Nursing Care of Patients with Community Acquired

Pneumonia in Adult as Assessed by

Level IV Nursing Students in
Tondo Medical Center

A Thesis Presented to
The Family Clinic Colleges
College of Nursing

In Partial Fulfillment of the

Requirement for the Subject
Nursing Care Management 105

By:
Group 1:
Aguinaldo, Ralph Arvin
Andaya, Lean Roma P.
Busuego, Pheobe
Calumpit, Laura Tiffany
Cantor, Irene S.
 Approval Sheet

This thesis proposal entitled, “Nursing Care of Patients with Community Acquired
Pneumonia in Adult as Assessed by Level IV Nursing Students in Tondo Medical Center”
prepared and submitted by Group 1 in partial fulfillment of the requirements for the subject
NURSING RESEARCH, has been examined and is recommended for acceptance and approval
for ORAL EXAMINATION.

_______________________________
Professor

Acknowledgement

The researchers would like to thank the following individuals:

 First of all, the researchers would like to thank Ms. Cleotilde C. Reyes, their research instructor
for being patience in teaching them and supporting in the conducting of the study to have a meaningful
and successful study.

To the Family Clinic Library, the researchers would like to thank the library staff and the
employees for their kindness and allowing the researchers to use the library for conducting the study.

To their parents, for their continued supervision and support, not only in financial matters but
also for kindness and consideration in conducting this study.

To their friends, for their help, care, and concerned. Also to their co-researchers that contribute
and share knowledge in conducting this study.

Most of all, the researchers want to thank their beloved Almighty God, for the blessings and
graces for guiding their research study to be successful.

Table of Contents
Title Page..............................................................................i
Approval Sheet.....................................................................ii
Acknowledgement...............................................................iii
Table of Contents.................................................................iv
CHAPTER 1-THE PROBLEM AND ITS BACKGROUND
Introduction............................................................1-2
Statement of the Problem........................................3
Assumption.............................................................4
Significance of the Study........................................4-5
 Scope and Delimitation of the Study......................5
Definition of Terms.................................................6
Theoretical Framework...........................................7-8
CHAPTER II- REVIEW OF RELATED LITERATURE AND STUDIES
Local Literature.........................................................9-11
Foreign Literature......................................................11-13
CHAPTER III- RESEARCH METHODOLOGY
Research Design.........................................................14
Instrument Use...........................................................14
Preparation of the Instrument.....................................15
Validation of the Instrument.......................................15
Administration of the Questionnaire...........................15
Sampling Technique....................................................16
Treatment of Data........................................................16
Bibliography.............................................................................17
Appendices:
APPENDIX A – Approval Letter
CHAPTER I
THE PROBLEM AND ITS BACKGROUND

Introduction

Pneumonia is an inflammation of the lung parenchyma caused by various microorganisms,

including bacteria, mycobacterium, chlamdiae, mycoplasma, fungi, and parasites viruses.
“Pneumonitis” is a more general term that describes an inflammatory process in the lung tissue that
may predispose or a place the patient at risk for microbial invasion. Pneumonia is the most common
cause of death from infectious disease.
Community- Acquired Pneumonia occurs either in the community setting or within the first
48 hours after hospitalization or institutionalization. Causative agents for CAP that requires
hospitalization are most frequently S. Pneumoniae, H. Influenzae, Legionella, Pseudomonas aeruginosa
and other gram- negative rods.
Pneumonia varies in its signs and symptoms depending on the causal organism and the
presence of underlying disease. The patient with pneumonia usually has a sudden onset of chills,
rapidly rising fever and pleuritic chest pain that is aggravated by deep breathing and coughing. The
patient is severely ill, with marked Tachypnea, accompanied by other signs of respiratory distress.
 The pneumonia is treated in administration of the appropriate antibiotics as determined by the
results of a Gram stain.

