Central Luzon Doctors’ Hospital
Educational Institution
San Pablo, Tarlac City
In partial fulfillment of the requirements in NCM
102(RLE-Community health Nursing)
A case Study on:
BRONCHO PNUEMONIA
Submitted to:
Ma’am Raelyn Benavides RN,MSN
Clinical Instructor
Submitted by:
Baluyot, Janella
Baybin, Flori An
Corpuz, Tina
Jayme,
Leh, Luisa Tsina G.
Manzano, Ezra D.
Rafael, Diana Joy
Silverio, Everlasting
INTRODUCTION:
Our patient baby K is an eleven month baby who lives at San Pablo,
Tarlac City. Baby K was bought to the center together with her
parents who complains at cough, colds, and fever for 1 week. She
was diagnosed with bronchopneumonia.
Bronchopneumonia is an acute inflammation of the smaller bronchial
tubes with regular with irregular areas of considilation due to spread
of the inflammation into peribronchial cuveoli and the alveoli or dust
of the lungs. It is type of pneumonia characterized by an
inflammation of the lung generally associated with and following
amount with bronchitis.
Our group choose this case to acquire knowledge about
bronchopneumonia, we would use this knowledge to promote
awareness about this sickness, most especially to the people in the
community who has a little knowledge about this sickness.
OBJECTIVES:
State the present health history of the client.
To determine the cephalocaudal assessment obtained from the
client.
Trace the pathophysiology of the client’s disease
Discuss the nature of the nature of the drugs given to the client.
Provide the family with therapeutic interventions
Nursing Health History B
a. General Description of Client
Baby K is 66 cm in height. She appeared to be drowsy in appearance. When she went to the center to consult she was suffering from difficulty of breathing, cough, colds and fever. She was diagnosed with Bronchopneumonia, in additional to that baby K also looked weak.
b. Health Perception-Health Management Patterns
Baby K’s mother stated that she already had her fever for almost a week. The mother administered tempra to cure her fever.
c. Nutritional-Metabolic Pattern
The patient is still breast feeding. But due to her sickness baby K lost her appetite.
d. Elimination Pattern
Because of loss of appetite baby K’s elimination pattern was lessen. She only defecates 1-2 times a day.
e. Activity-Exercise Pattern
Baby K’s primary activity would be crawling or trying to walk. f. Sleep-Rest Pattern
As stated by the mother, Baby K’s sleep pattern is kind of disturbed because of her sickness.
g. Cognitive-Perceptual Pattern
Baby K has no sensory defect. She communicates through crying and some baby talk.
h. Self-Perception – Self-Concept Pattern: i. Role-Relationship Pattern
At this point of time, we cant still point out baby K’s role relationship because she is still an infant, though her mother states that she is a behave baby.
j. Sexuality-Reproductive Pattern
Patient baby K is still a baby she is still in oral stage according to Sigmund Freud’s theory.
k. Coping-Stress Tolerance Pattern
Baby K’s copes through crying, because she is still an infant. l. Value-Belief Pattern
Nursing health history A Patient: Baby K
Date of Admission: November 19 2012 Ward: Tibag, health center
Age: 11 months old Sex: female
C/S: single
Religion: Roman Catholic I. Chief complaint
Cough colds and fever for 1 week. II. Past medical history
A. Immunization/tests + BCG +DPT +OPV +HEP B +Measles B. Hospitalizations.
Baby k’s first admission was November 19 2012. Upon consultation at Tibag RHU they immediately confined her at Tarlac Provincial Hospital. She stayed at NICU for 5 days and 3 days at pedia ward and was discharged November 16, 2012. C. Injuries NONE D. Transfusions NONE E. Medications suprax. (cefiximine) (zinc sulfate) Diazinc F. Allergies
NONE
III. Family History
Parents Health status
or cause of death Disease present in the family L D Mr. R Mrs. M
IV. Social and personal history
Birthplace: Tarlac Provincial Hospital Education: N/A
Birthday: December 10, 2011 Ethnic background: Pampango
Client’s position in the family: Youngest child Residence: San Pablo, Tarlac City
Home Environment: Concrete Occupation: N/A
Financial Support System: supported by her parents. Habits: none
Physical activity: Since baby K is still an infant, her activity are mostly crawling and trying to walk.
Brief Description of Average Day: She wakes up early and her siblings play with her. Baby K sleeps at noon and 8pm at night.
