STUDENT’S NAME: Jilkiah Mae A.

Campomanes

Name of the Patient: Feliciano Aranas Bugtay Age: 80

Diagnosis: Pneumonia

I. Brief Description of the Disease

A. Definition
 Pneumonia is an infection that inflames the air sacs in one or both lungs. It is
associated with alveolar edema and congestion that impair gas exchange.
The air sacs may fill with fluid or pus (purulent material), causing cough with
phlegm or pus, fever, chills, and difficulty breathing. Pneumonia is caused by
a bacterial or viral infection spread by droplets or by contact.

B. Risk factors
 Pneumonia can affect anyone. But the two age groups at highest risk are:
o Children who are 2 years old or younger
o People who are age 65 or older
Other risk factors include:
 Being hospitalized. You're at greater risk of pneumonia if you're in a
hospital intensive care unit, especially if you're on a machine that
helps you breathe (a ventilator).
 Chronic disease. You're more likely to get pneumonia if you have
asthma, chronic obstructive pulmonary disease (COPD) or heart
disease.
 Smoking. Smoking damages your body's natural defenses against the
bacteria and viruses that cause pneumonia.
 Weakened or suppressed immune system. People who have
HIV/AIDS, who've had an organ transplant, or who receive
chemotherapy or long-term steroids are at risk.

C. Signs and Symptoms or Clinical Manifestation

 Your symptoms can vary depending on what’s causing your pneumonia, your
age, and your overall health.
Signs and symptoms of pneumonia may include:
 Chest pain when you breathe or cough
 Confusion or changes in mental awareness (in adults 65 and older)
 Cough, which may include phlegm
 Fatigue
 Fever, sweating and shaking chills
 Lower than normal body temperature (in adults older than age 65
and people with weak immune systems)
 Nausea, vomiting, or diarrhea
 Shortness of breath

D. Management/Nursing Interventions
1. Administer oxygen as prescribed
2. Monitor respiratory status
3. Monitor for laboured respirations, cyanosis, and cold and clammy skin
4. Encourage coughing and deep breathing and use of incentive spirometer
 5. Position client in semi-fowler position to facilitate breathing and lung
expansion
6. Monitor pulse oximetry
7. Monitor and record color, consistency, and amount of sputum
8. Encourage fluids up to 3L a day to thin secretions unless contraindicated
9. Administer antibiotics as prescribed
10. Administer antipyretics, bronchodilators, cough suppressants, mucolytic
agents, and expectorants as prescribed
11. Prevent the spread of infections by handwashing and the proper disposal of
secretions

II. Patient’s Signs and Symptoms or Clinical manifestations

 Cough that produce greenish mucus.
 Shortness of breath
 Rapid, shallow breathing
 Fatigue
 Sharp or stabbing chest pain when breathing or coughing
 Fever
 ANATOMY AND PHYISOLOGY

Name of the Affected Organ

LUNGS (alveoli)

Draw and label the affected organ

Function/s:
The lungs’ main role is to bring in air from the atmosphere and pass oxygen into the
bloodstream. From there, it circulates to the rest of the body. Inside the lungs, there are tiny
air sacs that take up the oxygen you breathe in and keep your body going. Although they're
microscopic, alveoli are the workhorses of your respiratory system. The alveoli are where the
lungs and the blood exchange oxygen and carbon dioxide during the process of breathing in
and breathing out. When we breathe in, the alveoli expand to take in oxygen. When we
breathe out, the alveoli shrink to expel carbon dioxide.

Reference/Source: https://www.healthline.com/health/alveoli-function
 PNEUMONIA

Affected Organ:
Lungs (alveoli)

Etiology/Causative agent:
Viruses, bacteria, and fungi
Risk Factors:
Modifiable:
Aspiration of gastric content or the
Aspiration 1. Smoking
bacteria/virus/fungi enters the lung 2. Hospitalization
________________________________ 3. Polluted Environment
Nonmodifiable:
1. Age
2. Genetic/Inheritance
3. Chronic disease
Inflammatory response 4. Immune system problem
________________________

Cavity extend to bronchus

______________________________

Promotion of abscess into encapsulated

_________________________________________

Tissue necrosis
_________________________________________

Increased production of sputum

_________________________________________

Sputum discharge
_________________________________________

S/Sx: Symptoms include:

 Chest pain when you breathe or cough
 Cough that produces phlegm or mucus
 Fatigue and loss of appetite
 Fever, sweating, and chills
 Nausea, vomiting, and diarrhea
  Shortness of breath
Along with these symptoms, older adults and people with weak immune systems
might be confused or have changes in mental awareness, or they might have a lower-
than-usual body temperature.

