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CASE STUDY
ON
PNEUMONIA

2. OBJECTIVES
• Define what is Pneumonia
• Trace the Pathophysiology of Pneumonia
• Enumerate the different signs and symptoms of pneumonia
• Formulate the different signs and symptoms of pneumonia
• Formulate and nursing care plans utilizing the nursing process
• To learn new clinical skills as well as sharpen once current clinical skills
required in the management of the patient of pneumonia
• To develop our sense of unselfish love and empathy in rendering nursing
care plan to our patient so that we may be able to serve future clients with
higher level of holistic understanding as well as individual care
INTRODUCTION
Pneumonia is an inflammation of the lungs caused by an infection. It is also
called Pneumonitis or Bronchopneumonia. Pneumonia can be a serious threat to
our health. Although pneumonia is a special concern for older adults and those
with chronic illnesses, it can also strike young, healthy people as well. It is a
common illness that affects thousands of people each year in the Philippines,
thus, it remains an important cause of morbidity and mortality in the country.
There are many kinds of pneumonia that range in seriousness from mild to life-
threatening. In infectious pneumonia, bacteria, viruses, fungi or other organisms
attack your lungs, leading to inflammation that makes it hard to breathe.
Pneumonia can affect one or both lungs. In the young and healthy, early
treatment with antibiotics can cure bacterial pneumonia. The drugs used to fight
pneumonia are determined by the germ causing the pneumonia and the
judgment of the doctor. It’s best to do everything we can to prevent pneumonia,
but if one do get sick, recognizing and treating the disease early offers the best
chance for a full recovery.
A case with a diagnosis of Pneumonia may catch one’s attention, though the
disease is just like an ordinary cough and fever, it can lead to death especially
when no intervention or care is done. Since the case is a toddler, an appropriate
care has to be done to make the patient’s recovery faster. Treating patients with
pneumonia is necessary to prevent its spread to others and make them as
another victim of this illness.
PATIENT’S HISTORY
a. Patient’s Profile
Name: R.C.S.B.
Age: 1 yr,1 mo.
Weight:10 kgs
Religion: Roman Catholic
Mother: C.B.
Address: Cebu City
Father: D.B
Address: California, USA
b. Chief Complaint: Fever

3. Date of Admission: 1st
admission
Hospital Number: 060000086199
c. History of Present Illness
2 days PTA – (+) cough
(+) nasal congestion, watery to greenish
(+) nasal discharge
Tx: Disudrin OD
Loviscol OD
Few hrs PTA - (+) fever, Tmax= 39.3 C
(+) difficulty of breathing
(+) vomiting, 1 episode
Tx: Paracetamol
Sought consultation at ER: Rx=BPN, Salbutamol neb.
IE: T = 38.3C, CR= 122’s, RR= 73’s
(+) TPC
SCE, (-) retractions, clear BS, (-) cyanosis, (-) edema
d. Past Illness
(-) asthma
(-) allergies
e. Family History
PMHx: (-) Asthma
(+) smoke (grandfather) father’s side
(+) smoke (father)
(+) diabetes (grandmother) father’s side
f. Activities of Daily Living
Sleeping mostly at night and during afternoon
Usually wakes up early in the morning (5AM) to be milkfed.
Eats a lot (hotdogs, chicken, crackers, any food given to her)
Active, responsive
BM (1-2 times a day)
Urinates in her diaper (more than 4 times a day)
Likes to play with those around her
g. Review of Systems
Neuromuscular: weakness of muscles
Integumentary: (-) cyanosis
Respiratory: tachypnea; (+) DOB; (+) coarse crackles, (+) wheezes,
Digestive: food aversion, vomits ingested milk

4. GORDON’S FUNCTIONAL PATTERN
Before
Hospitalization
During Hospitalization Interpretation
NUTRITION
ELIMINATION
EXERCISE
Patient eat her
meals 3 times a
day in almost ¼
of her mother’s
meal.
Commonly she
drinks milk and
eat rice.
Normally,
consumes 4
diapers daily.
She is active
and has long
period of
playing.
She only drink
formulated milk 3 times
a day in small bottle.
She consumes only 2
diapers.
Her play is limited. She
doesn’t move too much.
There are big
differences in her
nutrition before
and during
hospitalization,
she loss her
appetite in almost
75%.
Patients who are
hospitalized may
have an
inadequate
dietary intake
because of the
illness that
necesitated the
hospitalization or
the hospital’s
food is unfamiliar.
The consumption
of diapers before
and during
hospitalization
was decreased.
Decrease
elimination is due
to decrease food
intake.
Before she is
active but her
move during
confinement
becomes limited.
Decreased
activity is
because of the
intravenous fluid
attach to her thus
limiting her
movement to
prevent the
intravenous line