IV. Review of system: General Description: Weight Loss: + Night sweats: Anorexia: Fatigue: + Weakness: + Skin: Itch: + Rash: Lesion: Bruising: Bleeding:
Color Change: slightly pale Eyes: normal Vision: Diplopia: Blurring: Excessive Tearing: Ears: normal Earaches: Hearing Loss: Discharge: Tinnitus: Nose: Nasal flaring: + Obstruction: Epistaxis: Discharge:
Throat and Mouth: Sore Throat: Bleeding Gums: Tooth Aches: Decay:
Cough: + Sputumum : greenish to yellowish Neck: Swelling: Dysphagia: + Others: Extremities: normal Joint pains: Edema: Varicose Veins: Stiffness: Claudication: Deformities: Neurologic System: Headache: + Dizziness: Memory Loss: Fainting: Numbness: Tingling: Paralysis: Paresis: Seizures: Mental Health: Anxiety: + Sexual Problem: Depression: Fears: Insomnia: Breast: Lumps: Discharge: Pain: Bleeding: Cardiovascular: Chest pain: Palpitation: Dyspnea on exertion: + Edema: PND: Orthopnea:
Others: Gastrointestinal System: Food Tolerance: Heartburn: Nausea: Jaundice: Vomiting: Pain: Bloating: Excessive Gas: Constipation: Change in BM: Melena: Genitourinary System: Dysuria: Nocturia: Retention: Polyuria: Dribbling: Hematuria: Flank pain: Male: Penile Discharge: Lesions: Testicular pains: Others: Female:
Menarche: Old LMP: Cycle: CVS: Chest pain: Palpitation: + Dyspnea on Exertion: Edema: PND: Orthopnea: Others:
GIT: Food tolerance: Heartburn: Nausea: Vomiting: Pain: Bloating: Excessive Gas: Constipation: Change in BM: Melena: GU: Dysuria: Nocturia: Retention: Polyuria: Dribbling: Hematuria: Flank pain:
Male: Penile Discharge: Lesions:
Testicular Pain:
Others:
Female: Menarche LMP: Cycle: Others: Extremities: Joints Pain: Varicose Veins: Claudicatio: Edema : Stiffness : Deformities : Neuro : Headache : + Dizziness : Memory loss : Fainting : Numbness tingling : Paralysis : Presis : Seizures : Others :
Mental Health Status : Anxiety : + Depression : Insomia :
ANATOMY AND PHYSIOLOGY OF RESPIRATORY SYSTEM
The Nose
- Responsible in smelling something. It has two openings called nostrils; the air enters the nasal passages through the nostrils. The air that you breathe must be cleaned before reaching the lungs of the person. - Cilia are a tiny hair that is responsible for protecting a person from
germs. The cilia filter the smaller particles of dust and dirt.
- Mucous membrane is a moist tissue lining in the nose that also catches particles of dirt. It also warms and moistens the incoming air. There is also tiny blood vessel that also warm and moisten the passing air inside the nose.
The Pharynx
- The clean air travels from the nasal passages to the pharynx, It is located at the back of the throat. Divided into two tubes:
- Esophagus is the tube that connects the pharynx with the stomach. It carries food, liquids and saliva from your mouth to the stomach.
- Trachea or windpipe is a bony tube portion of the respiratory tract that connects the larynx with the bronchial parts of the lungs. Epiglottis is the flap cartilage located at the bottom of the pharynx. It opens and closes the trachea. It prevents the food from going to the trachea by closing it
during swallowing. The epiglottis is open to allow the flow of air in the breathing process most of the time.
The Larynx
- From the pharynx, the clean air moves down to the larynx.
- The Larynx or voice box is located between the pharynx and the trachea. Humans use the larynx to breathe, talk, and swallow.
- The larynx contains the vocal cords that vibrate when air passes through them.
The Trachea or Windpipe
- The trachea, or windpipe, is a bony tube portion of the respiratory tract that connects the larynx with the bronchial parts of the lungs that about 13 centimeters long.
- The inner wall of the trachea is also lined with cilia. The cilia catch the dust particles that reach the windpipe. The dust particles are then pushed out and up toward the throat and mouth for expulsion. This is why one coughs or sneezes just because of the dirt gets into the upper respiratory tract. The lower end of the trachea branches into two large tubes called the bronchi.
The Lungs
- The Lungs are the organs of respiration (in-charge for breathing). The left bronchus leads to the left lung while the right bronchus leads to the right lung. Each bronchus divides into smaller tubes called bronchial rami. The bronchial rami branches off further into smaller tubes calledbronchial tubes or bronchioles. At the ends of these bronchioles are the tiny air sacs calledalveoli.
