has the form of a hollow cavity. Found in the lung, the
pulmonary alveoli are spherical outcroppings of the respiratory sites of gas exchange with
the blood . Alveoli are particular to mammalian lungs. Different structures are involved in
gas exchange in other vertebrates. They contain some collagen and elastic fiber, and they
are lined with epithelium. The elastic fibers allow the alveoli to stretch as they fill with
air when breathing in. They then spring back during breathing out in order to expel the
carbon dioxide-rich air. The alveolar membrane is the gas-exchange surface.

Lungs:
Lungs form the most vital component of the human respiratory system. They are
located on the two sides of the heart. They are responsible for transporting oxygen from
the atmosphere into blood and releasing carbon dioxide from blood to the atmosphere.
B. THEORITICAL AND CONCEPTUAL FRAMEWORK OF
PNEUMONIA:

Risk Factor:
Predisposing Factor: >74 years old
Entry of microorganism to nasal >High Caloric Diet
Environment
Lifestyle >Alcoho Intake
Stress >Malnourished
Age >Dehydrsted
Diet >Infection
Invasion of the respiratory
Gender

Activation of the cough

immune response

Ineffective immune response

Results to

Invading lung Parenchyma

Release of endotoxins
and exotoxins

Continuous Mucus

Hazy portion of
the chest Dyspnea

Massive Inflammation
(Pneumonia)

Altered Gas Exchange

Consolidation
 C. DISCUSSION OF THE PATHOPHYSIOLOGY
THEORETICAL:
The invading organism causes symptoms, in part, by provoking an overly
exuberant immune response in the lungs. The small blood vessels in the lungs
(capillaries) become leaky, and protein-rich fluid seeps into the alveoli. This results in a
less functional area for oxygen-carbon dioxide exchange. The patient becomes relatively
oxygen deprived, while retaining potentially damaging carbon dioxide. The patient
breathes faster and faster, in an effort to bring in more oxygen and blow off more carbon
dioxide.

Mucus production is increased, and the leaky capillaries may tinge the mucus with blood.

Mucus plugs actually further decrease the efficiency of gas exchange in the lung. The

alveoli fill further with fluid and debris from the large number of white blood cells being

produced to fight the infection.

Consolidation, a feature of bacterial pneumonias, occurs when the alveoli, which are

normally hollow air spaces within the lung, instead become solid, due to quantities of

fluid and debris.

SYMPTOMATOLOGY:

SIGNS AND SYMPTOMS: SIGNS AND SYMPTOMS

MANIFESTED BY THE PATIENT:

• Cough (with mucus-like, greenish,

√
or pus-like sputum chills with
shaking ),
√
• fever,
√
• easy fatigue,
√
• chest pain (sharp or stabbing
 increased by deep breathing or
increased by coughing),

• headache,
√
• loss of appetite,

• nausea and vomiting, √

• general discomfort,
√
• uneasiness,
√
• ill feeling (malaise),
√
• joint stiffness (rare),

• muscular stiffness (rare), rales

• Additional symptoms that may be

associated with this disease: √

• shortness of breath, √

• clammy skin, nasal flaring,

• coughing up blood, √

• tacypnea, apnea,

• anxiety, √

• stress,

• tension, √

• abdominal pain .
X. MEDICAL MANAGEMENT

A. Diagnostic Studies and Findings

IDEAL SIGNIFICANCE

Sputum Tests • Presence of blood (an indication of infection).

• Color and consistency. If the sputum is opaque and

colored yellow, green, or brown, then infection is

likely. Clear, white, glistening sputum indicates no
infection.

Blood Tests
• White blood cell count. High levels indicate
infection.
• Blood cultures. They may be performed for detecting

the specific organism causing the pneumonia, but are

not often helpful in distinguishing harmful from
harmless organisms. They are accurate in only 10% to
30% of cases, and their use should generally be
limited to severe cases.
• Detection of antibodies to S. pneumoniae.

Researchers are using specialized techniques to detect

antibodies to S. pneumoniae (immune factors that
target specific foreign invaders), but it is not clear if
they are accurate.

Urine Tests
• A urine test (NOW) can detect S. pneumonia within
15 minutes. It may identify up to 77% of pneumonia
cases and may rule out the infection in 98% of
patients who do not have S. pneumonia.
X-Rays

• White areas in the lung called infiltrates, which

indicate infection.

• Complications of pneumonia, including pleural

effusions (fluid around the lungs) and abscesses.

ACTUAL:

Complete blood count result reference unit

Blood count
WBC 5. 90 4.8-10.8 10ˆ3/ul
RBC 4.43 4.2-5.4 10ˆ/ul
Hemoglobin 13.5 12.0-16.0 g/dl
Hematocrit 40.5 37.6-47 %
Platelet 337 130-400 10ˆ3/ul
Blood indices
MCV 91.0 81-99 fl
MCH 30.5 27.0-31.0 pg
MCHC 33.4 33.0-37.0 g/dl
RDW 13.4 11-16 %
PDW 12.3 9.0-14.0 %
MPV 8.6 7.2-11.1 fl
Relative differentia
Count
Neutrophil(%) 85.9 ↑ 40-74 %
Lymphocyte 11.0↓ 19-48 %
monocyte(%) 1.9↓ 3.4-9.0 %
Eosinophils(%) 1.1 0.0-7.0 %
Basophils(%) 0.1 0.0-1.5 %
Absolute differential
Count
Neutrophil(#) 5.11 1.9-8.0 10ˆ3/ul
Lymphocyte(#) 0.65 0.9- 5.2 10ˆ3/ul
monocyte(#) 0.11↓ 0.16-1.00 10ˆ3/ul
Eosinophils(#) 0.07 0.0-0.8 10ˆ3/ul
Basophils(#) 0.01 0.0-0.2 10ˆ3/ul

Significance:

Checks for presence of HCG in the blood. To determine levels of blood

components such as RBC, WBC and hemoglobin, hematocrit and platelet.

