Introduction

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 pneumonia is 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 pneumonia 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 are Streptococcus pneumoniae,
Haemophilus influenzae, and atypical organisms (i.e., 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
 Patient’s Profile

Ward: B-2
Date of Admission: August 18, 2010
Pt. Name: S.G.
Address:
Age: 42 y/o
Gender: Male
Birth date: May 15, 1968
Religion: Roman Catholic
Educational Status: Undergraduate (2nd year High school)
Nationality: Filipino
Civil Status: Married
Occupation: Army (TSG)
Health Care Financing:
Informant: Patient
Reliability: 100%

Admission Data
Chief complaint: chest pain
Initial diagnosis: Pneumonia community acquired moderate risk pleural effusion
Final Diagnosis: Pneumonia community acquired moderate risk pleural effusion
Attending Physician: Dr. Conciller

PAST HEALTH HISTORY

Patient had no history of hospitalization

PERSONAL AND SOCIAL HISTORY

The patient is a TSGT army, a non-smoker, occasional drinker with no allergy to food and drugs.

PRESENT HEALTH HISTORY

2 weeks prior to admission patient had productive cough initially whitish then yellowish phlegm.
No difficulty of breathing, fever was noted. No consultation for was noted for medication. 8 days
prior to admission, still with productive cough now associated with low grade fever. 3 days prior to
admission, patient experienced chest pain, he consult at CGEASH, he was given cefalexin 100mg 1
tab, ambroxol three times a day and mefenamic which gives relief.

1 day prior to admission he consulted back at CGEASH where chest x-ray was done which revealed
pneumonia and pleural effusion.
 GORDON’S FUNCTIONAL HEALTH PATTERN

BEFORE DURING HOSPITALIZATION INFERENCE/ANALYSIS

HOSPITALIZATION
HEALTH
PERCEPTION AND
HEALTH
MANAGEMENT
He rates his health as 4 out of 10 because of the It shows that the patient
The patient rates his severe abdominal pain. condition was aggravated
health 8 out of 10 as by his community acquired
the highest, because he pneumonia.
can do his work with
ease and other
activities, patient is a
non smoker and drinks
occasionally. He had
no traditional concept
of health and illness.

NUTRITIONAL AND
METABOLIC
PATTERN
The patient still drinks 8-10 glasses of water a It shows that the patient
The patient was fond day about 210ml per bottle, Patient weighs 58kg. had a weight loss because
of eating fish, of easy satiety.
vegetables and fruits; 3 day diet Recall
He drinks 10-12 Aug 18, 2010 Aug 19, 2010 Aug 20, 2010
glasses of water a day,
about 210ml per bottle, BREAKFAST BREAKFAST BREAKFAST
when asked about his
daily fluid intake. The 2 pieces of 2 pieces of 2 pieces of
patient weighs 65kg. bread, 1 cup bread, 1 cup bread, 1 cup
The patient had no of coffee of coffee of coffee
dental, skin, lesion LUNCH LUNCH LUNCH
problems.
1 cup of rice 1 cup of rice 1 cup of rice
1 piece tinola 1 piece fish 1 piece tinola
with with with
vegetable, 2 vegetable, 2 vegetable, 2
glasses of glasses of glasses of
water and water and water and
jellyace jellyace jellyace
DINNER DINNER DINNER

1 cup of rice 1 cup of rice 1 cup of rice

1/2 piece fish 1 piece fish 1 piece
with with chicken with
vegetable, 2 vegetable, 2 vegetable, 2
glasses of glasses of glasses of
water water water
 ELIMINATION
PATTERN

He defecated once a “Dumudumi ako ng dalawang beses sa isang It shows that his
day, soft to hard in araw, minsan ay tatlong beses pa, siguro kasi elimination pattern during
consistency and dark nagdidiarhea ako” as verbalized by the patient. hospitalization was
brown in color Regarding his urinary elimination he stated that abnormal because patient
Regarding his urinary he urinates 4-6 times a day about 735ml when verbalized that he defecates
elimination he stated measured. 2-3 times a day which the
that he urinates 4-6 normal in general is once a
times a day about day.
840ml when measured.
ACTIVITY
EXERCISE PATTERN
The patient was ordered to limit his activities but The patient was restricted
The patient’s activity do some walking for his exercise. of some activities because
was his work as an of his condition.
army; they do their
exercises every
morning.

