SULTAN KUDARAT EDUCATIONAL INSTITUTION

College of Nursing and Education, College of

Midwifery &Technical Vocational Courses
Tacurong City, Sultan Kudarat

A Simple Case Study on Community Acquired Pneumonia

In Partial Fulfillment of the Requirement on the Degree of
Bachelor of Science in Nursing

Submitted by:
Rafanan,Glycine Ariane Jem
Napao,Kerks Von Gladiel A.
Saliling, Mohammadin M.
Mulimpay, Amerah M.
Padios, Kyla Marie T.
Sabdula, Noraima S.
Pagayao, Uzama E.
Orbigo, Desiree D.
Ramadan,Dalal S.
Quezon,Nerish S.
Salik,Johaira S.

Clinical Instructor:
Princes C. Arandilla,RN,RM,MMHEA

Practice Clinical Instructor:

Princess Clennie E. Almazan,SN
Sairah Salibon Salim,SN

September 2023
TABLE OF CONTENTS

INTRODUCTION

NURSING ASSESSMENT

PHYSICAL EXAMINATION

ANATOMY AND PHYSIOLOGY

DOCTOR’S ORDER

LABORATORIES AND INTERPRETATIONS

DRUG STUDY

NURSING CARE PLAN

REFERENCES
INTRODUCTION

Background of the study

This is a case of a 68 year old woman who was diagnosed with Community Acquired Pneumonia
Community-acquired pneumonia (CAP) is a disease in which individuals who have not recently been
hospitalized develop an infection of the lungs (pneumonia). CAP is a common illness and can affect
people of all ages and often causes problems like difficulty in breathing, fever, chest pains, and a cough.
CAP occurs because the areas of the lung which absorb oxygen (alveoli) from the atmosphere become
filled with fluid and cannot work effectively. Community acquired pneumonia occurs throughout the
world and is a leading cause of illness and death. Causes of CAP include bacteria, viruses, fungi, and
parasites. CAP can be diagnosed by symptoms and physical examination alone, though X-rays,
examination of the sputum, and other tests are often used. Individuals with The kind of disease
sometimes require treatment in a hospital and are primarily treated with antibiotic medication.
Community-acquired pneumonia develops in people with limited or no contact with medical institutions
or settings. The most commonly identified pathogens are Streptococcus pneumonia, Haemophilus
influenza, and atypical organisms (ie, Chlamydia pneumonia, Mycoplasma pneumonia, Legionella sp).
Symptoms and signs are fever, cough, pleuritic chest pain, dyspnea, tachypnea, and tachycardia.
Diagnosis is based on clinical presentation and chest x-ray. Treatment is with empirically chosen
antibiotics. Prognosis is excellent for relatively young or healthy patients, but much pneumonia,
especially when caused by S. pneumonia or influenza virus, are fatal in older, sicker patients.

GENERAL OBJECTIVES

At the end of this study, the Nursing student will able to have a deeper understanding of what is
Community Acquired Pneumonia and the understanding of how we could provide appropriate
care/intervention for our client with this particular disease.

SPECIFIC OBJECTIVES:

At the end of this study the nursing student will be able to:

 To understand and identify the underlying cause of community acquired pneumonia ;

 To know the biographic data and medical history of the patient;

 To discuss the anatomy and physiology of the lungs;

 To know the drugs mechanism of action, indication, contraindication, side effect and nursing
responsibility;

 To establish essential nursing intervention to be implemented for the patient wellness and
recovery; and

 To establish a discharge planning for the patient.

NURSING ASSESSMENT

Patient Profile

Patient Y, a 68 years old, Filipino female who was born on August 16, 1955 in Poblacion Buluan
Maguindanao. She is currently living at Tumbao Mangudadatu Maguindanao. Her religion is Islam. Her
primary language is Maguindanaon. She was admitted last September 23, 2023 at 10 in the morning
with the chief complaint “Inuubo ako, nahihirapan ako huminga,” as verbalized. Her admitting physician
was Dr. Esmael Acob.

History of Present Illness

A few days prior to admission, the client has on and off difficulty of breathing, productive cough
associated at unconverted fever, body malaise and loss of appetite. On the following day, September 23,
2023 she seeks consultant at SKDH at 10:00 in the morning. 3 days during admission, upon seeing the
patient last September 26, 2023 she was able to communicate with us. During our assessment with the
patient we seen her with the following drugs Salbutamol, Norgesic Forte, Cetriaxone, Azithromycin and
NAC.

