SGT UNIVERSITY

FACUL
TY OFCASE
NURSI
STUDY

NG ON
PNEUM
ONIA
SUBMITTED TO SUBMITTED
Dr.Neeta Bhide BY
HOD MADHU
BALA
MSC(N)1ST YR
230424005
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IDENTIFICATION DATA:
Name: MASTER SAHITYA
Age: 2yrs.
Sex: Male
Address: Gurugram Sector10
Diagnosis: PNEUMONIA
Occupation: Retired
Marital status: Married
C.R no: 290416250.
Date of admission: 5/10/2023
Religion: Hindu
Name of ward: Emergency
Chief complain: Patient admitted with the complain of severe breathing difficulty,
fever, body ache, Restlessness for last 3 days and Cough last 15 days.
Present complain: Presently patient having generalized weakness, decreased appetite,
mild Fever, nausea for last one day.
Past medical history: Had a history of viral fever with cold and cough 2 months before
Past surgical history: No past surgical history.
BIRTH HISTORY:-
ANTENATAL:- Mother attended check up regularly , no illness during pregnancy, taken 2
doses of TT.
INTRANATAL:- Born through normal vaginal delivery,conducted by skilled person at
hospital ,no complications , no evidence of bith injury ,cried immediately afger birth,baby
weight was 2.6 kgs.
POSTNATAL:- No complication ,baby was pink and active ,breast feeding started after1/2
an hour , no evidence of congential anomalies.
Environmental history:
 Drinking water supply: There is safe water drinking supply.
 Environmental sanitation: Environmental sanitation is clean.
 Waste/Excreta disposal: Proper excreta disposal.
 Presence of flies/Rodents: No rodents and flies

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 Family Tree:

Arti Devi(28 years) Mr. Shivnath(32years)

RUBY(5YEARS) Sahitya(2years)

S.n Name Age/Sex Education Occupation Relation Health

o status
1. Shivnath 32/male 10th class DRIVER Self Tuberculosis
2. Arti Devi 28/female 7th class Housewife Wife Healthy
3. Ruby 5/Female 4th class Study Daughter Healthy
4. Sahitya 2/Male - - Son Unhealthy.

VITAL SIGN:

Vital sign 5/10/2023 6/10/2023 7/10/2023 8/10/2023

Temperature 100.5 Fahrenheit 98.2 Fahrenheit 97.4 Fahrenheit 97.1Fahrenheit
Pulse 96b/min 84b/min 78b/min 80b/min
Respiration 22b/min 20b/min 20b/min 18b/min
Blood pressure 130/80mm/hg 120/80mm/hg 110/80mm/hg 130/70mm/hg.

GENERAL SURVEY:
Length:- 75cms
Weight: 11kgs.
Personal Hygiene: well maintained.
Nutritional status: Normal.
Head circumference:- 45cms
Chest circumference:- 48cms
Mid arm circumference:-14cms

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PHYSICAL EXAMINATION:
General Appearance:
 Level of consciousness: conscious and oriented.
 Hygiene: well maintained.
 Activity: partially restricted due to disease condition.
 Posture and gait: normal
 Nourishment: patient is not taking full balanced diet so seems dull.
Skin and nails:
 Colors: normal
 Texture: dryness over the limbs region.
 Temperature : normal.
 Lesions: no macules, papules present.
 Clubbing: absent
 Cyanosis: present.
 Capillary refill time: 2 second.
Head:
 Colour of hair: black
 Shape of skull: symmetry.
 Scalp: absence of swelling, no dandruff.
 Pediculosis: not present.
 Texture: rough.
Eye:
 Vision: normal vision.
 Eyes brows: eye brows are normal.
 Conjunctiva: pale yellow in color
 Sclera: normal
 Corneal reflex: normal
 PERRLA: pupils are round and reactive to light, no dilation or constriction seen.
Ear:
 Hearing: normal.
 Tympanic membrane: no perforation and lesions are seen.
 Discharge: no discharge present.
Nose
 Nostrils: no discharge and flaring, absence of epistaxis.
 Nasal septal deviation: no deviation present.
 Sinuses: no sinusitis present.
Mouth:
 Lips: dry and crack.
 Odour: no foul smell is present.
 Mucous membrane and gums: ulceration present on the gums.