SLEEP- REST
PATTERN

The patient has 6-7 The patient has 4-6 hours of sleep, because of Patient’s sleep pattern was
hours of sleep. He had difficulty of falling asleep caused by warm interrupted because of the
no problem falling weather and having a difficulty of breathing environment and his
asleep. He doesn’t take sometimes as verbalized by the patient. condition.
any sleep medications,
As for his relaxation
he used to watch
movies before going to
sleep.
COGNITIVE –
PERCEPTUAL
PATTERN Patient’s had no hearing or
His hearing and vision were still the same. vision problems.
He had no hearing
difficulty. His eyes has
a 20/20 vision, He
stated that he still has
an intact memory. For
him exploring is the
best way to learn new
things.
SELF PERCEPTION
AND SELF-
CONCEPT PATTERN
He doesn’t feel good about himself; because he The patient’s perception of
He describes himself cannot do all the activities that he wanted. himself changed during
as a simple and joyful hospitalization because of
person. He feels good his condition.
about himself. There
are no changes on his
body.
ROLE-
RELATIONSHIP
PATTERN

The patient was living He cannot do his duty as a father, because he is in The patient’s family
with his wife and two the hospital right now, as verbalized by the experiences financial
kids; he stated that patient. problem sometimes which
they have no difficulty triggers the mind of the
handling problems. He patient that he cannot do
stated that his co- his role as a father.
workers and friends
are his social groups;
They experience
financial problems
sometimes.

SEXUALITY-
REPRODUCTIVE
PATTERN

The patient said that he The patient doesn’t experience any changes
doesn’t have any regarding his sexuality during his hospitalization.
changes or problems
Regarding sexual
relationships, he
doesn’t use any
contraceptives. He had
no genital problems.

COPING - STRESS
TOLERANCE
PATTERN

The patient doesn’t The patient’s wife was with him during
feel tense most of the hospitalization to help him cope with problems
time; His wife helps that he will encounter during his hospitalization.
him when he was
experiencing some
problems. There are no
changes in his life in
the last year or two.
 VALUE- BELIEF
PATTERN

The most important The patient prays every night before going to
thing in life for the sleep to ask for God’s graces and help.
patient was his family,
When asked about his
religion, he go to mass
every Sunday, there
are no factors
interfering on his
religion.
 PHYSICAL ASSESSMENT

AREA TO BE TECHNIQUE FINDINGS REMARKS

ASSESS
Head
Skull Palpation Rounded normocephalic and Normal
Inspection symmetrically smooth skull contour,
uniform consistency, absence of
nodules or masses. W/ frontal, parietal
and occipital prominences,
Scalp Inspection No lice and nits. Normal
Palpation No dandruff.
Hair Inspection Evenly Distributed hair, color varies Normal
mostly in black, smooth in texture &
shiny.
Face Inspection Symmetric facial movement, Normal
Palpation symmetric nasolabial folds.
Eyelids Inspection Skin intact; no discharge no Normal
discoloration, Lids close
symmetrically with scant amount of
secretions
Bilateral blinking, when lids open no Normal
visible sclera above corneas, and
upper and lower borders of cornea are
slightly covered
Eyebrows Inspection Hair evenly distributed skin intact; Normal
symmetrically aligned; equal
movement
Eyelashes Inspection Equally distributed; curled turned Normal
outward
Palpebral Inspection Equal in size Normal
fissures
Conjunctiva Inspection Both conjunctivas are shiny, smooth Normal
and red. There are no swelling,
lesions and moist.
Sclera Inspection Appears white and clear Normal
Iris Inspection Transparent, no shadows of light Normal
Pupil Inspection Black, equal size, round and smooth, Normal
Illuminated pupil constrictly, Non-
illuminated pupil dilates, constrictly
looking at near object, dilate looking
at far object
Eye Inspection Coordinated eye movements Normal
Movement