The treatment in the Community- Acquired Pneumonia is by administering an antibiotic which

is effective in killing the offending microorganism as well as managing any complications of the
infection. If the causative microorganism is unidentified, different antibiotics are tested in the
laboratory in order to identify which medication will be most effective. Often, however, no
microorganism is ever identified. Also, since laboratory testing can take several days, there is some
delay until an organism is identified. In both cases, a person's risk factors for different organisms must
be remembered when choosing the initial antibiotics (called empiric therapy). Additional consideration
must be given to the setting in which the individual will be treated. Most people will be fully treated
after taking oral pills while other people need to be hospitalized for intravenous antibiotics and,
possibly, intensive care. In general, all therapies in older children and adults will include treatment for
atypical bacteria. Typically this is a macrolide antibiotic such as azithromycin or clarithromycin
although a fluoroquinolone such as levofloxacin can substitute. Doxycycline is now the antibiotic of
choice in the UK for complete coverage of the atypical bacteria. This is due to increased levels of
clostridium difficile seen in hospital patients being linked to the increased use of clarithromycin.

The complications despite appropriate antibiotic therapy, severe complications can result from
Community- Acquired Pneumonia, including: Sepsis can occur when microorganisms enter the blood
stream and the immune system responds, Respiratory failure because Community- Acquired
Pneumonia affects the lungs; often individuals with Community- Acquired Pneumonia have difficulty
breathing. If enough of the lung is involved, it may not be possible for a person to breathe enough to
live without support, Pleural effusion and empyema occasionally, microorganisms from the lung will
cause fluid to form in the space surrounding the lung, called the pleural cavity, and Abscess rarely,
microorganisms in the lung will form a pocket of fluid and bacteria.

The prevention in addition to treating any underlying illness which can increase a person's risk
for Community- Acquired Pneumonia, there are several additional ways to prevent Community-
Acquired Pneumonia. Smoking cessation is important not only for treatment of any underlying lung
disease, but also because cigarette smoke interferes with many of the body's natural defenses against
Community- Acquired Pneumonia.

This study focus on nursing care to the patient suffering on Community Acquired Pneumonia
in Adult.
 STATEMENT OF THE PROBLEM
Major problem:
Nursing Care of Patients with Community Acquired
Pneumonia in Adult as Assessed by
Level IV Nursing Students in
Tondo Medical Center

Minor problem:
Specifically it sought to answer the following problem.
The study will be conducted to determine the proper nursing management to the disease
Pneumonia.
1. What is the demographic profile of respondents in terms of:
1. a. Age,
1. b. Gender, and
1. c. Economic Status?
2. What are the factors that greatly affect nursing management of patients with Pneumonia in relation
to:
2. a. Environmental,
2. b. Emotional, and
2. c. Sociological?
3. What are the nursing management that would alleviate patient suffering from Pneumonia in terms of:
3. a. Respiratory condition,
3. b. Proper care, and
3. c. Infection control?
 ASSUMPTION

A.1. There are different demographic profiles of the respondents in terms of age, gender, and economic
status.

A.2. There are different factors that can greatly affect the nursing management of patients with
Pneumonia in relation to: environmental, emotional, and sociological.

A.3. There are nursing management that would alleviate patients suffering from Pneumonia in terms of
respiratory condition, proper care, and infection control.

SIGNIFICANCE OF THE STUDY

This part of the study will discuss about the boundary or parameter of the study to be
investigated.

This study is beneficial for the researchers, student nurses, readers, future researchers, and
future affiliates.

The Researchers

Through this study, the researchers will be able to familiarize and be enlighten regarding the
proper nursing intervention for the pneumonia (adult).

Student Nurses

By this study, the researchers hoped that they will be able to increase the awareness of the
students regarding to the proper nursing care: that they will be able to impart the knowledge that they
have learn through research.

The Readers

The readers are the main consumers. They are the main target and subject. The readers will be
able to understand how the medications will be administered and they will be able to familiarize on this
kind of medications.
The Future Researchers

They will be able to use these data as a guide for them to get the ideas and if they are planning
to conduct the same study.

The Future Affiliates

This study will increase the awareness of the future affiliates about this data, maintenance of the
medication and will be able to familiarize this kind of medications.

Through this study, the researchers will be able to assessed the Nursing Care of Patients with
Community Acquired Pneumonia in Adult.

SCOPE AND DELIMITATION OF THE STUDY

The scope and delimitation of the study will discuss the subject matter and the target
respondents that will be covered in the study.