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  Tongue: dry but no lesions.
 Tonsils: no inflammation of tonsils present.
Neck:
 Nuchal rigidity: not present.
 Lymph nodes: no lymphadenopathy present.
 Thyroid gland: normal.
Chest:
Respiratory system
 Inspection: symmetrical.
 Barrel chest: present.
 Breathing pattern; 20breath/min.
 Palpitations: no mass.
 Percussion: resonance present.
 Auscultation: crackles respiratory sounds.
Cardiovascular system:
 Inspection: normal.
 Auscultations: S1 and S2 sounds are present, no abnormal sounds presents.
 Palpitations: not significant.
 Heartrate: 82beat/min.
 Pain: no chest pain present.
Abdomen:
 Inspection: Normal.
 Auscultation: bowel sound present.
 Percussion: normal.
 Palpation: normal.
Genitalia:
 Abnormal discharge: absent.
 STDS: no any STDS.
 Any enlargement: not present.
 Haemorrhoids: absent.
Extremities:
 Movement: the patient can move his extremities in all directions, no abnormality
present.
 Tremors: absent.
 Oedema: present.
 Varicose vein: absent.
Spine:
 Spina bifida: absent.
 Curvature defect: no lordosis, no scoliosis, no kyphosis present.

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Musculoskeletal system
Reflexes:
 Biceps: present.
 Triceps: present.
 Patellar: present.
 Ankle: present.
 Sensation: present.
 Gross Motor-steady gait, walks on heel toe, walks up and down upstairs
holdings wall.
 Fine Motor- picks up objects from floor, can build tower of 6-7 cubes, turn
pages one at a time, drink with glass.
 Autonomy vs. Shame and Doubt Occurs in the toddler age. (18 months-3
years). Child learns to feed themselves and do things on there own. Or they
could start feeling ashamed and doubt their abilities. Questions the child's
willpower.
 ANAL STAGE: According to Sigmund Freud it is the second stage of oral
development that occurs between 1 ½ until 3 years of age, in which the child’s
greatest pleasure involves the anus or the eliminative functions associated with
it. Child is getting proper toilet training.
 The Sensorimotor Period (0-2 yrs.)  According to Jean Piagent , Infants and
toddlers "think" with their eyes, ears, hands, and other sensorimotor equipment.
They learn to generalize their activities to a wider range of situations and
coordinate them into increasingly lengthy chains of behavior.
 Enjoys story Knows at least 4 body parts .Has a vocabulary of 300 words .
Refers to self by name
 Stages of Faith-Stage 0 – "Primal or Undifferentiated" faith (birth to 2
years). .It is characterized by an early learning of the safety of their
environment (i.e. warm, safe and secure vs. hurt, neglect and abuse). If
consistent nurture is experienced, one will develop a sense of trust and safety
about the universe and the divine. Conversely, negative experiences will cause
one to develop distrust with the universe and the divine. Transition to the next
stage begins with integration of thought and languages which facilitates the use
of symbols in speech and play.

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 DISEASE
CONDITION :

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8
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, oesophagus, and many lymph nodes.

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.

ANATOMY AND PHYSIOLOGY:

System involved – Respiratory system.

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The respiratory system consist:

 Nose
 Pharynx.
 Trachea.
 Bronchi.
 Bronchioles
 Alveoli.
 Lungs.

INTRODUCTION:-
Pneumonia is inflammation of the lung that is most often caused by
infection with bacteria, viruses, or other organisms. Occasionally,
inhaled chemicals that irritate the lungs can cause pneumonia.
Healthy people can usually fight off pneumonia infections.
However, people who are sick, including those who are recovering
from the flu (influenza) or an upper respiratory illness, have a
weakened immune system. This makes it easier for bacteria to grow
in their lung.