Visual Inspection 20/20 distance vision able to read Normal

Activity newsprint
Ears Inspection Color same as facial skin, Normal
symmetrical auricle – aligned with
outer canthus of eye, about 10 from
vertical. Mobile, firm and not tender,
 pinna recoils after it is folded
Ear canal Inspection Dry cerumen, no lesions, no pus, no Normal
blood, Pinkish clean with scant
amount of cerumen and a few cilia
Hearing Inspection Able to hear watch ticking at left and Normal
Acuity Weber/ Rhine right ear
test -Webers; sound hear in both ears
- Rhines test; sound hear in both ears,
able to hear a whisper spoken 2 feet
away
Nose Inspection Symmetrically and straight no Normal
Palpation discharge/Flaring, has a uniform
color, no swelling/ redness and
discharge on nasal cavities. Nasal
septum is intact and in midline air
moves freely as the client breathes
through the nares
Lips Inspection Symmetry in color; smooth white, Normal
pink gums, no retraction of gums and
a dry chapped lips
Teeth Inspection Complete without dentures Normal
Tongue Inspection Smooth tongue base with prominent Normal
veins, central position, pink color,
raised papillae
Uvula Inspection Positioned in midline of soft palate Normal
Soft Palate Inspection Light pink, shiny and smooth Normal
Hard palate Inspection Light pink, hard palate, more irregular Normal
texture
Tonsils Inspection Pink and smooth, no discharge and of Normal
normal size
Voice Voice is well modulated Normal
Neck Inspection Muscles equal in size; head centered; Normal
coordinated; smooth movements with
no discomforts
- Thyroid gland not visible on
inspection
Palpitation Lymph nodes not palpable Normal
-Trachea centered placement in
midline of neck; spaces are equal on
both sides
-Thyroid gland lobes are small,
smooth, centrally located, painless,
and rise freely with swallowing
Thorax Inspection Asterioposterior 1-2 diameter chest Normal
symmetric; vertically aligned

Uniform texture;
Palpation Chest wall intact; no tenderness/ Normal
masses full and symmetric chest
expansion bilateral symmetry and
frimetus heard
 3-5 cm;
Diaphragm (higher at right side)

Percussion Vesicular and bronchovesicular sound

Auscultation (+) crackles *alveoli is

collapsed by
fluid caused
by pneumonia
Abdomen Inspection Unblemished skin; uniform color, flat Normal
rounded, no evidence of enlargement
of liver/ spleen, symmetric contour;
symmetric

Movement cause by respiration, no

visible vascular pattern

Audible bowel sound

-Absence of arterial bruits
-Absence of friction rub

Auscultation Tympany over the stomach and gas-

filled bowels; dullness especially over
the liver and spleen

No tenderness. relaxed abdomen with

Percussion smooth consistent tension

Upper Normal
Extremities
Arms Inspection No muscle weakness Normal
Palpation No deformities on both arm
No swelling of joints
Palms Inspection No skin lesion Normal
Palpitation No callous
Fingers Inspection Joints: Normal
(-) Contractures
Nails: Convex curvature pinkish nail
 bed
Blanch test; return to its previous state
after 3-4 seconds.
Lower
Extremities
Legs Inspection Symmetrical in length, no Normal
lumps/masses present on both calves
-Has a bruises discoloration on both
lower portion of the legs

No tenderness

Palpation
Knees Inspection Normal
Sole Inspection White translucent tips; slightly pale in Normal
color
Toes Inspection No tender in palpation Normal
 ANATOMY AND PHYSIOLOGY
URINARY SYSTEM

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
 The respiratory tract extends from the mouth and nose to the alveoli. The upper
airway serves to filter airborne particles, humidify and warm the inspired gases. The
patency of the airway in the nose and oral cavity is largely maintained by the bony
skeleton, but in the pharynx is dependent upon the tone in the muscles of the tongue, soft
palate and pharyngeal walls.

