Community-acquired pneumonia (CAP) is a term used to describe one of
several diseases 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. CAP occurs because the areas of the lung which absorb oxygen (alveoli) from the atmosphere become filled with fluid and cannot work effectively.
CAP 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 CAP sometimes
require treatment in a hospital.
SIGNS AND SYMPTOMS difficulty in breathing, fever,
chest pains, cough TYPES OF CAP
Typical pneumonia usually is caused by bacteria such as Streptococcus pneumoniae. A
typical pneumonia usually is caused by the influenza virus, mycoplasma, chlamydia, legionella, adenovirus, or other unidentified microorganism. The patient’s age is the main differentiating factor between typical and atypical pneumonia; young adults are more prone to atypical causes,5,6 and very young and older persons are more predisposed to typical causes.
CLINICAL PRESENTATION
Pneumonia is an inflammation or infection of the lungs that causes them to function abnormally.
Pneumonia can be classified as typical or atypical, although the clinical
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Several symptoms commonly present in patients with pneumonia. ETIOLOGY Bacterial Chlamydia species Haemophilus influenza Legionella species Moraxella catarrhalis Mycoplasma pneumonia Staphylococcus aureus Streptococcus pneumonia Viral Adenovirus Influenza A B Parainfluenza Respiratorysyncytial virus Endemic fungi Blastomycosis Coccidioidomycosis Histoplasmosis EPIDEMIOLOGY
The epidemiology of CAP is unclear because few population-based statistics on the condition alone are available. The Centers for Disease Control and Prevention (CDC) combines pneumonia with influenza when collecting data on morbidity and mortality, although they do not combine them when collecting hospital discharge data. In 2001, influenza and pneumonia combined were the seventh leading causes of death in the United States,3,4 down from sixth in previous years, and represented an age-adjusted death rate of 21.8 per 100,000 patients.3 Death rates from CAP increase with the
RISK FACTORS
Age older than 65 years
Human immunodeficiency virus or immunocompromised Recent antibiotic therapy or resistance to antibiotics Comorbidities
Asthma
Cerebrovascular disease
Chronic obstructive pulmonary disease Chronic renal failure
Congestive heart failure DiabetesLiver disease Neoplastic disease INCIDENCE/PREVALENCE
The incidence of community-acquired pneumonia requiring hospitalization in the study counties in 1991 was 266.8 per 100,000 population; the overall case-fatality rate was 8.8%. Pneumonia incidence was higher among blacks than whites , was higher among males than females and increased with age
Name : C.G.
Birth date : April. 15. 2011
Address : Umboy San Antonio Biñan Laguna
Age : 5 months
Gender : female
Religion : Catholic
Nationality : Filipino
Admitting diagnosis : Pneumonia
Final diagnosis : Community Acquired Pneumonia
Chief Complaint : Difficulty of Breathing Attending Physician : Dra. A
Date of Admission : September, 12, 2011 Room Type : Pedia Ward
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HISTORY OF PRESENT ILLNESS
One week prior to admission, the patient’s mother stated that her daughter has a cough, fever and experience difficulty of breathing; she also noticed that her daughter’s lips are turning blue (cyanosis). They consulted at ONB-ER and was given antibiotic then admitted at pedia ward with Dra. Manalo Arzola as attending physician. The patient admitted last September 12, 2011 at around 5:00 pm.
PAST MEDICAL HISTORY
No past medical history, first time admitted at the hospital.
FAMILY HISTORY
(+) hypertension – paternal side (+) asthma – maternal side
PERSONAL AND SOCIAL HISTORY
Patient’s mother stated that baby C.G is her 2nd
child and has a twin which also experience having pneumonia before, she also stated that they live with her mother-in-law which have a rugby factory.
