St.

Anthony’s College
NURSING DEPARTMENT
San Jose, Antique
VISION
St. Anthony’s College is a Catholic Educational Institution committed to holistic
human formation through
Spirituality, Academic excellence and Community service.
MISSION
To provide quality, holistic, relevant educational programs, services and
experiences for our students and other stakeholders

NURSING PROCESS
I. VITAL INFORMATION

Name: LCA Date of Interview:

Feb 13, 2020
Age: 90
Informant: G.R.
Address: Bugarot, Guinbangga-an, San Jose, Antique Relationship to
Patient: Caregiver
Civil Status: Married
Date and Time Admitted: February 10, 2020
Chief Complaint: Cough and DOB
Ward: ICU
Bed No.: 5
Allergies: NONE
Religious Affiliation: Roman Catholic
Physician’s Initials: Dr. H.M.E.
Impression/Diagnosis: CAP-HR with Hypoxemia, HPN

II. CLINICAL ASSESSMENT

II.A: NURSING HISTORY

1. HISTORY OF PRESENT ILLNESS

Last January 27, 2020, two weeks prior to her admission at
Antique Medical Center, patient LCA experienced cough with no
associated signs and symptoms. Then a week prior to her
admission, she consulted a doctor and she was given medication
with temporary relief. Patient had poor appetite. On the day of
admission, a few hours before she was admitted she had 3
episodes of LBM and feeling of drowsiness. She had difficulty of
breathing which prompted her family to bring her to the hospital.

She was then admitted last February 10, 2020 with a chief
complaint of cough and difficulty of breathing and had an

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 St. Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

admitting diagnosis of Community Acquired Pneumonia –High

Risk with Hypoxemia

2. Past Health Problems/Status

a. Childhood Illness: Chickenpox, mumps, measles

b. Immunization: none
c. Allergies: none
d. Accidents and Injuries: none
e. Hospitalization for serious illnesses: pneumonia 2015
f. Medications:
 Cefipime (AXERA) 1gm IVTT
 Omeprazole (PROSEC) 40mg IVTT
 Salbutamol + Ipratropium (DUAVENT)
 Potassium Chloride (K-LYTE) 600mg
 Sodium chloride (RHEA) 1g
 Acetylcysteine (EXFLEM) 600mg
 Atorvastatin (LIPITOR) 80MG
 Clopidogrel bisulfate (PLOGREL) 75mg
 Iron+Folic Acid+Vitamin B Complex (HEMARATE FA)
 Montelukast levoceterizine (ZYKAST) 10/5mg 1 tab
 Norepinephrine bitartrate (NOREPIN) 1mg/ml

2. Family History of Illness:

Hypertension both parents

4. Patient’s Expectations
a. What he/she expects to occur during this hospitalization?
 “wish ka mga bata kag apo na nga maayad dun si lola”, as
verbalized by patient’s caregiver
b. What he/she expects regarding nursing care.
 “nami man ang anda serbisyo sa mga pasyente”, as verbalized
by patient’s caregiver

5. Patterns of Functioning

a. Breathing Patterns
Irregular respiratory patterns
 History of chest pain, and cough

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 St. Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

Usual Remedy
 Rest and elevate head while lying to bed when chest pain occurs
Manner of Breathing
 Normal
b. Circulation
Usual Blood Pressure
 130/80 mmHg

c. Sleeping Patterns
Usual Bedtime: 7:00 pm
Number of Pillows: 4 (2 at the foot, 2 at the head)
Bedtime Rituals: Watching TV
Problems regarding sleep: none
Usual Remedy: none

d. Drinking Patterns (Tabular Form)

Kinds of Fluid in 24 hours/Amount in ml or Number of
Bottles
 3 glasses of water a day

e. Eating Patterns (Tabular Form)

Usual Food Taken Time (Quantity)

Congee Breakfast 1 cup

Congee with fried fish Lunch 1 cup

banana Dinner 1pc

Boiled kamote Snacks 1pc

Food Likes: vegetables, fish, congee

Food Dislikes: pork

f. Elimination Patterns
1. Bowel Movement
Frequency: once a day
Problems or Difficulties: constipation
Usual Remedy: lactulose
2. Urination
Frequency: 3x a day
Problems: none
Usual Remedy: none

