INTRODUCTION
Overview of the Disease
Pneumonia is a type of lung infection. It can cause breathing problems and other symptoms. In
community-acquired pneumonia (CAP), you get infected in a community setting. It doesn’t happen in a
hospital, nursing home, or other healthcare center. Many germs can grow inside your body and cause
disease. Specific types of germs can cause lung infection and pneumonia when they invade. This can cause
your respiratory system to work poorly. For example, oxygen may not be able to get into your blood as
easily. That can cause shortness of breath. If your body can’t get enough oxygen to survive, pneumonia
may lead to death. Sometimes these germs can spread from person to person. When someone infected with
one of these germs sneezes or coughs, you might breathe the germs into your lungs. If your immune system
doesn’t kill the germs first, the germs might grow and cause pneumonia.
CAP can result from infection with many types of germs. These include bacteria, viruses, fungi, or
parasites. Symptoms from pneumonia can range from mild to severe. Certain types of germs are more likely
to lead to serious infection.
CAP is more common during the winter months, in older adults. But it can affect people of any
age. It can be very serious especially in older adults, young children or people with other health problems.
Anatomy and Physiology of the affected system
The lungs are the major organs of the respiratory system, and are divided into sections, or lobes.
The right lung has three lobes and is slightly larger than the left lung, which has two lobes.
The lungs are separated by the mediastinum. This area contains the heart, trachea, esophagus, and
many lymph nodes. The lungs are covered by a protective membrane known as the pleura and are separated
from the abdominal cavity by the muscular diaphragm.
With each inhalation, air is pulled through the windpipe (trachea) and the branching passageways
of the lungs (the bronchi), filling thousands of tiny air sacs (alveoli) at the ends of the bronchi. These sacs,
which resemble bunches of grapes, are surrounded by small blood vessels (capillaries). Oxygen passes
through the thin membranes of the alveoli and into the bloodstream. The red blood cells pick up the oxygen
and carry it to the body's organs and tissues. As the blood cells release the oxygen they pick up carbon
dioxide, a waste product of metabolism. The carbon dioxide is then carried back to the lungs and released
into the alveoli. With each exhalation, carbon dioxide is expelled from the bronchi out through the trachea.
The respiratory tract is divided into two main parts: the upper respiratory tract, consisting of the
nose, nasal cavity and the pharynx; and the lower respiratory tract, consisting of the larynx, trachea, bronchi
and the lungs.
The trachea, which begins at the edge of the larynx, divides into two bronchi and continues into the
lungs. The trachea allows air to pass from the larynx to the bronchi and then to the lungs.
The bronchi divide into smaller bronchioles which branch in the lungs forming passageways for
air. The terminal parts of the bronchi are the alveoli. The alveoli are the functional units of the lungs and
they form the site of gaseous exchange.
Pathophysiology
Aspiration of oropharyngeal secretions is the most common route of lower respiratory tract
infection; thus the nasopharynx and oropharynx constitute the first line of defense for most infectious
agents. Another route of infection is through the inhalation of microorganisms that have been released into
the air when an infected individual coughs, sneezes, or talks, or from aerosolized water, such as that from
contaminated respiratory therapy equipment. This route of infection is most important in viral and
mycobacterial pneumonias and in Legionella outbreaks. Endotracheal tubes become colonized with bacteria
that form biofilms (protected colonies of bacteria that are resistant to host defenses and treatment with
antibiotics) and can seed the lung with microorganisms, especially during endotracheal suctioning.
Pneumonia also can occur when bacteria are spread to the lungs in the blood from bacteremia that can result
from infection elsewhere in the body or from intravenous drug use.
In healthy individuals, pathogens that reach the lungs are expelled or controlled by mechanisms of
self-defense. If a microorganism overcomes the upper airway defense mechanisms, such as the cough reflex
and mucociliary clearance, the next line of defense is the airway epithelial cell. Airway epithelial cells can
recognize some pathogens directly (e.g., Pseudomonas aeruginosa and Staphylococcus aureus). However,
the most important guardian cell of the lower respiratory tract is the alveolar macrophage, which recognizes
pathogens through its pattern-recognition receptors (e.g., Toll-like receptors). Macrophages present
infectious antigens to the adaptive immune system, activating T cells and B cells with the induction of
cellular and humoral immunity. Release of TNF-α and IL-1 from macrophages and chemokines and
chemotactic signals from mast cells and fibroblasts contributes to widespread inflammation in the lung with
recruitment of neutrophils from the capillaries of the lungs into the alveoli.
