CASE STUDY_II-F_GROUP 4.

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LYCEUM-NORTHWESTERN UNIVERSITY
Dagupan City
COLLEGE OF NURSING

PNEUMONIA
CASE STUDY
BY BSN III -

Brando Bautista
Clinical Instructor

I. INTRODUCTION

A 4 -month-old male patient (Patient X) from San Carlos City, was admitted to the Medical ward in Blessed
Family Doctors General Hospital on April 5, 2024 (7:07 pm ) with pneumonia. Symptoms are present as respiratory
distress of various degrees, suspicious appearing tracheal aspirates, cough, bradypnea, high or low temperature, poor
feeding, abdominal distension, and lethargy.

His general practitioner has prescribed Ceftazidime, Gentamicin, Paracetamol, Bacillus clausii, Zinc sulfate,
Salbutamol nebule (all taken via IV insertion)The general practitioner had also noted an audible wheezing when the
patient is breathing. He uses a heparin IV locking device (hep-lock) due to pneumonia.

The patients' family history includes high blood (mother side) and asthma have paternal side.

Past medical history, past surgical history, social history are not significant.

His current medications include Salbutamol 1 nebule every 15 mins x 3 doses inhaled daily, Paracetamol 50 mg
IV every 4 hours for temp > 38.5C, Bacillus clausii 1 capsule BID (2x a day), Zinc sulfate drops 1 ml OD (once a
day),Ceftazidime 170 mg IV every 8 hours, Gentamicin 20 mg IV every 24 hours.

II. OBJECTIVES

General Objectives:
● To be able to apply the knowledge and attitude developed throughout the making of this case presentation and to
understand what the necessary nursing care is for a client who hasl pneumonia.

Specific objectives:
● To acquire adequate knowledge about pneumonia.
● To be familiar with the client’s medication with their therapeutic and adverse effects.
● To be informed in the different laboratory and diagnostic procedures.
● To be able to formulate the appropriate nursing care plan that will help improve the client’s condition.

III. OVERVIEW OF ANATOMY & PHYSIOLOGY

The lungs are the principal organs of respiration. Each lung is cone-shaped, with its base resting on the diaphragm
and its apex extending superiorly to a point about 2.5 cm above the clavicle. The right lung has three lobes, called the
superior, middle, and inferior lobes. The left lung has two lobes, called the superior and inferior lobes. The lobes of the
lungs are separated by deep, prominent fissures on the lung surface. Each lobe is divided into bronchopulmonary segments
separated from one another by connective tissue septa, but these separations are not visible as surface fissures. Individual
diseased bronchopulmonary segments can be surgically removed, leaving the rest of the lung relatively intact, because
major blood vessels and bronchi do not cross the septa. There are nine bronchopulmonary segments in the left lung and ten
in the right lung.

The main bronchi branch many times to form the tracheo-bronchial tree (see figure 15.5). Each main bronchus
divides into lobar bronchi as they enter their respective lungs. The lobar bronchi (or secondary bronchi), two in the left
lung and three in the right lung, conduct air to each lobe. The lobar bronchi in turn gives rise to segmental bronchi (or
tertiary bronchi), which extend to the bronchopulmonary segments of the lungs. The bronchi continue to branch many
times, finally giving rise to bronchioles. Each respiratory bronchiole subdivides to form alveolar ducts, which are like
long, branching hallways with many open doorways. The doorways open into alveoli which are small air sacs. The
primary function of the lungs is the gas exchange mechanism known as respiration (or breathing). In respiration, oxygen
from incoming air enters the blood, and carbon dioxide, a waste gas from the metabolism, leaves the blood.

FIGURE 15.5 article-Lungs---Anatomy-of-t-ice.jpg DrxHTOzX0AAsi1T.jpg

IV. DESCRIPTION OF THE DISEASE

Pneumonia is an infection in one or both of the lungs. It causes the air sacs of the lungs to fill up with fluid or pus.
It can range from mild to severe, depending on the type of germ causing the infection, your age, and your overall health.
Onset may be within hours of birth and part of a generalized sepsis syndrome or after 7 days and confined to the lungs.
Signs may be limited to respiratory distress or progress to shock and death. Diagnosis is by clinical and laboratory
evaluation for sepsis.

V. PATHOPHYSIOLOGY (PARADIGM)

Pneumonia may be noninfectious or infectious. Non-infectious pneumonia can result from the aspiration of water,
food, liquids (including saliva), vomit, poisonous gases, chemicals, or smoke. Infectious pneumonia develops when an
organism penetrates the mucosa of the airway and multiplies in the alveolar spaces. Pneumonia-causing germs can be
transferred through a person's surroundings, interactions with other individuals, invasive devices, medical supplies or
equipment, and workers (Parasites; Ignatavicius & Workman, 2015).