Urine Analysis:

URINALYSIS RESULT REFERENCE Units

RANGE
Physical
characteristics Dark yellow
Color Clear
Transparency 5.0 5-6
Ph 1.015 1.003-1.035
Specific gravity
Chemical
characteristics - - mg/dl
Protein - - mg/dl
Glucose - - mg/dl
Ketone 1 up to 2 mg/dl
Urobilinogen - - mg/dl
Leukocytes - - mg/dl
Blood 0.5 - mg/dl
Bilirubin - -
Nitrite - - mg/dl
Ascorbic acid
Microscopic findings 3 2-18 /ul
Red blood cells 9 6-14 /ul
White blood cells None * /ul
Bacteria 2 * /ul
Squamous

epithelial cells
Mucus threads 15 * /ul
epithelial cells 15 * /ul
Mucus threads

Significance:

To test the presence of any bacteria and any microorganisms that will produce a

positive result to the test.

B. Treatment and Procedures

IDEAL ACTUAL

• Respiratory support with oxygen,  O2 of 2.0 mg/dL

if needed.
 cefuroxime
• Antibiotics, with the decision

based on test results for specific  ciprofloxacin

organisms or if organisms are
unknown based on individual risk
factors.

C. Medications

IDEAL ACTUAL

 Cefuroxime  Cefuroxime

 Ciprofloxacin  ciprofloxacin

 Metronidazole  Metronidazole

D. Diet

IDEAL: ACTUAL:
low-fat diet Low sodium, low fat diet
XI. NURSING MANAGEMENT

A. Actual Care Given

These are the following nursing intervention that I rendered to my patient during his

confinement.

 Established rapport to patient and significant other

 Encouraged verbalization of feelings and anxieties to provide immediate care.

 Handwashing before and after contact with patient

 To reduce transmission of microorganisms

 Promoted a safe and comfortable environment

 Maintained a quiet and calm environment

 Positioned patient safely and comfortably

 Bedside care done

 Bed making done

 Provided privacy

 Provided psychosocial support to the client

 Vital signs taken

 Monitored vital signs every four hours

 Assessed patient’s pain by using pain scale

 Monitored intake and output

 Increased fluid intake

  Encouraged patient to eat nutritious and balanced food as prescribed

 Encouraged ambulation

 To increase peristaltic movement to help his defecate

B. Problems Encountered During the Implementation of Nursing Care

Patient refused to increase his fluid intake because he feel he will vomit every

time food or water is taken through her mouth.

C. Restorative Measures Used

Restorative measures done by the student is established rapport to the client and

to the significant others. Provided privacy by proper draping. Explained to the client the

purpose of the medications. Encouraged patient to verbalized feelings and anxieties to

provide immediate remedy. Encouraged client to increase fluid intake and to have a walk

to increase peristaltic movement that will help her to defecate.

D. Evaluation

After rendering care to the patient, thus, providing his needs and comfort, the patient was

finally convinced to increase her fluid intake and to ambulate .He was always ready to

participate in performing procedures. Rapport was built between students and patient.

E. Patient Teaching

 Hygiene

 Taking a daily bath

 Nutrition

 Encouraged patient to increase fluid intake

 Encouraged patient in eating nutritious foods as prescribed

  Informed the importance of avoiding foods high in cholesterol salty foods.

 Medication

 Encouraged patient to take only the prescribed medications following the

doctors instruction in taking the medications

 Informed patient to report immediately to the doctor any signs of adverse

effects

 Informed client the importance of taking the prescribed medication.

XII. CONCLUSION

This study is beneficial not only for me as a student nurse but also to my patient. I

appreciated doing this study because it made me realized that simple pneumonia should

be given attention to prevent further complications .It is important for us to know the

signs and symptoms of pneumonia for us to manage it properly and not to worsen the

said disease.

X111. RECOMMENDATION

For the students,I recommend to apply what they have learned in this care study.

As a future nurse, we are the ones who are mostly in contact with the patient and

therefore who are most likely to know what they need. By being knowledgeable on how

to manage care for those clients suffering from Community-Acquired Pneumonia we

will be able to provide comfort to our clients. For the school, may this care study could

possibly help the nursing students. This will give them the knowledge, enhance skills,
and develop positive attitudes in providing proper management and care to their clients.

XIII1. IMPLICATION OF THE STUDY TO

A. Nursing Education

Having this care study about Community-Acquired Pneumonia, it will enable us

to upgrade our knowledge in this constantly updated modern scientific world of medicine

that will enhance our skills in providing care to our clients that have Community-

Acquired Pneumonia.

B. Nursing Practice

This study helps to improve our skills in the area and enhances our ability to

render a family-centered care especially to the client with Community-Acquired

Pneumonia . This enhances our confidence in rendering to our patient effectively. This

study imparts basic nursing skills in order for the student nurses to develop an effective

and appropriate nursing intervention.

C. Nursing Research

It is necessary to do research because the world of medicine is of

constantly updated with science and new technology. So we need to update ourselves for

new trends that will improve the lives of our patients. This research would make the

students to become more interested in facts and information about Community-Acquired

Pneumonia. This care study will provide and enhance the students learning on how to

properly manage their clients with Community-Acquired Pneumonia.