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BODY PARTS NORMAL FINDINGS ACTUAL FINDINGS
Scalp size-varies somewhat
shape-symmetrical and round
-Absence of masses -No Lesions
-symmetrical
Hair color-varies
amount and distribution texture-fine to coarse, pliant presence of parasites-none -black -normal - fine to course -with parasites Face symmetry-symmetrical
facial features-features vary, symmetrical, centered head position
-symmetrical facial movement -symmetrical
Eyes conjunctiva and sclera-bulbar
and palpebral conjunctiva is pink with no discharge; sclera is white
-pinkish and no discharge -white sclera
VITAL SIGNS
Temperature Cardiac Rate Respiratory Rate
36 °C 125 bpm 51 cpm
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Nose external nose
-skin appearance-color: same as face
-shape-symmetrical appearance
internal nose
-appearance-mucosa pink and moist with uniform color and no lesions
-color same as face
-with clear watery discharge -not tender
-mucosa pink and moist -no lesions
Mouth Open and close mouth for
symmetry and alignment-lips and surrounding tissue relatively symmetrical in net position and with smiling
-proportional and symmetrical with the face
-no lesions, swelling, drooping
Lips color-
in white- pink
in dark-may have bluish hue or frecklelike pigmentation consistency- moist, smooth with no lesions
-pink
-smooth, no lesions
Tongue symmetry and texture-moist
symmetrical appearance; midline fissure present movement-smooth color-pink
-in central position -moist
-moves freely
-no lesions or swelling
Ears size and shape- ears equal size
and similar appearance
-equal
-similar in appearance -same color as facial skin
Skin generalized color light to dark brown texture-smooth, soft temperature and moisture-warm, dry
turgor-pinched skin returns immediately to original position
edema-no swelling, pitting, or edema
-light brown -smooth, soft -warm
-pinched skin returns
immediately to original position -no edema and lesions
Neck appearance/movement-smooth,
controlled movements; range of motion
flexion, extension, lateral abduction, rotation
-smooth no lesions -no swelling
Thoracic and lung Inspection
Anterior and posterior thorax- Intercostals spaces-even and relaxed
Chest symmetry-equal
Position of sternum-level with ribs
Position of trachea-midline Respiration patterns/auscultate
-intercostal spaces even and relaxed
-symmetry equal
-sternum is level with the ribs -shallow/labored breathing -crackles heard upon auscultaion
Abdomen Contour-rounded or flat
Symmetry-symmetrical
Surface motion-no movement or slight peristalsis visualized over aorta
-globular shape
-muscles used for labored inspiration
Palms Color-pink
creases
-pink -(3)three
Finger nails Color-pink nail bed
Shape-round nail with 160 nail base
Texture-nail is round, hard, hard immobile in dark skin: may be thick
Condition of nail bed-smooth, firm, and pink
-pink
- round w/ 160° nail base -long and dirty
-normal capillary refill
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The Lungs constitute the largest organ in the respiratory system. They play an
important role in respiration, or the process of providing the body with oxygen and releasing carbon dioxide. The lungs expand and contract up to 20 times per minute taking in and disposing of those gases.Air that is breathed in is filled with oxygen and goes to the trachea, which branches off into one of two bronchi. Each bronchus enters a lung. There are two lungs, one on each side of the breastbone and protected by the ribs. Each lung is made up of lobes, or sections. There are three lobes in the right lung and two lobes in the left one. The lungs are cone shaped and made of elastic, spongy tissue. Within the lungs, the bronchi branch out into minute pathways that go through the lung tissue. The pathways are called bronchioles, and they end at microscopic air sacs called alveoli. The alveoli are surrounded by capillaries and provide oxygen for the blood in these vessels. The oxygenated blood is then pumped by the heart throughout the body. The alveoli also take in carbon dioxide, which is then exhaled from the body.
