I. INTRODUCTION This is a case of a 74 year old woman who was diagnosed with Community Acquired Pneumonia. Pneumonia is an inflammation or infection of the lungs most commonly caused by a bacteria or virus. Pneumonia can also be caused by inhaling vomit or other foreign substances. In all cases, the lungs' air sacs fill with pus , mucous, and other liquids and cannot function properly. This means oxygen cannot reach the blood and the cells of the body. Most pneumonias are caused by bacterial infections.The most common infectious cause of pneumonia in the United States is the bacteria Streptococcus pneumoniae. Bacterial pneumonia can attack anyone. The most common cause of bacterial pneumonia in adults is a bacteria called Streptococcus pneumoniae or Pneumococcus. Pneumococcal pneumonia occurs only in the lobar form. An increasing number of viruses are being identified as the cause of respiratory infection. Half of all pneumonias are believed to be of viral origin. Most viral pneumonias are patchy and the body usually fights them off without help from medications or other treatments. Pneumococcus can affect more than the lungs. The bacteria can also cause serious infections of the covering of the brain (meningitis), the bloodstream, and other parts of the body. Community-acquired pneumonia develops in people with limited or no contact with medical institutions or settings. The most commonly identified pathogens areStreptococcus pneumoniae, Haemophilus influenzae, and atypical organisms (ie, Chlamydia pneumoniae,Mycoplasma pneumoniae, 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 many pneumonias, especially when caused by S. pneumoniae or influenza virus, are fatal in older, sicker patients. II. PATIENT PROFILE Name: E. Costales Age: 74 years old Sex: Female Religion: Roman Catholic Date Admitted: September 17, 2009 at exactly 11:15 AM Admission diagnosis: COPD not in exacerbation Final diagnosis: Community Acquired pneumonia (CAP)moderate Risk III. PATIENT HISTORY Chief Complaint: Difficulty of Breathing General Data: This is a case of a 74 year old female Filipino, presently residing in Adelina 3 Binan, Laguna who was admitted in Perpetual Help Hospital on September 17, 2009. History of Present Illness: 5 days prior to admission, patient had positive signs and symptoms of cough, yellowish pleghm, persistent fever and back pain. Knowing that these signs and symptoms were just forms of little discomforts, she self medicated with paracetamol. However, she noticed no changes and experienced difficulty of breathing so she sought medical consultation. IV. PHYSICAL ASSESSMENT Date Assesed: September 17, 2009 Time Assessed: Vital Signs: Blood Pressure: 110/60 Temperature: 35.7 C Pulse rate: 78bpm Respiratory rate: 26 breaths/min General appearance: The patient is awake, lying on bed, conscious and coherent with an IVF of PNSS and side drip of D5W with incorporation of aminophylline on the right arm. V. ANATOMIC AND PHYSIOLOGY OVERVIEW The Lungs The lungs are paired, cone-shaped organs which take up most of the space in our chests, along with the heart. Their role is to take oxygen into the body, which we need for our cells to live and function properly, and to help us get rid of carbon dioxide, which is a waste product. We each have two lungs, a left lung and a right lung. These are divided up into 'lobes', or big sections of tissue separated by 'fissures' or dividers. The right lung has three lobes but the left lung has only two, because the heart takes up some of the space in the left side of our chest. The lungs can also be divided up into even smaller portions, called 'bronchopulmonary segments'. These are pyramidal-shaped areas which are also separated from each other by membranes. There are about 10 of them in each lung. Each segment receives its own blood supply and air supply. Air enters your lungs through a system of pipes called the bronchi. These pipes start from the bottom of the trachea as the left and right bronchi and branch many times throughout the lungs, until they eventually form little thin-walled air sacs or bubbles, known as the alveoli. The alveoli are where the important work of gas exchange takes place between the air and your blood. Covering each alveolus is a whole network of little blood vessel called capillaries, which are very small branches of the pulmonary arteries. It is important that the air in the alveoli and the blood in the capillaries are very close together, so that oxygen and carbon dioxide can move (or diffuse) between them. So, when you breathe in, air comes down the trachea and through the bronchi into the alveoli. This fresh air has lots of oxygen in it, and some of this oxygen will travel across the walls of the alveoli into your bloodstream. Travelling in the opposite direction is carbon dioxide, which crosses from the blood in the capillaries into the air in the alveoli and is then breathed out. In this way, you bring in to your body the oxygen that you need to live, and get rid of the waste product carbon dioxide. VI. PATHOPHYSIOLOGY Virulent Microorganism Streptococcus Pneumoniae Microorganism eneters the nose( nasal passages) Passes through the larynx, pharynx, trachea Microorganism enters and affects both airway and lung parenchyma Airway damage Lung invasion Infiltration of