BRONCHOPNEUMONIA
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Transcript of BRONCHOPNEUMONIA
POLYTECHNIC COLLEGE OF DAVAO DEL SURMacArthur Highway, Digos City
A CASE STUDY OF Empyema Thoracis, Left secondary to
BPN severe Community Acquired Pneumonias/p Chest Thoracostomy Tube
IN PARTIAL FULFILLMENTOF THE REQUIREMENTS IN
RLE/NCM 103
Presented to Mr. Sajid S. Uy, RN
1
Presented by
Radee King R. Corpuz
May, 2009
INTRODUCTION
Pneumonia is an inflammation of the lungs caused by
an infection. It is also called Pneumonitis or
Bronchopneumonia. Pneumonia can be a serious threat to
our health. Although pneumonia is a special concern for
older adults and those with chronic illnesses. It can also
strike and young and healthy people as well. It is a
common illness that affects thousands of people each year
2
in the Philippines, thus, it remains an important cause of
morbidity and mortality in the country.
There are many kinds of pneumonia that range in
seriousness from mild to life-threatening. In infectious
pneumonia, bacteria, viruses, fungi or other organisms
attack the lungs, leading to inflammation that makes it hard
for an individual to breathe. Pneumonia can affect one or
both lungs. In young and healthy individual, early treatment
with antibiotics can cure bacterial pneumonia. The drugs
used to fight pneumonia are determined by the germ
causing pneumonia and the doctors findings.. It is best to
do everything we can to prevent pneumonia, but if one get
sick, recognizing and treating the disease early offers the
best chance for a full recovery.
A case with a diagnosis of Pneumonia may catch
one’s attention, though the disease is just like an ordinary
cough and fever, it can lead to death especially when there
is no immediate intervention done. Since the case is a
toddler, an appropriate care has to be done to promote
faster recovery for the patient. Treating patients with
3
pneumonia is necessary to prevent its spread to others and
make them as another victim of this illness.
Bronchopneumonia is an illness of the lungs which is
caused by different organism like bacteria, viruses, and
fungi and characterized by acute inflammation of the walls
of the bronchioles. It is also known as pneumonia. It is
common in women and causes 6% in mortality rate.
Streptococcus pneumoniae (pneumococcus) and
Mycoplasma pneumoniae both are the common bacterium
which causes bronchopneumonia in the adults and children.
Acute inflammation of the walls of the smaller
bronchial tubes, with varying amounts of pulmonary
consolidation due to spread of the inflammation into
peribronchiolar alveoli and the alveolar ducts; may become
confluent or may be hemorrhagic.
In United States, pneumonia is the most common
cause of death from infectious diseases. It accounts for
almost 66,000 deaths per year and ranks as the seventh
leading cause of death in the United States (Brunner and
4
Suddarth’s Medical-Surgical Textbook, pp
628/pneumonia).
In Philippines, the case of pneumonia is one of leading
cause of mortality and morbidity among Filipinos, 75-85%
of the population acquired the disease and the one affected
the disease are those who are in low income status and the
below poverty line individual. (www.DOH.org/pneumonia)
Our patient Baby C, was 1 year old, living at
Gravahan, Matina Proper, Davao City, was admitted at
Davao Medical Center last March 28, 2009, at 6:37pm,
with chief complain of difficulty of breathing.
According to her mother, she noticed that her baby is
having substernal retraction with rapid shallow breathing
while asleep.
The family immediately took the baby to Davao
Medical Center, and was diagnosed with BPN severe,
Community Acquired Pneumonia.
Weeks after, the doctors suggested for placement of
chest thoracostomy tube, due to the accumulation of pus in
the pleural space.
5
IDENTIFICATION OF THE CASE
A.PERSONAL PROFILE
Name : Baby C
Address : Gravahan, Matina Proper, Davao
City
Age : 1 year
Gender : Female
Civil status : Single
Occupation : none
Admitting Doctor : Dr. Veralou L. Sojor
Admitting Diagnosis : Empyema Thoracis, Left secondary to
BPN severe Community Acquired Pneumonia s/p Chest Thoracostomy Tube
Religion : Roman Catholic
Nationality : Filipino
Educational Attainment: none
Spouse name : Mr. J
Occupation : Mini Store owner
6
Chief Complaint : Difficulty of breathing,
Dyspnea
Date of admission : March 28, 2009; 6:37pm
B.Background/History
DM HPN CA ASTHMA
Maternal - - - -
Paternal - - - -
The parents of the client both manifest negative (-)
history of the following diseases: DM, Hypertension,
Cancer, Asthma as interviewed.
