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CASE STUDY: PNEUMONIA

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Nikkisia Napalit

on 10 March 2013

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Transcript of CASE STUDY: PNEUMONIA

3.PERSONAL HISTORY 7. Diagnostic and Laboratory Procedures

( indications, purposes, results) (abnormal/normal) PNEUMONIA Case Study II. A. ASSESSMENT Agravantes, Dennise
Napalit, Bea Nikkisia
Soliman, Mark Allen
Celena Suchadoll Pneumonia is an acute or chronic disease characterized by inflammation of one or both lungs.
It can be usually caused by the bacteria (e.g. Streptococcus pneumoniae), viral (e.g. Influenza virus) fungi (e.g. Candida species), mycoplasma pneumoniae, and various chemicals. Objectives Nurse-centered:
After the completion of the case study, the group will be able to.. •Demonstrate that his condition improved after receiving quality care throughout the conduction of the study.
• Receive the possible nursing care needed for the client as understood in through the client’s improvement during the study. Client-centered:
After the completion of the case study, the client/client’s SO will be able to: 9. THE PATIENT’S ILLNESS Accomplished by: I.INTRODUCTION A.Pathophysiology (Book-based) “My next breath may very well be in your lungs.
Store it wisely, because my life depends on it.”
-Jarod Kintz, This Book Title is Invisible This case may help them determine the prevention and management of the disease and the roles as the being a fellow health care providers.
The opportunity to work on this case study benefits each member, expanding their knowledge on this specific condition.
Allowing them to carry out the task with full responsibility and accountability to what has been entrusted for their care. When those microorganisms reach the lungs, the air sacs (alveoli) become inflamed and fluid filled with fluid and pus.
This greatly affects the air sacs (alveoli) of the lungs, as it becomes filled with liquid, resulting to significant reduction in oxygenation.
With the reduction of oxygenation, which is required especially for our blood, it cannot promote the body cells to work properly. The group had chosen this case so that they could attain more knowledge concerning Pneumonia.
As it is an interesting and well-known disease condition, this got their attention.
They opened up to the opportunity willingly as allowed this as our chance to research more about. •Put into action the health teachings given by the researchers for the client’s health promotion.
•Understand the nature of the disease and lifestyle which might have contributed to his condition.
• Know the nature and purpose of the medical management of the patient as the significant others encourage to comply.
•Achieve optimum level of functioning. •Gather relevant data regarding to the patient’s medical condition.
•Understand the different laboratory and diagnostics procedure, their indication, and their essential relationship to the disease condition.
•Gain more knowledge and understanding of the existing disease condition; the pathophysiology, the etiology, and the risk factors involve in its development and progression. • Clarify to the client of the different treatments, the importance of the different treatments, the medications administered, and the mechanisms of action and adverse effects of the medications administered.

• Formulate appropriate nursing plans based on the prioritized health needs of the patient.

• Provide patient and family health teachings enabling participation for the patient’s care.

• Evaluate the patient’s condition after the implementations of appropriate nursing care given; through the proper assessment indicated for the client. II. NURSING PROCESS 1.PERSONAL DATA
Patient Pink
Filipino female
two months
Roman Catholic
December 31, 2013
San Juan, Apalit, Pampanga
Lives in Sucad, Apalit, Pampanga with her family Admitted in Jose B. Lingad Memorial General Hospital
February 23, 2013
2:00 in the afternoon
Pneumonia 4.HISTORY OF PAST ILLNESS 5.HISTORY OF PRESENT ILLNESS 6.PHYSICAL EXAMINATION (IPPA-Cephalocaudal Approach) 8.ANATOMY AND PHYSIOLOGY

RESPIRATORY SYSTEM Pathophysiology (Patient-Centered) II. B. PLANNING
NCPs Ineffective airway clearance R/T accumulation of mucus AEB presences of crackles in breath sounds.
Ineffective breathing pattern R/T Pneumonia
Impaired gas exchanged related to presence of secretions as evidenced by nasal flaring and lethargy secondary to Pneumonia
Risk for infection r/t inadequate secondary defenses (decrease hemoglobin, hematocrit, and immuno-suppression) Ineffective airway clearance R/T accumulation of mucus AEB presences of crackles in breath sounds.
Risk for delayed development R/T inadequate nutrition AEB inability to suck.
Impaired gas exchanged related to presence of secretions as evidenced by nasal flaring and lethargy secondary to Pneumonia
Risk for infection r/t inadequate secondary defenses (decrease hemoglobin, hematocrit, and immuno-suppression).
II. C. IMPLEMENTATION 1. MEDICAL MANAGEMENT
2. NURSING MANAGEMENT II.D. EVALUATION
1.Client’s Daily Progress Chart
2. Discharge Planning END :)
Thank you and Godbless.
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