Reference/Source: https://www.webmd.com/lung/understanding-pneumonia-basics

LABORATORY/DIAGNOSTIC STUDIES

Date/Exam Patient’s Normal Significance/Interpretation

Results Values
Hematology/Complete
Blood Count
         RBC
         WBC
              Eosinophil 5.14 4.50 – 5.90 Within normal range

              Basophil 1.8 0-7 Within normal range

              
2.6 0-2.5 A slightly elevated basophils may indicate a
Neutrophil chronic inflammation

         Platelet
          54.6 37-80 Within normal range

76 150-450 Low platelet level indicates thrombocytopenia,

Hemoglobin which is a well-known marker of adverse
outcome in patients diagnosed with pneumonia
         Hematocrit 15.4 14-17.5
Within normal range.
47.1 41.5-50.4
Within normal range.

Blood Gas Analysis

pH 7.367 7.350 – 7.450 Within normal range.

pCO2 18.5 35.0-45.0 A low pCO2 is compatible with a respiratory

alkalosis.

pO2 115.0 80 – 100 Elevated pO2 levels are associated with:

 Increased oxygen levels in the inhaled air.
HCO3 10.8 22 – 26 Low bicarbonate levels in the blood are a
sign of metabolic acidosis.

O2 Sat 99 >95 Within normal range.

Clinical Chemistry:
LDH 1,560.09 <480 An increase in serum lactate dehydrogenase
(LDH) activity is commonly taken to support the
presumptive diagnosis of Pneumocystis carinii
pneumonia

Reference/Source: https://pubmed.ncbi.nlm.nih.gov/7634877/#:~:text=An%20increase%20in
%20serum%20lactate,a%20variety%20of%20extrapulmonary%20disorders.

CT SACN/MRI/CHEST X-RAY/KUB RESULT:

Opacity and infiltrates are visible in both lungs and is not expanded. Heart is enlarged
(cardiomegaly).

DRUG STUDY
 Name of the Mechanism of Action Indications Side Effects Nursing
Drug (by system) Responsibilities
Generic Ceftriaxone works by Ceftriaxone is used
name: inhibiting the for the treatment of CNS: Before:
Ceftriaxone mucopeptide synthesis the infections Dizziness, Determine history of
in the bacterial cell wall. (respiratory, skin, headache, hypersensitivity
Brand name: The beta-lactam moiety soft tissue, UTI, ENT) sweating, reactions to
Rocephin of ceftriaxone binds to caused by Flushing, cephalosporins and
carboxypeptidases, susceptible seizures (high penicillins and
Classification: endopeptidases, and organisms.11 doses) history of other
Cephalosporin transpeptidases in the Organisms that are allergies, particularly
Antibiotics bacterial cytoplasmic generally susceptible Hemato: to drugs
membrane. These to ceftriaxone Blood clots,
enzymes are involved in include S. bleeding, Inspect injection
Dosage: cell-wall synthesis and pneumoniae, S. eosinophilia, sites for induration
2 gm cell division. Binding of pyogenes (group A hemolytic and inflammation
ceftriaxone to these beta-hemolytic anemia,
Frequency: enzymes causes the streptococci), leukopenia, During:
every 24H enzyme to lose activity; coagulase-negative thrombocytosis Note IV injection
therefore, the bacteria staphylococci, Some sites for signs of
Route: produce defective cell Enterobacter spp, H. Local: phlebitis (redness,
Intravenous walls, causing cell influenzae, N. Phlebitis at IV swelling, pain)
death. gonorrhoeae, P. site,
Timing: mirabilis, E. coli, After:
Klebsiella spp, M. GI: Monitor for
catarrhalis, B. Diarrhea, manifestations of
burgdorferi, and nausea, hypersensitivity
some oral vomiting, upset
anaerobes. stomach, pain Report any signs of
or swelling in bleeding.
Contraindications tongue,
Severe allergic Report loose stools
reaction to any type or diarrhea
of cephalosporin promptly.
antibiotic