C.Medical History
According to the medical history of the client,
Baby C had no other diagnosed illness except,
7
bronchopneumonia, before the patient experienced
episodic fever and cough due to environmental factor.
Baby C. was hospitalized due to persistent cough with
yellowish mucus secretion. Baby C had completed the
immunization process done in there Barangay Health
Center.
D.History of Present Illness
4 days prior to admission, Baby C experienced on
and off high fever, with substernal retraction, rapid
and shallow breathing. With yellowish mucus
secretion present productively.
E. Socio-economic background
The family of baby C was very supportive, they
have provided all her medication. Specially her
medicine and payments for other diagnostic
procedures to be done for her early and faster recovery
8
DEFINITION OF TERMS
Bradypnea – slower than normal rate (<10
breaths/minute), with normal dept and regular rhythm
(Brunner and Suddart’s Medical-Surgical Textbook, Chpt
21,pp 572)
Dyspnea – distressful sensation of uncomfortable breathing
that may be caused by certain heart conditions(Brunner and
Suddart’s Medical-Surgical Textbook, Chpt 23,pp 625)
Empyema – inflammatory fluid and debris in the pleural
space. It results from an untreated pleural-space infection
9
that progresses from free-flowing pleural fluid to a complex
collection in the pleural space. (Brunner and Suddart’s
Medical-Surgical Textbook, Chpt 23,pp 625)
Hypoxemia – decrease in arterial oxygen tension in the
blood (Brunner and Suddart’s Medical-Surgical Textbook,
Chpt 21,pp 625)
Mycoplasma pneumonia – another type of Community
Acquired Pneumonia (CAP), occurs most often in children
and young adults and is spread by infected respiratory
droplets through person-to-person contact(Brunner and
Suddart’s Medical-Surgical Textbook, Chpt 23,pp 630)
Pleural effusion – abnormal accumulation of fluid in the
pleural space(Brunner and Suddart’s Medical-Surgical
Textbook, Chpt 23,pp 625)
Pleural cavity – the area between the parietal and visceral
pleurae a potential space(Brunner and Suddart’s Medical-
Surgical Textbook, Chpt 23,pp 625)
10
Substernal Retraction – indrawing beneath the
breastbone, commonly manifested to infant and neonate
with respiratory distress(Fundamentals of Nursing, Seventh
Edition, Vital Signs unit VII, pp 507)
Thoracentesis – insertion of a needle into the space to
remove fluid that has accumulated and decrease pressure on
the lung tissue; may also be used diagnostically to identify
potential causes of a pleural effusion(Brunner and
Suddart’s Medical-Surgical Textbook, Chpt 23,pp 625)
Thoracostomy - done to drain fluid, blood, or air from the
space around the lungs(Brunner and Suddart’s Medical-
Surgical Textbook, Chpt 23,pp 625)
11
ANATOMY AND PHYSIOLOGY
12
13
A respiratory system functions to allow gas
exchange. The gases that are exchanged, the anatomy or
structure of the exchange system and the precise
physiological uses of the exchanged gases vary depending
on the organism.
In humans and other mammals, for example, the
anatomical features of the respiratory system include
airways, lungs, and the respiratory muscles. Molecules of
oxygen and carbon dioxide are passively exchanged, by
diffusion, between the gaseous external environment and
the blood. This exchange process occurs in the alveolar
region of the lungs.
14
The respiratory system can be conveniently
subdivided into an upper respiratory tract (or conducting
zone) and lower respiratory tract (respiratory zone), trachea
and lungs.
The conducting zone starts with the nares (nostrils) of
the nose, which open into the nasopharynx (nasal cavity).
The primary functions of the nasal passages are to: 1) filter,
15
2) warm, 3) moisten, and 4) provide resonance in speech.
The nasopharnyx opens into the oropharynx (behind the
oral cavity).
The oropharynx leads to the laryngopharynx, and
empties into the larynx (voicebox), which contains the
vocal cords, passing through the glottis, connecting to the
trachea (wind pipe).
The trachea leads down to the thoracic cavity (chest)
where it divides into the right and left "main stem" bronchi.
