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Pulmonary Congestion Secondary To Pneumonia
Pulmonary Congestion Secondary To Pneumonia
Pulmonary Congestion Secondary To Pneumonia
Congestion
secondary to
Pneumonia
INTRODUCTION
Life is short, health should be valued
Globally, community-acquired pneumonia (CAP) is one of the
most important serious infectious diseases, with an increasing
incidence in many parts of the world and an increasing rate of
serious complications (Brown, 2013)
As part of the burden of respiratory infections, CAP is well
recognized to be a leading cause of death among the infectious
diseases (Torres, 2013).
In the Philippines, pneumonia is the third leading cause of
morbidity (2001) and mortality (1998) in Filipinos based on the
Philippine Health Statistics from the Department of Health.
The Department of Health (DOH) reported that pneumonia has
been the No. 1 killer disease in Davao City from 2010 to 2013
with a total of 2,291 deaths out of 8,258 cases.
GENERAL OBJECTIVE
the group aims to conduct a case study particularly on a
patient with oxygenation problems, present a thorough
study of the patient’s condition, and most especially, to
provide holistic and effective nursing care to the patient
by relating and implementing the knowledge that has
been imparted by the university.
SPECIFIC OBJECTIVES
Cognitive:
General Pain
“Wala akong nararamdaman na sakit pero mabilis lang ako hingalin at mapagod.”
Integumentary System
“Pakiramdam ko parang ang tuyo ng kutis ko. Ang putla putla ko na rin di naman
to ganito nuon, ngayon lang nung nagkasakit ako. Sabay to siya sa pag hihingal at
ubo ko.”
Musculoskeletal System
“Humina katawan ko lalo na nung may lagnat ako. Madali lang rin ako mapagod.”
Hair
“Wala naman akong problema sa buhok ko. Natural naman na unti unting
namumuti na siya. Wala rin akong maramdaman na pagkakati ng anit.”
Head
“Okay lang naman ulo ko. Sakto tulog ko rito sa ospital kaya di sumasakit ulo ko.
Wala naman akong mga sakit sa ulo na nararamdaman”
Eyes
“Wala akong reklamo parte sa paningin ko. Di ko kailangan mag suot ng mga
salamin. Di naman rin ako nahihilo pag nag lalakad.”
Ears
“Wala akong problema parte sa aking mga tenga. Wala naming lulmalabas at wala
naman akong naririnig na “ringing”.”
Nose and Sinuses
“Wala naman akong sipon pero hinihingal talaga ako.”
Teeth
“Wala naman akong problema sa ngipin, di naman sumasakit at wala naman akong
sira sa ngipin.”
Respiratory System
“Nahihirapan ako huminga kaya naisip naming magpa ospital. Grabe rin ang aking
ubo nun.”
Cardiovascular System
“Dumaan na ako ng pagka stroke noong 2013 kaya nag iingat na talaga ako ngayon.
May highblood rin ako ngayon.”
Peripheral Vascular System
“Okay naman ang pakiramdam ng aking mga kamay at paa di naman sila nag
mamanhid.”
Gastrointestinal System
“Wala naman akong problema sa aking pag babawas, di rin sumasakit ang aking
tiyan.”
“Ang dumi ko ay soft pero di sobrang basa, brown lang rins siya hindi pula o itim.”
Genito-urinary System
“Wala rin akong problema sa pag iihi ko sama sa aking pag dudumi.”
PHYSICAL
ASSESSMENT
General Assessment
Physical assessment of Patient “Button” was done at the Davao Medical School
Foundation Ward 2A last September 4, 2018. While patient was lying down, semi-
fowler’s position in the bed, wearing loose comfortable clothing that was
appropriate for age, gender and setting. Patient appeared tired. Patient “Button”
was oriented to time, place and person. He displayed a good attention span and was
very cooperative throughout the whole physical assessment. He displayed no
involuntary movements and was logical throughout the interview. Both nonverbal
and verbal responses were appropriate. His current weight is 64kg, current height is
172 which is a BMI of 21.63 (normal). With and IV line infusing Plain Normal Saline
Solution at 60cc/hr. Patent and infusing well.
Abnormalities: Patient appeared tired.
Vital Signs
Temperature – 38.2C
Abnormalities: High Temperature, High Pulse Rate, High Heart Rate, High Respiratory Rate and High
Blood Pressure.
Pain
Abnormalities: No abnormalities found.
Eye Assessment
Abnormalities: Eyebags.
Ear Assessment
Abnormalities: No abnormalities noted.
Abdomen Assessment
Abnormalities: No abnormalities found
Genito-Urinary Assessment
Abnormalities: No abnormalities noted.
ExtremitiesAssessment
Abnormalities: No Abnormalities found.
MentalStatus
Abnormalities: No Abnormalities found.