A. ETIOLOGY (RISK FACTORS)

Pneumonia has several different causes including viruses, bacteria and fungi. The most common cause of
pneumonia is called streptococcus pneumoniae and the second most common cause of bacterial pneumonia is haemophilus
influenzae type b (Hib).

Risk Factors:
● Age less than 2 years old and adults age 65 and older
● Exposure to certain chemicals, pollutants, or toxic fumes
● Lifestyle habits, such as smoking, heavy alcohol use, and malnourishment
● Being in a hospital, especially if you are in the ICU. Being sedated and/or on a ventilator raises the risk even
more.
● Having a lung disease
● Having a weakened immune system
● Have trouble coughing or swallowing, from a stroke or other condition
● Recently being sick with a cold or the flu

B. DISEASE PROCESS

Most pneumonia occurs when failure of local and systemic defense mechanisms allows these pathogens to
infiltrate the lungs and proliferate, indicating that this triggers the immune system. Infiltration of neutrophils and other
pro-inflammatory mediators produces alveolar and interstitial inflammation. If this inflammation goes unchecked, it may
show that damage produces leaky alveolar walls and pulmonary capillaries; as a result, the alveoli fill with fluid, pro-
inflammatory molecules, blood cells, and pathogens, and gas exchange is impaired.

C. MANIFESTATIONS (SIGNS AND SYMPTOMS)

● Cough – which may be dry, or produce thick yellow, green, brown or blood-stained mucus (phlegm)
● Difficulty breathing – your breathing may be rapid and shallow, and you may feel breathless, even when
resting
● Rapid heartbeat
● Fever
● Feeling generally unwell
● Sweating and shivering
● Loss of appetite
● Chest pain – when you breathe and cough

VI. LABORATORY AND DIAGNOSTIC TEST

Pneumonia can be identified in various age groups using specific signs and symptoms. Fever, tachypnea, nasal
flaring (in babies), and low oxygen saturation are signs of pneumonia. Whenever these outcomes are present, especially in
babies, the risk of pneumonia rises significantly. A symptom or sign's specificity is limited, thus its absence does not
necessarily rule out pneumonia.
If pneumonia is suspected, common tests and procedures may includes:
● Chest X-ray. This test makes images of internal tissues, bones, and organs.
● Blood tests. A blood count looks for signs of an infection. An arterial blood gas test looks at the amount of
carbon dioxide and oxygen in the blood.
● Sputum culture. This test is done on the mucus (sputum) that is coughed up from the lungs and into the mouth.
It can find out if your child has an infection. It's not routinely done because it is hard to get sputum samples from
children.
● Pulse oximetry. An oximeter is a small machine that measures the amount of oxygen in the blood. To get this
measurement, the provider tapes a small sensor onto a finger or toe. When the machine is on, a small red light can
be seen in the sensor. The sensor is painless and the red light does not get hot.
● Chest CT scan. This test takes images of the structures in the chest. It is very rarely done.
● Bronchoscopy. This procedure is used to look inside the airways of the lungs. It is very rarely done.
● Pleural fluid culture. This test takes a sample of fluid from the space between the lungs and chest wall (pleural
space). Fluid may collect in that area because of pneumonia. This fluid may be infected with the same bacteria as
the lung. Or the fluid may just be caused by the inflammation in the lung.
● Arterial blood gas. To measure the concentration of certain substances in your blood, including oxygen, carbon
dioxide, and pH. This test may be performed to determine whether you will be able to continue breathing on your
own, or whether you may need treatment with additional oxygen therapy or mechanical ventilation.
● Urine antigen tests. A urine sample can help with identifying certain bacteria that could be causing the infection.
● Thoracentesis. A needle can be passed through the chest, back, or between the ribs in order to withdraw excess
fluid in the chest cavity. This fluid can be examined in a laboratory to identify organisms responsible for
pneumonia.