The subdivision of the bronchus are: primary, secondary,
and tertiary divisions (first, second and third levels). In all,
they divide 16 more times into even smaller bronchioles.
The bronchioles lead to the respiratory zone of the
lungs which consists of respiratory bronchioles, alveolar
ducts and the alveoli, the multi-lobulated sacs in which
most of the gas exchange occurs.Ventilation of the lungs is
carried out by the muscles of respiration.
Ventilation occurs under the control of the autonomic
nervous system from the part of the brain stem, the medulla
oblongata and the pons. This area of the brain forms the
respiration regulatory center, a series of interconnected
16
neurons within the lower and middle brain stem which
coordinate respiratory movements.
The sections are the pneumotaxic center, the apneustic
center, and the dorsal and ventral respiratory groups. This
section is especially sensitive during infancy, and the
neurons can be destroyed if the infant is dropped or shaken
violently. The result can be death due to "shaken baby
syndrome.”
Inhalation is initiated by the diaphragm and supported
by the external intercostal muscles. Normal resting
respirations are 10 to 18 breaths per minute. Its time period
is 2 seconds. During vigorous inhalation (at rates exceeding
35 breaths per minute), or in approaching respiratory
failure, accessory muscles of respiration are recruited for
support. These consist of sternocleidomastoid, platysma,
and the strap muscles of the neck.
Inhalation is driven primarily by the diaphragm. When
the diaphragm contracts, the ribcage expands and the
contents of the abdomen are moved downward. This results
in a larger thoracic volume, which in turn causes a decrease
in intrathoracic pressure. As the pressure in the chest falls,
17
air moves into the conducting zone. Here, the air is filtered,
warmed, and humidified as it flows to the lungs.
During forced inhalation, as when taking a deep
breath, the external intercostal muscles and accessory
muscles further expand the thoracic cavity.
Exhalation is generally a passive process, however active
or forced exhalation is achieved by the abdominal and the
internal intercostal muscles.
The lungs have a natural elasticity; as they recoil from the
stretch of inhalation, air flows back out until the pressures
in the chest and the atmosphere reach equilibrium.
During forced exhalation, as when blowing out a
candle, expiratory muscles including the abdominal
muscles and internal intercostal muscles, generate
abdominal and thoracic pressure, which forces air out of the
lungs.
The right side of the heart pumps blood from the right
ventricle through the pulmonary semilunar valve into the
pulmonary trunk. The trunk branches into right and left
pulmonary arteries to the pulmonary blood vessels. The
vessels generally accompany the airways and also undergo
18
numerous branchings. Once the gas exchange process is
complete in the pulmonary capillaries, blood is returned to
the left side of the heart through four pulmonary veins, two
from each side.
The pulmonary circulation has a very low resistance,
due to the short distance within the lungs, compared to the
systemic circulation, and for this reason, all the pressures
within the pulmonary blood vessels are normally low as
compared to the pressure of the systemic circulation loop.
Virtually all the body's blood travels through the lungs
every minute. The lungs add and remove many chemical
messengers from the blood as it flows through pulmonary
capillary bed . The fine capillaries also trap blood clots that
have formed in systemic veins.
The major function of the respiratory system is gas
exchange. As gas exchange occurs, the acid-base balance of
the body is maintained as part of homeostasis. If proper
ventilation is not maintained two opposing conditions could
19
occur: 1) respiratory acidosis, a life threatening condition,
and 2) respiratory alkalosis.
Upon inhalation, gas exchange occurs at the alveoli,
the tiny sacs which are the basic functional component of
the lungs. The alveolar walls are extremely thin (approx.
0.2 micrometres), and are permeable to gases. The alveoli
are lined with pulmonary capillaries, the walls of which are
also thin enough to permit gas exchange. All gases diffuse
from the alveolar air to the blood in the pulmonary
capillaries, as carbon dioxide diffuses in the opposite
direction, from capillary blood to alveolar air. At this point,
the pulmonary blood is oxygen-rich, and the lungs are
holding carbon dioxide. Exhalation follows, thereby ridding
the body of the carbon dioxide and completing the cycle of
respiration.
In an average resting adult, the lungs take up about
250ml of oxygen every minute while excreting about
200ml of carbon dioxide. During an average breath, an
adult will exchange from 500 ml to 700 ml of air. This
average breath capacity is called tidal volume.