DEFINITION:-
Pneumonia is a breathing (respiratory) conditions in which there is an
infection and inflammations of the lungs parenchyma cells. Pathologically
there is consolidation of alveoli or infiltration of the interstitial tissue with
inflammatory cell or both.
ETIOLOGY:

Book Etiology Patient Etiology

1. Bacterial infections Master Sahitya had recent viral infections 2
2. Viral or Fungal infections. months before.
3. Aspiration pneumonia
4. Who had a recent viral infections
5. People with low immune system.
6. Hospital acquired infection.
7. Community acquired pneumonia

PATHOPHYSIOLOGY:

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 Infections,aspirations,low immunity,pollutants etc.

Neutrophillic/Lymphatic Infiltrations

Acute/Chronic Inflammation

Increased Capillary Permeability

Fluid/Cellular Exudation

Edemaof Mucuous Membrane

Hypersecretion Of Mucua

Persistent Cough, Stages Of Congestion In The Alveolar Spaces With Fluid And
Hemorrhagic Exudates.

CLINICAL MANIFESTATION:

Book symptom Patient symptom

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 1. Chest pain Chest pain sudden onset last few days.
2. Dry cough Dry cough.
3. Fever Fever.
4. Difficulty in breathing while Present
lying down. Present
5. Shortness of breath. Present
6. Persistent hiccups. Absent
7. Difficulty in physical activity. Present
8. Bloody sputum Present
9. Fatigue. Present
10. Dyspnoea. Present
11. Night sweating Present
12. Headache Absent

DIAGNOSTIC EVALUATION:

Name of the investigations patient investigation

1. Assessment of symptoms, medical Symptoms- revealed shortness of breath and
history, risk factors. coughing.

Medical history- there is no medical history.

2. Physical examination Done

3. Chest x ray Done
4. Blood text Increased WBC, increased ESR.
5. Mantoux Done.
6. Chest x ray Not done.

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LABORATORY STUDIES:

Investigation Patient value Normal value Remarks.

Haemoglobin 10.5 13-17 gm % Normal

ESR 115mm 00-20 Increased

Urea 46 18-40 mg/dl Increase.

Creatinine 1.18 0.70-1.20mg/dl Normal.

Uric acid 6.4 2.00-7.70mg/dl Normal.

Sodium 138 135-145.00mmol/l Normal.

Potassium 4.0 3.50-5.50mmol/l Normal.

Chloride 103 96.00-106mmol/l Normal.

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 Bilirubin total 0.74 0.1-1.0mg/dl Normal.

Bilirubin direct 0.17 0-2 mg/dl Normal.

SGOT 36 5-40mg/dl Normal.

SGPT 38 5-35mg/dl Increase.

Total protein 35 10-32 mg/dl Increase.

Albumin 8 0.6-8mg/dl Normal.

ABG REPORT:

Ph-7.4

Pco2-41.4

Po2-112.9

HCO3-26.1

MEDICAL MANAGEMENT:

BOOK MANAGEMENT PATIENT MANAGEMENT

PHARMACOLOGICAL: PHARMACOLOGICAL:

First line drugs:  Ethambutol

 Rifampicin
 Isoniazid INH or H  Rabeprazole
 Rifampicin RMP or R  Neb. Budecort and Duolin
 Ethambutol EMB or E  Tab. Siffy 200mg (BD)
 Streptomycin SM or S  Tab. Supradyn 17 AB P/O OD.
 Pyrazinamide PZA or Z  Tab. Metroprolol (BD)
 Tab. Nexito Plus (HS).

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 SURGICAL MANAGEMENT:-

 Drainage of plural effusion by continuous suction.

 Reduction of pneumothorax.