Reference/Source: https://go.drugbank.com/drugs/DB01212

http://www.robholland.com/Nursing/Drug_Guide/data/monographframes/C050.html

Name of the Drug Mechanism of Indications Side Effects Nursing

Action (by system) Responsibilities
Generic name: Reversibly binds Pneumonia, lower
 Azithromycin to the 50S respiratory tract CNS: Before:
ribosomal subunit infections, Headache, Assess
Brand name: of susceptible pharyngitis/tonsilli dizziness, hypersensitivity to
Zithromax organisms and tis, gonorrhea, insomnia azithromycin,
consequently nongonococcal erythromycin, or
Classification: inhibits protein urethritis, skin and GI: any macrolide
Anti-infective, synthesis. skin structure Diarrhea, antibiotic;
macrolide infections due to nausea, gonorrhea or
antibiotic susceptible vomiting, syphilis,
organisms, otitis stomach pseudomembranou
Dosage: media, Mycobacte pain, s colitis, hepatic or
500mg/cap, 1 cap rium avium– constipation, renal impairment,
intracellulare com lactation
Frequency: plex infections,
Once daily acute bacterial Culture site of
infection
sinusitis.
Route:
Oral Contraindications During:
Hypersensitivity to Administer on an
Timing: azithromycin, empty stomach 1
erythromycin, or hr before or 2–3
any of the hr after meals.
macrolide
After:
antibiotics.
Monitor for and
report loose stools
or diarrhea

Reference/Source:
http://www.robholland.com/Nursing/Drug_Guide/data/monographframes/A092.html

https://www.rnpedia.com/nursing-notes/pharmacology-drug-study-notes/azithromycin/

Name of the Mechanism of Indications Side Effects Nursing

Drug Action (by system) Responsibilities
Generic name: Long-acting Dexamethasone and
Dexamethasone synthetic ciprofloxacin otic suspension is CNS: Before:
adrenocorticoid indicated for bacterial Headache, Assess for
Brand name: with intense infections with inflammation in dizziness, hypersensitivity.
Decadron, antiinflammatory acute otitis media and acute insomnia,
Dexamethason (glucocorticoid) otitis externa. Intramuscular depression, During:
e Intensol, activity and and intravenous injections are anxiety
Dexasone, minimal indicated for a number of
Solurex, mineralocorticoid endocrine, rheumatic, collagen,
Baycadron activity. dermatologic, allergic, CV: After:
Antiinflammatory ophthalmic, gastrointestinal, Monitor for S&S of
Classification: action: Prevents respiratory, hematologic, RESPI: a hypersensitivity
Corticosteroids accumulation of neoplastic, edematous, and reaction
, Anti- inflammatory other conditions. Oral tablets GI:
inflammatory cells at sites of are indicated for the treatment Upset
agents infection; inhibits of multiple myeloma. An stomach, Monitor and report
phagocytosis, intravitreal implant is indicated stomach S&S of Cushing's
Dosage: lysosomal for some forms of macular irritation, syndrome
6mg enzyme release, edema and non-infectious vomiting,
and synthesis of posterior uveitis affecting the nausea,
Frequency: selected chemical posterior of the eye. Various bloating
Once Daily mediators of ophthalmic formulations are
inflammation; indicated for inflammatory
Route: reduces capillary conditions of the eye.
IVTT dilation and
permeability. Contraindications
Timing: Immunosuppressi Systemic fungal infection, acute
on: Not clearly infections, active or resting
understood, but tuberculosis, vaccinia, varicella,
may be due to administration of live virus
prevention or vaccines (to patient, family
suppression of members), latent or active
delayed amebiasis. Ophthalmic use:
hypersensitivity Primary open-angle glaucoma,
immune reaction. eye infections, superficial
ocular herpes simplex, keratitis
and tuberculosis of eye. Safe
use during pregnancy (category
C), lactation, or in children is
not established.