20
The respiratory system lies dormant in the human
fetus during pregnancy. At birth, the respiratory system is
drained of fluid and cleaned to assure proper functioning of
the system. If an infant is born before forty weeks
gestational age, the newborn may experience respiratory
failure due to the under-developed lungs.
This is due to the incomplete development of the
alveoli type II cells in the lungs. The infant lungs do not
function due to the collapse of the alveoli caused by surface
tension of water remaining in the lungs. Surfactant is
lacking from the lungs, leading to the condition. This
condition may be avoided if the mother is given a series of
steroid shots in the final week prior to delivery. The
steriods accelerate the development of the type II cells.
21
A transverse section of the thorax , showing the contents of
the middle and the posterior mediastinum . The pleural and
pericardial cavities are exaggerated since normally there is
22
no space between parietal and visceral pleura and between
pericardium and heart
In human anatomy, the pleural cavity is the body
cavity that surrounds the lungs. The lungs are surrounded
by the pleura, a serous membrane which folds back upon
itself to form a two-layered, membrane structure. The thin
space between the two pleural layers is known as the
pleural space; it normally contains a small amount of
pleural fluid. The outer pleura (parietal pleura) is attached
to the chest wall.
The inner pleura (visceral pleura) covers the lungs and
adjoining structures, i.e. blood vessels, bronchi and nerves.
The parietal pleura is highly sensitive to pain; the visceral
pleura is not, due to its lack of sensory innervation.
The pleural cavity, with its associated pleurae, aids
optimal functioning of the lungs during respiration. The
23
pleurae are coated with lubricating pleural fluid which
allows the pleurae to slide effortlessly against each other
during ventilation. Surface tension of the pleural fluid also
leads to close apposition of the lung surfaces with the chest
wall. This physical relationship allows for optimal inflation
of the alveoli during respiration. Movements of the chest
wall, particularly during heavy breathing, are coupled to
movements of the lungs since the closely opposed chest
wall transmits pressures to the visceral pleural surface and,
hence, to the lung itself.
24
ETIOLOGY AND SYMPTOMATOLOGY
Etiology
Ideal Actual JustificationPredisposing Factor
Age (+)
Specifically 6 months and above children has low immune system, that can’t resist any bacterial infection, such as airborne transmission. Our patient is, 1 year old baby girl and she acquires the said disease in their community
Exposure (living)
(+)
The family of the pt owned a little “sari-sari” store, which is the source of the family’s income and which is situated near the road, as interviewed the client was often baby sited at their store
Precipitating FactorsDaily
Activities(+) Daily activities of an
individual can be a causal factor of the disease. Playing is the common activity at a very young age (1y/o). This individual is
25
not conscious of the environment.
Diet (+)
The patient common food intake are rice, hotdogs, eggs, chocolates, candies, sometimes fruits ( banana ), combination of breast and formula milk.
Mycoplasma pneumonae
and environmental
factors
(+)
Such as exposure to certain viruses and foods early in life, may trigger the autoimmune response. Our patient is living in a poor environment, because they’ve live in a dusty place where near the highway, where many vehicle passed by. Vehicular smoke and dust particles can be the carrier of the bacteria, viruses.
26
Symptomatology
Ideal Actual Justification
Cough with greenish or
yellow mucus(-)
The bronchioles contain submuscosal gland, which produce mucus that covers the inside lining of the airways. Infected bronchioles produce greenish or yellow mucus secretions.
Fever(+)
On and Off high fever, cause by infection in the body, invaded by specific viruses or bacteria, our body produces body defenses in order to fight.
Chest pain (-) Caused by infection in the
27
lining of the airway
Bradypnea (+)
Presence of foreign pathogens, and fluid accumulation in the airway lining may cause slow breathing pattern, depth and rhythm
Shortness of breath
(+)
Accumulation on the lining of airway, presence of mucus secretion and pathogenic bacteria invades in the body
Loss of appetite
(poor feeding)(+)
Due to compensatory mechanism such as low immune response, any infection due to a disease will result to the loss of appetite
28
COMPLICATION
Empyema
is inflammatory fluid and debris in the pleural space.
It results from an untreated pleural-space infection that
progress from free-flowing pleural fluid to a complex
collection in the pleural space.