Neutrophils are critical phagocytes that kill microbes through the formation of phagolysosomes
filled with degradative enzymes, antimicrobial proteins, and toxic oxygen free radicals. Neutrophils have
also been found to extrude a meshwork of proteins called a neutrophil extracellular trap (NET) that can
capture any bacteria that have not yet been phagocytosed. Unfortunately, many pathogens, such as the
pneumococcus, can release a deoxyribonuclease (DNase) that cleaves the NET and thus escapes neutrophil
defense. The release of inflammatory mediators and immune complexes can damage bronchial, mucosal,
and alveolocapillary membranes, causing the terminal bronchioles and acini to fill with infectious debris
and exudate. In addition, some microorganisms release toxins from their cell walls that can cause further
lung damage. Obstruction of bronchioles and accumulation of exudate in the acinus lead to V̇/Q̇
mismatching, hypoxemia, and dyspnea.
CLIENT DATABASE
Client Profile
The patient, PT, is a 91-year-old female from Virac, Catanduanes, Philippines. She was born on November
21, 1931. She is of full Filipino blood and is a Roman Catholic.
Chief complaint
The patient was brought to the emergency room with complaints of productive cough and difficulty of
breathing.
History of Present Illness
The patient was admitted to CDHI last week because of Dengue fever. Ten days prior to admission, the
patient has an onset of productive cough with whitish phlegm with body weakness, and loss of appetite.
The cough was
Family History
Their family has a history of hypertension; however, no family history of diabetes, tuberculosis, cancer,
rheumatic fever, and mental illness was reported.
Medical History
The patient was diagnosed with hypertension for 20 years and is maintaining medication of Losartan 100mg
OD, Cavedilol 6.25 mg 1 tab BID, Clopidogrel 75 mg, and Simvastatin 10 mg. The patient was admitted
multiple times because of hypotension probably drug-induced. She also underwent Thyroidectomy last
1980, gave birth to 9 children, and has no known allergies to food and medications.
PATIENT ASSESSMENT
Physical Assessment
The patient was awake, afebrile, and weak-looking. She has pinkish palpebral conjuctivae,
symmetrical chest expansion, crackles on both lung fields, normal precordium, normal rate and rhythm, full
pulses on both upper and lower pulses, and no edema noted. The vital signs are within normal range, with
body temperature of 36.5 degrees Celsius, respiration rate of 26, pulse rate of 93, oxygen saturation of 95%,
and blood pressure of 130/80 mmHg that is slightly higher than normal.
Laboratory Examination and Diagnostic Test Findings
Hematology
All patients with CAP being assessed in emergency departments or admitted to hospital should
have oximetry, measurement of serum electrolytes and urea levels, and a full blood count to assist in
assessing severity. Blood gas measurement is also recommended, as it provides prognostic information (pH
and Pao2 ) and may identify patients with ventilatory failure or chronic hypercapnia (Paco2 ). If the patient
has known or suspected diabetes mellitus, measurement of blood glucose also assists in assessing severity.
TEST
RESULT
REFERENCE RANGE
Hemoglobin
132
110 - 160 g/L
Hematocrit
39.3
37 - 54%
RBC
3.73
3.5 - 5.50 x 10^12/L
WBC
6.06
4 - 10 x 10^9/L
Segmenters
66.94
40-75%
Lymphocytes
27.13
20-50%
Eosinophils
0.86
0.40-8.0%
Monocytes
5.04
3-10%
Differential Count
Basophils
Platelet Count
0.00-1.00%
138
150 - 400 x 10^9/L
Note: A low white blood cell count usually means your body is not making enough white blood cells. It can
increase your risk of getting infections. If your basophil level is low, it may be due to a severe allergic
reaction. If you develop an infection, it may take longer to heal.
Chest x-ray
This is the cardinal investigation. In the appropriate setting, a new area of consolidation on chest x-ray
makes the diagnosis, but x-ray is a poor guide to the likely pathogen. Other causes of a new lung infiltrate
on chest x-ray include atelectasis, non-infective pneumonitis, haemorrhage and cardiac failure.
Occasionally, the chest x-ray initially appears normal (eg, in the first few hours of S. pneumoniae
pneumonia and early in HIV related P. jiroveci pneumonia).
Study: CHEST (AP VIEW)
Clinical History: Body Weakness
FINDINGS:
Suspicious densities are seen in both upper lobes.
The heart is enlarged.
The aorta is segmentally calcified.
The trachea is midline.
The hemidiaphragms and costophrenic angles are intact.
The osseous structures and soft tissues are unremarkable.
IMPRESSIONS:
Apicolordotic view is suggested to further evaluate the upper lobes.
Cardiomegaly
Atherosclerotic aorta
Note: This means that the radiologist saw something in the top area of the lungs but without clear details,
therefore a different way of repeating the chest X-ray (using different position) might help to see better this
area of the lung. Another alternative will be obtaining a chest CT scan to evaluate the upper areas of the
lungs.