Reference/Source: https://go.drugbank.com/drugs/DB01234
http://www.robholland.com/Nursing/Drug_Guide/data/monographframes/D022.html
https://fadavispt.mhmedical.com/content.aspx?bookid=1873&sectionid=139007808

Name of the Mechanism of Action Indications Side Effects Nursing

Drug (by system) Responsibilities
 Generic Colchicine’s exact Prevent acute attacks
name: mechanism of action of gout as CNS: Before:
Colchicine is unknown, but it’s prophylactic or Sensory Assess for
involved in leukocyte maintenance motor hypersensitivity
Brand name: migration inhibition; therapy. neuropathy
Colcrys reduction of lactic Assess for kidney
acid production by Prevent attacks of GI: or liver problems
Classification: leukocytes, resulting gout in patients Diarrhea,
Anti-gout in decreased deposits undergoing surgery. nausea, During:
drug of uric acid; and vomiting, Administer oral
interference with Acute gout, acute abdominal drug with milk or
kinin formation. gouty arthritis. pain food to reduce
Dosage: Colchicine also possibility of GI
0.5g/tab, 1 reduces the Familial upset.
tab
inflammatory Mediterranean fever
response to deposited After:
Frequency: Amyloidosis Monitor for dose-
uric acid crystals and
Twice a day suppressant related adverse
diminishes
phagocytosis. effects
Route: Dermatitis
Oral herpetiformis Monitor for early
suppressant signs of
Timing: colchicine
Hepatic cirrhosis
toxicity
Primary biliary
cirrhosis Monitor I&O
ratio and pattern
Contraindications
Contraindicated in
patients
hypersensitive to
drug and in those
with blood
dyscrasias or serious
CV, renal, or GI
disease. Use
cautiously in
geriatric or
debilitated patients
and in those with
early signs of CV,
renal, or GI disease.

Reference/Source:
http://www.robholland.com/Nursing/Drug_Guide/data/monographframes/C108.html

https://glowm.com/resources/glowm/cd/pages/drugs/c081.html

Name of the Mechanism of Action Indications Side Effects Nursing

 Drug (by system) Responsibilities
Generic name: One theory is that In general,
Paracetamol, acetaminophen acetaminophen is used CNS: Before:
Acetaminophe increases the pain for the treatment of Check that the
n threshold by mild to moderate pain patient is not
inhibiting two and reduction of CV: taking any other
Brand name: isoforms of fever. It is available over Low blood medication
Tylenol cyclooxygenase, COX- the counter in various pressure, fast containing
1 and COX-2, which forms, the most heartbeat paracetamol.
Classification: are involved in common being oral
Non-opioid prostaglandin (PG) forms. RESPI: During:
analgesic synthesis. Acetaminophen injectio Administer
Prostaglandins are n is indicated for the GI: tablets or caplets
responsible for management of mild to Nausea, whole or
Dosage: eliciting pain moderate pain, the stomach pain, crushed and give
300mg sensations. management of loss of with fluid of
Acetaminophen does moderate to severe pain appetite patient's choice.
Frequency: not inhibit with adjunctive opioid
cyclooxygenase in analgesics, and the After:
Route: peripheral tissues reduction of fever. Monitor for
IVTT and, therefore, has Because of its low risk of S&S of:
no peripheral anti- causing allergic hepatotoxicity
Timing: inflammatory effects. reactions, this drug can
Though acetylsalicylic be administered in
acid (aspirin) is an patients who are
irreversible inhibitor intolerant to salicylates
of COX and directly and those with allergic
blocks the active site tendencies, including
of this enzyme, bronchial
studies have shown asthmatics. Specific
that acetaminophen dosing guidelines should
(paracetamol) blocks be followed when
COX indirectly. administering
acetaminophen to
children.
Contraindications
Hypersensitivity to
acetaminophen or
phenacetin; use with
alcohol.