5. REST AND SLEEP
HYGIENE
SUBSTANCE USE
She was able to
consume 8
hours of
sleeping
normally.
She had a
schedule for
naps, twice a
day.
Regularly, she
takes a bath
early morning
with the
assistance of
her mother.
Before
admission:
patient took
Patient takes a nap 20 to
30 minutes a day and
she sleeps 3-4 hours
only.
She never takes a bath.
Her mother would do
sponge bath for her.
Physician orders the ff:
Salbutamol (ventolin)
Cefuroxime (Zinacef)
to get tangle to
her.
Before
hospitalization,
she had a normal
normal sleep
pattern but during
hospitalization he
had abnormal
sleep pattern.
Respiratory
condition can
disturb an
individual sleep.
Shortness of
breath often
makes sleep
difficult. Hospitals
environment also
affects the sleep.
Environmental
and lack of
ventilation can
affect sleep.
Before
hospitalization,
the patient takes
a bath regularly.
But during
confinement, she
never takes a
bath and thus
needs the
assistance of her
mother for sponge
bathing.
This is due to
environmental
setiing. The
hospital might not
have available
facilities for
bathing.
Medications
before and during
confinement

6. Disudrin once a
day
Loviscol once a
day
Paracetamol differed.
During
confinement,
additional or
revision of
medications
happen for it will
be based on
laboratory
findings.
GENOGRAM
No hereditary illness in mother’s side. In her father’s side, her father and
grandfather are occasional smokers. Her grandmother is dagnosed as diabetic.
PATIENT’S HEALTH ASSESSMENT
General Appearance
• Posture – the patient is crying and irritated when in lying position.
• Skin color – she has whitish skin color.
• Hygiene – sponge bath done by her mother, no unpleasant odor, wears
clean clothes.
• Verbal – she wants to be cuddled by her mother and cries when put in
bed.
• Non-verbal – the patient is rolling in the bed and grasping anything she
saw.

7. VITAL SIGNS
Normal Findings Actual Findings Interpretation
Temperature
Cardiac Rate
Respiratory Rate
36.5 – 37.5 ° C
120 – 160 bpm
30 – 60 cpm
38.3° C
122 bpm
73 cpm
The patient is
having fever.
Fever is a sign
there is
something wrong
with the body
system and her
fever is due to her
present illness.
Cardiac rate is
within normal
range.
Shows increased
respiratory rate.
Patient is
experiecning
tachypnea.

8. ANATOMY AND PHYSIOLOGY
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

9. 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 over each other during breathing.

10. PATHOPHYSIOLOGY
Pneumonia is a serious infection or inflammation of your lungs. The air sacs in
the lungs fill with pus and other liquid. Oxygen has trouble reaching your blood. If
there is too little oxygen in your blood, your body cells can’t work properly.
Because of this and spreading infection through the body pneumonia can cause
death. Pneumonia affects your lungs in two ways. Lobar pneumonia affects a
section (lobe) of a lung. Bronchial pneumonia (or bronchopneumonia) affects
patches throughout both lungs.
Bacteria are the most common cause of pneumonia. Of these, Streptococcus
pneumoniae is the most common. Other pathogens include anaerobic bacteria,
Staphylococcus aureus, Haemophilus influenzae, Chlamydia pneumoniae, C.
psittaci, C. trachomatis, Moraxella (Branhamella) catarrhalis, Legionella
pneumophila, Klebsiella pneumoniae, and other gram-negative bacilli. Major
pulmonary pathogens in infants and children are viruses: respiratory syncytial
virus, parainfluenza virus, and influenza A and B viruses. Among other agents
are higher bacteria including Nocardia and Actinomyces sp; mycobacteria,
including Mycobacterium tuberculosis and atypical strains; fungi, including
Histoplasma capsulatum, Coccidioides immitis, Blastomyces
dermatitidis, Cryptococcus neoformans, Aspergillus fumigatus, and
Pneumocystis carinii; and rickettsiae, primarily Coxiella burnetii (Q fever).
The usual mechanisms of spread are inhaling droplets small enough to reach the
alveoli and aspirating secretions from the upper airways. Other means include
hematogenous or lymphatic dissemination and direct spread from contiguous
infections. Predisposing factors include upper respiratory viral infections,
alcoholism, institutionalization, cigarette smoking, heart failure,chronic
obstructive airway disease, age extremes, debility, immunocompromise (as in
diabetes mellitus and chronic renal failure), compromised consciousness,
dysphagia, and exposure to transmissible agents.
Typical symptoms include cough, fever, and sputum production, usually
developing over days and sometimes accompanied by pleurisy. Physical

