Case Study Pneumonia by pcherukumalla

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    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.

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


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.

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.

                                    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.
                                                  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


Increase pyrogen in the body                             DIFFICULTY OF BREATHING


                                Necrosis of pulmonary tissue

                                Overwhelming sepsis

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

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

     Metabolism: Hepatic; half life 80-120min.
     Distribution: Crosses Placenta; enters breast milk
     Excretion: Urine
     Replacement therapy in adrenal cortical insufficiency
     Hypercalcemia; associated with cancer
     Short term inflammatory disorders
     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


     Metabolism: Hepatic; half life 6.25 hr
     Excretion: Urine (30%)
       Mucolytic Adjuvant therapy for abnormal, viscid, or inspissated mucus
secretion in acute and chronic bronchopulmonary disease
       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.

   NT        S        C                           ES                  ON         E                        ON

 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.
                                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
                                                exercises.         the lungs and

                                                                    4.Fluids aid in
                                                4. Encouraged       mobilization
                                                increase in fluid   and
                                                intake.             expectorations
                                                                    of secretions

                                                                    5.Aids in
                                                5.Administered      mobilization of
                                                mucolytics as       secretion.

                    6.Fluids are
                    required to
6.Provided          replace
supplemental        insensible loss
fluids.             and aids in
(IVF: PNSS)         mobilization of

                    progress and
                    effects of
chest Xray, ABG
and pulse
oximetry results.

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