NURSING CARE PLAN
ASSESSMENT
Objective Data:
 Productive cough
 Difficulty of
breathing
DIAGNOSIS
Ineffective Airway
Clearance related
to presence of
secretions
secondary to
Community
Acquired
Pneumonia
PLANNING
After 8 hrs of
nursing
interventions, the
client’s difficulty
of breathing will
be relieved
INTERVENTION
 Monitor RR,
taking note of the
depth and rate,
BP, PR
Rationale: To
establish baseline data
and monitor changes
 Auscultate lung
fields, noting
presence of
adventitious
breath sounds
Rationale: To
determine possible
bronchospasm or
obstruction
 Elevate head of
bed to high
fowler’s
Rationale: To
facilitate breathing
and lung expansion
 Provide health
teachings
regarding
coughing deep
breathing
exercises
Rationale: To
facilitate in the
expulsion of mucus
 Administer
medications such
as expectorants
as ordered
EVALUATION
After 8 hrs of
nursing
intervention, goal
was met as
evidenced by
decrease
difficulty of
breathing
Objective Data:
 Productive
cough
 DOB
 Body malaise
Ineffective
Breathing pattern
related to airway
obstruction and
infection as
evidenced by
difficulty of
breathing, cough
and restlessness
Rationale: To reduce
bronchospasm and
mobilize secretions
After 8 hrs of
 Assess breath
nursing
sounds and other
intervention the
vital signs.
patient will
Rationale: Monitor for
maintain an
changes in lung
effective breathing sounds, respiratory
pattern with normal rate and depth, and
respiratory rate,
oxygen saturation
depth and oxygen
closely for worsening
saturation and
or improvement.
patient will
 Assess for pain.
incorporate
Rationale: Pain can
breathing
cause increased
techniques to
blood pressure, heart
improve breathing
rate, and ineffective
pattern
breathing patterns.
 Apply oxygen.
Rationale: Apply the
lowest amount of
oxygen required to
support ventilation.
 Reposition the
patient.
Rationale: Patients
who cannot
reposition
themselves may
become slumped in
bed which prevents
proper expansion of
the lungs. Elevate
the HOB and keep
the patient in SemiFowlers or Highfowler’s position as
tolerated to promote
oxygenation.
 Teach the patient
pursed-lip
breathing.
Rationale: Pursed-lip
breathing is a
technique that allows
for controlled
ventilation. The
breath is inhaled
through the nose
then slowly exhaled
through pursed lips
allowing for a
prolonged
expiration.
After 8 hrs of
nursing
intervention the
patient will
maintain an
effective
breathing pattern
with normal
respiratory rate,
depth and oxygen
saturation and
patient will
incorporate
breathing
techniques to
improve breathing
pattern
Objective Data:
 weak looking
 poor appetite
 DOB
Risk of infection
related to
community
acquired
pneumonia
STO:
 Administer
the patient will be
prescribed
able to achieve
antimicrobial
timely resolution of
agents as ordered
current infection
Rationale: To prevent
without
relapse of pneumonia,
complications
the patient needs to
complete course of
LTO:
antibiotics as
patient will be able prescribed
to verbalize
 Check the
understanding on
presence of
how to prevent or
elevated
reduce risk of
temperature and
infection
give paracetamol
as prescribed
Rationale: Fever is
one sign of infection
that needs immediate
interventions to
prevent worsening of
the illness
 Encourage the
patient to eat
healthy foods
that can enhance
the immune
function and take
necessary
vitamins needed
Rationale: It enhances
the immune function
of the body
STO:
the patient was
able to achieve
timely resolution
of current
infection without
complications
LTO:
patient was able
to verbalize
understanding on
how to prevent or
reduce risk of
infection
PHARMACOLOGIC THERAPY
Name of Drug
AZITHROMYCIN
500 mg 1 tab od
BRAND NAMES:
Azasite, Zithromax
Mechanism of
Action
Azithromycin is
from a group of
medicines
called
macrolide
antibiotics.
Macrolide
antibiotics work
by killing the
bacteria that
cause the
infection.
Azithromycin is
available on
prescription as
Contraindication
Contraindicated
with
hypersensitivity to
azithromycin,
erythromycin, or
any macrolide
antibiotic.
Adverse Reaction




Use cautiously with 

gonorrhea or
syphilis,
pseudomembranous 
colitis, hepatic or
renal impairment,
lactation.
Feeling sick
(nausea)
Diarrhoea
Being sick
(vomiting)
Losing your
appetite
Headaches
Feeling dizzy or
tired
Changes to your
sense of taste
Nursing Responsibility
Culture site of
infection before
therapy.
Administer on an
empty stomach 1 hr
before or 2–3 hr after
meals. Food affects the
absorption of this drug.