Empyema most commonly occurs in the setting of
bacterial pneumonia. About 20-60% of all cases of
pneumonia are associated with parapneumonic effusion.
With appropriate antibiotic therapy, parapneumonic
effusions most often resolve without complications, and
they are of little clinical significance. The resulting
infection and inflammatory response can proceed until
adhesive bands form. The infected fluid becomes loculated
pus in the pleural space.
29
Pleurisy
is an inflammation of both layers of the pleurae
(parietal and visceral). Pleurisy may develop in conjunction
with pneumonia or an upper respiratory tract infection, TB,
or collagen disease: after trauma to the chest, pulmonary
infarction, or PE; in patients with primary or metastatic
cancer; and after thoracostomy. The parietal pleura has
nerve endings; the visceral pleura does not. When the
inflamed pleural membranes rub together during
respiration.
Lung abscess
is an acute or chronic infection of the lung, marked by
a localized collection of pus, inflammation, and destruction
of tissue. Lung abscess is the end result of a number of
different disease processes ranging from fungal and
bacterial infections to cancer.
30
Pericarditis
Refers to an inflammation of the pericardium, the
membranous sac enveloping the heart. It may be a primary
illness or it may develop during various medical and
surgical disorders. One of the cause of pericardits, is
disorders of adjacent structures: myocardial infarction,
dissecting aneurysm, pleural and pulomonary disease
(pneumonia)
31
PATHOPHYSIOLOGY
32
Predisposing factorsAge (very young)Gender Exposure (living)
Pathological Entry (inhalation)of organism: Bacteria or Viruses
Precipitating factorsDaily ActivitiesEnvironmentDiet
Occurrence of localized inflammation
Mucus production
Bacteria invades alveolar cellin the lungs
Bronchopneumonia
Pulmonary Edema
Manifested by wheezing
Diminished surfactant productionFormation of Hyaline membrane
Sign and SymptomsFeverCoughChest painRapid, shallow breathingShortness of breathHeadacheLoss of appetiteFatigue
Airway Obstruction
If disorder is Treated,Normal breathing patternNormal respiratory rate and Breath sounds
If disorderDaily ActivitiesEnvironmentDieturs:EmpyemaLung AbscessPleurisyPericarditis
Chest ThoracostomyChest ThoracostomyTubeTube
33
Etiologic agents gain entry into the respiratory tract
through either inhalation or aspiration of secretions. The
pathogen creates a localized inflammatory reaction on the
airway mucosa that results in swelling and increased mucus
production. Significant inflammation and obstruction may
result in wheezing.
As entering the pathogen in the body compensatory
mechanism: body line of defense such as cilia, whipping
motion that propels mucus and foreign substances away
from the lungs toward the lungs, for expectoration. As
more pathological microorganism into the respiratory tract,
cilia may injure in some way, the escalator or the whipping
mechanism may have less effective.
The bacteria or viruses as progressively entering into
the lungs, it may reach to alveolar cell, type II cells lose
their structural integrity and surfactant production is
diminished, a hyaline membrane forms, and pulmonary
edema develops.
Accumulation of mononuclear cells in the submucosa
and perivascular space, resulting in partial obstruction of
34
the airway. They clinically manifest as wheezing and
crackles.
