Pneumonia Case Study

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The current paper discusses the progression of pneumonia explained in the case study and a care plan. Pneumonia is an infection that affects the lungs and is caused by viruses, bacteria, parasites, or fungi. The disease causes inflammation of the alveoli, which are the fluid-filled sacs that absorb oxygen for breathing. The topic is important for the reason that pneumonia is a life-threatening illness, affecting the respiratory system. Hence, it is essential to understand the underlying anatomic features of the disease progression and interventions.


Pneumonia affects the air sacs of the lungs. Therefore, a pathogen affects the alveoli of the lungs for the microorganisms to develop. According to the case study, the patient smokes 40 packs per year, which must have caused inflammation on the lungs. The air sacs are, thus, filled with a purulent material or pus, which produces the thick, dark, and rusty sputum. The pus causes breathing difficulties and fever, which prompts the patient to cough in efforts to get rid of the sputum. The cough along with fever is a life-threatening condition to an old person, especially, in the case of a 65- year-old man (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2012). The case indicates that the patient takes cold medicine but still claims to be unwell, meaning that the disease has progressed. Moreover, it is apparent that the appropriate diagnosis, which is pneumonia, is prevalent to the aged, because they have a weakened immune system as well as a variety of other health problems.

Signs/ Symptoms

The symptoms of pneumonia vary depending on the severity of the disease. Besides, such factors as age, germ causing the infection, and the overall health contribute to the signs and symptoms of the disease. According to the given case, the patient is 65, meaning that he has a weakened immune system. As a result, the overall health is poor, because the patient takes cold medicine but the condition does not heal with ease. The issue of the cold indicates that the symptoms are mild (Buttaro et al., 2012). Besides, the patient experienced the symptoms four days ago, which is not a long period. Other symptoms of pneumonia experienced by the client include anorexia, shortness of breath, and the cough, which produces pus, as well as the chills and fever.

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Progression Trajectory

The most common type of pneumonia is the community-acquired one (Stupka, Mortensen, Anzueto, & Restrepo, 2009). Quite often, patients fall sick when they are outside the hospital or in the community setting. Community-acquired pneumonia (CAP) is common among the aged, who are above the age of 65 (Stupka et al., 2009). The impact of the disease for these individuals is far greater than for the other groups. However, the studies have depicted that CAP among the elderly continues to be the leading cause of death as the annual incidence is four times higher than the younger population (Stupka et al., 2009). The elderly persons have twice higher chances of dying from the illness compared to the general population; hence, there is a need for understanding microbiology, pathophysiology, as well as treatment and prevention of the affliction.

Diagnostic Testing

Various tests are required, especially, in the case where pneumonia is suspected. In the case of the 65-year-old man, pneumonia is likely to be detected due to the exemplary symptoms such as pus. Consequently, a physical exam is among the first steps which should be conducted with the use of a stethoscope to check for crackling sounds or abnormal bubbling. Subsequently, the relative diagnostic tests are conducted, beginning with a sputum test. Accordingly, a sample of fluid should be taken from the man’s lungs to pinpoint the cause of the illness (Buttaro et al., 2012). The sputum is expelled from the lower respiratory tract when a patient coughs (Buttaro et al., 2012). The pathogens or the bacterial sputum cultures detect the cause of the disease in individuals who are suspected to have pneumonia. A second diagnostic test is blood testing, which is used to confirm or identify the type of organism that causes the infection. A third test is the chest X-ray, which helps a practitioner to determine the location or extent of infection. Even though the method cannot tell the kind of organism causing pneumonia, it is imperative to patients who are older than 65. A fourth diagnostic test that could be applied to the patient is pulse oximetry. The test measures the oxygen level in the blood (Buttaro et al., 2012). Under those circumstances, it is apparent that pneumonia makes it hard to breathe when the level of blood oxygen is little. As a result, the method of diagnostic testing determines the amount of oxygen that moves to the bloodstream.