- The bronchioles and alveoli look like the branches of a tree. Bronchi is the biggest branches that arecovered by cilia and a thin film of mucus. Dust and pollen are trapped by the mucus before they reach the alveoli. - Each of the lungs has 300 million alveoli. Alveolus is surrounded by tiny
blood vessels called capillaries. These are the smallest of blood vessels that help to distribute oxygenated blood from the arteries to the tissues and to feed deoxygenated blood from the tissues back to the veins.
Alteration in net bacterial lung resistance caused by either: -Decreased bactericidal ability of the alveolar macrophages -Extreme virulence of the bacteria -Increased susceptibility of host to infection Acute inflammation occurs that causes excess water and plasma proteins go to the dependent areas of the lower lobes RBCs, fibrin, and polymorphonuclear leukocytes infiltrate the
alveoli
Containment of the bacteria within the
segments of pulmonary lobes by cellular recruitment Consolidation of
leukocytes and fibrin within the
affected area Stage of congestion:
Engorgement of alveolar spaces with fluid and hemorrhagic exudates
Proliferation and rapid spread of
organism through the lobe
Stage of red hepatization:
Coagulation of exudates occurs resulting to the red appearance of the affected lung
Stage of gray hepatization:
The decrease in number of RBC in the exudates is replaced by neutrophils; which infiltrate the alveoli making the lung tissue to be solid and grayish in color
PHYSICAL EXAMINATION General Survey:
Height: 66 cm. Weight: 7.2 kg. Skin:
Color: Slightly pale Turgor: Decreased skin turgor
State of Hydration: Good Bruises: None Eyes:
Sclera: Moist
Pupils: Pupils Equally Reactive to Light and Accommodation VITAL SIGNS:
Capillary Refill: 1-2 secs. Urine Output: 4 diapers a day
DATE/ TIME CR (bpm) RR (cpm) TEMP. (C)
12-04-12 122 25 36.8
BODY POSITION AND ALIGNMENT:
Supine Fowlers Semi-Fowlers
Others:
Sitting at parent’s lap
Alignment: Appropriate Inappropriate
MENTAL ACUITY:
Oriented Coherent Appropriately Responsive
Others:
Disoriented Incoherent Inappropriately Responsive
SENSORY/MOTOR RESTRICTIONS:
Amputation Paralysis Deformity Fracture
EMOTIONAL STATUS:
Apprehensive Angry/Hostile Depressed Euphoric
OTHER HEALTH RELATED PATTERNS:
Fatigue Restlessness Weakness Coughing
Insomnia Dizziness Pain ENVIRONMENT:
Room Temperature: Adequate Inadequate
Lighting: Adequate Inadequate
SAFETY:
Violations of safety measures: Bed has no side rails ACTIVITIES OF DAILY LIVING:
CANNOT PERFORM:
Feeding Brushing Teeth Bathing Transferring Dressing Combing
PHYSICAL EXAMINATION FINDINGS SKIN
Slightly pale in color Warm and Dry HEAD/ SKULL
Skull is round ( normocephalic and symmetric, with frontal parietal and occipital prominences). Smooth skull contour, non tender and free from masses and depression.
Head circumference: 42 cm. FACE
Symmetric facial features and movements. EYES
With white, moist, and glossy sclera. Iris are equal in size and pupils are rounded, both eyes are symmetrically responsive to light, coordinated and moved with parallel alignment.
Conjunctivas are slightly thinned. Cornea is transparent, smooth and moist. Iris and pupil are round and uniform in color.
EARS
Ears are of equal sizes and similar in appearance Non tender upon palpation
NOSE AND SINUSES
Asymmetric and tender. Mucosa is pink. MOUTH AND PHARYNX
Lips in net position, no lesions
Pink and dry lips. Pink and moist gums. The dorsal and ventral portion of the tongue were both smooth
Pink and smooth soft palate and hard palate NECK
Muscles are symmetrical, head centered. Coordinated and smooth movements with no discomfort.
THORAX/ RESPIRATORY
With rapid and shallow respirations noted
Use of accessory muscles noted with respiratory rate of 25cycles/min. Chest move in or retract during inhalation
Productive cough noted Pursed- lip breathing noted
Crackles heard over both lower lobes Rales heard on late inspiration
Bronchial breath sounds heard over lung periphery Chest circumference: 49 cm.