Reference/Source: https://go.drugbank.com/drugs/DB00316

http://www.robholland.com/Nursing/Drug_Guide/data/monographframes/A006.html
https://www.nursingtimes.net/archive/paracetamol-22-04-2004/

NURSING CARE PLAN

Defining Nursing Scientific Analysis Goal of Care Nursing Rationale
Characteristics Diagnosis (short term) Interventions

Subjective Ineffective Alveoli are tiny air After 3-4 Independent:

Cues: airway sacs in your lungs hours of 1. Assess the rate, 1.Tachypnea, shallow
“Maglisod kog clearance that take up the appropriate rhythm, and respirations and
ginhawa.” related to oxygen you nursing depth of asymmetric chest
increased breathe in and intervention, respiration, movement are
sputum keep your body the patient chest frequently present
production going. Although will display movement, and because of the
Objective as evidenced they're patent use of discomfort of moving
Cues: by cough and microscopic, alveoli airway. accessory chest wall and/or fluid
 HR: 121 dyspnea are the workhorses muscles. in the lung due to a
 RR: 36 of your respiratory compensatory
 O2 Sat: 75% system. When you response to airway
breathe in, the obstruction. Altered
alveoli expand to breathing patterns
take in oxygen. may occur together
When you breathe with accessory
out, the alveoli muscles to increase
shrink to expel chest excursion to
carbon dioxide. facilitate effective
When there is an breathing.
infection, it causes 2. Assess cough 2. Coughing is the
the alveoli to effectiveness most effective way to
become inflamed and remove secretions.
and fill up with productivity Pneumonia may cause
fluid or pus. That thick and tenacious
can make it hard secretions in patients.
for the oxygen you 3. Observe the 3.Changes in sputum
breathe in to get sputum color, characteristics may
into your viscosity, and indicate infection.
bloodstream, odor. Report Sputum that is
which eventually changes. discolored, tenacious,
causes difficulty in or has an odor may
breathing. increase airway
resistance and
warrant further
intervention.
4. Assess the 4. Airway
patient’s clearance is hindered
hydration with inadequate
status. hydration and
thickening of
5. Elevate the secretions.
head of the 5.Doing so would lower
bed, change the diaphragm and
position promote chest
frequently. expansion, aeration of
lung segments,
mobilization, and
expectoration of
6. Teach and secretions.
assist the 6. Deep breathing
patient with exercises facilitates
proper deep- maximum expansion
breathing of the lungs and
exercises smaller airways, and
improves the
7. Maintain productivity of cough.
adequate 7. Fluids,
hydration by especially warm
forcing fluids to liquids, aid in the
at least 3000 mobilization and
mL/day unless expectoration of
contraindicated secretions. Fluids help
maintain hydration
and increases ciliary
action to remove
secretions, and
reduces the viscosity
of secretions. Thinner
8. Assist and secretions are easier
monitor effects to cough out.
of nebulizer 8. Nebulizers humidify
treatment the airway to thin
secretions and
facilitates liquefaction
and expectoration of
Dependent: secretions.
1. Administer
medications, as
ordered. 1. Mucolytics increase
or liquefy respiratory
secretions. Expectorants
increase productive
cough to clear the
airways. They liquefy
lower respiratory tract
secretions by reducing
its viscosity.
Bronchodilators are
medications used to
facilitate respiration by
dilating the airways.
Analgesics are given to
improve cough effort by
reducing discomfort,
but should be used
cautiously because they
can decrease cough
2. Assist with effort and depress
bronchoscopy respirations.
 and/or 2. Bronchoscopy is
thoracentesis, if occasionally needed to
indicated. remove mucous plugs,
drain purulent
secretions, obtained
lavage samples for
culture and sensitivity.
Thoracentesis is done to
drain associated pleural
effusions and prevent
atelectasis.
Reference/Source: https://nurseslabs.com/pneumonia-nursing-care-plans/
https://www.lung.org/lung-health-diseases/lung-disease-lookup/pneumonia/learn-about-
pneumonia#:~:text=The%20infection%20causes%20the%20lungs,%2C%20chills%2C
%20and%20trouble%20breathing.