Past Health History

Patient has been diagnosed with asthma since childhood, which improved during puberty, but then
reappeared four years ago. Patient reported three episodes of pneumonia over the past 10 years. She
did not endorse recent international travel. Patient reported that she had experienced having HPN,
DDM, and OBA. Whenever she smells and inhales pollutants and fume insecticides her pneumonia is
triggered. She added that when she inhales these allergens, she has chest tightness at dyspnea.

FAMILY HISTORY

The health background of their family and relatives shows that most of their family members are
healthy. There are twelve siblings,8men and 4women. The patient has 8 children's all of whom are
healthy and not sick. Only the patient have ever had health problem. And this was the only thing that
was talked about during the conversation, according to the patient and their son.

ENVIRONMENTAL HISTORY

The patient environmental history indicates that they mentioned a clean environment, far from a
river,and the water they consume is also mineral.
PHYSICAL EXAMINATION

MEASUREMENT: Height:151cm

Weight:53 kg

BMI:23.24

Vital signs: BP:110/70

RR:23 bpm

PR:83 bpm

Temp:37 °c

SKIN

The skin of the patient is brown in color and smooth not dry, The patient also have scar in her both
lower extremities.

HEAD

The patient head is symmetrical,her hair is smooth not dry ,the Color of hair is black and white.

EYE

The eyes are symmetrical, eyebrows are black in color and the patient can see clearly.

EAR

The external pinna is abnormal because not the same, and has no discharge the color is brown same as
the skin, There is no lesion noted and the patient can hear properly.

NOSE

The patient nose is symmetrical in size, there is no lesion and discharge noted, the patient can smell
properly but cannot breath properly.

MOUTH

The patient mouth lips is smooth not dry, there is no lesion inside the tongue is not dry and the color is
pink.
NECK

The patient can move her neck properly ,the color is the same as the body, there is no lesion noted ,The
skin is not dry.

CHEST

The chest is symmetrical ,no lesion noted, the patient breast is symmetrical, the breath sound is
abnormal.

ARM

The patient arm is symmetrical ,there is no lesion and scars in her arm and forearm ,the color is the
same as the body ,the fingers nails are long and yellowish.

ABDOMEN

NO lesion and abdomen pain is reported.

LEGS

The patient leg is symmetrical in size,the color is same as the body,it has scars in her leg.

TOE

The toe of the patient is symmetrical in size,It has scars and the color is brown. The foot nails is
yellowish and the other is dead.
ANOTOMY AND PHYSIOLOGY

Anatomy Of The Lungs

Right lung

The lung on your right side is divided into three lobes: the superior, the middle and the inferior. It’s
shorter than your left lung, but also wider than your left lung. Both of your lungs are covered with a
protective covering called pleural tissue.

Left lung

Your left lung has two lobes: the superior and the interior. Your left lung is smaller than the right
because your heart is where the middle lobe on your left lung would be. Your left lung has two parts
that your right lung doesn’t have: the cardiac notch (where your heart fits) and the lingula, an extension
of the superior lobe.
Pharynx

Your pharynx (throat) is a multitasking muscular funnel that helps you breathe and directs food and
liquid to your digestive system. You can keep your pharynx healthy by quitting smoking and protecting
yourself from infections.

Larynx

Your larynx is a hollow tube in the middle of your neck, just above your trachea (windpipe) and behind
your esophagus. It makes it possible for you to make sounds, which is why it’s also called your voice box.
It also lets air pass from your throat to your trachea and on to your lungs.

Trachea

The trachea is the long tube that connects your larynx (voice box) to your bronchi. Your bronchi send air
to your lungs. Your trachea is a key part of your respiratory system. The trachea is made of rings of
cartilage. It is lined with cells that produce mucus. This mucus keeps allergens, dust particles or other
debris out of your lungs.

Thorax

The Thorax is an irregularly shaped cylinder with a narrow opening, called as superior thoracic aperture;
and inferiorly it is a relatively large opening called as inferior thoracic aperture. The superior thoracic
aperture is open from where it enables the continuity of the thorax together with the neck; whereas the
inferior thoracic aperture is closed by the diaphragm.