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Treatment Options

There are various treatment options for individuals with pneumonia. The most common medications for the discussed illness are antibiotics. However, special care is given to children and the aged, for those who are above 65 years. The cure for the infection is the target of the care providers who make every effort to prevent complications during the treatment process. As a result, the treatment of pneumonia depends on a patient’s age, the severity of pneumonia, and the overall health conditions. For this reason, antibiotics are the common medicines for pneumonia. A care provider needs to identify the type of bacteria that causes the pneumonia to determine the appropriate drug to treat it. Different antibiotics are recommended in cases where the symptoms fail to improve (Buttaro et al., 2012). A second treatment option is cough medicine. It is apparent that individuals with pneumonia often develop a cough which aids to unblock content in the lung pores. Therefore, patients require cough medicine to calm the discomfort caused when coughing. Even though coughing moves and loosens fluid from the lungs, it is imperative to eliminate it completely. As a result, patients with pneumonia are advised to use cough suppressants with the lowest dose to enable them to rest. As noted in the case, the patient had fever which never went down even after using medicines. In this scenario, it is important to use pain relievers, which are taken along with the antibiotics. Such drugs include ibuprofen or aspirin, and acetaminophen, among others.

Disorder and Normal Development

The signs and symptoms of pneumonia make the disorder different from the normal development. For instance, the patient, mentioned in the case study, smokes; it is a condition that can develop the signs as a result of the behavior. However, it is important to understand that the lifestyle also contributes to the availability of pneumonia. It is apparent that smoking damages the lungs and makes it difficult for the body to defend itself against diseases and germs. Besides, the diagnostic test confirmed that the patient had decreased breath sounds, meaning that he had difficulty breathing, which is not normal in development. Again, the patient had a bilateral expiratory wheezing caused by the inability of the lungs to exhale, which is an abnormal respiratory sound (Sarkar, Madabhavi, Niranjan, & Dogra, 2015). Notably, an understanding of the various lung sounds, conducted through auscultation, is important to determine the underlying pathophysiology. As a result, the patient in the case study decreased expiratory breath sounds, suggesting for the availability of pneumonia due to the presence of the wheezing sounds. Besides, the wheezes indicate airway obstruction, which is abnormal.

Physical and Psychological Demands

The consequences of pneumonia are detrimental to an individual’s life. According to the case study, the patient is married and has been smoking and drinking beer. Being an old person, it is hard for the man to control his behavior as he requires critical care. The condition has affected his way of thinking as he does not believe in the drugs likely to improve his condition. It is apparent that the client was diagnosed with hypertension and osteoarthritis in the past. Since then, the patient takes drugs for the two illnesses even though he has a different problem. It is important to connote that a patient with pneumonia lacks the ability to care for himself. Besides, the disorder stresses the patient’s family, especially, when he indicates that he does not believe in some medications. In this, the healing process becomes complicated as it is difficult to provide the appropriate care. As a result, pneumonia places cognitive impairments on patients, the reason they claim to be unfamiliar with medications (Buttaro et al., 2012). The brain problems often require nursing home admissions to relief the burden of caring from the patient’s family to care providers in the healthcare setting. Besides, the brain problems hinder the patient from understanding the consequences that behaviors such as drinking beer and smoking have on his health.

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Key Concepts with Patient and Family

A nurse practitioner should discuss precautionary measures with the patient and the family to avoid the spread of the disease. It is apparent that the patient’s coughs and, consequently, produces pus which is likely to cause infection to the family. As a result, several key concepts need to be passed to the patient and his family. First, the patient and the family should be informed about respiratory hygiene and etiquette to avoid disease contamination. Indeed, they should be educated about how respiratory infections are transmitted and the ways in which they can be prevented. A second concept is hand hygiene which should be stressed to both the patient and the family. The patient should wash hands after coughing. He should also use tissues when coughing and dispose them properly since pneumonia is an infectious disease. These concepts prevent infection to the family, enabling the care providers to achieve optimal disorder management and outcomes.

Interdisciplinary Team Personnel

The patient in the case study needs interdisciplinary team personnel that will improve the outcomes of the healing process. It is apparent that the healthcare field does not encompass individuals who have knowledge of all other nursing fields. As a result, it is imperative to have interventional specialties who provide non-technical and technical skills or aid to the patient. The issue also explains the need to have coordination between the nurse professionals while performing the complex tasks. Besides, the professionals require leadership and communication skills to work well with the rest of the members. In this, the patient requires individuals who have interrelated skills depending on the type of illness. It is evident that the patient does not conform to the pneumonia medications, because he does not believe in them, as mentioned earlier. It is clear that the illness has affected the brain of the patient, causing problems. Therefore, the patient requires a nurse psychologist to intervene in the actions, attitudes, and cognitions of the patient, leading to patient coordination, which is a fast way to recovery. If this is achieved, the patient will agree to take the appropriate medications.