Upon Neurologic Assessment
Olfactory
Patient was able to identify the smell of the alcohol and the cologne.
Optic
Peripheral field intact upon confrontation
Oculomotor
Eyes exhibit PERRLA
Trochlear
Both eyes exhibit purposeful movements and as necessary
Trigeminal
Facial sensations are intact and can be felt equally and bilaterally. Patient can frown
and smile at will and jaw strength was equally bilateral.
Abducens
Both eyes show coordinated, voluntary and purposeful movement
Facial
Patient reported that he could taste his previous meal. Patient can frown, smile,
wink both eyes and purse lips
Vestibulocochlear
Patient can hear words at different distances.
Glossopharyngeal
Patient was able to swallow without pain and difficulty
Vagus
Uvula rises at the midline and patient can swallow without difficulty
Accessory
Patient can move neck both left and right, front and back without pain and difficulty.
Patient can shrug shoulders one by one and at the same time without difficulty.
Hypoglossal
Patient can protrude tongue at the midline without difficulty and can pronounce
various words properly
ETIOLOGY
PREDISPOSING FACTORS
FACTORS PRESENCE RATIONALE JUSTIFICATION
AGE PRESENT Respiratory muscle strength decreases with Patient’s age is 64 years
age and can impair effective cough, which is old, therefore he’s more
important for airway clearance. The lung vulnerable to ventilatory
matures by age 20–25 years, and thereafter failure.
aging is associated with progressive decline
in lung function. The alveolar dead space
increases with age, affecting arterial oxygen
without impairing the carbon dioxide
elimination.
Family History of PRESENT Genetic factors likely play some role in high Patient stated that his
Hypertension blood pressure, heart disease, and other father is also suffering
related conditions. However, it is also likely from hypertension.
that people with a family history of high
blood pressure share common environments
and other potential factors that increase
their risk.
PRECIPITATING FACTORS
PNEUMONI PRESEN Bacterial or viral pneumonia infections Patient is positive of
A T are quite common; however, occasionally community acquired
become complicated as a collection of pneumonia as seen in his
fluid develops in the section of the lung chart
that is infected.
SEDENTARY PRESENT A sedentary lifestyle is a type of lifestyle with Patient have lived a
LIFE STYLE little or no physical activity. A person living a sedentary lifestyle as
sedentary lifestyle is often sitting or lying down evidenced by inactive
while engaged in an activity like reading, lifestyle such as watching T.V
socializing, watching television, playing video for hours while lying on a
games, or using a mobile phone/computer for sofa. He, also, is not into
much of the day doing any light exercises at
all.
SMOKER PRESENT Tar and smoke particulates that enter the Patient stated that he can
airways and lungs with each cigarette cause consume 1 pack of cigarettes
irritation and inflammation. Over time scar a day.
tissue replaces lung tissue as the body
attempts to repair itself from repeated damage
and protect itself from further damage. This
scar tissue gradually destroys the alveoli and
bronchioles, the lung’s smallest structures, and
SYMPTOMATOLOGY
SIGNS & PRESENCE RATIONALE JUSTIFICATION
SYMPTOMS
DYSPNEA PRESENT Due to the increased volume in the body, Upon physical
there will be shifting of fluids. The fluid will assessment, the patient
be accumulated in the air spaces and cannot breathe fast
parenchyma of the lungs and leads to enough or deeply
impaired respiratory gas exchange and may enough.
cause dyspnea.
FROTHY SPUTUM ABSENT Even though the fluid in pulmonary edema During exposure, the
is a transudate, there is blood in it. This is patient did not show any
substantiated by the fact that there are manifestation of having
microhemorrhages in acute lung congestion frothy sputum.
and hemosiderin laden macrophages or
'heart failure cells' in long standing
pulmonary congestion on histology.
WBC ABOVE PRESENT The WBC is expected to rise up White blood cell count
NORMAL in response to bacterial showed above normal
infection. levels: 10.67.
BILATERAL PRESENT Crackles are often associated with Based on assessment, patient
CRACKLES inflammation or infection of the manifested bilateral crackles
small bronchi, bronchioles, and on his chest and on chest X-
alveoli. Crackles that do not clear Ray, fluid build-up was
after a cough may indicate present.
pulmonary edema or fluid in the
alveoli.
PATHOPHYSIOLOGY
DOCTOR’S ORDER
Laboratory Tests
NURSING
THEORIES
Florence Nightingale’s
Environmental Theory
Nightingale’s theory focuses on the role that the
environment plays on the patient’s overall health
The group had formulated a set of goals for the patient that she
should be able to attain to reach her optimum health.
comply
on the medications as ordered to
manage his pain and other symptoms
to
come into duty stock with the knowledge
needed for the entire shift.
The School of Nursing Faculty
continue
giving that world class care they
have been giving to patients ever since