Hematogenous spread of bacteria from an extra-
pulmonary infection site—bacteria from another infected
site can be carried in the blood to the lungs
Resulting from these infections causes the lungs to
become stiff and less distensible, thereby decreasing tidal
volume. The patient must increase his respiratory rate to
maintain adequate ventialtion
MEDICAL MANAGEMENT
Under Dr. Veralou L. Sojor, M.D
03/28/09
35
Admit patient at IMCU transferred to SVIX under blue level IIo v/s q 4hr, BF with SAPo CBC, Pt. U/Ao CXR
IVF D5IMB at 20cc/hr Meds:
o Chloramphenicol at IVTT q8hro Paracetamol, PRNo Salbutamol Nebuli
03/29/09
Ff up CBC Ff U/A Ff up CXR
03/30/09 For ABG, CBC, PC and U/A Continue IVF at same rate Continue Meds
o Start chloramphenicolo Cefuraxime 335mg IVTT q8hrso Amikaxin 75mg IVTT, ODo Decrease Salbutamol Neb, q4
03/31/09 Still for Na+, K+, Ca+, Mg+ Still for LP Review CXR-APL Continue IVF at same rate as ordered
36
Continue Meds:
o Cefutaximeo Amikacino Paracetamol
04/01/09 V/S q4 with O2 Sat Still for NPO LP done, place pt on bed flat x4hrs
04/02/09 Rpt CXR-APL today Ff up CSF analysis, GS/CS Ff up sugar and protein Continue Meds:
o Cefutaximeo Amikacino Paracetamolo Cloxacilline
04/17-24/09 D5IMB at 45cc/hr Meds:
o Cloxacilline (D12)o Pencillin Mg (D9)o V/S q4hr
04/18/09 Cloxalline (D12-13) Pencillin Mg (D10)
37
04/19/09 Cloxalline (D13-
14) Pencillin Mg
(D10)04/20/09
Cloxalline (D14) Pencillin Mg
(D11)04/22/09
Cloxalline (D15) Pencillin Mg
(D12)04/23-24/09
Cloxalline (D13) Pencillin Mg
(D11)
04/25/09 Cloxalline (D14) Pencillin Mg
(D12) Rpt CXR –APL Insert CTT
04/26/09 Retained CTT Drained every
shift04/27/09
D5IMB at 45cc/hr
Meds:o Pencillin
Mg (D13)o Cloxacilline
(D15)
Laboratory
38
Hematology
Test ResultNormal Values
Clinical Significance
Remarks
CBC+Plt Hemoglobin – H 3.5
F: 1.86-2.48mmol/L
Obstructive Pulmonary dse, Failure of oxygenation
-increased-
Hematocrit – .50
F: 0.37-0.47
dehydrated-increased-
RBC – H 6.59
F: 4.2-5.4
Pulmonary disease
-increased-
WBC – H 4.52
5.0-10.0
Overwhelming viral infection
-decreased-
Neutrophil – L 48
55-75 Viral infection -decreased-
Lymphocytes –26
20-40% - normal range-
Monocytes – 4
2-10 -normal range-
Eosinophil – 4
1-8 -normal range-
Basophil – 0 0-1 -normal range-
Platelet count – 200,000/cu mm
-normal range-
39
Laboratory Chemistry
Test ResultNormal
Values
Clinical
significanceRemarks
Na+144.0
0
135-
145mmol/L
-normal
range-
K+ H 5.9 3.5-5mmol/LTissue
breakdown-increased-
Ca+ 2.502.15-2.55
mmol/L
-normal
range-
Serum
Mg+
H
1.42
0.62-
0.95mmol/L
Excess
ingestion of
Mg+-
containing
antacids
-increased-
Laboratory
40
ABG
Test ResultNormal
Values
Clinical
significanceRemarks
pH 7.42 7.35-7.45 -normal range-
pCO2 41.6 35-45 -normal range-
HCO3 27.6 22.0-27.0Depressed
respiration-increased-
O2 Sat 98.2% 80-100% -normal range-
Cf CO2 28.6 23.0-30.0 -normal range-
PO2 74.0 80-100
Chronic
obstructive
lung
disease
-decreased-
41
MEDICAL MANAGEMENT
Ideal Management
Antibiotics are prescribed based in Gram stain
results and antibiotic guidelines (resistance patterns,
risk factors, etiology must be considered).
Combination therapy may also be used.
42
Supportive treatment includes hydration,
antipyretics, antihistamines, or nasal decongestants.
Bed rest is recommended until infection shows
signs of clearing
Oxygen therapy is given for hypoxemia
Respiratory support includes endotracheal
intubation, high inspiratory oxygen concentrations,
and mechanical ventilation
Treatment of atelectasis, pleural effusion, shock,
respiratory failure, or superinfection is instituted, if
needed
For groups at high risk for community-acquired
pneumonia, pneumococcal vaccination is advised
Increased fluid intake to thin viscous and tenacious
secretions
43
44
45
46
47
NURSING ASSESSMENT
Physical Assessment
Neurological
48
The patient had a GCS score of 11, she can able to
express self through crying and understand given by her
mother, patient is able to interact person-to-person.
Eye/Vision
Our patient, have pale conjunctiva due to high grade
fever and generalized weakness upon admission
Ears/Hearing
Our patient doesn’t have hearing problem, no
discharges, symmetrical, no swelling and tenderness. Can
respond normal voice tone
Nose
Our patient doesn’t have nasal problem, no
discharges, no swelling and tenderness noted upon
inspection and, uniform in color.