Larynx
The larynx lies at the level of upper cervical vertebrae, C4-6, and its main
structural components are the thyroid and cricoid cartilages, along with the smaller
arytenoid cartilages and the epiglottis, which sit over the laryngeal inlet. A series of
ligaments and muscles link these structures, which, by a co-ordinated sequence of
actions, protect the larynx from solid or liquid material during swallowing as well as
regulating vocal cord tension for phonation (speaking). The technique of cricoid pressure
is based on the fact that the cricoid cartilage is a complete ring, which is used to compress
the esophagus behind it against the vertebral bodies of C5-6 to prevent regurgitation of
gastric contents into the pharynx. The thyroid and cricoid cartilages are linked anteriorly
by the cricothyroid membrane, through which access to the airway can be gained in an
emergency.

Trachea and bronchi

The trachea extends from below the cricoid cartilage to the carina, the point where
the trachea divides into the left and right main bronchus, with a length of 12-15cm in an
adult and an internal diameter of 1.5-2.0cm. The carina lies at the level of T5 (5th thoracic
vertebra) at expiration and T6 in inspiration. Most of its circumference is made up of a
series of C-shaped cartilages, but the trachealis muscle, which runs vertically, forms the
posterior aspect.
When the trachea bifurcates, the right main bronchus is less sharply angled from the
trachea than the left, making aspirated material more likely to enter the right lung. In
addition, the right upper lobe bronchus arises only about 2.5cm from the carina and must
be accommodated when designing right-sided endobronchial tubes

Lungs and pleura

The right lung is divided into 3 lobes (upper, middle and lower) whereas the left has only 2
(upper and lower), with further division into the broncho-pulmonary segments (10right, 9 left). In
total there are up to 23 airway divisions between trachea and alveoli. The bronchial walls contain
smooth muscle and elastic tissue as well as cartilage in the larger airways. Gas movement occurs by
tidal flow in the large airways. In the small airways, by contrast, (division 17 and smaller) it results
from diffusion only.
The pleura is a double layer surrounding the lungs, the visceral pleura enveloping the
lung itself and the parietal pleura lining the thoracic cavity. Under normal circumstances
the interpleural space between these layers contains only a tiny amount of lubricating
fluid. The pleura and lungs extend from just above the clavicle down to the 8th rib
anteriorly, the 10th rib laterally and the level of T12 posteriorly.
The lungs have a double blood supply, the pulmonary circulation for gas exchange
with the alveoli and the bronchial circulation to supply the parenchyma (tissue) of the
lung itself. Most of the blood from the bronchial circulation drains into the left side of the
heart via the pulmonary veins and this deoxygenated blood makes up part of the normal
physiological shunt present in the body. The other component of physiological shunt is
from the besian veins, which drain some coronary blood directly into the chambers of
the heart.
The pulmonary circulation is a low-pressure (25/10mmHg), low-resistance system with a
capacity to accommodate a substantial increase in blood flowing through it without a
major increase in pressure. Vascular distension and recruitment of unperfused capillaries
achieve this. The main stimulus which produces a marked increase in pulmonary vascular
resistance is hypoxia.
 PATHOPHYSIOLOGY

Predisposing Factor:
>Environment

Streptococcal
Pneumoniae

Enters through nose or

mouth by inhalation

Passes to the Pharynx, Larynx

and Trachea

Microorganism enters and

affects both airway and lung
parenchyma

Airway damage Lung invasion

Infiltration of bronchi Flattening of

Epithelial Cells
Infectious organism lodges Necrosis of
stimulation in bronchiole Macrophages and
bronchial tissues
Leukocytes
Alveolar wall collapse
Narrowing of air Mucus and phlegm
passage production
Increase pyrogens in the
body
COUGHING
FEVER DIFFICULTY OF Productive
BREATHING (yellowish sputum)
 LABORATORY RESULTS:

Laboratory/ Actual Result Normal Value Analysis/Inference Reference

Diagnostic Test
Complete blood
count/ August 18,
2010
Normal Diagnostic and Laboratory
WBC count 6.90 5.0-10 Test Reference(MOSBY)

Diagnostic and Laboratory

Hemoglobin 13.6gms/dl (M:13.5 – 18;) Normal Test Reference(MOSBY)

(M: 0.35-0.51) Normal Diagnostic and Laboratory

0.39
Test Reference(MOSBY)
Hematocrit

Diagnostic and Laboratory

Lymphocytes 0.20 0.25-0.35 Abnormal Test Reference(MOSBY)