Inhaling is due to contractions of the diaphragm and of muscles between the ribs. Exhaling results from relaxation of those muscles. Each lung is surrounded by a two-layered membrane, or the pleura, that under normal circumstances has a very, very small amount of fluid between the layers. The fluid allows the membranes to easily slide
Non Modifiable Factors: Age Modifiable Factors: Environment Diet Bacteria and Viruses Entry of microorganism to nasal passages Invasion of the respiratory system
Activation of immune response (mucus production) Ineffective immune response results to overwhelming infection Invading lung parenchyma
cough Release of endotoxins and exotoxins Continues mucus production exotoxins Massive inflammation (pneumonia fever
Altered gas exchange cyanosis dyspnea
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NARRATIVE
Infectious organism enter the lung when airborne droplets are inhaled, but can also reach the lung through the bloodstream when there is an infection in another part of the body. Many bacteria live in parts of the upper respiratory tract, such as the nose, mouth and sinuses, and can easily be inhaled into the alveoli. Once inside, bacteria may invade the spaces between cells and between alveoli through connecting pores. This invasion triggers the immune system to send neutrophils, a type of defensive white blood cell, to the lungs. The neutrophils engulf and kill the offending organisms, and also release cytokines, causing a general activation of the immune system. This leads to the fever, chills, and fatigue common in bacterial and fungal pneumonia. The
neutrophils, bacteria, and fluid from surrounding blood vessels fill the alveoli and interrupt normal oxygen transportation.
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DATE PROGRESS NOTES DOCTOR’S ORDER RATIONALE NURSING CONSIDERATIONS 9/12/11 2:05 pm Wt : 5.3 kg Please admit
under the service of Dra. Arzola Secure consent for admission Monitor VS q 4 hrs -Patients have different preferences and needs.
-To ensure that the patient’s mother understood and agreed on everything explained by the physician regarding to her baby’s condition. -To document acute changes and trends over time and unexpected changes and values that deviate significantly from a patient’s normal values are brought to the attention of -Familiarize the patient’s mother with the room and hospital facilities
-The nurse’s responsibility is to ensure that an informed consent has been obtained voluntarily from the patient’s mother by the physician. The signed consent form is placed in a
prominent place on the patient’s chart.
-The nurse
assessed individual client and
determined that the client is medically stable or in a chronic condition and not fragile and that the vital sign measurement is considered routine for the client.
NPO IVF : D5 0.3 NaCl 500 cc, 39 > cc x 24 ° x a6.17 mcgtts/min cardiac and ventilatory status. -To prepare the patient for diagnostic procedure. It helps to prevent risks of aspiration. Aspiration pneumonia (where food particles can be regurgitated from the stomach into the lungs) is a life-threatening complication because it causes severe damage to the lungs requiring artificial ventilation and hospitalization. - Replacement therapy particularly in extracellular fluid deficit accompanied by acidosis. -Instruct the
patient’s mother not to feed the baby.
- The nurse monitors IV
infusions frequently to make sure that the fluid is flowing at the intended rate.
Diagnostic tests: CBC UA -Complete blood count is used to determine blood components and the response to inflammatory process and streptococcal infection. -Urinalysis yields a large amount of information about possible disorders of the kidney and lower urinary tract, and systematic disorders that alter urine composition. Urinalysis data include color, specific gravity, pH, and the presence of protein, RBC’s,WBC’s, bacteria, -Explain test procedure to the patient’s mother. Apply manual pressure over the puncture site and monitor for oozing of blood or hematoma formation. Follow up results. - Instruct and demonstrate on the patient’s mother how to get the midstream urine. Follow up results. The nurse should be able to establish a base line as guide for deviations and monitoring for stability of these values.
For CXR Medications: Cefuroxime 150mg IV q 8 ANST (-) Paracetamol 60mg IV q 4° for fever T > 38.5 °C Salbutamol ½ neb + 1 cc NSS q 390 -It is used to rule out respiratory problems causes of referred pain. In some cases, chest abnormalities cause pain in the abdominal area. -Cefuroxime is a cephalosporin antibiotic. It treats many kinds of infections such as cholecystitis. -Paracetamol is a analgesics and Antipyretics drugs use to relieve fever and mild to
moderate pain.
-Salbutamol is antiasthmatic
-Tell the patient that he must wear gown and must remove all metal object and jewelry from his neck and chest. Assist patient in assuming appropriate
position. Reassure the patient that the amount of radiation exposure s minimal. Follow-up results.
Moderate high back rest 02 at 1-2 LPM Inform AP (attending physician) bronchospasm in patient with acute respiratory infection -To provide patent, unobstructed airway , maximum lung excursion -To prevent hypoxemia; to provide more oxygen to the body in order to promote health. -Attending Physician will be sufficiently comprehensive to describe the clinical problem, pertinent history, and physical findings to enable continuity of care by others -Instruct the patient’s mother to elevate head of the bed and do not leave her daughter unattended. - Instruct the patient’ smother on the method of administering oxygen safely.
