TABLE OF CONTENTS

GENERAL OBJECTIVES/SPECIFIC OBJECTIVES…………...…1

INTRODUCTION OF CASES…………………………………….….2
BIOGRAPHIC OF DATA…………………………………….………..3
HEALTH HISTORY…………………………………………………....4
GORDON FUNCTIONAL ASSESSMENT…………………….….…5
ANATOMY AND PHYSIOLGY……………………………................9
PATHOPHYSIOLOGY………………………………………………...12

PHYSICAL ASSESSMENT………………………………………...…13

NURSING MANAGEMENT…………………...................................17

DISCHARGE PLANNING…………………………………………......18
Objectives This case study is aimed to broaden the student’s knowledge
for Community Acquired Pneumonia by obtaining sufficient information
which could serve as a guide for student nurses who will be focusing on
the same case and it is also designed to enhance skills and attitudes in
the application of nursing process and management of the procedure.

Specific Objectives To gain enough knowledge and understand the

entire course of the procedure. To know the client’s personal data, her
family profile past health history, current medical history, and physical
assessment. To review the anatomy and physiology of the respiratory
system. To correlate the results of the diagnostic procedures to its
normal values. To formulate the drug study. To develop an effective
nursing care plan in which the client may benefit. To identify patient’s
health needs and problems in order to identify goals to promote the
general health of the patients by providing proper interventions
through the application of nursing process.
 INTRODUCTION

Pneumonia is a disease known to humanity from antiquity. Pneumonia is an

acute inflammation of the pulmonary parenchyma that can be caused by various
infective and non-infective origins, presenting with physical and radiological
features compatible with the pulmonary consolidation of a part or parts of one or
both lungs (Seaton, Seaton, Leitch, & Crofton, 2000). Pneumonia signifies a
pulmonary inflammatory process. The most significant and striking l. Feature of
which is consolidation (Kasper et al., 2005). Community acquired pneumonia is an
acute. Illness acquired in the community with symptoms suggestive of LRTI.
Together with the presence of a chest radiograph of intra-pulmonary shadowing
which is likely to be new and has no clear alternative cause (Seaton, Seaton,
Leitch, & Crofton, 2000). Pneumonia is one of the leading causes of death and
morbidity, both in developing and developed countries and is the commonest
cause (10%) of hospitalization in adult and children (Hall et al., 20011) Increasingly
newer microbiological agents some of which are well known and some are very
new pathogens has revolutionized the understanding of pneumonia, and this led
to the extensive use of modern antibiotics (J. Bartlett, 2000). In the late twentieth
and twenty-first century, newer microbial agents have emerged like –
opportunistic lung infection in patients with HIV infection and post organ
transplant patients (J. Bartlett, 2000). All these have led to the need for an
understanding of the immunological status of the individual. With the beginning
of an antibiotic era, the mortality rate leveled off and remained constant. This
mortality rate is heavily weighted against elderly. This predilection of pneumonia
for elderly is not new and led William Osler in 1898 to describe as ‘friend of the
aged’ J. (G. Bartlett et al., 2000). The actual incidence of pneumonia acquired in
the community is unknown and undoubtedly primary care physicians treat many
pneumonia episodes as ‘lower respiratory tract infection’ or ‘bronchiolitis’
without recourse to chest radiographs (Stocks, Turnidge, & Crockett, 2004).
BIOGRAPHIC DATA

Patient Kabaling, Dangenan Elia , a maguindanaon female, 67 years old was

born on May 19. 1955 at Paglat, Maguindanao, Sultan Kudarat where she lived.
She was admitted on April 29, 2023 at 10 am, She was admitted at Sultan Kudarat
Doctors Hospital.

HEALTH HISTORY

According to the pt. she was admitted multiple times with the same condition.

PRESENT HEALTH HISTORY

Condition starter last week ago as onset of productive cough, fever tolerated few
days PTA accompanied by difficulty of breathing. When her condition are getting
worsened, her with the family decided to send her to the hospital for the
admission and further medication.

