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Community Acquired Pneumonia Moderate Reactive
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Community Acquired Pneumonia Moderate Reactive

ABSTRACT The case study allows the researchers to enhance their knowledge and skills about a certain disease that they encountered in the area while giving quality nursing care to the patient. This is a study about Community Acquired Pneumonia, a condition in which there is an infection of the lungs. It is caused by Bacteria and the most common pneumonia-causing germ in adults is Streptococcus pneumoniae (pneumococcus). Symptoms included Cough, Fever and Dyspnea. Diagnosing Community acquired Pneumonia would include Chest xray and sputum exam. In order to gather information, the researchers have done physical assessment and interviewed the clients relative, and at the same time, review the patients medical chart. These things had caused problems to the researcher for they were not able to continuously gather information due to the physical condition of the patient and availability of both parties.

To improve the health of the patient, nursing and medical intervention was done. Some of this would include pharmacologic management, vital signs taking, input and output monitoring. The study discussed about the outcomes of different medical and nursing intervention that was rendered to the patient and his response to the said interventions.

Introduction

There are several health concerns that are not clear for many, causes and treatment of different diseases for instance. The study will provide better understanding of a particular disease, community-acquired pneumonia(CAP),which is common disease in the country.

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.

Community-acquired pneumonia develops in people with limited or no contact with medical institutions or settings. The causes of CAP include bacteria,viruses,fungi, and parasites. The most commonly identified pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and atypical organisms (ie, Chlamydia pneumoniae,Mycoplasma pneumoniae, Legionella sp). Symptoms and signs are fever, cough, pleuritic chest pain, dyspnea, tachypnea, and tachycardia. CAP can be diagnosed by symptoms andphysical examination alone, though x-rays, examination of the sputum, and other tests are often used. Individuals with CAP sometimes require treatment in a hospital. CAP is primarily treated with antibiotic medication . Some forms of CAP can be prevented by vaccination.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.

According to world health organization (issued on october 2011)pneumonia is the leading cause of death in children worldwide . It kills an estimated 1.4 million children under the age of five years every year more than AIDS, malaria and tuberculosis combined.

In local statistics ,DOH said that Pneumonia is the 5th leading cause of death in the Philippines with 34,958 Filipinos dying of the illness during the period . This was from year 2006.

LIMITATIONS

The researchers had been through some troubles like not enough time to finish, lack of funds in doing the case study, but they endured and survived all these through the cooperation of each member of the group and through the support of their mentor. As a matter of preference, the researchers desired to finish the study ahead of time but for some reasons, accomplishing some tasks were deferred. Time is indeed a great factor in doing the case, for it limits the things that should be done by the researchers. Every deadline is strictly observed thats why each member participated. Lack of reference materials had once caused the researchers to put off the tasks to another day because nothing would be done properly and effectively if they would still continue. They should be prepared enough and avoidance of errors should also be taken into consideration. The sources of the information about our client were also limited because the client himself is unable to speak. The researchers rely on the clients wife and son for the past history and other information.

PATIENTS PROFILE

Patient EB is a 71 year old male, married, he is a Roman Catholic. He currently lives at Paraaque City. He was born on October 17, 1940, he is the third son of Mr. and Mrs. X. Last January 11, 2012 on 5:10 PM he was admitted at Pasay City General Hospital with the chief complaint of three days fever, his attending Physician is Dr. Manzanilla. His initial medical diagnosis was Community Acquired Pneumonia Moderate Risk to consider Urinary Tract Infection status post Cerebrovascular Accident 2008 Hypertension Electrolyte Imbalance.

Two weeks (December 28, 2011) prior to admission, he is still experiencing cough, and there was a decreased fluid intake, loss o On January 1, 2012 around 2:00 am, patient EB was exposed to cold weather outside their house due to unexpected fire raised o Three days (January 8, 2012) prior to admission, cough is continuous and developed fever. The patient did not take any medicat On January 10, 2012 around 5:00 pm, patient EB was rushed to Emergency Room of Pasay City General Hospital with the chief On January 11, 2012 at 5:10 pm, patient EB was admitted to Male Medical Ward 2 with the admitting diagnosis of Community Ac

Past Medical History Patient EB first had his hospitalization when he had Cerebrovascular Accident last August 2008 and first admitted in San Juan de Dios Hospital, Pasay City but the family of the patient s choice of hospital is Pasay City General Hospital so the treatment was continued there. On March 2011, the patient had vomit blood so he was rushed again in Emergency Room of Pasay City General Hospital and had his Chest X-ray and the impression was Pulmonary Tuberculosis. The family was alarmed so they decided to have a second opinion. They brought the X-ray film in San Lazaro Hospital and the final impression was Pneumonia, right. On July 2011, the patient fell down from their stair and thought that it was only because of weakness due to aging. The incident was followed three times more on the succeeding months until October 2011that the patient is losing his consciousness and the patient cannot walk anymore, and there is already decorticated posturing. When the patients family noticed of these physical changes, they decided to bring him on OPD Pasay City General Hospital. When he had his CT scan of the head in Protacio Hospital, the impression was Suspicious Infarct, Right Basal Ganglia.

