Perpetual Help College of Manila

1240 V. Concepcion St., Sampaloc, Manila

COLLEGE OF NURSING

PNEUMONIA with PLEURAL EFFUSION

GRAND CASE STUDY

Presented to the Faculty of College of Nursing

In partial fulfillment of the requirements for the subject

Nursing Care Management (NCM) 103
First Semester SY 2017-2018

Submitted to:

Mrs. Evelyn Constantino MAN, RN

Mrs. Gina Ladanan MAN, RN

Submitted By:

BALNEG, Midelyn C.
DE VERA, Sheena Mae B.
JACALA, Josel Jordan Mara T.
PUNZALAN, April A.

October 10, 2017

 TABLEOFCONTENTS

Consent Form ………………………………………………………………………………..

General & Specific Objectives ……..………………………………………………………

Introduction ……..…………………………………………………………………………...

Nursing History ……………..……………………………………………………………….

Physical Assessment ……………………………………………………………................

Review of System ………….………………………………………………………………..

Pathophysiology …………….………………………………………………………………

Laboratory and Diagnostic Results ……………….……………………………………..

Medical Management ……………………………………………………………………….

Pharmacologic Studies ……………………….……………………………………………

Nursing Care Plan ……….……………………………………………………………….....

Discharge Plan …….………………………………………………………………………...

References ……………………………………………………………………………………
General Objectives:

After our 2 weeks duty, we will be able to gain knowledge, acquire reliable information and
determine the health concerns about Pneumonia, for us to perform the appropriate nursing
intervention that will address our patient’s needs.

Specific Objectives:

At the end of this study, we will be able to:

1. Identify the risk factors and clinical manifestations of Pneumonia with Pleural Effusion.
2. Assess the different signs and symptoms of the underlying disease.
3. Formulate and establish appropriate nursing care plan that will help improve our
patient’s condition.
4. Provide the appropriate nursing intervention for our patient’s medical condition.
5. Provide health teachings to the patient and her support system in preparation for
discharge plan.
6. Improve our skills and knowledge in taking care of a patient that has Pneumonia with
Pleural Effusion.

INTRODUCTION
 Pneumonia is an infection of the lungs caused by various microorganisms, like bacteria,
mycobacteria, fungi, and viruses in patients whose resistance has been altered. Pneumonitis is
a more general term that describes an inflammation in the lung tissue that could cause a
patient at risk for microbial invasion. Pneumonia causes inflammation of the air sacs of the
lungs or known as alveoli. It affects the ventilation of the patient and the process of diffusion
during gas exchange, producing a discharge that interferes with the diffusion of oxygen and
carbon dioxide. White blood cells, mostly neutrophils, also shift into the alveoli and fill the
normally air-filled spaces. Areas of the lung are not adequately ventilated because of
secretions and mucosal edema that cause partial obstruction of the alveoli. The lung is filled
with fluid or also termed as Pleural Effusion, making it difficult for a patient with Pneumonia to
breathe normally and effectively. For some older adults and people with heart failure or chronic
lung problems, Pneumonia can quickly become a life-threatening condition.

The most common cause of Pneumonia are bacteria and viruses in the air we breathe.
Our body usually prevents these microorganisms from infecting our lungs but sometimes these
organisms can overpower our immune system, even if our body is generally healthy. Even with
treatment, some people with Pneumonia, especially those with high-risk groups, may
experience complications including bacteremia, difficulty of breathing, pleural effusion and lung
abscess. Other patients may experience an upper respiratory tract infection like nasal
congestion or sore throat, and the onset of symptoms of pneumonia is gradual and nonspecific.
Signs and symptoms of pneumonia may also depend if the patient has underlying condition.

During our duty, as evidenced on our patient that has Pneumonia with Pleural Effusion,
we were able to notice some of the symptoms of the disease that the patient has such as
difficulty of breathing, cough with yellow sputum, and respiratory rate of 31 interpreted as
tachypnea.

We chose Pneumonia with Pleural Effusion as our case study due to the fact that we
would like to obtain more knowledge and better understanding about the disease. So that we
could confidently formulate the appropriate nursing care plan suitable for our patient, with
regards to providing nursing interventions and responsibilities that are befitting to the patient’s
recovery of well-being.

Genogram
DECEASED DECEASED
DECEASED DECEASED
(Heart Attack) (Unknown cause)
(Due to Old (Hypertension)
Age)

DECEASED
ALIVE

(Head Injury)
(Hypertension)

ELDEST
(Pneumonia YOUNGEST
SISTER
with Pleural BROTHER
(Hypertension
Effusion)
) (Alive)
 PHARMACOLOGIC STUDIES

Drug Name Dosage Classification Indication Drug Action Contra Adverse Nursing Rationale
indication Effects Responsibilities

GENERIC Anti- Treatment Inhibits cell- Contraindic CNS:

NAME: 4.5 g. + infectives; for wall ated in headache,  Obtain  To have
Piperacillin + 90cc PNSS Extended- moderate to synthesis patients insomnia, history of a base
Tazobactam q6H spectrum severe during hypersensiti fever, hypersensitiv line data
penicillin; nosocomial bacterial ve to drug seizure, ity to if patient
BRAND Beta- or multiplicatio or other agitation, penicillins, is
NAME: Route: I.V. lactamase community- n. penicillins anxiety, cephalospori allergic
Zosyn inhibitor. acquired dizziness, ns, or other to drug.
pneumonia Use pain. drugs prior to
caused by cautiously in CV: chest administratio
piperacillin- patients pain, edema, n.
resistant, with hypertension
beta- bleeding , tachycardia.
lactamase- tendencies, EENT:
 To be
producing uremia, rhinitis.
 Monitor able to
strains of S. hypokalemi GI: diarrhea,
patient disconti
aureus and a, and constipation,
carefully nue
by allergies to nausea,
during the drug
piperacillin other drugs, abdominal
and
and especially pain, first 30 min
notify
tazobactam- cephalospor dyspepsia, after physicia
susceptible. ins, stool initiation of n if
because of changes,
the infusion allergic
possible vomiting.
for signs of respons
cross- GU:
hypersensitiv e is
sensitivity. candidiasis,
ity. noted.
interstitial
nephritis.
Hematologic:  Monitor vital
leukopenia, signs.
neutropenia,  Cardiac
thrombocyto arrhyth
penia,
anemia, mias,
eosinophilia. hyperten
Respiratory: sion and
dyspnea. fever as
Skin: a sign of
pruritus, adverse
rash.  Advise reaction.
Other: patient to
anaphylaxis, report
hyper adverse
sensitivity  To
reactions
reaction, prevent
inflammation, promptly.
any
phlebitis at complic
IV site.  Advise
ation.
patient to
report
discomfort at
the IV site.

 Discomf
ort may
indicate
sign of
allergic
reaction.
Drug Name Dosage Classificatio Indication Drug Contraindic Adverse Nursing Rationale
n Action ation Effects Responsibilities
GENERIC Central Treatment Unknown. Contraindic CNS:  Assess if  Drug
NAME: 50mg./tab nervous for Thought to ated in dizziness, patient is may
Tramadol . q8H system moderate bind to patients headache, allergic to contain
PRN for drugs; to opioid hypersensiti somnolence, Tramadol. ingredi
BRAND pain. Opioid moderately receptors ve to drug vertigo, ents
NAME: analgesics; severe and inhibit or other seizures, that
Ultram Route: Synthetic, pain. reuptake of opioids, in anxiety, might
P.O. centrally norepineph breastfeedin asthenia, cause
active rine and g women, CNS allergic
analgesic. serotonin. and in those stimulation, reactio
with acute confusion, ns.
intoxication coordination
from disturbance,  Assess BP &  To
alcohol, euphoria, RR before know
hypnotics, malaise, and the
centrally nervousness, periodically patient’
acting sleep during s
analgesics, disorder. administratio reactio
opioids, or CV: n. n to
psychotropi vasodilation. drug.
c drugs. EENT: visual
Serious disturbances.  Reassess  To
hypersensiti GI: patient’s know
vity constipation, level of pain the
reactions nausea, at least 30 effectiv
can occur, vomiting, minutes after eness
usually after abdominal administratio of the
the first pain, n. drug.
dose. anorexia,
Patients diarrhea, dry  Give drug  For
with history mouth, before onset better
of dyspepsia, of intense analges
anaphylacti flatulence. pain. ic
c reaction to GU: effect.
codeine and menopausal  Advise  To
other symptoms, patient to prevent
opioids proteinuria, take drug as possibl
maybe at urinary prescribed e drug
increased frequency, and do not depend
risk. urine increase ence.
retention. dose or
Use Musculoskel dosage
cautiously etal: interval
in patients hypertonia. unless
at risk for Respiratory: ordered by
seizures or respiratory prescriber.
respiratory depression.
depression Skin:
; in patients diaphoresis,
with pruritus,
increase rash.
intracranial
pressure or
head injury,
acute
abdominal
conditions,
or renal or
hepatic
 impairment
; or in
patients
with
physical
dependenc
e on
opioids.

Drug Name Dosage Classificati Indication Drug Action Contraindic Adverse Nursing Rationale
on ation Effects Responsibilities
GENERIC Anti- Treatment Inhibits - CV:  Assess for  To ensure
NAME: 300mg./tab infectives; for bacterial Contraindic thrombophlebit allergy to that the
Clindamycin , 2 tabs Lincomycin pneumonia. protein ated in is. Clindamyc patient
q8H derivative. synthesis by patients GI: nausea, in, history has no
BRAND binding to hypersensiti abdominal of asthma allergy to
NAME: Route: P.O. the 50S ve to drug pain, diarrhea, or other drug
Cleocin subunit of or vomiting. allergies,
the lincomycin. Hematologic: allergy to
ribosome. thrombocytope tartrazine.
-Use nia, transient
cautiously in leucopenia,  Verify  To ensure
neonates eosinophilia. patient’s that the
and patients Hepatic: identity. medicatio
with renal or jaundice. n is given
hepatic Skin: to the right
disease, maculopapular patient.
asthma, rash, urticaria.
history of GI Other:  State the  It is the
disease, or anaphylaxis. importanc patient’s
significant e and right and
allergies. purpose of to
the drug establish
to the rapport.
patient.
 Administer  To avoid
the right alterations
dose at in the
the right effectiven
time. ess of the
drug.

 Observe  Possible
patient for risk for
signs and superinfec
symptoms tion due to
of normal
superinfec flora
tion. reduced/
elimminat
ed.