VII. MEDICAL MANAGEMENT (DRUG STUDY)

NAME OF THE CLASSIFICATION INDICATION SIDE EFFECTS NURSING

DRUG IMPLICATIONS

Ceftazidime Antibiotic Serious infections ● May increase ➢ If large doses

Cephalosporins (third caused by sensitive ALP, ALT, AST, are given, therapy
generation) strains of bilirubin, and IDH is prolonged, or the
pseudomonas levels. May patient is at high
aeruginosa, decrease Hb level. risk, monitor the
Escherichia coli, ● May increase patient for
Proteus, klebsiella, eosinophil count. superinfection.
Serratia, or May decrease ➢ Monitor patient
staphylococcus granulocyte and for diarrhea and
WBC count. treat appropriately.
● May prolonged
PTT and PT, and
increased INR.
● May falsely
increase serum or
urine creatinine
level in tests using
Jaffe reaction.
May cause false-
positive results of
coombs test and
urine glucose tests
that use cupric
sulfate, such as
Benedict reagent
and clinitest.

DOSAGE MECHANISM OF CONTRAINDI- ADVERSE EFFECTS

ACTION CATION

170mg IV Q8H Inhibits cell-wall Contraindicated in ● dizziness,

synthesis,promoting patients anxiety,
osmotic instability; hypersensitive to nausea, vomiting,
usually bactericidal. drug or other constipation,
cephalosporins. abdominal pain,
CDAD
● acute renal
failure, renal
impairment
● Eosinophilia
● Thrombocy-
topenia
● Hypokalemia
● Rash
● hypersensitiv-
ity reaction, drug
resistant bacterial
infection
Table 1

NAME OF THE CLASSIFICATION INDICATION SIDE EFFECTS NURSING

DRUG IMPLICATIONS

Gentamicin Aminoglycosides Serious UTI and ● May increase ➢ Weigh patient

lower respiratory ALT, AST, and review renal
tract infection; skin bilirubin, BUN, function studies
gynecologic intra- creatinine, LDH, before therapy
abdominal, bone and nonprotein begins.
and joint, and CNS nitrogen levels. ➢ Watch for signs
infection; ● May decrease and symptoms of
bacteremia; and Hb and serum superinfection
septicemia caused calcium, (specially upper
by susceptible magnesium, respiratory tract)
microorganisms sodium, and such as continued
such as potassium levels. fever, chills and
streptococci ● May increase increased pulse
(including eosinophil count. net.
streptococcus May decrease ➢ Therapy usually
pneumoniae and platelets and continues for 7 to
streptococcus WBC counts, 10 days if no
pyogenes). such as Benedict response occurs in
reagent and 3 to 5 days, stop
clinitest. therapy and obtain
new specimens for
DOSAGE MECHANISM OF CONTRAINDI- ADVERSE EFFECTS culture and
ACTION CATION sensitivity testing.
30mg IV Q24 Inhibits protein Contraindicated in ● dizziness,
synthesis by binding patients anxiety
directly to the 30S hypersensitive to ● nausea,
ribosomal subunit; drug or other vomiting,
bacterial. cephalosporin. constipation,
abdominal pain,
CDAD
● acute renal
failure, renal
impairment
● Eosinophilia
● Thrombocy-
topenia
● Hypokalemia
● Rash
● hypersensitiv-
ity reaction, drug
resistant bacterial
infection
Table 2

NAME OF THE CLASSIFICATION INDICATION SIDE EFFECTS NURSING

DRUG IMPLICATIONS

Paracetamol Acetaminophen ● Mild pain or ● May increase ➢ Use liquid form

fever AST level. May for children and
● Mild to decrease glucose, patients who
moderate pain; potassium, difficulty of
with adjunctive phosphorus, swallowing
opioid magnesium, ➢ In children, don’t
analgesics; albumin, and Hb exceed 5 doses in 24
fever level and hours.
hematocrit. ➢ Advise parents
● May decrease that the drug is only
neutrophil, WBC, for short-time of use;
RBC, and platelet urge them to consult
counts. prescriber if giving
● May cause false- to children for longer
positive test results than 5 days or adults
for urinary 5- for longer than 10
hydroxyindoleacetic days.
acid. May falsely ➢ Tell
decrease glucose parents/patient not to
level in home use for marked fever
monitoring systems. (temp higher than
103.1 F° or 39.5 C°),
DOSAGE MECHANISM OF CONTRAINDI- ADVERSE EFFECTS fever persisting
ACTION CATION longer than 3 days or
recurrent fever
50 mg IV Q4 Thought to produce Contraindicated in ● agitation (IV), unless directed by
analgesia by inhibiting patients anxiety, fatigue, prescriber.
prostaglandin and other hypersensitive to headache, insomnia,
substances that drugs. IV form is pyrexia
sensitize pain contraindicated in ● HTN,
receptors. Drugs may patients with hypotension,
relieve fever through severe hepatic peripheral edema,
central action in the impairment or periorbital edema,
hypothalamic heat- severe active liver tachycardia (IV)
regulating center. disease. ● nausea, vomiting,
abdominal pain,
diarrhea,
constipation (IV)
● oliguria (IV)
● hemolytic
anemia, leukopenia,
neutropenia,
pancytopenia,
anemia
● Jaundice
● hypoalbuminemia
(IV)
● muscle spasms,
extremity pain (IV)
● abnormal breath
sounds, dyspnea,
hypoxia, atelectasis,
pleural effusion,
pulmonary edema,
stridor, wheezing
● rush, urticaria,
infusion-site pain
(IV), pruritus.