This study is to assessed the proper Nursing Management on Community Acquired Pneumonia
in adult. This study will take place within the premises of the Family Clinic Inc. – Colleges at 1452 A.
II Lacson Avenue, Sta Cruz, Manila. The students will be 106 students from Level IV that will be base
on the total population enrolled. This study will be conducted this 2nd semester of the school year
2010-2011

Definition of Terms
This part of the topic will give meaning to the unfamiliar words that they will used in this study.
Its purpose is to enrich the reader’s vocabulary and be able to used this terms whenever needed.

The researchers enumerate the following terms that will be used in the conduct of the study. The
terms that will be use are medical terms on which the person who will read this study can fully
understand what the study is all about.

Community- Acquired Pneumonia - occurs either in the community setting or within the first 48
hours after hospitalization or institutionalization.

Gram negative - relating to, or being a bacterium that does not retain the violet stain used in Gram's
method.

Lung parenchyma - although often used to refer solely to alveolar tissue, term describes any form of
lung tissue including bronchioles, bronchi, blood vessels, interstitium, and alveoli.

Mycobacterium - Any of various slender, rod-shaped, aerobic bacteria of the genus Mycobacterium,
which includes the bacteria that cause tuberculosis/pneumonia and leprosy.

Mycoplasma - Any of numerous parasitic, pathogenic microorganisms of the genus Mycoplasma that
lack a true cell wall, are gram-negative, and need sterols such as cholesterol for growth. In humans, one
species is a primary cause of nonbacterial pneumonia

Pneumonia - is an inflammation of the lung parenchyma caused by various microorganisms, including

bacteria, mycobacteria, chlamdiae, mycoplasma, fungi, parasites and viruses.

Respiratory distress- A condition in which patients with lung disease are not able to get enough
oxygen.

Tachypnea- characterized by rapid breathing and increased breathing rate.

THEORETICAL FRAMEWORK

Florence Nightingale

Nightingale’s theory

•The founder of educated and scientific nursing and widely known as

"The Lady with the Lamp”

•First nursing theorist

•Environmental Theory, which incorporated the restoration of the usual health status of the
nurse's clients into the delivery of health care.
Environmental factors affecting health

In Any deficiency in one or more of these factors could lead to impaired functioning of life
processes or diminished health status.

•Adequate ventilation has also been regarded as a factor contributing to changes of the patient's
process of illness recovery

•Pure or fresh air

•Pure water

•Sufficient food supplies

•Efficient drainage

•Cleanliness

•Light (especially direct sunlight

Nightingale also stressed the importance of keeping the client warm, maintaining a noise-free
environment, and attending to the client's diet in terms of assessing intake, timeliness of the food, and
its effect on the person. Set the stage for further work in the development of nursing theories. Her
general concepts about ventilation, cleanliness, quiet, warmth, and diet remain integral parts of nursing
and health care today.

CHAPTER II

Review of Related Literature and Study

Related literature is about the discussions of facts and principles to which the researcher’s study
is related. These references are usually printed and found in books, magazines, encyclopedia and other
publications.
Local

According to health experts (Manila Bulletin), pneumonia sometimes leads to death because
cases of pneumonia, especially in the barrios, are left untreated either because of knowledge deficit
about the symptoms of pneumonia or lack of money to pursue treatment. These factors usually
aggravate pneumonia and reflect the type of healthcare a country has. I will update this post in the near
future to discuss the Philippine healthcare system from a researcher’s point of view. I know many
Filipinos are not given proper care particularly those from far-flung localities. That is the reason why
cold weather in the Philippines can has already taken its toll on the people. Cases of pneumonia and
deaths caused by pneumonia might continue to rise until February due to the cold weather reaching an
all-time low of 7.5 degrees Celsius in Baguio City since 1961 (which recorded a 6.3 degrees Celsius
reading on January 18).

According to Maria Charisse Y. Lim, MD and Albert L. Rafanan, MD, FCCP, Majority of
physicians at our institution are not adherent to the local guidelines. Adherence to local Philippines
management guidelines on CAP improves survival and decreases the frequency of mechanical
ventilatory support. The Clinical complications: This study validates the Philippine guidelines in the
local setting. A focused and concerted effort for dissemination and adherence of the said guidelines by
the medical societies is needed. The Methods: Retrospective cohort of patients > 16 years old with
CAP from January 1, 2005 to June 30, 2005. Patients were risk-stratified according to the guidelines.
Therapy was considered guideline concordant if it agreed with the recommended therapeutic regimen
for that specific classification. Outcomes measured were mortality, use of mechanical ventilation and
length of hospital stay.