The interdisciplinary team personnel also involve a dietician. It is evident that the patient, being an aged person, requires knowledge of eating the right foods to gain energy. The dietician should provide knowledge of practicing a healthy lifestyle by eating a balanced diet, full of vegetables and fruits. Besides, the patient affirms that he does not do physical exercise, which is important for a strong immune system. Therefore, the dietician should collaborate with the nurse practitioner to provide a healthy lifestyle. The dietician should also point the dangers of smoking and alcohol consumption for an aged person. The present health condition, which is a consequence of his lifestyle, can be rectified if the patient gets the right information, enabling him to achieve optimal disorder management and outcomes.

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Facilitators and Barriers

It is simpler to manage the disorder due to the fact that the patient’s provided the history of the past illness as well as information on the present medical history, likely to be used in the treatment process. Definitely, the medical history is a facilitator to achieve positive outcomes. Besides, the patient provides challenges to the management of the disorder; in that, he does not conform to the review of the systems. It is apparent that the patient’s history was reviewed, and it did not relate to the present illness. In this, it is difficult to ascertain the other parts of the patient’s body that relate to the illness. For instance, the patient could have chest pain due to the cough; hence, the complex needs are not presented. The case also indicates that the patient consumes beer and smokes, meaning that he does not care about the outcomes of the healing process. Another barrier is the cognitions or the brain problems. It is evident, from the case study, that the client does not believe in some medications and consumes medications that he was prescribed on a previous illness. The issue is a challenge to optimal disorder management and outcomes. Again, the fact that the client is an aged person is a barrier to effective disorder management, because such individuals incur multiple readmissions, especially when they develop multiple illnesses, placing a burden to the healthcare system.

Strategies to Overcome Barriers

The aforementioned barriers need to be overcome to achieve optimal disorder management and outcomes. First, the review of the systems should be assessed to provide a set of interrelated responses. The patient should be interrogated about the feelings in the nose, chest, and throat to identify the extent of a cough or flu. On a different note, the patient should be asked to quit smoking and end the consumption of beer to prevent the lungs of absorbing more fluids, a condition that is likely to hinder optimal disorder management and outcomes. The patient should receive treatment to ease the brain problems, a condition that will improve disorder management as he will agree to consume the Pneumovax medications, which he ignores. The barrier accompanied with age can be overcome through close monitoring, identifying any recent illnesses which the patient experiences.

Care Plan Synthesis

Patient: The patient is a 65-year old black male.

Subjective Data:

Client complaints: The man complains of a cold and has developed chills, as well a productive cough that is thick and dusty.

HPI: The client experienced the cold and the chills four days ago. He had been taking cold medicine that helped to relieve his fever even though he claims to be unwell. The cough is accompanied by thick, dark, and rusty sputum. He has been a smoker with a 40 pack year history. He also drinks one-two beers every night and denies history of illegal drug use. He visited the office after taking the cold medicine that did not relieve his fever.

PMH: The patient has had hypertension and osteoarthritis in the past. He has not taken flu shots or Pneumovax in the past, because he does not believe in them.

Review of systems: the client does not conform to the systems review.

Medications: the client takes one tablet of the 100mg Losartan. He denies taking Pneumovax and flu shots, because he does not believe in the medications.

Allergies/reactions: the patient has no known drug allergies.

Family History: The client’s family history was reviewed, and it does not add to his past or present condition.

Social / Personal History:

Occupation: The patient is a retired truck driver.

Lifestyle: The client is married. However, much about his way of life is not mentioned.

Diet: The patient’s diet is not mentioned. He does not exercise on a regular routine.

Substance abuse: The client smokes 40 packs per year and drinks one to two beers per night. He does not engage in any illegal drug use.

Client awareness of abilities, disease process and health care needs: The client does not fully understand his condition. It is apparent that he smokes and takes beer even after experiencing the cough and other health problems such as hypertension. Besides, the client takes medications for the previous diagnosis and does not believe in the medicines likely to heal his present condition. In such case, it is clear that he does not understand the disease process. The patient partially understands the healthcare needs, because he visited the hospital after feeling unwell. He also takes cold medicine even though he does not feel well. He is not aware of his abilities, because he refuses to take medicine and believes that cold medicine can relieve fever.

Objective Data:

Vital Signs: The client’s blood pressure is 130/84, meaning that he has hypertension. The blood pressure level also indicates that the previous illness, which is hypertension, was not successfully treated. As a resuly, the patient has developed pneumonia in addition to hypertension, meaning that his body immunity is weak. The oxygen saturation of 92% suggests that the patient has a low circulation of blood. Other vital signs such as temperature, pulse, and respiration are 99.6, 94, and 24, respectively. The pulse rate of 94 is considered a high, compared to the normal rate of 60-90 beats per minute. The respiration rate of 24 indicates that the client has an increased rate, which is a serious condition. The patient has a BMI of 28, meaning that he is overweight.