11. examination may detect tachypnea and signs of consolidation, such as crackles
with bronchial breath sounds. This syndrome is commonly caused by bacteria,
such as S. pneumoniae and H. influenzae.
NURSING ACTIONS
INDEPENDENT
 positioning of the patient with head on mid line, with slight flexion
rationale: to provide patent, unobstructed airway , maximum lung excursion
 auscultating patient’s chest
rationale: to monitor for the presence of abnormal breath sounds
 provide chest and back clapping with vibration
rationale: chest physiotheraphy facilitates the loosening of secretions
 considering that the patient is an infant, and has developed a strong
stranger anxiety
as manifested by “white coat syndrome” , it is a nursing action to play with the
patient.
rationale: to establish rapport, and gain the patients trust
DEPENDENT
 administer due medications as ordered by the physician, bronchodilators,
anti pyretics and anti biotics
rationale: bronchodilators decrease airway resistance, secondary to
bronchoconstriction,
anti pyretics alleviate fever, antibiotics fight infection
 placing patient on TPN prn
rationale: to compensate for fluid and nutritional losses during vomiting
COLLABORATIVE
 assist respiratory therapist in performing nebulization of the patient
rationale: nebulization is a favourable route of administering bronchodilators
and aid in expectorating secretions, hence patient’s breathing
PHYSICIAN’S ORDER SHEET
11/19/06
Admit patient to CHH under the service of Dr. Vitan secure consent for
admission and management, TPR every shift then record. May have diet
for age with strict aspiration precaution, IVF D5 0.3NaCl 500cc to run at
62-63mgtts/min.May give paracetamol 125mg 1supp/rectum if oral
paracetamol is not tolerated.
11/20/06
For urinalysis, IVF to follow D5 0.3 NaCl 500 at SR (62-63mgtt/m Use
zinacef brand of cefuroxime 750mg- given ½ vial 375mg every 8hours,
nebulize (Ventolin 1 nebule) every 6 hours, paracetamol drugs prn every
4hours (Temp 37.8).
11/21/06

12. Continue cefuroxine and nebulizer every 6 hours. May not reinsert IVF,
revise Cefuroxime IV to Cefuroxime 500mg via deep Intramuscular
BID,continue management.
11/22/06
Continue management and refer.
DISCHARGE PLANNING
 Take the entire course of any prescribed medications. After a patient’s
temperature returns to normal, medication must be continued according to the
doctor’s instructions, otherwise the pneumonia may recur. Relapses can be far
more serious than the first attack.
 Get plenty of rest. Adequate rest is important to maintain progress
toward full recovery and to avoid relapse.
 Drink lots of fluids, especially water. Liquids will keep patient from
becoming dehydrated and help loosen mucus in the lungs.
 Keep all of follow-up appointments. Even though the patient feels
better, his lungs may still be infected. It’s important to have the doctor monitor
his progress.
 Encourage the guardians to wash patient’s hands. The hands come in
daily contact with germs that can cause pneumonia. These germs enter one’s
body when he touch his eyes or rub his nose. Washing hands thoroughly and
often can help reduce the risk.
 Tell guardians to avoid exposing the patient to an environment with
too much pollution (e.g. smoke). Smoking damages one’s lungs’ natural
defenses against respiratory infections.
 Give supportive treatment. Proper diet and oxygen to increase oxygen
in the blood when needed.
 Protect others from infection. Try to stay away from anyone with a
compromised immune system. When that isn’t possible, a person can help
protect others by wearing a face mask and always coughing into a tissue.
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