NURSING DIAGNOSIS:

 Ineffective airway clearance due to thick pleural fluid as evidenced by wheezing

sound and dyspnea.
 Ineffective breathing pattern related to dyspnea as evidence by spirometer.
 Activity intolerance related to fatigue, fever as evidence by inability to stand,
restlessness.
 Imbalanced nutrition related to anorexia, disease condition tuberculosis, persistent
coughing as evidence by weight loss and weakness in body.
 Risk for impaired gas exchange due to at risk for excess or deficit in oxygenation and
carbon dioxide elimination at the alveolar capillary membrane.
 Knowledge deficit related to disease condition, treatment as evidence by patient
verbalization, restlessness, mood swings.
 Activity intolerance related to imbalance between oxygen demand, possibly
evidenced by report of fatigue, weakness, dyspnoea.

NURSING PROCESS 1ST

ASSESSMENT DIAGNOSIS GOAL PLANNING IMPLEMENTATION RATIONAL EVALU

ATION

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Subjective Impaired Improved To assess the To assessed the To know Patient
data: nutritional appetite condition of client. condition of client. the feel
Patient says status less and condition better
that I am than body nutritiona To check vital signs. To checked vital of client. and
having loss requirement l status of signs temp-98.1 improve
as evidence by client. Resp-22, pulse- To the
of appetite.
patient 78b/min. obtained nutritiona
verbalisation. base line l status.
data.
To give small To given small
frequent diet to the frequent diet to the To improve
client. client. the
Objective nutritional
data: status of
the client.
patient To give food To given food
refusal of according to likes of according to the likes To increase
food. patient. of patient. appetite.

To improve
To give nutritious To given nutritional health
food to the client. food to the client. status.

NURSING PROCESS 2ND

ASSESSMENT DIAGNOSIS GOAL PLANNING IMPLEMENTATION RATIONAL EVALU

ATION

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Subjective Altered body To To assess the To assessed the To know Patient
data: thermoregula maintain condition of client. condition of the feel
tion related to normal patient. condition better
Patient says infection as body To check vital of patient. and body
that I am evidence by temperat signs. To temperat
having blood ure obtained ure
fever from investigation. To give To checked vital data. normal.
last night. antipyretics as signs. To reduce
prescribed by temperatur Vital
Objective doctor. To given inj. e. signs
data: paracip as
To give cold prescribed by temp-
Checked sponge to the doctor. To reduce
vital signs. patient. fever.
To given cold
Temp-100.4 To give sponge to the To improve
proper rest patient. bodyache.
Pulse- to the
102b/min patient.

Resp-22b/ To given
min proper rest
to the
B.P- patient.
110/80mm/
hg.

NURSING PROCESS 3RD

ASSESSMENT DIAGNOSIS GOAL PLANNING IMPLEMENTATION RATIONAL EVALU

ATION

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Subjective Knowledge To To assess the Assessed the To check Explaine
data: deficit related provide previous previous the status d the
patient to present complete knowledge of the knowledge of the of importan
complaints condition as knowled pt. pt. knowledge ce of the
that he has evidence by ge of the present
no idea request for disease treatmen
what information. condition t and
doctors are and investiga
talking on treatment Ask the patient to To know the exact Asked tion
rounds and . ventilate his area of concern. various
feelings. questions
why the
from the
samples are
patient to
taken collect
frequently. some data.
To increase
some
Clear the knowledge
doubts and of the
Objective area of patient All the
data: concern of regarding doubts and
Patient the patient. the disease queries
looks tensed condition. were
and solved one
confused, by one.
asking for Provided
briefing the
requiring appropriat
the present e and up to
disease date status
condition of the
patient
disease
condition.

DETAILS OF SUMMARY CARE:

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5/10/23
General condition
General condition of the patient was assessed. Patient was conscious, oriented to time place
and person. Vital sign checked and there was increased pulse rate, B.P. history was taken
blood glucose was 134 mg/dl. Physical examination performed.
Vital signs:
Temperature: 98.6degree Fahrenheit
Pulse: 104b/min.
Respiration: 20b/min.
B.P: 150/80mm/hg.