Table 3

NAME OF THE CLASSIFICATION INDICATION SIDE EFFECTS NURSING

DRUG IMPLICATIONS

Bacillus clausii Antidiarrheals ● acute diarrhea ● gas ➢ Shake drug well

with duration of ● bloating before
≤ 14 days due to administration.
infection, drugs ➢ Monitor patient
or poisons. from unusual effects
● chronic or from drug.
persistent ➢ Administer drug
diarrhea with within 30 minutes
duration of >14 after opening the
days. container.

DOSAGE MECHANISM OF CONTRAINDI- ADVERSE EFFECTS

ACTION CATION

1 capsule BID ● Contributes to Not for use in ● hypersensitivity

the recovery of the immune reactions (rash,
intestinal compromised angioedema,
microbial flora patients (cancer urticaria) bacterial
altered during the patients on infection.
course of chemotherapy,
microbial patients taking
disorders of immune
diverse origin. suppressant
● Produces various medications).
vitamins,
particularly group
B vitamins thus
contributing to
correction of
vitamin disorders
caused by
antibiotics and
chemotherapeutic
agents.

Table 4

NAME OF THE CLASSIFICATION INDICATION SIDE EFFECTS NURSING

DRUG IMPLICATIONS

Salbutamol nebule Therapeutic Indicated for the ● headache ➢ Assess lung

bronchodilator symptomatic relief ● feeling nervous sounds, PR and RP
and prevention of ● restless before drug
bronchospasm due ● excitable and/or administration and
to bronchial asthma, shaky during peak of
chronic bronchitis, ● fast, slow or medication.
reversible uneven heartbeat ➢ Administer
obstructive airway ● bad taste in the accurately because
disease, and other mouth advance reactions
chronic and tolerance might
bronchopulmonary occur.
disorders in which ➢ Monitor
bronchospasm is a respiratory rate,
complicating factor, oxygen saturation
and/or the acute and lung sounds
prophylaxis against before and after
exercise- administration.
induced ➢ Auscultate lungs
bronchospasm. presence of
adventitious breath
DOSAGE MECHANISM OF CONTRAINDI- ADVERSE EFFECTS sound that may
ACTION CATION signal pulmonary
edema airway
1 nebule Q1 x3 It relieves nasal Patients with a ● Difficulty resistance or
doses congestion and history of breathing bronchospasm.
reversible hypersensitivity to
bronchospasm by any of its
relaxing the smooth components.
muscles of the
bronchioles.

Table 5

NAME OF THE CLASSIFICATION INDICATION SIDE EFFECTS NURSING

DRUG IMPLICATIONS

Zinc sulfate Mineral and Replacement and ● Gastric ➢ Monitor

supplemental supplementati-on irritation progression of zinc
therapy in patients ● nausea deficiency symptoms
who are at risk for ● vomiting during therapy.
zinc deficiency.

DOSAGE MECHANISM OF CONTRAINDI- ADVERSE EFFECTS

ACTION CATION

1 ml OD Serves as a cofactor for Hypersensitiv-ity or ● abdominal pain,

many enzymatic allergy to any dyspepsia, nausea,
reactions. Required for components in the vomiting,
normal growth and formulation. diarrhea, gastric
tissue and smell. irritation, gastritis
● irritability,
lethargy
● headache,
dizziness
Table 6

VIII. SURGICAL MANAGEMENT

● Assess rate, depth of respirations and chest movement.
● Auscultate lung fields.
● Elevate head of bed.
● Assist and demonstrate client with frequent deep-breathing exercises, splinting the chest and coughing.
● Suctioning is done as indicated
● Force fluids to at least 2500 mL per day, unless contraindicated, as in HF.
● Thoracotomy is the standard surgery for pneumonia.
● It requires general anesthesia and an incision to open the chest and view the lungs. The surgeon most times has
to remove dead or damaged lung tissue. In extreme cases the entire lobe of the lung is removed.