Family Medical History

Patient EB is the third son of Mr. XF and Mrs. XM. His father were already dead because of aging at the age of 85 years old, as well as his mother who died because of aging and has glaucoma at the age of 84 years old. He has five living siblings namely: BB1 85 years old, BB2 80 years old, BB3 69 years old, BB4 55 years old, BG5 52 years old. His four other siblings were already dead namely: XG1 who died when she was 69years old because of Hypertension, XB2 Who died when he was 67 years old because of Diabetes Mellitus and Hypertension, XB3 who died when he was 48 years old because of vehicular accident, and XG4 who died when she was 30 years old for unknown reason. Patient EB`s wife, Mrs. EBW who is 69 years old has Diabetes Mellitus. Their children namely EBB1 48 years old, EBG3 44 years old, EBB4 42 years old, EBG5 40 years old, EBG6 38 years old, EBB7 36 years old and EBB8 33 years old are all healthy and no diagnosed disease except for their 2nd son who is EBB2 46 years old has Diabetes Mellitus and Hypertension.

Social History

Patient EB is husband of Mrs. EBW for 49 years. They were blessed to have eight children. He took his elementary education in Rizal Elementary School, Rizal de Naga, Surigao del Norte in the year 1952. His secondary education was in Ormoc National High School, Ormoc, Leyte. He did not finish his secondary education and reached only at third year level in the year 1955.

He first worked at LARAP Jose Panganiban, Camarines Norte as a Miner from 1968-1974. On the year 19741976, he was Operator of Heavy Equipment at Dionisio & Morillo Logging Company, Polilio, Quezon. He was a Pipefitter at Engineering Equipment, Antipolo on the year 1976-1977. On the year 1977-1980, he became Pick Up Delivery Forwarder at Affiliated Cargo Express, MIA Rd., Pasay City. On the year 1981-1994, he was a vendor of food in MIA Domestic Airport. On the transportation terminal in Polilio, Quezon, he was vendor of souvenir items from the year 1995-2008. On the middle part of 2008 until today, he does not have occupation no more

Patient EB is a smoker for 39 years. He started to smoke when he was 7 years old and stopped on the year 1986. He can consume 1 pack of cigarette everyday. He is also a alcoholic drinker but only drinks occasionally. When the patient is still able to walk, he loves to take a walk and jog around.

Environmental History

Patient EB is currently residing on Pildera 1 MIA Rd. Paranaque City. Their house is a two storey building. The house is built by cement but not yet fully furnished. Their supply of electricity is coming from MERALCO , have sufficient light throughout the house. The water supply is coming from Maynilad. All water usage even the drinking consumption is from the water of Maynilad. The neighbourhood is made up of a bit crowded houses but enough to walk comfortably going outside. Some neighbours are smoking. The house is a bit near to the highway of MIA road.

VITAL SIGNS

Vital Signs Blood Pressure Temperature Pulse Rate Respiratory Rate

Actual 130/90 mm/hg 36.8c 80 bpm 24 bpm

Expected 100/60 130/80 mmHg 36.5 - 37.5 c 60 100 bpm 12 -20 bpm

Nursing Implications Normal Normal Normal

Skin Color

Skin is light brown in color.

Above normal, Tachypnea. Put patient in a high fowlers position to promote physiological ease of maximal inspiration. Administer oxygen as ordered Slightly light brown to Normal dark brown.

July 16, 2012 (Handled During the RLE Duty) 12:00 pmVital Signs Actual Expected Nursing Implication

Blood Pressure

130/90 mm/hg

100/60 130/80 mmHg

Normal

Temperature

37.3c

36.5 - 37.5 c

Normal

Pulse Rate

95 bpm

60 100 bpm

Normal

Respiratory Rate

24 bpm

12 -20 bpm

Above normal, Tachypnea Put patient in a high fowlers position to promote physiological ease of maximal inspiration. Administer oxygen as ordered. Normal

Skin color

Skin is light brown in color.

Slightly light brown to dark brown.

Vital Signs

Actual

Expected

Nursing Implication

Blood Pressure

140/90 mm/hg

100/60 130/80 mmHg

Above Normal

Temperature

37.5c

36.5 - 37.5 c

Normal

Pulse Rate Respiratory Rate

101 bpm 25 bpm

60 100 bpm 12 - 20 bpm

Normal Above normal, Tachypnea Put patient in a high fowlers position to promote physiological ease of maximal inspiration. Administer oxygen as ordered.

Skin color

Skin is light brown in color.

Slightly light brown to dark brown.

Normal