According to Jane Gacus, City Health statistician, said there were at least 531 deaths due to
pneumonia recorded in the city. She said the record is based on the actual medical mission conducted
during the “People to People Program.”Dr. Jerome Basang, family and community medicine consultant
at the Northern Mindanao Medical Center, said death due to pneumonia occurs reportedly by “taking
for granted the signs and symptoms of the disease.”Pneumonia, he said, is an abnormal inflammatory
condition of the lungs resulting from a variety of causes, including infection with bacteria, viruses,
fungi or parasites, and other chemical or physical injury to the lungs. He said the typical symptoms
associated with pneumonia include cough, chest pain, fever and difficulty in breathing.“Pneumonia is a
common illness that will occur in all age groups. If taken for granted, it may result to death among the
elderly and people who are chronically and terminally ill,” Basang said.
 According to DOH Pneumonia remains in the list of the leading causes of morbidity and
mortality in the Philippines. It ranked third among the causes of morbidity and fourth among the causes
of death in 2000. There was an increase in the morbidity trend for pneumonia from 1990 to 1996. This
may be due to improved case finding and reporting with the intensification of the program to control
acute respiratory infections during this period. The morbidity trend decreased slightly from 1997 to
2000 but the number of cases remained high at 829 cases per 100,000 populations in 2000. On the other
hand, there is a decreasing trend of mortality from pneumonia in the general population from1990 to
2000 despite the high number of cases per year. The mortality rate from pneumonia decreased from
64.7 deaths per 100,000 population in 1990 to 42.7 deaths per 100,000 in 2000 (PHS). This reflects
improvement in the diagnosis and treatment of cases. The region with the highest reported mortality
rate from pneumonia is Western Visayas (74.6 deaths per 100,000 population) followed closely by
Ilocos (73.7 per 100,000)and Cagayan Valley (59.2 per 100,000) with ARMM having the lowest
reported death from pneumonia at 2.5 deaths per 100,000 followed by Central Mindanao (15.6 per
100,000) and Western Mindanao (21.3 per 100,000) (PHS 2000).

According to Gene Ong, M.D.,Melecia Antonio-Velmonte, M.D. and Myrna T. Mendoza,

M.D. Fellow, and Consultants, Infectious Disease Section, College of Medicine, Philippine
General Hospital, University of the Philippines manila) Pneumonia continues to be a leading cause
of morbidity and mortality in the Philippines. It was the number 4 cause of morbidity and number 1
cause of mortality in all age groups.1 for patients 15 years old and above, for the year 1989, pneumonia
was the 5thleading cause of morbidity with 43,513 cases reported and was the second leading cause of
mortality with 17,561 cases reported. Even in industrialized nations, such as the United States,
pneumonia remains a significant problem with 500,000 hospital admissions annually, ranking as the 6th
leading cause of mortality in the U.S.2 Management of pneumonia remains difficult because the precise
etiology is uncertain in as much as 50% of cases. In the 1989 Philippine Health Statistics, the average
mortality rate of patients between the ages 15 and 64 is around 30/100,000 population, while for those
65 years old and above/the mortality rate is around 396/100,000 population. Given the high mortality
rate of pneumonia especially in patients 65 years old and above, it is imperative that the initial empiric
therapy be instituted and that it be based on current information on the microbiological etiologies of
community-acquired pneumonia. The general objective of the study is to determine h t e common
etiologic agents for community-acquired pneumonia in adults seen or admitted to the Philippine
General Hospital. The specific objects are: to determine the etiologic agents of pneumonia in the
elderly, and to be able to recommend a rational choice for initial empiric therapy of community-
acquired pneumonia.

Foreign

According to J.B. Lippincott (119-120; Medical Surgical Nursing) Pneumonia is an

inflammatory process involving respiratory bronchioles, alveolar space and walls and lobes caused
primarily by specific organisms (bacteria, viruses, fungi, parasites, mycoplasm, or chemical irritants). It
can be classified as bacterial or nonbacterial.

