A Case Presentation on Pneumonia

8/18/2019 A Case Presentation on Pneumonia

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PRESENTED BY:

Camille Honeyleith L. Fernando, RNMSN IB

A CASE PRESENTATION ONPNEUMONIA

(With respiratory alkalosis)


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Presentation

• On October 11,2015, a 29 yearsold lady accompanied by herfamily arrived at the EmergencyDepartment complaining of

diculty of breathing !ssociated"ith fever, generali#ed body ache$ productive cough for % days


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EXAMINATION

!n&ious, 'onfused (emperature ) *+1'-lood pressure ) 1*0.90 mm of /g

ulse rate )12+ bpmespiratory ate ) * per minuteO&ygen saturation of 903 room air


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• /er symptoms started % days ago "ithmild fever , cough, headache for "hichshe self4medicated "ith -iogesic and!mbro&ol tablet

• !fter initial improvement, she had a"orsening of symptoms starting 2 days

ago "ith high fever, generali#ed bodyache accompanied "ith mild dicultyof breathing , so she decided to cometo the hospital


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!6( '788'!7 /86(O:)4o surgery or hospitali#ation ever before

;!


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Laoratories

*0aO2>%

%

/'O*>2?p/

>%50

@-'412,+00.cumm

latelet421*,000.cumm

6egmenters4 0%?7ympocytes402

/gb41?2grms3/ct4 ?1vol3

Arinalysis)@ithin normallimits


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C!EST X"RA# RE$EALE%

'/E6() (here is opacity in the right lo"er

lobe

/eart is not enlargedDiaphragm and sulci are intactOsseous structures are

unremarBable

8


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@/!( 86 (/E C!7AE O; '/E6( 4!: 8EA


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Pne*+

on

iaisa

nin,

a++atory

(on-

itiono.

theL*n/s)

a0e(tin

+ ainl

the

air"s

a(sorAl1

eoli

'ACTERIAL(Most

o++on)

2UN

3AL

$IRAL

PNEUMONIA AN% ITS T#PES

%RU3S

A*to"i++*ne-iseases


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RIS42ACTORS


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P%TH&PHYSI&L&'Y


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CLINICAL MANI2ESTATIONS O2 PNEUMONIA

2e1er

Rapi- or -i5*lt reathin/ Non" pro-*ti1e Co*/h Loss o. appetite Chills Rale6 Crakles

Whee7in/!ea-aheMyal/ia

R*nnin/ nose

2ati/*e Sharp or stain/ hest pain

8hih inreases on reathin/ E&essi1e s8eatin/ or la++y skin


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T!ERAP#

O2

THERAPY

FL(ID

%IET

STEROIDS

ANTI-

PYRETICS

ANTIBIOTICS

C!ESTP!#SIO9

RE3ULAR

INVESTIGATIONS

/E


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Rele1antN*rsin/

%ia/nosis

8neGectiveair"ay

clearance

related toretained

secretions

8mpairedutritionalstatus .t

diseasecondition

isB of infection .t

disease process,

!n&iety.t

Diseasecondition

8mpaired gase&change .t

Disease process

Activity

Intolerance& Self

Care

Deficit R/T

Disease

condition


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A 1 6 8 9 F '

! 1 E

0 7 ! 9

6evere6hortness of

-reath

(achycardia, (achypnoea

estless,'onfusion

IMPAIRE% 3ASEXC!AN3E R6T

POOR LUN3COMPLIANCE

Proppe- :*ppositionO&y/en therapyNe*lisationtherapy!e+o-yna+i

+onitorin/Meh9$entilationA*s*ltationS*tionin/A'3 analysis

Chest Physio ;Spiro+etry

6O2


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!n&ious ,estless Depressed 7ots of Hueries

!n&iety .(;ear of

AnBno"n

Outcome

e4assurance'ounselingroper

e&planationarticipation in

care9

A 1 6 8 9 F '

! 1 E

0 7 ! 9


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;everresence of

EGusion'ongested

7ung

/igh risB of infection.(

Disease condition

Proper Hand WashingMaintained Aseptic techniqueMonitored temperature Antibiotics & Steroids givenBlood for T! "! #S$ chec%edBlood ! rine & Sputum 'S chec%ed

High Protein diet givenH(giene maintained9

A 1 6 8 9

F '

!

1 E 0 7 ! 9


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Dull $ @eaB!ppearance 6O- ;atigue

Activity Intolerance

& Self Care Deficit

R/T Disease

condition

Comfortable position provided ROM exercise provided

Sponge bath, Back care provided Position changed

Encouraged activit as per smptom tolerance

N

U R S I N 3 C A

R E P

L A N


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T!AN4 #OU 2OR

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A Case Presentation on Pneumonia

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