Nebulize ĉ salbutamol q 6°
Reassessment c/o NOD
High back rest
CPR PRN -Salbutamol is antiasthmatic drugs. It relieve bronchospasm in patient with acute respiratory infection -To evaluate patient’s condition and identify new patient problems needing different interventions according to a revised plan -facilitate chest expansion to improve ventilation. -To restore and maintain circulation and to provide oxygen if the petient has stopped breathing (respiratory arrest) -reassess the patient periodically, establish a plan of care based on the patient
reassessment
-Instruct the
patient’s mother to elevate head of the bed and do not leave her daughter unattended.
9/13/11 9:35 am 4:30 pm RR: 51 cpm (-) DOB May have MF ĉ SAP TF: D5 0.3 NaCl 500 cc x 16-17 mcgtts/min IVF : D5 IMB 500 cc x 10 hrs 02 ĉ 4LPM thru funnel PRN -The patient is at a big risk of throwing up and it getting into their lungs which can cause aspiration pneumonia - Replacement therapy particularly in extracellular fluid deficit accompanied by acidosis. - Replacement therapy particularly in extracellular fluid deficit accompanied by acidosis. -To prevent hypoxemia; to provide more oxygen to the body in order to promote health.
Have the patient be fed, head elevated almost 90 degrees while feeding
- The nurse monitors IV
infusions frequently to make sure that the fluid is flowing at the intended rate.
- The nurse monitors IV
infusions frequently to make sure that the fluid is flowing at the intended rate.
- Instruct the
patient’ smother on the method of administering oxygen safely.
9/15/11 6:45 am 3:30 pm IVF D5IMB 500 cc x 10° TF: D5IMB 500 cc x 10° Cefaclor drops 1ml TID x 5 days Salbutamol neb ½ + 1cc NSS TID x 5 days TF: OPD after 1 week which can cause aspiration pneumonia - Replacement therapy particularly in extracellular fluid deficit accompanied by acidosis. - Replacement therapy particularly in extracellular fluid deficit accompanied by acidosis. -Cefaclor is a cephalosporin drugs. It used in the treatment of upper and lower respiratory infection -Salbutamol is antiasthmatic drugs. It relieve bronchospasm in patient with acute respiratory infection - The nurse monitors IV infusions frequently to make sure that the fluid is flowing at the intended rate.
- The nurse monitors IV
infusions frequently to make sure that the fluid is flowing at the intended rate.
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September 13,2011
Result Normal values Interpretation
Hemoglobin 115 110 – 140 gm / L
DECREASED Indicates decreased
oxygen level in the blood/anemia Hematocrit 0.36 0.37 – 0.47 NORMAL RBC 4.1 4.5 – 5 x 1012 / L DECREASED Indicate hypoxemia or decreased oxygen production Total WBC 4.2 5 – 10 x 109 / L DECREASED Indicates presence of infection
Platelet count 290 150 – 400 x 109 / L NORMAL
Differential count:
Segmenters 0.30 0.50 – 0.70 NORMAL
Eosinophil 0.70 0.20 – 0.80 NORMAL
h
September 13,2011
September 13,2011
Results Normal Values Interpretation
Color Yellow Yellow NORMAL
Transparency Slightly Hazy Clear to slightly hazy NORMAL
Specific Garvity 1.015 1.015-1.025 NORMAL
PH Neutral 4.5-8.0 NORMAL
Albumin Negative Negative NORMAL
Sugar Negative Negative NORMAL
WBC 0-2/ HPF 0-2/ HPF NORMAL
RBC 0-1 / HPF 0-2/ HPF NORMAL
Bacteria Negative Negative NORMAL
Epithelial cells Few Few
Results Normal Values Interpretation
Consistency Mucoid formed ABNORMAL
Indicate presence of bacterial infection
Color Green Yellow-brown ABNORMAL
Indicate diarrhea