Clinical
Chemistry
August 18, 2010

Creatinine 111.70 80-115 Normal Diagnostic and Laboratory

Test Reference(MOSBY)

Normal
Sodium 142.7 mmol/L 135 – 148 Diagnostic and Laboratory
Test Reference(MOSBY)

4.22 mmol/L Diagnostic and Laboratory

Potassium 3.5 – 5.3 Normal Test Reference(MOSBY)

16 Diagnostic and Laboratory

ALT(SGPT) 9-72 Normal Test Reference(MOSBY)
9

AST(SGOT) 8-56 Normal Diagnostic and Laboratory

Test Reference(MOSBY)
 COURSE IN THE WARD

August 18, 2010

Patient was admitted at 7Delta were antibiotics were started immediately, After 5 days of
treatment patient showed good clinical improvement, no fever, no difficulty of breathing.
 NURSING CARE PLAN

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

Subjective: Ineffective After 4 hours  Auscultate  To After 4 hours of

“Nahihirapan breathing of nursing chest to identify nursing
ako huminga” pattern interventions evaluate precipitatinterventions
as verbalized by related to the patient character or ing the patient
the patient. respiratory will establish presence of factors. established a
muscle an effective breath effective
Objective: fatigue as respiratory sounds/secreti  To clear respiratory
Dyspnea evidenced by pattern. ons. secretion pattern.
dyspnea and s.
verbal  Suction
complaint of airway as  To
the patient needed. promote
physiolo
 Elevate height gical
of bed. ease of
maximal
 Administer inspiratio
oxygen at n.
lowest
concentration  For
as indicated. managem
ent of
 Encourage underlyin
slower and g
deeper pulmonar
respirations. y
condition
.

 To assist
client in
taking
control
of the
situation.
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Subjective: Bowel After 8 hours  Note stool  To After 8 hours of

incontinence of nursing characteristics provide nursing
“Dumudumi related to interventions compara interventions
ako ng diarrhea as the patient  Auscultate tive the patient
dalawang beses evidenced by maintain a abdomen. baseline. maintain a
sa isang araw, verbal report regular effective regular
minsan ay of the patient. bowel  Identify foods  To bowel function.
tatlong beses functioning that may eliminat
pa, siguro kasi as possible. cause e or
nagdidiarrhea problem. identify
ako” as foods
verbalized by  Identify foods that may
the patient. that promote cause
bowel diarrhea.
Objective: regularity.
 To aid in
Diarrhea  Encourage maintain
patient to eat ing a
high fiber regular
foods and bowel
drink plenty pattern.
of water if
possible.
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Subjective: Sleep After 8 hours  Note  To After 8 hours of

deprivation of nursing environmental identif nursing
“Patient related to interventions factors y interventions
verbalized that uncomfortable the patient affecting sleep. contrib the patient
he had 4-6 environment. will report uting reports
hours of sleep. improvement  Encourage factors improvement in
in sleep patient to to his sleep pattern.
Objective:
pattern. restrict sleep
caffeine and pattern.
other
stimulating  Provid
substances es
from late compar
afternoon or ative
evening. baselin
e.
 Suggest
abstaining  To
from daytime elimina
naps. te
factors
 Identify foods that
that promote disrupt
bowel s sleep
regularity. pattern.
 Instruct in  It
relaxation impairs
techniques. ability
to
sleep at
night

 To
decreas
e
tension
,
prepare
for
sleep.
 DRUG STUDY

Classification: Anti-infectives

INDICATI CONTRAINDIC SIDE NURSING

DRUG NAME ACTION
ON ATION EFFECTS CONSIDERATION
GENERIC Respiratory Inhibits Hypersensitivity Diarrhea, • Observe
NAME: tract protein to clarithromyc nausea, patients vital signs
Clarithromycin infections synthesis in, abnormal • Monitor for
including at the level erythromycin, taste, signs and symptoms
BRAND streptococcal of the 50S or other dyspepsia, hypersensitivity
NAME pharyngitis, bacterial macrolide anti- abdominal
sinusitis, ribosome infectives pain/discom
Biaxin bronchitis fort &
and • Concurrent use headache
DOSAGE pneumonia of pimozide
Adult:
100mg