Physical Assessment Findings: Mr. J has a negative PE which suggests the presence of thrombosis. The existence of the decreased breathing sounds in the right middle lobe, as well as the positive egophony and bronchophony in the right middle lobe, signifies the presence of pneumonia (Sarkar et al., 2015).

Client’s Locus of Control and Readiness to Learn: The patient is not willing to learn, because he experienced the cold four days ago and took self-prescription medications which never worked. However, he is cooperative, because he made an urgent visit to the hospital after developing the chills and the cough with pus.

ICD-10 Diagnoses/client problems: The ICD-10 code for pneumonia is J18.9 in the case where the organism is unspecified. The client had hypertension and osteoarthritis, which did not heal. Presently, the client is taking hypertension medicines. Apart from encompassing these previous problems, the client has symptoms of pneumonia, some of which include the decreased breath sounds and the cough with sputum (Ishigami et al., 2012). Taking into consideration all these facts, it is clear that the client has a weak immune system which could be the cause of the numerous health problems. Besides, the patient’s condition could be differentiated with asthma, even though the most striking symptoms represent those of pneumonia. Patients with asthma have breathing problems as it is the case with the client. Other pulmonary illnesses which could be confused with pneumonia include reactive airway disease, the respiratory distress syndrome, or COPD (Stupka et al., 2009). These illnesses encompass symptoms that are closely related to those of pneumonia.

Advanced Practice Nursing Intervention Plan

Patient’s socio-cultural background: The patient is a black male as noted in the case. The understanding of the socio-cultural background can impact optimal disorder management. Thus, the care provider should have knowledge of cultural diversity which is a challenge to practitioners. The knowledge of the socio-cultural background by the nurse should help her to create and deliver services that are based on the cultural, social, and linguistic needs of the patient. Besides, the healthcare system should be a culturally competent one to improve the quality of care and the overall health outcomes. Again, the fact that the client is a black male requires the care providers to have knowledge of training on cross-cultural issues to create policies that reduce linguistic and administrative barriers related to patient care. In this, it is possible to eliminate ethnic and racial health disparities, likely to improve patient care.

Key issues identified: The case study points to the past and present conditions of the patient. Apart from the issue of pneumonia, the patient suffered from hypertension. However, the blood pressure is still high, meaning that the patient has not recovered from hypertension. Besides, this also means that the patient has pulmonary hypertension, caused by his lifestyle (Ishigami et al., 2012). Mr. J is noted to smoke and consume one to two beers per night. Again, beer is taken during the night, meaning that it is cold. As a result, the pulmonary hypertension must have led to the present health condition, which involves a cough with sputum (Ishigami et al., 2012). At the same time, the patient does not do physical exercises on a regular basis, meaning that his body immune is weak. The situation is also the cause of the numerous health problems, added to his elderly age.

Disorder management: The health problems experienced by the patient need to be identified and treated to ease the discomfort and pain that the client undergoes. However, this can be achieved through follow-ups from the clinic. It is evident that the client experienced a cough four days ago and visited the clinic to obtain help. In this same manner, the hospital should make arrangements with the client to visit in order to check on the progress of his health. Since the previously diagnosed hypertension relates to pneumonia, the care providers should make every effort to provide quality care and optimal disorder management. Besides, the client needs information on the right diet to boost his immunity. Much information regarding the social status of the client is important to identify any lifestyle issues that could be a barrier to disorder management.


The symptoms of the 65-year-old man relate to pneumonia. It is apparent that the patient had earlier been diagnosed with hypertension. Based on the present illness, the client must have had pulmonary hypertension which led to the difficulty breathing. It is also evident that the client engages in behavior that worsens his condition, especially the normal functioning of the lungs. Some of these practices include smoking and alcohol consumption which could be the cause of the fluid from the lungs. Again, the client does not do regular physical exercises, which is the cause of the diverse health problems. The lack of adequate exercise also facilitates a weak immunity. Much has not been told about the social history of the patient. As a result, it is not clear whether the patient’s lifestyle contributes to his present or past condition. To conquer all these health problems, it is important for the care provider to understand the socio-cultural background of the patient. In this, the practitioner will have the potential to meet the client needs, leading to recovery. The care provider also needs to make follow-up plans with the patient to manage the disorder since the client is aged.

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