Etiology and Incidence:

1. Causative organism in bacterial pneumonia include:

a. Streptococcus pneumoniae ( hemolytic type A) accounts for 90% of cases
b. Staphylococcus areus
c. Haemiphilus influenza n(type B)
d. Klabsiella pneumoniae, Pseudomonas Aeruginosa, Escherichia coli, Enterobacter and
other gram negative enteric bacilli.
2. Cause of Nonbacterial pneumonia include:
a. Mycoplasma pneumoniae
b. Influenza virus, parainfluenza viruses and other viral infections.
c. Pneumocystis carinii
d. Asperigullus fumigatus.
2. Pneumonia is the most common cause of death from infectious disease in North
America.

According to Irene L. Beland (298-299) the severity of illness and course of pneumonia
usually lasts 2 to 3 weeks with complete resolution. Fatality with treatment is rare today in the middle
aged group. Severe complications can raise Atelactasis and Pleural effusion (empyema).

Lung consolidation in stages:

 Red hepatization (blood serum and cells pour into the alveoli)
 Gray hepatization, alveoli are packed with RBC’s and fibrinous exudates
 Resolution by phagocytosis
Effect on adequacy of respiratory function decrease in surface for the exchange of gases.Focuses of
Nursing Interventions are bed rest, fluid encouragement, collection of sputum, mouth care and teaching
on prevention and methods of treatment
 According to Suzzane C. Smeltzer and Brenda G. Bare, Community acquired pneumonia has
the highest occurrence in winter months. Incidence greatest in elderly in patients with COPD, heart
failure, alcoholism etc. Leading infections cause of illness worldwide among young children, persons
with underlying chronic health conditions and the elderly. Death occurs in 14% of hospitalized adults
with invasive disease.

Treatment:

 Penicillin
 Alternate antibiotic therapy such as Cefotaxamine, Cetriaxone
 Antipseudomonal floroquinolones ( levofloxacin, gatifloxacin, moxifloxacin)
According Heidi Stevanson;Vaccination Liberation,an Associated Press report, Wyeth
"anticipated" the spread of new strains of pneumonia and ear infection bacteria as a result of their
vaccine! They are in the process of testing another one, and plan for its use by the general public in the
next year or two. This one would address 18 strains of pneumonia-causing bacteria.Thanks to Wyeth,
the FDA, and the entire medical system, we have a developing virulent and deadly pneumonia that's
likely the direct result of a vaccine. Rather than taking a step back and considering withdrawing
Prevnar, the approach in both the U.S. and U.K. has been to up the ante: develop another vaccine,
presumably to cover more bacteria. There is no reason to believe that this won't result in an even more
virulent strain of pneumonia than the one already created.

According to Sascha Dublin, MD, PhD, a physician at Group Health and assistant
investigator at Group Health Center for Health Studies said that she's a fan of statins. However, she
admitted in the press statement that some of the claims concerning their benefits could be bogus. "But
now we and some others have found that statins may have gotten some unearned credit for health
benefits that they don't actually have, including preventing pneumonia," Dublin said. She also spoke
out against suggestions from researchers that expensive randomized controlled trials should be
conducted to see if statins can prevent or treat infection. "Our study indicates that such trials would be
an ill-advised use of limited research funds at this time," she added.The new study focused on
relatively healthy people between the ages of 65 and 94 who had healthy immune systems and did not
reside in a nursing home. Dr. Dublin used the same group of patients, with their records coded to
protect their privacy, in earlier Group Health research that was published in The Lancet last year. That
research demonstrated another widely accepted medical "fact" was also wrong: the flu vaccine
provided the elderly with little to no protection from pneumonia.
 CHAPTER III

RESEARCH METHODOLOGY

In this chapter the researchers design which will be presented is concerned on the method of
research, instrument to be used, preparation and validation of the instrument, administration of the
instrument, the sampling technique and the treatment of the data. It will serve as the foundation in
measuring the focus of this study.

RESEARCH DESIGN

The researchers’ design will make use of the descriptive research design. This design best suits
the study for it aims to determine which opinion or beliefs prevail, outcomes and effects, advancements
and developing trends. The descriptive research design will help the study in determining the present
condition, changes in the environment and elements that will be included in the problem.

