1. Kingdome of Saudi Arabia
Ministry of higher education
University of hail
Critical nursing
Case study: Pneumonia
Talal Qassem Shapi

2. 
patient's Name(initials): A. H. M
Unit:: micu
Medical diagnosis: old CVA And pneumonia
DEMOGRAPHIC DATA
Name : Ayed Hamad Motlaq Al Shammary.
Age: 80 yr.
Educational level:: NON
Occupation: NON
Admission date: At 16.30 22635
Sex:: Male
Nationality:: Saudi

3. HEALTH HISTORY
HISTORY OF PRESENT ILLNESS:
The Patient Has Short Of Breath With Low Level Of
Conciseness With Hypertension According To The Pt.
Family He Was Bedridden Since 10 Yr. Ago Because Of
CVAAnd Yesterday He Has Cough And Short Of Breath
And Hypertension .
PAST MEDICAL HISTORY:
HTN. Bedsores. OLD CVA. Hemiplegia .
FAMILY MEDICAL HISTORY:
He Had History Of Hypertension And Bed Redden since
10yr ago.

4. DISEASE PROCESS
DEFINITION
 Pneumonia: is an
inflammatory process
involving the terminal
airways and alveoli of the
lungs caused by
infectious agents.

5. SING AND SYMPTOMS

6. Cause:
 Pneumonia is due to infections caused
primarily by bacteria or viruses and less
commonly by fungi and parasites.

7. Etiologic Agents
 S.aureus
 Enterobacteriaceae
 P.aeruginosa
 Acinetobacter sp.
 Polymicrobial
 Anaerobic bacteria
 Legionella sp.
 Aspergillus sp.
 Viral

8. PHYSICAL ASSESSMENT
 Inspection
 SOB
 diaphoresis
 chills
 respiratory distress
 palpation
 decreased chest
expansion or asymmetry
 lymphadenopathy

9. PHYSICAL ASSESSMENT
 percussion
 dull
 decreased
diaphragmatic
excursion
 auscultation
 bronchial breath sounds
in periphery
 decreased air entry
 wheezes and crackles

10. DIAGNOSTIC TESTS ,PROCEDURES
 Chest x-ray shows presence extent of pulmonary disease
typically consolidation.
 Gram stain and culture and sensitivity test of sputum my
indicate offending organism.
Blood culture detects bacteremia (bloodstream
invasion)occurring with bacterial pneumonia.
 Immunologic test detects microbial antigens in serum,
sputum and urine.

11. DIAGNOSTIC TESTS ,PROCEDURES
ResultInvestigation
very prominent wedge-shape area of
airspace consolidation in the right lung
CXR
Sinus TachycardiaECG
20.09WBC
9.2HGB
413PLT
213CREAT
32BUN

12. Chest x-ray
 A chest X-ray showing
a very prominent
wedge-shape area of
airspace consolidation
in the right lung
characteristic of
bacterial pneumonia.

13. Vital Signs:
SPO2B.PR.RTempH.RTime
96%119/823836.993Admission
94%105/673637.91039AM
96%109/704038.310710AM
97%123/81413810711AM
95%111/773937.98612MD
97%110/803037.91071PM

14. medication
Nursing
intervention
doseindicationclassificationmedication
Give slowly with
diluted by NS
1.2mg
TID
i.v
infectionAntibiotic
Amoxicillin and
clavulanate
potassium
Augmentin
Give slowly with
diluted by NS
500mg
OD
i.v
Bacterial
infection
Antibiotics
fluoroquinolones
levofloxacin
Observe human
albumin in
blood
100ml
OD
i.v
To replace
blood volume
loss
Human proteinHuman
albumin
Observe any
sing of bleeding
4ml
OD
sc
immobilityAnticoagulant
Sodium
enoxaparin
Clexane
Give slowly1g
QID
i.v
Pain
fever
Pain reliever
acetaminophen
paracetamol

15. Nursing process
Assessment
 With unproductive cough
 With wheezes and crackles auscultated on left lower
lung field.
 Presence of clear watery discharge from her nose.
 Short of breath.

16. Nursing Diagnosis
 Ineffective airway clearance related to presence of
secretions secondary to pneumonia.

17. goal
 Short Term
 After 3-4 hours of
nursing interventions,
the patient’s respiration
will improve and
difficulty of breathing
will be relieved.
 Long Term
 After 3 – 4 days of
nursing interventions,
the patient will maintain
a patent airway.

18. NURSING INTERVENTIONS
 Monitor and record V/S.
 Auscultate lung fields, noting areas of
decreased/absent airflow and adventitious breath
sounds.
 Assist patient to change position every 30 minute
 Provide health teachings regarding effective coughing
and deep breathing exercise.
 Encourage to increase fluid intake.
 Administer meds as ordered.

19. Evaluation
 Short Term:
 After 3-4 Hours Of
Nursing Interventions,
The Patient’s Respiration
Have Improved goal is
met.
 Long Term:
 After 3 – 4 Days Of
Nursing Interventions,
The Patient Have Been
Able To Maintain A
Patent Airway goal is
met.

20. Assessment
 Flushed Skin.
 Skin Warm To Touch.
 Temperature Higher Than 37.6c
 Dehydration.

21. Nursing Diagnosis
 Risk For Infection Rt
Inadequate Primary
Defenses.

22. goal
 Short term
 After 4°h of nursing
intervention the pt.'s
temperature will drop
from 38.4 °C to 37 °C
 Long term:
 After 2-3 days of nursing
intervention the patient
will be free from
hyperthermia.

23. NURSING INTERVENTIONS
 Give antipyretic as order.
 Assess skin temperature and color.
 Monitor WBC count.
 Encourage fluid intake orally or intravenously as
ordered.
 Measure intake and output.

24. Evaluation
 Short term:
 After 4h° of nursing
intervention the pt.'s
temperature drop from
38.4 °C to 37.4 °C or
lower. goal is met
 Long term:
 After 2-3 days of Nursing
intervention , the patient
free from hyperthermia.
Goal is met.

25. PATIENT EDUCATION
 Eating Well Balanced Meals
 Adequate Rest
 Avoiding Upper Respiratory Infections Or Getting
Promptly Treatment For Early Symptoms
 Drinking Large Amounts Of Fluids To Thin Secretions
And Replace Fluid Loss
 Avoiding Spread Of Infections By Washing Hands
And Properly Dispose Of Tissues
 Avoid Smoking; Perform Coughing And Deep
Breathing exercises.