Classification: Anti-infectives

DRUG INDICATIO CONTRAINDIC SIDE NURSING

ACTION
NAME N ATION EFFECTS CONSIDERATION
GENERIC Treatment of Binds to • Serious Diarrhea, • Assess for
NAME: respiratory, bacterial hypersensitivity nausea, signs of infections
Cephalosporin skin, bone cell wall to penicillin vomiting, • Before
s and joint membrane cramps, initiating therapy,
infections. , causing rashes, obtain a history of
BRAND cell death. anaphylaxis reaction to penicillin
NAME and cephalosporins

Cefuroxime

DOSAGE
Adult:
200-400mg
every 12 hr
Classification: Anti-asthmatic
DRUG CONTRAINDIC ADVERSE NURSING
INDICATION ACTION
NAME ATION REACTION CONSIDERATION
GENERIC Treatment of Patient with a A small
NAME: A β- history of
acute adrenergic increase in Great care is also
ferrous severe asthma sensitivity to heart rate
sulfate stimulant components of needed in patients
& in routine which has a may occur with cardiovascular
management salbutamol. in patients
highly disease eg, ischemic
of selective who inhale heart disease,
BRAND chronic bronc a large
NAME: action on arrythmia or
hospasm unre the dosage tachycardia,
Aero-vent sponsive to of salbuta
nebules receptors in hypertension.
conventional bronchial mol. This
therapy. muscle and is not Care is also required
DOSAGE: usually when
5mg in
therapeutic accompani sympathomimetic
doses, it has ed by any agents are given to
little or no changes in patients with
action on the diabetes mellitus or
the cardiac electrocard closed-angle
receptors. iogram. glaucoma.
Other side
effects An increased risk of
which arrhythmias may also
occur with occur if
very high sympathomimetic
doses agents are given to
ofsalbutam patients receiving
ol by cardiac glycosides,
inhalation quinidine or tricyclic
are antidepressants.
peripheral
vasodilatat
ion and the
fine tremor
of skeletal
muscle.
Classification: Mucolytics

DRUG INDICATIO CONTRAINDIC SIDE NURSING

ACTION
NAME N ATION EFFECTS CONSIDERATION
GENERIC Mucolytic in Degrades • Hypersens drowsiness. • Assess
NAME: the mucus, itivity to the Vasodilation , respiratory function
Acetylcystein management allowing drug bronchial/trac (lung sounds,
e of conditions easier heal irritation, dyspnea) and color,
associated mobilizati chest amount, and
BRAND with thick on and tightness, consistency of
NAME viscid mucous expectorat increased secretions before and
secretions ion secretions, immediately
Bronchoflem nausea, vomit following treatment
ing, stomatitis to determine
DOSAGE effectiveness of
Adult: therapy
200-mg
 DISCHARGE PLANNING

• MEDICATION
Advise client to take medicine as prescribed by the Physician. Medicines used to treat pneumonia
may include antibiotics to cure the infection.

• EXERCISE
Take adequate rest. If tolerated, do light exercises such as walking. And also do deep breathing and
coughing

• TREATMENT
Medications should be taken exactly as prescribed by a physician. If it is not helping, call the
doctor. Do not quit taking it unless told to do so by a doctor. Nebulize as ordered by the doctor, and
drink plenty of water to loosen secretions.

• HEALTH TEACHING
Comply with the treatment regimen: place the client in a comfortable position. Encourage deep
breathing and cough exercises.

• OUT-PATIENT
Comply with the scheduled follow-up check up.

• DIET
Eat healthy and nutritious food. Eat fruits rich in vitamin C or take vitamin C to increase the
resistance of the client against infection. Increase fluid intake if not contraindicated to the patient.

• SPIRITUAL
Pray for faster recovery.
 A Clinical Case Study Utilizing Nursing Process
At Armed Forces of the Philippines Medical Center

COMMUNITY ACQUIRED PNEUMONIA

In Partial fulfilment of the requirement for N104

Presented By:
Lanorias, Bomel T.

Presented To:

Anielyn G. Penetrante, RN, MAN

Clinical Instructor

Date
September 11, 2010