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 St. Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

g. Exercise:
 none

h. Personal Hygiene
1. Bath
Type: Shower bath
Frequency: Once a day
Time of Day: around 8am- 9am
2. Oral Care
Frequency: once a day
Care of Dentures: n/a
3. Shaving
Frequency: n/a
4. Use of Cosmetics none

i. Recreation
 Watching TV

j. Health Supervision
 Monthly visit to the doctor

B. PSYCHOSOCIAL ASSESSMENT

1. Psychosocial Nursing Assessment

Lifestyle Information:

 Soft diet
 Cannot walk

Normal Coping Patterns:

 Eats congee
 Using wheelchair

Understanding of Current Illness:

 She understand her illness

Personality Style:

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NURSING DEPARTMENT
San Jose, Antique

 Patient is impatient

History of Psychiatric Disorder: none

Recent Life Changes or Stressors:

 Being hospitalized
 Thinking of her illness

Major Issues Raised by Current Illness:

 None

2. Mental Status Examination

Appearance

 Neat, clean, has good eye contact

Behavior

 Calm, appropriate

Speech

 Appropriate, soft

Mood/Affect

 Appropriate, worried, anxious

Thoughts

 Appropriate

Ability to abstract

Impaired: NO

Memory

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 St. Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

Impaired recent memory: NO

Impaired remote memory: NO

Number of objects able to remember after 5 minutes: _4_

Description: name, grandchildren, husband

Concentration

Able to focus: YES

Able to subtract backwards by 7’s from 100 correctly until number

__no_

Orientation

Person________ Time_________ Place_________ Situation_________

Judgment

Realistic decision making: no

Insight

Good

Description: She wants to go home

II.C: CLINICAL INSPECTION

Date and Time Taken: February 13, 2020

II.B.1. Vital Signs

T=36° PR=127
BP=130/80 RR=22

II.B.2. Height: 4’1

II.B.3. Weight: 51.4 kg
II.B.4.
General appearance: Patient appears awake and alert and is conscious to

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 St. Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

time, place and person. She is afebrile with vital signs taken and recorded as
follows:

VS: BP= 100/70 mmHg; PR=67 bpm; RR= 12 bpm; T=36.7 C/Axilla

Skin: Uniform in color, poor skin turgor, pale, with edema in both feet, with
dry kin ulcer at right hip

Skull: Round, symmetrical, normocephalic, absence of nodules and masses

Face: Symmetrical, absence of nodules and masses

Eyes: Round and symmetrical, equally distributed eyelashes and eyebrows,

no discoloration on eyelids, eyelids close symmetrically, blinks involuntarily,
pale conjunctiva

Ears: Symmetrical with no discharges, auricles aligned with the outer

canthus of the eye

Nose: Symmetrical and straight, both nares are patent, no tenderness

Mouth: Dry and pale lips

Neck: jugular veins are not distended, neck muscles are equal in size

Chest/Lungs: Has symmetrical chest expansion, presence of diffused

crackles on both lung fields upon auscultation

Abdomen: flabby, soft and slightly globular in shape, with 25 bowel sounds
per minute, presence of resonance upon percussion

Extremities: Equal in size and length, presence of edema, both lower and
upper extremities move with coordination, with pale nailbeds

II.D. OTHER SOURCES OF LABORATORY

1. CLINICAL CHEMISTRY

Name of Examination: Urinalysis

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 St. Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

Definition: A urinalysis is a group of physical,

chemical, and microscopic tests. The
tests detect and/or measure several
substances in the urine, such as
byproducts of normal and abnormal
metabolism, cells, cellular fragments,
and bacteria.
Preparation: None.
Purpose: To screen for, help diagnose and/or
monitor several diseases and conditions,
such as kidney disorders or urinary tract
infections (UTIs)
Date: February 10, 2020

Results Normal Significance of

Values Abnormal Results
*Physical
examination

Color: Pale straw

Transparency: Hazy
Specific gravity: 1.015

*Chemical
Analysis 7.5
Negative
pH: Trace
protein:
glucose:

*Microscopic
Findings 15-20 /hpf
2-5 /hpf
Pus cells:
Red Blood Cells:

*Crystals Few
Few
Amorphous: Many
S. Epithelial cell: Few
Bacteria:
Mucus Thread:

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 St. Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

Name of Examination: Electrolyte test

Definition: An electrolyte test is used to
monitor the effectiveness of
treatment for an imbalance that
affects the functioning of an organ.
Your electrolyte level may be
checked if you're prescribed
certain medications, such as
diuretics or angiotensin-converting
enzyme (ACE) inhibitors, which are
often used to treat high blood
pressure.
Preparation: None
Purpose: To detect a problem with the
body's electrolyte balance.
Date: February 10, 2020

Results Normal Values Significance of

Abnormal Results
Sodium 119.00 mmol/L 135 – 148 mmol/L Decreased level indicates
hyponatremia
Potassium 2.60 mmol/L 3.5 – 5.3 mmol/L Decreased level indicates
hypokalemia
Calcium 1.15 mmol/L 1.13 – 1.32 Within normal limits

Name of Examination: Fasting Blood Sugar

Definition: A blood glucose test measures the
amount of glucose in your blood.
Preparation: For a fasting blood glucose test, you
can’t eat or drink anything but water for
eight hours before your test. You may
want to schedule a fasting glucose test
first thing in the morning so you don’t
have to fast during the day.
Purpose: A blood glucose test is used to find out if
your blood sugar levels are in the healthy
range. It is often used to help diagnose
and monitor diabetes.

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 St. Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

Date: February 10, 2020

Results Normal Values Significance of

Abnormal Results
5.96 mmol/L 3.3-5.5 mmol/L Increased level
may indicate pre-
diabetes

Name of Examination: Uric Acid Blood Test

Definition: It determines how much uric acid is
present in your blood. The test can help
determine how well your body produces
and removes uric acid.
Preparation: You may need to fast (refrain from eating
or drinking) for four hours before the
test.
Purpose: Most commonly, the test is used to:
o diagnose and monitor people with gout
o monitor people who are undergoing
chemotherapy or radiation treatment
o check kidney function after an injury
o find the cause of kidney stones
o diagnose kidney disorders
Date: February 10, 2020
Results Normal Values Significance of
Abnormal Results
215.50 umol/L F: 143 – 357 umol/L Within normal limits

Name of Examination: The BUN/Creatinine ratio blood test

Definition: Once a person performs both a BUN
and Creatinine test, doctors can use the
combined results to find the BUN-to-
creatinine ratio. The BUN and creatinine
tests alone are excellent methods of
testing liver and kidney health, but
together, doctors get a much better
understanding of your kidney health and
can provide a more accurate diagnosis to
kidney-related issues.

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 St. Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

Preparation: High-protein diets may cause abnormally

high BUN levels, while low-protein diets
may lead to low BUN levels . It is best to
be properly hydrated and consume a
normal amount of protein before taking
the BUN/Creatinine Ratio Test.

Purpose: The main reasons to take a

BUN/Creatinine Ratio test are to evaluate
the health of your kidneys, to diagnose
kidney disease, and to monitor the
effectiveness of treatments related to
kidney disease or damage.
BUN/Creatinine ratio test results have
been proven to be one of the best ways
diagnose acute or chronic renal disease,
gastrointestinal bleeding, and urinary
tract blockages.

Date: February 10, 2020

Blood Urea Nitrogen Test

Results Normal Values Significance of
Abnormal Results
3.67 mmol/L >60 years: 2.9 – Within normal limits
8.2

Creatinine Test
Results Normal Values Significance of
Abnormal Results
60.60 umol/L F: 45 – 84 umol/L Within normal limits

Name of Examination: Liver function tests

Definition: Help determine the health of your liver
by measuring the levels of proteins, liver
enzymes, and bilirubin in your blood. The
ALT test measure enzymes that your liver
releases in response to damage or
disease. The albumin test measures how
well the liver creates albumin.
Preparation: Certain medications and foods may affect
levels of these enzymes and proteins in

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 St. Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

your blood. Your doctor may ask you to

avoid some types of medications, or they
may ask you to avoid eating anything for
a period of time before the test. Be sure
to continue drinking water prior to the
test.