PAST HEALTH HISTORY

According to the patient she was admitted multiple times before with the same
reason “Community Acquired Pneumonia”.

FAMILY HISTORY

According to the patient her mother and his father has history of hypertension.
And her father died because of the chronic diabetes accompanied by
hypertension.
ENVIRONMENTAL HISTORY

According to the patient there environment is unsafe because of the scattered

trash like plastics, and hazardous because of the undisciplined vehicle but because
they customary and their whole clan and ancestor was lived there that’s why they
also lived there. They use to drink tap water. Their house is near at the road and
river that’s why she can immediately inhale a polluted air.

PSYCHOLOGICAL AND CULTURAL HISTORY

According to the patient the language they use in communicating is

maguindanaon and regularly they practice samba.

LIFESTYLE

According to the patient she likes to eat vegetables and the dish she likes is
afritada and adobong manok.

PATTERNS OF HEALTH CARE

According to the patient every time she felt ill she immediately drink a drugs for
cough, etc. But sometimes she drink some herbal medicine and if her condition
will not improve and got worst that the only time she will seek medical advice or
go to hospital.
GORDON’S FUNCTIONAL HEALTH PATTERN
Health Perception and Health Management

Prior Hospitalization:

According to the patient, when she got sick or any illness she go first to the
herb doctor to be treated rather than to hospital. She already know that she had
a condition but she still don't want to go to the hospital because she believe that
it can be treated by the healer on their place.

During Hospitalization:

According to the patient since her condition become worsen, she already
decide to consult to the doctor and listen on what is good to her especially in her
health.

2. Nutrition/metabolism Pattern

Prior Hospitalization:

According to the patient, she eats more of fruits and vegetables, eats her
meal thrice a day with snack in between, can drink up to 1.5L of water 4-5 glasses
a day, drinks coffee in the morning and in the afternoon and she claimed has no
allergies in any foods.

During Hospitalization:

According to the patient, she now eat only the foods that prescribed to her
and healthy such as fruits and vegetables.

3. Elimination Pattern

Prior Hospitalization:

According to the patient she eliminate 2-3 time a day and urinates 3 times a
day without any discomfort.

During Hospitalization:
 According to the patient, she voids 1-2 times a day her urine color is yellow.
There is no discomfort during urinating.

4. Activity and exercise Pattern

Prior Hospitalization:

The patient is ambulates within the house, she does household chores, she
takes a walk at their neighbors to visit and buy at the store. She also does simple
exercise on the upper and lower extremities by means of shaking and stretching
and able to bath herself.

During Hospitalization:

Now that she admitted, everything change in her activities because of her
condition and her children are the one who do cleaning in their house and takes
good care of her.

5. Sleep/Rest Pattern

Prior Hospitalization

The patient stated, she can sleep for 7-8 hours per night, her earliest time
in going to sleep 8:30 pm and wakes up at 4 am. She sometimes takes a nap at
noon about 1-3 hours, but patient experienced difficulty of sleeping sometimes
but she read bible before sleeping to easily sleep she doesn’t uses any medication
to promote sleep.

During hospitalizations

The patient is distracted and sleep interrupted due to discomfort,

administration of medication and visitors, but with rest intervals usually naps for
4 to 5 hours.

6. Cognition and Perception Pattern

Prior Hospitalization
 According to the patient she can communicate and understand well. She is
conscious and alert. She loves to do conversation with her family and to her
neighbors.

During Hospitalization

According to the patient she can communicate and understand but

sometimes she become confused and she just only wants to rest because of her
discomfort.

7. Self-Perception/Self Concept Pattern

Prior to hospitalizations

The patient manage to practice healthy lifestyles so as not too seek medical
condition, she consider herself as a strong mother, happy for life as a mother and
wife. She feel good all the time and continue her simple lifestyle.

During hospitalizations

Now that the patient was admitted, stated that she slightly weak but still
manages to appear calm and relaxed, and need some rest to feel better, within a
few days she can have now fast recovery. Hopeful to be relieved and treated.