ABDOMEN
Paler than skin color, no rashes and lesions Flat in contour
Soft and non tender
Chest circumference: 43 cm. UPPER AND LOWER EXTREMITIES
Texture is uniform. Peripheral pulses were strong and palpable. Radial pulse is 103 beats per minute.
NAILS
Slightly soft, white nails Capillary refill of 1 second
Nursing Care Plan Assessme nt Nursing Diagnosis Scientific explanation Planning Nursing Intervention Rationale Expected outcome Subjective : -“hindi siya makahing a”as verbalized by the mother -feeling breathless Objective: -nasal flaring -altered chest excursion -decreased inspiratory /expiratory pressure Ineffective breathing pattern r/t excessive mucous production There is an obstruction of the airway due to too much production of secretions and where there is a inadequate ventilation that alter in depth and rate of breathing After 3 hours of proper nursing interventio n the patient will be able to establish effective respiratory pattern Provide adequate rest periods administer oxygen at lowest concentratio n as indicated suction airway as needed administer analgesic as prescribed maintain emergency equipment in accessible location to limit fatigue and conserve energy for manage ment of respirato r y distress to clear secretion s promote deeper respirati on and cough when ventilator support might be needed After 3 hours of proper nursing interventi on the client was able to establish effective breathing pattern
Assessment Nursing Diagnosi s Scientific Explanation Planning Nursing Intervention Rationale Evaluation “Iyak siya ng iyak, parang masakit yung lalamunan niya” as verbalized by the mother. O: observed evidenced of pain, Expressive behavior: crying Acute pain related to persiste nt cough Cough occurs when there is irritation of the throat and it is cause by an unknown etiology or known etiology. It is categorize by productive or unproductive . After 1 hour of nursing intervention the client’s mother wil report that pain is relieved and the child will relax. Asses for referred pain as appropriate observe nonverbal cues/pain behaviors Prevent comfort measures. Instruct or encourage use of relaxation techniques such as focused breathing. Suggest parent to be present during procedures encourage bed rest periods To help determine possibility of underlying condition or organ Observatio ns May not be congruent with verbal reports or may be only indicator present when client is unable to verbalize. to promote nonpharma cological pain manageme nt To distract attention and reduce tension. To comfort child to prevent fatigue After 1 hour of nursing interventio n the patient’s mother verbalized that her child is at ease and pain free
ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC EXPLANATION PLANNING NURSING INTERVENTION RATIONALE EVALU ATION s>”nahihirapang
huminga ang anak ko”as verbalized by her mother.
O> Restlessness with nasal flaring >Warm, flushed skin. >minimal colorless nasal secretion. > tachycardia >irritability >cough Ineffective airway clearance related to accumulation of tracheo bronchial secreation. Mucus is produced at all times by the membranes lining the air passages. When the membranes are irritated or inflamed, excess mucus is produced and it will retain in tracheobronchial tree. The inflammation and increased in secretions block the airways making it difficult for the person to maintain a patent airway. In order to expel excessive secretions, cough reflex will be stimulated. After 3-4 hours of nursing intervention the patients will be able to demonstrate improve airway clearance
>Monitor and record vital signs
>Assess patient’s condition.
>Elevate head of bed and encourage frequent position changes.
> Keep back dry and loosen clothing >Auscultate breath sounds and assess air movement .
>Monitor child for feeding intolerance and abdominal distention
>Instruct the patient to provide an increased fluid intake for the child
> Instruct the patient to provide adequate rest periods for the child
> Give expectorants and bronchodilators as ordered.
>Administer oxygen therapy and other medications as ordered.
>To obtain baseline data
>To know the patient’s general condition >To promote maximal inspiration, enhance expectoration of secretions in order to improve ventilation >To promote comfort and adequate ventilation >To ascertain status and to note progress
>To avoid compromising the airway To help liquefy the secretions
To help liquefy the secretions
> Rest will prevent fatigue and decrease oxygen demands for metabolic demands
> To clear airway when secretions are blocking the airway
> indicated to increase oxygen saturation. After 3-4 hours of NI, pt. shall have Demonst rated improve airway clearance
Drug study
Drug Dosage Contraindication Side Effect Adverse effect Nursing Responsibilities Cefixime Brand name: Suprax 200mg Hypersensitivity to cephalosporin Diarrhea Nausea Head ache or Dizziness Stomach upset/pain Abnormal thinking GI Bleeding Adequate fluid intake Maintain a well balanced diet while taking this
medicine.
Take the medicine as prescribed by the doctor.