Mouth/Tongue/Teeth/ Speech
The patient’s had a crack and pallor lips, reddened
gums, with distant teeth. And the patient had a slurred
49
speech. Tongue is slightly pale.
Throat/Neck
Neck is symmetrical with head, can turned head from
right to left gradually, but with resistance, no palpable
lymph nodes
Respiratory System
Patient use accessory muscle in order to breathe
normally, presence of wheezes and rales is heard upon
auscultation and in normal hearing, with respiratory rate
of 48cpm
Circulatory/Cardiovascular
Patient has an O2 Sat of 98%, heart rate of 90bpm,
and and blood pressure reading of 80/50, pulse rate was
50
130bpm with skipping beats. No edema, swelling, good
capillary refill less than 3secs.
Gastrointestinal
Flat abdominal contour, audible bowel sound, no
tenderness or distention. Thorax had dullness of sound due
to decrease confluent and pleural effusion
Genitourinary
Patient had excessive urination, with minimum of
800cc per diaper
Muscoloskeletal
The patient had normal upper and lower extremeties,
symmetrical and no tenderness,
Integumentary
The patien’st skin was warm to touch,with
temperature of 38°C , febrile,with good skin turgor
51
NURSING MANAGEMENT
NURSING ASSESSMENT AND DIAGNOSIS
Assess for fever, chills night sweats, pleuritic-type
pain, fatigue, tachypnea, use of accessory muscle,
bradycardia or relative bradycardia, coughing, and
purulent sputum, and auscultate breath sounds for
consolidation
Note changes in temperature, pulse; amount, odor, and
color of secretions; and breath sounds
Frequency and severity of cough
Degree of tachypnea or shortness of breath
Changes in chest x-ray findings
52
Assess the characteristic of drained pus from the lungs
of the patient.
Assess for complication, including continuing or
recurring fever, failure to resolve, atelectasis, pleural
effusion, cardiac complication, and superinfection
Encourage bronchial hygiene, such as increased fluid
intake and directed coughing to remove secretions.
Put patient into moderate high back rest for lung
expansion and clearing, and to cough effectively and
prevent retention of mucopurulent sputum,
NURSING THEORIES
Florence Nightingale
53
Her Notes on Nursing emphasized that a clean environment, warmth, ventilation, sunlight, and a quiet environment lead to good health.
Reaction: a non-stimulating environment is essential especially for our patient, in a way that it promotes faster recovery on our patient through minimizing external and stressful stimuli such as limiting visitors during resting periods that may worsen the situation of our client.
Virginia Henderson
Virginia Henderson defined nursing as "assisting individuals to gain independence in relation to the performance of activities contributing to health or its recovery"
Hildegard Peplau
Hildegard Peplau used the term, psychodynamic nursing, to describe the dynamic relationship between a nurse and a patient. She identified nursing roles of the nurse and in our case this three roles fitted us for our client:
Counseling Role - working with the patient on current problems
Teaching Role - offering information and helping the patient learn
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Reaction: As a nursing student, we had many roles to perform to our patient. One of these roles is being a councilor. As a councilor, it is our duty to lessen if not alleviate the client’s problem.
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HEALTH TEACHINGS
PRIMARY
1. Instruct the SO to have patient an oxygen therapy for continuous normal breathing, and or breathing exercise
2. Instruct the SO to kept the patient away in open place such as in road where their store located and dusty place, to prevent inhalation of airborne microorganisms
3. Instruct the SO to maintain the patient proper diet that she can tolerate, such as fruits, to help promote wellness.
4. Advice the SO to monitor patient’s fluid intake or adequate hydration, to help her body re-hydrate to prevent fluid imbalance.
5. Instruct SO to assist patient in performinf self-hygience activities she cannot tolerate, to help her maintain her activities of daily living.
6. Encourage SO to perform self care activities within her level of own ability
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7. Assist patient to perform as much as possible and then to call for assistance. Collaborate with patient for progressive activity before and after schedule activity.