Bronchi

The bronchi are the two large tubes that carry air from your windpipe to your lungs. You have a left and
right main bronchus in each lung. After the main bronchi, these tubes branch out into segments that
look like tree branches. Many respiratory conditions, such as asthma or bronchitis, can affect your
bronchi.

Bronchial Tubes

Bronchial tubes are the semi-rigid, muscular structures that carry air to the lungs. The purpose of the
lungs is to get oxygen to the blood where it can be transferred to the cells of the body. The lungs are
spongy and a pinkish/grey color. The bronchial tubes are lined with mucus and cilia that carry unwanted
things out of the lungs. The smooth muscle of the bronchial tubes and bronchioles is flexible and can
change their diameter to change the amount of air moving through the passageway.

Bronchiole

The bronchioles or bronchioli are the smaller branches of the bronchial airways in the lower respiratory
tract. They include the terminal bronchioles, and finally the respiratory bronchioles that mark the start
of the respiratory zone delivering air to the gas exchanging units of the alveoli.
Alveoli

Alveoli are tiny, balloon-shaped air sacs located at the end of the bronchioles, the branch-like tubes in
the lungs. The alveoli move oxygen and carbon dioxide (CO2) molecules into and out of your
bloodstream.

DOCTOR’S ORDER

09/23/23  Please admit patient to room of choice under the service of

Dr. Acob
 Secure consent for admission
 Diet as tolerated
 IVF: PNSS 1L @ 80cc/hr

 Labs:

CBG, PC, ECG 12L

UA

Chest X-ray PA view

ABG

S, Na, S, K

MEDS:

 Norgesic Forte, 1tab TID PRN for headache

 Ceftriaxone 2gm IV OD ANST

 Azithromycin 500mg/tab, 1tab OD

 NAC 600mg/tab 1tab OD in ½ glass H2O

 S/O: Monitor VS q4h

Monitor I&O qshift

 Dr. Acob informed refer accordingly

9/24/23  DOB
  >Salbutamol nebulization’s q8h

 Refer

LABORATORIES AND INTERPRETATIONS

Test Result Normal Range Interpretation

Hemoglobin 146 g/L 120 – 160 g/L Normal
Platelet 286 150 - 400 Normal
Segmenter 0.64 0.55 - 0.65 Normal
Lymphocyte 0.28 0.20 - 0.40 Normal
Monocyte 0.07 0.03 - 0.07 Normal
Eosinophil 0.05 0.02 - 0.05 Normal
Hematocrit 43% 40% - 50% Normal

URINALYSIS

Test Result Interpretation

Urinalysis Color: Dark Yellow Presence of infection and acid
Transparency:
Slightly hazy
Specific Gravity: 1
010
Reaction: Acidic
Sugar Trace Normally, urine contains very little or no glucose.
Albumin Negative Not present
Bacteria Moderate Considering had slightly infection or had UTI
White Blood 3-7 Indicates infection, inflammation, and contamination.
Cell
Red Blood 0-1 It is a sign of infection in urinary tract.
Cell
Uric Acid Rare May indicate severe liver disease, low protein diet, heavy metal
Crystals poisoning, Wilson’s disease or some type of cancer.
DISCHARGE PLANNING

MEDICATION

Ceftriaxone Sodium; 1 tab q 12 h - Anti-infective –

Tramadol Hydrochloride; 1 tab q 12 h - Analgesic –

Ranitidine Hydrochloride; Anti ulcerative drug

EXERCISE

Light/walking exercise - deep breathing exercise

TREATMENT

Taking medications as prescribed helps the patient0 conditions to prevent further complications
following your healthcare providers instructions regarding activity, exercise and follow up checkup.

HEALTH TEACHING

Taking medications after meals to prevent abdominal upset along with Ranitidine Hydrochloride to
decrease the risk of having ulcerative colitis.

OUT PATIENT

The patient will be able to verbalized understanding of causative factors and appropriate interventions
of his condition.

DIET

Increased protein intake to provide muscle tissues growth. Provide low salt diet to preventi fluid
accumulation in between cells.

SUPPORT SYSTEM

Assess level of anxiety of the client over Pneumothorax. - Determine whether he doesn't want any
support system or offer additional comfort to the client.
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June 2018.

"Pneumonia Causes – Mayo Clinic". www.mayoclinic.org. Retrieved 2015-05-18.

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