INSTRUMENT USED

In this study, the researchers will used questionnaires as their instrument. Questionnaires will be
an effective instrument for the study because it will give the respondents privacy for them to answer the
questions honestly. The questions that will present will be carefully selected based on the nursing care
of patients with Community Acquired Pneumonia in Adult. The format that will be used is Likert-scale
(i.e., a scale of 1 to 5) to determine the respondent’s degree of agreement to a statement.

PREPARATION OF THE INSTRUMENT

 The questionnaires will be gathered from different literatures related to the problem. Upon
completion of the questions, it will be forwarded to some nursing students for validation of the
questionnaires. Any correction, clarification, comments and suggestion will be highly considered and
appreciated. After such corrections it will be incorporated and finalization will be made to assure the
reliability of the questionnaires.

VALIDATION OF THE INSTRUMENT

When the questionnaires are made on its final form, it will be subjected to a dry-run to ensure
its validity and reliability before proceeding to the distribution of questionnaires to the respondents.

It will then be distributed to a selected Level IV Students of the Family Clinic Colleges of
Nursing.

ADMINISTRATION OF THE QUESTIONNAIRES

Copies of the questionnaire will be distributed by the researchers for every respondents and give
a day to answer each and every question of the questionnaires. When the time is due, the questionnaires
will then be collected. In instance that a respondents did not comply in answering all question, they will
be given another day for the completion of the questionnaires.

SAMPLING TECHNIQUE

The researchers will choose simple random technique in this study. This technique is a selection
of random results based on elements from a sampling frame that enumerates all the elements and each
will have an equal chance as a subject of the study.

TREATMENT OF DATA
 The researchers will use the percentage and frequency method and the weighted mean in the
study. To get the percentage, the numbers of frequency is divided to the total number of the respondents
and then multiply by 100%.

FREQUENCY AND PERCENTAGE FORMULA

Formula:

F
P = ──── X 100%
N

Bibliography

Local literature:
1. Chong Hua Hospital, Cebu City, Philippines the Department of Health–Center for Health
Development Western Visayas (DOH-CHD) (Pg. 132)

2. Department of Health promoting quality of Health care Philippines

3. Infectious Disease Section, College of Medicine, Philippine General Hospital, University

of the Philippines manila

4. Manila Bulletin Publishing Corporation 2010

5. Sun. Star Cagayan de Oro newspaper on March 24, 2010. (pg.11)

Foreign literature:

1. Brunner and Suddhart’s Textbook of Medical and Surgical Nursing 11th edition
( chapter 23 pages 520-531)

2. Irene L. Beland; Clinical Nursing, Pathophysiology and Psychosocial Approaches 2nd

Edition

(pg 298-299)

3. J.B Lippincott’s Medical Surgical Nursing Chapter 6 (pg 119-121)

4. Journal of the American Medical Association, Postilicensure Safety Surveillance for 7-

Valent Pneumococcal Conjugated Vaccine, Wise et al, 292(14)1702

5. Schlienger RG, Fedson DS, Jick SS, Jick H, Meier CR. Statins and the risk of pneumonia:
a population-based, nested case-control study. Pharmacotherapy2007; 27:325-32.

APPROVAL LETTER
FAMILY CLINIC INC. COLLEGES
A.H LACSON AVE. STA.CRUZ MANILA

DR. FLORA B. VILLALON

Dean, College of Nursing

Thru:
Mrs. Rosemarie I. Magallanes R.N M.A.N
Assistant Dean, College of Nursing

Dear Madame:

Good day! In connection to our research subject we, Group 1 would like to request to use this
title for our thesis proposal.

“Nursing Care of Patients with Community Acquired Pneumonia in Adult as

Assessed by Selected Level IV Nursing Students in
Tondo Medical Center”

In this regard, we would like to request for your approval regarding this matter.
 Thank you very much and God bless.

Respectfully yours,

Aguinaldo, Ralph Arvin

Andaya, Lean Roma P.
Busuego, Pheobe
Calumpit, Laura Tiffany
Cantor, Irene S.

Noted by:

Ms. Cleotilde C. Reyes

Research Professor