8. Role-Relationship Pattern

Prior to hospitalizations

The patient is married with children’s, close to her grandchildren and loves
her family so much. Well-supported and loved by her family with close
relationship.

During hospitalizations

According to the patient, well- supported by the family and still plays the
role of a mother despite condition by means of reminding important matters to
her children.
9. Sexuality reproduction pattern

Prior to hospitalizations

The patient is married, they intercourse with her husband once a week.
She has no history of Sexually Transmitted Disease or any disease affecting her
genital.

10. Coping- Stress Tolerance Pattern

Prior Hospitalization:

Before hospitalization, she do communicating with her children and to her

neighbors if she feel stress. She also do gardening as part of her coping stress.

During Hospitalization:

Now that the patient is admitted she still wants to rest and lay down on
her bed that doing anything. She only make conversation with her children lesser.

11. Value-Belief Pattern

Prior hospitalization:

She is a catholic and they are attending mass every Sunday. She believe
that everything happens has a reason. She also strongly believe that God is a
saviour.

During Hospitalization

According to the patient, she still have hope and still believe that
everything happens for a reason. The patient always prays to God for guidance
and a past recovery, and she always thanks God for all, despite of the hardships in
her life.
ANATOMY AND PHYSIOLOGY

ANATOMY
 PHYSIOLOGY

Structure Location Function

Sinuses Sinuses are air-filled The lining of the sinuses
spaces located within produces mucus that
the bones of the skull helps to moisturize and
and face. clean the nasal
passages.
Pharynx It is located in the The pharynx serves as a
back of the throat and passageway for both air
extends from the base and food.
of the skull to the level
of the sixth cervical
vertebra
Larynx Also known as the The larynx is involved in
voice box located in the cough reflex, which
the neck between the helps to clear the airway
base of the tongue of mucus, debris, and
and the trachea other irritants.
Trachea The trachea, also Provide a pathway for
known as the air to flow into and out
windpipe, is a tube- of the lungs.
shaped structure that
is part of the
respiratory system
Lungs Pair of cone-shaped Facilitate the exchange
organs located in the of oxygen and carbon
chest that make up dioxide between the air
the primary organs of and the bloodstream.
the respiratory
system.
Bronchial Tube The bronchial tubes, known as bronchi, are
 also known as bronchi, part of the respiratory
are part of the system and are located
respiratory system in the chest Provide a
and are located in the pathway for air to flow
chest in and out of the lungs.
Bronchioles Bronchioles are the Responsible for
smallest branches of delivering air to the
the bronchial tubes, alveoli
which are part of the
respiratory system
Alveoli The alveoli are small, They are the primary
thin-walled sacs site of gas exchange
located at the ends of between the air and the
the bronchioles in the bloodstream
lungs
 PATHOPHYSIOLOGY

The pathophysiology of Community Acquired Pneumonia involves both

host defense and microbial virulence factors. Constant exposure to contaminated

air and frequent aspiration of nasopharyngeal flora makes lung parenchyma

susceptible to virulent microorganisms, commonly reaching the lower respiratory

tract as inhaled and contaminated microdroplets. Mucociliary clearance and

cough reflex are important initial defenses against infection and can be inhibited

by neurologic diseases and conditions that impair the mucociliary mechanism

DROPLETS NASOPHARYNX
MICROASPIRATION
NASOPHARYNX
 ↓IMMUNE

FUNCTION
PNEUMONIA
↓CLEARANCE
PHYSICAL EXAMINATION

On examination, patient is:

Drowsy and Lethargic

Vitals:

 Temp: 36. 2°C

 BP: 120/70 mmHg
 PR: 90 bpm
 RR:30bpm

Skin:

 Light brown
 Evenly colored skin tone
 Skin is dry

Hair:

 Hair is black
 Long ang wavy
 Slightly oily
 Smooth
 (-) infection

Scalp:

 (+) dandruff
 (-) lesion or lump.
 (-) no swelling or tenderness
Eyes:

 Equal movement of eyebrow

 Pupil is equal
 The color of the pupil is black
 Lashes are short

Face:

 Has a mole in the cheek and chin

 Symmetric facial movement

Ears:

 Good hearing
 Symmetrical , no discharges
 (-) tenderness

Nose:

 Uniform color
 Symmetric
 (-) tenderness

Mouth:

 Lips is symmetrical
 Dry lips
 Pale lips
 No presence of lesions or ulcer
 Slightly pale color of the tongue
 3 teeth are remove

Neck and Throat:

 Have mole
  Difficultly moving the neck

Nails:

 Fingernail and toenails are slightly clean and not to long

Extremities:

 Symmetrical in size and length

 Muscle: symmetrical in size
 Bone: no presence of bone deformities
 Joints: no swelling and tenderness
 NURSING MANAGEMENT
 Assess respiratory symptoms. Symptoms of fever, chills, or night sweats in a
patient should be reported immediately to the nurse as these can be signs
of bacterial pneumonia.
 Assess clinical manifestations. Respiratory assessment should further
identify clinical manifestations such as pleuritic pain, bradycardia,
tachypnea, and fatigue, use of accessory muscles for breathing, coughing,
and purulent sputum.
 Physical assessment. Assess the changes in temperature and pulse;
amount, odor, and color of secretions; frequency and severity of cough;
degree of tachypnea or shortness of breath; and changes in the chest x-ray
findings.
 Assessment in elderly patients. Assess elderly patients for altered mental
status, dehydration, unusual behavior, excessive fatigue, and concomitant
heart failure.
 Encourage fluids up to 3 L a day to thin secretions unless contraindicated.
 Administer antipyretics, bronchodilators, cough suppressants, mucolytic
agents, and expectorants as prescribed.
 Assess client’s positionin in semi-Fowler position to facilitate breathing and
lung expansion frequently and ambulate as tolerated to mobilize secretions
 Provide a balance of rest and activity, increasing activity gradually.
 DISCHARGE PLANNING
MEDICATION:

- Medication should be taken as ordered and prescribe by the physician to

avoid any complication and help manage the condition of the patient
- Cefixime 200mg/tab BID x 7days
- NaHCO3 650mg/tas TID
- FeSO4 + FA /tas TID
- Losartan 100mg/tas OD at 6am
- Febuxostat 40mg/tas as OD
- Carvedilol 6.25mg/tas OD
- Essentiale forte 2 tabs TID x 14days
- Legalon 140mg/tas TID x 14days
- Gliclazide 80mg/tas BID
- Betahistine 24mg/tas qrn as needed for dizziness
EXERCISE:

- Encourage to do mild exercise such as walking

- Instruct to avoid strenuous activities such heavy objects.
TREATMENT:

- Remind the importance of taking medication in the right time and right dose.
- Sleep in a room with good ventilation
- Limit your activity to avoid fatigue
HYGIENE:

- Must take a bath daily and do oral care

- Keep your hands clean
- Maintain proper hygiene
DIET:

- Diet as tolerated is advice by attending physician to sustain her nutritional

needs
- Renal diet, low salt low fat diet, diabetic diet.
 - Feed in upright position
- Do not feed if dyspneic
OUT PATIENT: Instruct the patient to attend follow up check up gave by physician.

A SIMPLE CASE STUDY

OF COMMUNITY ACQUIRED PNEUOMONIA

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS ON

THE DEGREE OF BACHELOR OF SCIENCE IN NURSING

PRESENTED BY:
TABIRAO, ASHLEY PAUL

TAMANO, MAE ALEXES

TMABAK, REHAN

TAMONDONG, JUNABETH

TATAK, NADHEA-NOR

TENDING, ALJAHER

UNTONG, ROFAIDA

UPAM, SALAHUDIN

UTTO, BAI PUTRA

UTTO, LOVELY ROSE

VERNEL,ZENNETE GEANNE

VILLANUEVA, ANDREI MIGUEL

ZAMAN, RAISA

PRESENTED TO:
CHRISTIAN G. DELA CRUZ, RN
ARMANDO G. CABAÑA, RN
CLINICAL INSTRUCTOR