SALBUTAMOL +
IPRATOPRIUM 1
NEB Q6
Classification:
Anticholinergic
capsules, tablets
and a liquid that
you swallow. It
can also be
given by
injection, but
this is usually
only done in
hospital.
The
combination is
used to treat
conditions
where breathing
is a problem,
such as COPD,
chronic
bronchitis and
emphysema.
They work by
relaxing and
opening up the
air passages,
making
breathing easier
and improving
shortness of
breath, chest
tightness and
wheezing
Keep taking the
medicine, but talk to
your doctor or
pharmacist if these
side effects bother
you or do not go
away.
Contraindicated
with
hypersensitivity to
atropine or its
derivatives, soy
bean or peanut
allergies (aerosol).
Headache,
dizziness, nausea,
dry mouth, shaking
(tremors),
nervousness, or
constipation may
occur.
If any of these
Use cautiously with effects last or get
narrow-angle
worse, tell your
glaucoma, prostatic doctor or
hypertrophy,
pharmacist
bladder neck
promptly
obstruction,
pregnancy,
lactation.






CARVEDILOL 6.25
MG tablet BID
Carvedilol is a
type of
medicine called
a beta blocker.
Like other beta
blockers,
carvedilol
works by
You should not
take carvedilol if
you have asthma,
bronchitis,
emphysema, severe
liver disease, or a
serious heart
condition such as
Common side
effects of carvedilol
include headaches
and feeling tired or
dizzy. Do not stop
taking carvedilol
suddenly. This can
make your
Protect solution
for inhalation
from light.
Store unused
vials in foil
pouch.
Use nebulizer
mouthpiece
instead of face
mask to avoid
blurred vision
or aggravation
of narrowangle
glaucoma.
Can
mix albuterol in
nebulizer for up
to 1 hr.
Ensure
adequate
hydration,
control
environmental
temperature to
prevent
hyperpyrexia.
Have patient
void before
taking
medication to
avoid urinary
retention.
Teach patient
proper use of
inhaler.
Monitor BP and pulse
frequently during dose
adjustment period and
periodically during
therapy.
Assess for orthostatic
hypotension when
assisting patient up
SIMVASTATIN 20mg
tab OD
slowing down
your heart rate
and making it
easier for your
heart to pump
blood around
your body. It
also works like
an alpha
blocker to
widen some of
your blood
vessels. This
helps lower
your blood
pressure
Using acetylCoA as a
substrate,
mevalonic acid
is formed, and
subsequent
reactions lead
to the formation
of cholesterol.
Simvastatin
acts on the ratelimiting step
and serves as an
HMG-CoA
reductase
inhibitor,
consequently
leading to
decreased
cholesterol
concentrations
heart block, "sick
condition worse,
sinus syndrome," or especially if you
slow heart rate
have heart disease
(unless you have a
pacemaker).
Avoid drinking
alcohol within 2
hours before or
after taking
extended-release
carvedilol (Coreg
CR)
Patients with
contraindications to
simvastatin
pharmacotherapy
include those with
active liver disease,
including those
who have elevated
hepatic enzymes,
pregnancy, and
women who may
become pregnant or
who are
breastfeeding







from supine position.
If heart rate decreases
below 55 beats/min,
decrease dose.
Monitor intake and
output ratios and daily
weight.
constipation
stomach
pain
nausea
headache
memory loss
or
forgetfulness
confusion
itchy or red
skin




SULTAMICILLIN
750 mg tab OD
Sultamicillin
interrupts
bacterial cell
wall synthesis,
which is the
The use of
sultamicillin is
contraindicated in
individuals with a
history of an
The common side
effects of
SULTAMICILLIN
are nausea,
vomiting, diarrhoea,
Ensure that
patient has tried
a cholesterollowering diet
regimen for 3–
6 mo before
beginning
therapy.
Give in the
evening;
highest rates of
cholesterol
synthesis are
between
midnight and 5
AM.
Advise patient
that this drug
cannot be taken
during
pregnancy;
advise patient
to use barrier
contraceptives.
Arrange for
regular followup during longterm therapy.
Consider
reducing dose
if cholesterol
falls below
target.
Monitor liver,
kidney functions
regularly while
protective
covering of
bacteria. This
leads to death
of bacterial
cells, thereby
offering
effective
infection
control.
allergic reaction to
any of the
penicillins. Serious
and occasionally
fatal
hypersensitivity
reactions (including
anaphylactoid and
severe cutaneous
adverse reactions)
have been reported
in patients
receiving therapy
with beta- lactams.
and skin rash. Most
of these side-effects
do not require
medical attention
and will resolve
gradually over time.
However, you are
advised to talk to
your doctor if you
experience these
side-effects
persistently.


taking this
medication.
It may cause
dizziness, do not
drive a car or
operate machinery
while taking this
medication.
Avoid excess
dosage