Purpose: Liver tests can help determine if your

liver is working correctly.
Date: February 10, 2020
The (ALT) Alanine Aminotransferase test
Results Normal Values Significance of
Abnormal Results
7.80 u/L Up to 31 Within normal limits

Albumin Test
Results Normal Values Significance of
Abnormal Results
30.38 g/L 34-48 Decreased level
indicates infection

Name of Examination: Lipid Test

Definition: A lipid panel typically includes:
 Total cholesterol—measures all the
cholesterol in all the lipoprotein particles
 High-density lipoprotein cholesterol (HDL-C)
—measures the cholesterol in HDL particles;
often called "good cholesterol" because
HDL-C takes up excess cholesterol and
carries it to the liver for removal.
 Low-density lipoprotein cholesterol (LDL-C)
—calculates or measures the cholesterol in
LDL particles; often called "bad cholesterol"
because it deposits excess cholesterol in
walls of blood vessels, which can contribute
to atherosclerosis. Usually, the amount of
LDL-C is calculated using the results of total
cholesterol, HDL-C, and triglycerides.
 Triglycerides—measures all the triglycerides
in all the lipoprotein particles; most is in the
very low-density lipoproteins (VLDL).
Preparation: Typically, fasting for 9-12 hours (drinking
water only) before having your blood

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 St. Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

drawn is required, but some healthcare

practitioners allow non-fasting lipid
testing.
Purpose: To assess your risk of developing
cardiovascular disease (CVD); to monitor
treatment of unhealthy lipid levels
Date: February 10, 2020
Total cholesterol
Results Normal Values Significance of
Abnormal Results

3.66 mmol/L Adult: 3.63 – 5.15 Within normal limits

mmol/L

HDL Cholesterol
Results Normal Values Significance of
Abnormal Results

1.39 mmol/L M/F : > .91 mmol/L Within normal limits

LDL Cholesterol
Results Normal Values Significance of
Abnormal Results
2.14 mmol/L Adult: < 3.4 Within normal limits
mmol/L

Triglycerides
Results Normal Values Significance of
Abnormal Results

0.67 mmol/L Adult: < 1.70 Within normal limits

mmol/L

2. HEMATOLOGY
Name of Examination: Complete Blood Count (CBC)
Definition: The complete blood count (CBC) is
a test that evaluates the cells that
circulate in blood. Blood consists of
three types of cells suspended in

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 St. Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

fluid called plasma: white blood

cells (WBCs), red blood cells
(RBCs), and platelets (PLTs). They
are produced and mature primarily
in the bone marrow and, under
normal circumstances, are released
into the bloodstream as needed.
 Evaluation of white blood cells: WBC
count; may or may not include a WBC
differential
 Evaluation of red blood cells: RBC
count, hemoglobin (Hb), hematocrit
(Hct) and RBC indices, which includes
mean corpuscular volume (MCV),
mean corpuscular hemoglobin (MCH),
mean corpuscular hemoglobin
concentration (MCHC), and red cell
distribution width (RDW). The RBC
evaluation may or may not include
reticulocyte count.
 Evaluation of platelets: platelet count;
may or may not include mean platelet
volume (MPV) and/or platelet
distribution width (PDW)
Preparation: None
Purpose: To determine your general health
status; to screen for, diagnose, or
monitor any one of a variety of
diseases and conditions that affect
blood cells, such as anemia,
infection, inflammation, bleeding
disorder or cancer
Date: February 10, 2020

Results Normal Values Significance of

Abnormal Results

Hemoglobin: 110.00 g/l F:120 – 160 g/l Decreased level may

indicate vitamin deficiency
anemia
Hematocrit: 0.32 L/L F: 0.37 – 0.47 L/L Decreased level indicates
anemia
RBC: 3.52 x1012/L F: 4.2 – 5.4 x1012/L Decreased level indicates
vitamin B6, B12 or folate
deficiency