IX. NURSING CARE PLAN

ASSESSMENT NURSING PLANNING IMPLEMENT- RATIONALE EVALUAT-

DIAGNOSIS ATION ION
Subjective Data: Ineffective Short-term Goal: Independent: Short-term
“Nahihirapan na Airway After 1 hour of ➢ Establish To gain the trust Goal:
siyang huminga at Clearance nursing rapport with and cooperation. After 1 hour of
mataas ang lagnat related to intervention, the patient and SO. nursing
niya” as verbalized bronchial patient’s intervention,
by the patient’s inflammation as temperature will ➢ Monitor vital the goal met.
sister. evidenced by decrease to 37.5℃. signs. Vital signs provide The patient’s
dyspnea and a accurate indication temperature
Objective Data: body After 3 hours of of core decreased to
● Cleft lip temperature of nursing temperature. 37.5℃.
and cleft 38.8℃. intervention, the
palate. patient’s watcher ➢ Provide a To help lower the After 3 hours of
● Wide-eyed should be able to tepid sponge body temperature. nursing
look; verbalize bath. intervention,
restlessness. understanding of To promote clear the patient’s
● 38.8℃ cause(s) and ➢ Promote a flow are in the watcher
body therapeutic well-ventilate-d patient’s area. One verbalizes
temperature. management area to patient. way of promoting understanding
regimen. heat loss. of cause(s) and
therapeutic
After 4 hours of To ascertain management
nursing ➢ Auscultate current status and regimen.
intervention, the breath sounds note effects of
patient’s respiration and assess air treatment in After 4 hours of
will improve and movements. clearing airways. nursing
difficulty of intervention,
breathing will be To determine the patient’s
relieved. education and respiration
➢ Assess support needs. improved and
Long-term Goal: significant difficulty of
After 3 - 4 days of other’s breathing
nursing knowledge of relieved.
intervention, the contributing
patient should be causes, treatment Long-term
able to maintain plan, specific Goal:
airway patency and medications, and After 4 days of
with a normal body therapeutic nursing
temperature of 36.5 procedures. intervention,
- 37.5℃. the goal met.
Dependent: The patient
➢ Administer maintains
paracetamol as airway patency
Reduces fever. as evidenced by
ordered.
absence of
➢ Administer dyspnea and
ceftazidime as with a normal
To treat certain body
ordered. infections caused temperature of
by bacteria 36.5℃.
including
pneumonia.
To decrease
➢ Administer breathlessness.
oxygen as
ordered.
Collaborative: To ensure
➢ Discuss the continuous
condition of the intervention.
patient with
other members
of the health care
team.

Table 7

X. EVALUATION & DISCHARGE PLANNING

When you're in the Hospital

The health care providers provide help to your child to treat and feel better.
Bronchopneumonia in Children - Discharge
Now that your child is going home, follow the health care provider's instructions on
helping your child continue healing at home. Use the information below as a reminder.

What to expect at Home

Your child will still have symptoms of pneumonia after leaving the hospital.
● Coughing will slowly get better in 1–2 weeks.
● Your child's energy level may take 2 weeks or more to return to normal.
● Sleeping and eating may take up to a week to return to normal.

Home Care
Breathing warm, moist (wet) air helps loosen the sticky mucus that may be choking your child. Other things that
may help include:
● Use a cool-mist humidifier in the baby's room to keep the air moist.
● Place a humidifier with the warm water by your child's bed or close to your child.
● Place a warm, wet washcloth loosely near your child's nose and mouth.

This are the vaccines that will need your child to prevent other infection such as:
● Flu (Influenza) vaccine
● Pneumonia vaccine
Also, make sure all your child's vaccines are up to date.

Eating and Drinking

Make sure your child's drink enough.
Bottle feed or Breastfeed your baby smaller amounts more often.
Some drinks may help relax the airway and loosen the mucus such as:
● Water
● Apple juice
● Gelatin
● Broth

Medicines
Only bacterial pneumonia is helped by antibiotics.
● Your child must complete the course of antibiotics as prescribed by the doctor.
● Warm fluids for coughing spasms.
● Do not miss any doses.
● Follow up Check up.

When to Call the Doctor

You should call your child’s doctor if your child:
● Has trouble breathing or is breathing much faster than usual
● Has a bluish or gray color to the fingernails or lips
● Breathing Faster than 50 to 60 breaths per minute ( when not crying )
● Has trouble sleeping
● Has a fever for more than a few days after taking antibiotics
● Making a grunting noise
● Irritable