bronchi flattening of epithelial cells Infectious organism lodges macrophages and leukocytes Stimulation in bronchioles necrosis of bronchial tissues mucus and phlegm production Alveolar collapse narrowing of air passage COUGHING Productive/non-productive Increase pyrogen in the body DIFFICULTY OF BREATHING FEVER Necrosis of pulmonary tissue Overwhelming sepsis DEATH VII. Medical Management VIII. Diagnostic Exam Chest X-ray Result: Impression: There are reticolunodular opacities on both lungfields with upward traction of left hilus. There are dilated thick walled bronchi noted on both lower lobes. Heart is not enlarged. Aortic knob is sclerotic other visualized structures are unremarkable. Findings are suggestive of Extensive PTB, Bilateral with cicatrical changes, left upper lobe.Bacteriologic correlation is suggested. Clinical Chemistry Result: Sodium: 124.9 mmol/L Normal: 135.0-148mmol/L Hematology Result: Hct: 0.29 Normal: 0.37-0.47 WBC: 23.5x10 Normal: 5.0-10.0x10 Segmenters: 0.87 Lymphocytes: 0.13 Urinalysis: Color: Light Yellow Transparency: Slightly Hazy Reaction: (pH) 6.0 Protein: +1 Glucose: negative Specific Gravity: 1.010 Pus cells: 3-4/HPF RBC: 2-3/hpf Crystals: A Urates: Many Mucus threads: few Cast: Fine Granular cast : 1-2/HPF IX. Drug Study Generic Name: Hydrocortisone Sodium succinate Brand Name: Solu-Cortef Classification: Corticosteroid, short acting Dosage: 100mg IV, q 6 hours Pharmacokinetics: Metabolism: Hepatic; half life 80-120min. Distribution: Crosses Placenta; enters breast milk Excretion: Urine Indications: Replacement therapy in adrenal cortical insufficiency Hypercalcemia; associated with cancer Short term inflammatory disorders Contraindications: Infections, especially tuberculosis, fungal infections, amoebiasis, hepatitis B, liver disease, liver cirrhosis, active or latent peptic ulcer. Adverse Reaction: Vertigo, headache, hypotension, shock, thin, fragile skin, petechiae, amenorrhea, muscle weakness. Nursing Considerations: 1. Give daily before 9AM to mimic normal peak diurnal corticosteroid levels and minimize HPA suppression. 2. Space multiple dose evenly throughout the day. 3. Use minimal dose for minimal duration to minimize adverse effects. 4. Use alternate day maintenance therapy with short acting corticosteroids whenever possible. Generic Name: Acetylcysteine Brand Name: Fluimucil Classification: Mucolytic Agent Dosage: Pharmacokinetics: Metabolism: Hepatic; half life 6.25 hr Excretion: Urine (30%) Indications: Mucolytic Adjuvant therapy for abnormal, viscid, or inspissated mucus secretion in acute and chronic bronchopulmonary disease (pneumonia,asthma,TB). Contraindications: Contraindicated with hypersensitivity to acetylcysteine; use caution and discontinue if bronchospasm occurs. Adverse Reaction: Nausea, rhinorrhea, bronchospasm especially in asthmatics, stomatitis,and urticaria. Nursing Considerations: 1. dilute with normal saline solution or sterile water for injection. 2. Administer the ff drugs separately because they are incompatible with acetylcysteine: tetracyclines, hydrogen peroxide, trypsin. 3. Use water to remove residual drug solution on the patient’s face after administration by face mask. 4. Inform patient that nebulization may produce an initial disagreeable odor, but will soon disappear. X. NURSING CARE PLAN Problem: Difficulty of breathing Diagnosis: Ineffective Airway Clearance related to increased mucus production. ASSESSME DIAGNOSI SCIENTIFI OBJECTIV INTERVENTI RATIONAL EVALUATI NT S C ES ON E ON REASON Subjective: Ineffective Increased Short term Independent: Goal half airway mucus goal: met. “nagrereklamo clearance production is 1.Assessed 1.Tachypnea, nga yang si related to often caused After 3-4 hours rate/depth of shallow After 4 hours of nanay na increase by an of intervention, respiration and respiration are nursing nahihirapan mucus underlying patient will chest movement. usually intervention, siya huminga, production illness. If expectorate present. patient dami din kasi mucus is the secretions expectorated plema eh” as effectively and 2.Lowers most 2.Elevated head diaphragm, secretion and verbalized by prevalent RR will of bed and RR decreased relative. decrease from promoting symptom, it is changed position chest from 26/min to usually 26 to normal frequently. 22/min. Objective: range of 16- expansion, caused by mobilization *RR- 26 something 20/min. and simple like expectoration allergies or of secretion. the common Long term *Dyspnea cold. Other goal: illnesses that *(+)non- result in After 3 days of productive excessive intervention, cough mucus patient will production maintain 3.Deep *Use of patent airway accessory include breathing as evidenced 3.Assisted patient facilitates muscle pneumonia, by normal RR. with frequent maximum flu and deep breathing expansion of bronchitis exercises. the lungs and smaller airways. 4.Fluids aid in 4. Encouraged mobilization increase in fluid and intake. expectorations of secretions Collaborative: 5.Aids in 5.Administered mobilization of mucolytics as secretion. indicated. (Fluimucil) 6.Fluids are required to 6.Provided replace supplemental insensible loss fluids. and aids in (IVF: PNSS) mobilization of secretions. 7.Follows progress and effects of 7.Monitored disease chest Xray, ABG process. and pulse oximetry results.