6/10/2023
General condition of the patient was fair. Patient was conscious, oriented to time place and
person. Vital sign checked and there was increased pulse rate, B.P. history was taken blood
glucose monitor every 6th hourly and was 124 mg/dl at 10 a.m.
Vital signs:
Temperature: 97.3degree Fahrenheit
Pulse: 98b/min.
Respiration: 20b/min.
B.P: 130/80mm/hg.

7/10/2023
General condition of the patient was good. Patient was conscious, oriented to time place and
person. Vital sign checked and found stable. Patient was put on oxygen with 4 liter/min.
Vital signs:
Temperature: 98.1degree Fahrenheit
Pulse: 88b/min.
Respiration: 18b/min.
B.P: 110/80mm/hg.

8/10/2023

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General condition of the patient was good. Patient was conscious, oriented to time place and
person. Vital sign checked and found stable.
Vital signs:
Temperature: 98.6degree Fahrenheit
Pulse: 80b/min.
Respiration: 18b/min.
B.P: 110/70mm/hg.

DIET PLAN:
 Eat plenty of fruits and vegetables.
 Choose fresh foods, including poultry, dry and fresh legumes, toned milk, eggs, plain
rice oatmeal.
 Avoid convenience food, Chinese food, fast food.
 Be careful of condiments-ketchup, mayonnaise, mustard, pickles, olives.
 Follow tips for heart healthy dinning out, but limit how frequently to eat. Patient got
better and now patient is taking discharge.
 Right amount of carbohydrates including food like brown rice and fibers help to
control cholesterol level and blood sugar level.
SERVE MORE VEGETABLES:
Fruits, whole grain and legumes. Just about everyone could stand to eat more plant-based
foods. They are rich in beer and other nutrients, and they can taste great in a salad, as a side
dish.
Choose fat calories wisely by:
Limit saturated fats. Avoid artificial trans fats as much as possible.
Serve a variety of protein: rich foods. Balanced meal and vegetables source of protein.
Serve the right kinds of carbs: include foods like brown rice, oatmeal, quinoa and sweet
potato.
Encourage hydration: staying hydrated makes you feel energetic and eat less. Encourage
your loved one to drink 32 to 64 ounce of water daily, unless your doctor has told them to
limit.
Keep serving sizes in check: it can help to use smaller plates and glasses, and to check food
labels to see how much is in a serving, since its easy to eat more than you think.

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SUMMARY OF NURSING CARE:
Patient came with the complain of severe restlessness due to breathing difficulty and was
provided oxygen support for the management. Via medicines, nebulization, and chest
physiotherapy with oxygen supply and management of tuberculosis. patient got better and
now patient is taking discharge.

PROGNOSIS:

Book prognosis Patient prognosis

According to the book the prognosis of the According to the patient condition the
tubercular pleural effusion depends on the prognosis of the client is not good. But
level of severity of the disease condition. cooperate well.

As stated by the doctors and the laboratory

investigations on comparison with the book
the patient she is a known case of
tuberculosis.

Levels of severity are high for the patient.

Complication:-
 Pleural Effusion.
 Empyema
 Lung Abscess.
 Airway Injury.
 Sepsis.
 Chronic Lung Disease

HEALTH EDUCATION:

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 Educate patient to take plenty of fluids.
To give proper rest and sleep.
To make child to sleep in head elevated at30
degree to ease the breathing..
Add fruits and vegetables to patient diet.
Do not take spicy and heavy meal.
Avoid taking junk foods.
Advise patient and family not to discontinue
medications without doctors permission.
 Advise for follow up.

BIBLIOGRAPHY:

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 A textbook of Medical Surgical Nursing:
editor BT Basavanthappa; published by:
JAYPEE Brothers Medical Publishers (P)
LTD; edition 2nd.
Lippincott Manual Of Nursing practice, 10th
edition, Walter publishers, page no. 820-835.
 A textbook of BRUNNER and SUDDARTH’S

Textbook of Medical Surgical Nursing; Editor

Suzanne C. Smeltzer, Brenda G Bare, Janice
L.Hinkle; Published by Wolters Kluwer
Health; edition 12th ; volume 1; page no.580-
595.

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