SECONDARY
1. Administer medications regularly as ordered by the physician
2. Advice SO to the patient to have proper nutrition to enhance immune system
TERTIARY
1. Instruct SO to comply patient’s medication regimen
2. Discuss the importance of having a regular check-up with his physician, with the mother or with the parents.
DISCHARGE PLAN
When the doctor noted that the patient is for discharge
it is very important to continue the medication depending
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on the duration the doctor ordered for the total recovery of
the patient. Patient with Bronchopneumonia severe
Community Acquired Pneumonia needs to have deep
breathing exercise for lung expansion and clearing for
progressive normal breathing pattern and have adequate
rest periods. It is also important to maintain proper hygiene
to prevent further infection.
The client must relax in order to recover her present
condition and instructed significant others for minimal
exposure, to an open environment such as dusty and smoky
area, which airborne microorganisms are present that can
be a high risk factor that may cause severity of her
condition. The diet of the patient is also a factor for fast
recovery. Encouraged to eat nutritious foods intended for
respiratory problem patient, the family of the patient plays
a big role for the fast recovery.
Regular consultation to the physician can be factor for
recovery to assess and monitor her condition
M- advice SO not to skip patient’s medication that the doctor ordered
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E- instruct SO, keep away the patient in smoky area or dusty environment
T- oxygen therapy, for maintenance
H- separate utensils for the patient and other personal things that will be use for the whole family
O- provide SO information about how to control or prevent the spread of the disease, present on your patient
D- encourage patient to eat nutritious food such as vegetable and fruits especially those that contains vitamin C
S- provide emotional support and provide care for the mother
PROGNOSIS
Good Poor JustificationDuration of Illness
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Duration of illness is good since the condition occur and she was given ample treatment.
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Onset of Illness -
At the onset of illness, the patient experienced poor respiration (DOB)
Compliance to Medication -
Patient can afford to sustain the needed laboratory exams and the feasibility of having the condition
Family Support
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The family members supported the patient both financially and emotionally.
Environment
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The hospital setting is not well ventilated and may promote for further infection of the patient’s current situation.
Age
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Patient is 1 year old therefore she has a good chance of recovering for her immune system is still generating in the process of development.
Precipitating Factors
-
The patient manifested all the factors that may lead to Bronchopneumonia sev, CAP which urged the family and the health provider to set-up the proper action
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Percentage
Good: 4/7x100=42.85/43%
Poor: 3/7x100= 57.14/57%
Overall Prognosis
The prognosis is good, because the duration of illness,
compliance of medication, family support and age are the
contributing factors that result to have a good prognosis
EVALUATION
Through our hardship in preparing for this research,
as we try to interact and communicate to our patient and
her family in a good manner for us to gather the specific
and accurate data that we needed that could help us in
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studying the disease which could lead us into successful
research.
The patient’s condition is in recovery period as she
had already undergone medication therapy for her
present condition, which thereby prevented occurrence
of complications. They are financially capable in
sustaining such respiratory condition and the medications
after. Her mother is the one taking good care of her in
throughout her hospitalization, giving emotional and
moral support.
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IMPLICATION
Nursing Practice
- this can be used as a guide for practice by other nurses. They may get many relevant ideas in giving proper care and interventions to patients with related illness or those who have the same illness (BPN severe with Community Acquired Pneumonia)
Nursing Education
- this study may serve as a helpful learning tool for student nurses. They may utilize this
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complied study as their reference for research; this will also give them good examples on nursing managements, and nursing diagnoses, which will be a very useful guide when they will be making their own Nursing Care Plans.
Nursing Research
- students may use this compilation as their guide for research. This will hand them good views and factual ideas which will be very essential for their added learning on knowledge for BPN severe with Community Acquired Pneumonia
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REFERENCES
Medical-Surgical, Brunner and Suddart 11th Ed,
Respiratory function and Gas Exchange/pneumonia,
pp 628-631
Medical-Surgical, Brunner and Suddart 11th Ed,
Diagnostic Test and Results, pp 2148-2152
Handbook for Medical-Surgical Nursing, 11th Ed,
Management for Respiratory function,pneumonia,
pp665-668
www.americanthoracicsociety.com/ thoracostomy
http://www.springerpub.com/prod.aspx?
prod_id=72628
wikipedia.org/wiki/Pneumonia
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wikipedia.org/wiki/Pleural cavity
www.medicinenet.com/Bronchopneumonia/
article.htm
www.who.int/topics/bronchopneumonia
www.DOH.org/bronchopneumonia_prevalence
www.vetmed.wsu.edu/ClientEd/diabetes
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