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 St. Anthony’s College
NURSING DEPARTMENT
San Jose, Antique

WBC: 8.13 x109/L 4.5 – 11 adult Within normal limits

MCV: 91.50 fl F:83.89 – 100.66 fl Within normal limits
MCH: 31.10 pa F: 27.27 – 33.27 pa Within normal limits
RDW: 13.70 %

Differential count
Neutrophils: 58 %
Juvenile: %
Stab: % 2-5 %
Segmenters: 58 % 50 – 70% Increased level may
Eosinophils: 8% 1 – 4% indicate infection

Basophils: % 0 – 1%
Lymphocytes: 26 % 20 – 40 %
Monocytes: 8% 4 – 8%
Platelet count: 300 103u/L 150 – 450 103u/L

3. RADIOLOGICAL EXAMS AND OTHER SPECIAL EXAMS

Name of Examination: X-ray
Definition: X rays are electromagnetic radiation that
differentially penetrates structures within the
body and creates images of these structures
on photographic film or a fluorescent screen.
These images are called diagnostic x rays.
Preparation: No special preparation is needed for fixed plate
x rays unless contrast material is used.

Purpose: Diagnostic x rays are useful in detecting

abnormalities within the body. They are a
painless, non-invasive way to help diagnose
problems such as broken bones, tumors, dental
decay, and the presence of foreign bodies.

Date: February 10, 2020

Results: Chest AP View
Poor inspiratory result.
There is haziness in the lower lungs.
The trachea is at midline.
The aorta is atherosclerotic.
The cardiac silhouette is not enlarged.
The costophrenic sulci are intact.
The hemidiaphragms are smooth.
The rest of the visualized soft tissues and
osseous structure appear unremarkable.

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NURSING DEPARTMENT
San Jose, Antique

Impression: Pneumonia, lower lungs

Atherosclerotic Aorta
To rule out pleural effusion, bilateral
Significance: The result shows that patient is congruent to
the diagnosis of pneumonia

IV. TEXTBOOK DISCUSSION

a. Definition
Pneumonia is an infection of the lower respiratory tract caused by bacteria,
viruses, fungi, protozoa, or parasites. It is the eighth leading cause of death
in the United States. The incidence and mortality of pneumonia are highest
in the elderly. Risk factors for pneumonia include advanced age, immuno-
compromised, underlying lung disease, alcoholism, altered consciousness,
smoking, endotracheal intubation, malnutrition, and immobilization. The
causative microorganisms influence the symptoms and signs with which the
patient presents, how the pneumonia should be treated and the prognosis.

Pneumonias can be classified into several ways. Pathologists originally

classified them according to the anatomic changes that were found in the
lungs during autopsies. As more became known about the microorganisms
causing pneumonia, a microbiologic classification arose, and with the advent
of x-rays, radiological classification. Another important system of
classification is the combined clinical classification, which combines factors
such as age, risk factors for certain microorganism, the presence of
underlying lung disease and underlying systemic disease, and whether the
person has recently been hospitalized.

The combined clinical classification, now the most commonly used

classification scheme, attempt to identify the person’s risk factors when he
or she first comes to medical attention. The advantage of this classification
scheme over previous systems is that it can help guide the selection of
appropriate initial treatments even before the microbiologic cause of
pneumonia is known. There are two broad categories of pneumonia in this
scheme: community-acquired pneumonia and hospital-acquired pneumonia.
A recently introduced type of healthcare-associated pneumonia lies between
this two categories.

Community-acquired pneumonia develops in people with limited or no

contact with medical institutions or settings. CAP tends to be caused by
different microorganisms than those infections acquired in the hospitals. The
characteristics of the individual are important in determining which etiologic
microorganism is likely. For example, immunocompromised persons tend to
be susceptible to opportunistic infections that are uncommon in normal
adults. In general, nosocomial infections and those affecting

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NURSING DEPARTMENT
San Jose, Antique

immunocompromised individuals have higher mortality rate community-

acquired pneumonias.

The most common community-acquired pneumonia is caused by

Streptococcus pneumoniae, which has a relatively low mortality rate,
although it is higher in the elderly. Mycoplasma pneumoniae is a common
cause of pneumonia in young people especially those living in group housing
such as dormitories and army barracks. Influenza is the most common viral
community-acquired pneumonia in adults. Legionella species, which also
cause CAP, can contaminate cooling systems and water supplies leading to
outbreaks of disease. Signs and symptoms of CAP are fever, cough, 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 and healthy patients, but many pneumonias,
especially when caused by Streptococcus pneumoniae and influenza virus,
are fatal in older, sicker patients.

According to the World Health Report by the World Health

Organization, lower respiratory infections, which include community-acquired
pneumonia, ranks ninth among the leading causes of mortality on individuals
aging 15 to 59 worldwide and ranks fourth on individuals aging 60 and over,
and that it is the leading killer of children worldwide.

CAP is one of the most common entities seen in Filipino adults. It is the
most common infectious disease prompting hospitalization and the first and
fifth leading cause of morbidity and mortality in the Philippines, respectively.

Incidence rates mentioned above is primarily the reason of the group for
choosing this case. The prevalence of community-acquired pneumonia in the
local and foreign communities needs attention and through this study, CAP
would be known better and would be helpful for the group to effectively play
their role as advocates of their patients care and well-being. This will serve
as an important tool for them to render proper nursing care, facilitate health
promotion and perform appropriate interventions to individuals with such
condition.

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NURSING DEPARTMENT
San Jose, Antique

b. Anatomy and Physiology

of
organs/systems involved

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NURSING DEPARTMENT
San Jose, Antique

Pathophysiology (Schematic Diagram)

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NURSING DEPARTMENT
San Jose, Antique

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NURSING DEPARTMENT
San Jose, Antique

c. Management
The initial management of CAP depends on the patient's severity
of illness; underlying medical conditions and risk factors, such as
smoking; and ability to adhere to a treatment plan. The need for
hospitalization is the first decision that needs to be made after
CAP is diagnosed or suspected.
1. Medical

d. Medical Management

The management of pneumonia centers is a step-by-step process

that zeroes on the treatment of the infection through
identification of the causative agent.

 Blood culture. Blood culture is performed for identification

of the causal pathogen and prompt administration of
antibiotics in patients in whom CAP is strongly suspected.
 Administration of macrolides. Macrolides are recommended
for people with drug-resistant S. pneumoniae.
 Hydration is an important part of the regimen because
fever and tachypnea may result in insensible fluid losses.
 Administration of antipyretics. Antipyretics are used to
treat fever and headache.
 Administration of antitussives. Antitussives are used for
treatment of the associated cough.
 Bed rest. Complete rest is prescribed until signs of
infection are diminished.
 Oxygen administration. Oxygen can be given if hypoxemia
develops.
 Pulse oximetry. Pulse oximetry is used to determine the
need for oxygen and to evaluate the effectiveness of the
therapy.
 Aggressive respiratory measures. Other measures include
administration of high concentrations of oxygen,
endotracheal intubation, and mechanical ventilation.
e. Nursing Management

Nurses are expected to perform both dependent and

independent functions for the patient to aid him or her
towards the restoration of their well-being.

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NURSING DEPARTMENT
San Jose, Antique

Nursing Assessment

Nursing assessment is critical in detecting pneumonia. Here

are some tips for your nursing assessment for pneumonia.

 Assess respiratory symptoms. Symptoms of fever, chills,

or night sweats in a patient should be reported
immediately to the nurse as these can be signs of
bacterial pneumonia.
 Assess clinical manifestations. Respiratory assessment
should further identify clinical manifestations such as
pleuritic pain, bradycardia, tachypnea, and fatigue, use of
accessory muscles for breathing, coughing, and purulent
sputum.
 Physical assessment. Assess the changes in temperature
and pulse; amount, odor, and color of secretions;
frequency and severity of cough; degree of tachypnea or
shortness of breath; and changes in the chest x-ray
findings.
 Assessment in elderly patients. Assess elderly patients for
altered mental status, dehydration, unusual behavior,
excessive fatigue, and concomitant heart failure.

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