SACRED HEART MEDICAL CENTER ANGELES CITY

A CASE STUDY ENTITLED

BRONCHOPNEUMONIA RIGHT LOBE

Submitted By: Bundalian, Kim T. Forte, Rachelle Almario, Camille Dawn Yamat Peejay

I.

OBJECTIVES

Goal: After this case study we will be able to know what Bronchopneumonia is, how its acquired and prevented, its prevention and treatment of the occurrence of brnochopneumonia After the discussion of this case study you will be able to: Fully understand the anatomy and physiology of the respiratory tract Comprehensively understand the disease process Provide prompt and appropriate interventions to alleviate the condition Make a plan of care intended for the noted problems Impart health teachings on the management of signs and symptoms and the prevention of recurrence of BPN.

II.

EPIDEMIOLOGY

Respiratory-related illness is a common disease worldwide. These types of diseases are present in varied types, one of which is Bronchopneumonia (BPN). Globally speaking, BPN affects a significant number of people. According to the Center for Disease Control and Prevention, pneumonia kills more than 4 million people every year half of these deaths occur among children less than 5 years of age. This is greater than the number of deaths from any other infectious disease, such as AIDS, malaria or tuberculosis. The WHO Child Health Epidemiology Reference Group estimated the median global incidence of clinical pneumonia to be 0.28 episodes per child-year. This equates to an annual incidence of 150.7 million new cases, of which 11-20 million (7-13%) are severe enough to require hospital admission. Ninetyfive percent of all episodes of clinical pneumonia in young children worldwide occur in developing countries. Although the diagnosis is usually made on the basis of radiographic findings in developed countries, the World Health Organization (WHO) has defined pneumonia solely on the basis of clinical findings obtained by visual inspection and timing of the respiratory rate. III. Demographic Data:

a. Personal History We as a group decided to give a code name to patient which is Gangnam. Mr. Gangnam is 57 year old male American born at United States of America. He is divorced with no children. He has a business in America however he decided to live here in the Philippines. At present, he and his newly partner which is a Filipina reside at Doa Maria Subdivision Angeles City. He is a Roman Catholic.

b. Socio Economic and Cultural Factors Mr. Gangnam is a Businessman. He stays with his newly partner lives in Doa Maria Subdivision Angeles City. He lives in an urban area wherein pollution is present due to some commercialize area or structure. . He drinks alcoholic beverages and smoke occasionally. He loves to eat fruits, beef, fish and vegetables. He also likes to eat junk foods, processed foods and soda. His daily routine was eating, watching TV and surfing the net. He also works in the computer to monitor his business in America. He usually sleeps late due to sleeping problem. Mr. Gangnam finishes colleges with a business degree course and had a business in America wherein its income came from. When it comes to beliefs and practices, Mr. Gangnam doesnt believe because he believe that if there is unusual occurrence of an illness it should be directly consult to a professional so that this incidence would not be worst and can be prevented. There source of water was come from a Mineral water and they have a close drainage. There garbage was collected twice every week by a Truck accompanied by a garbage collector.

C. Pertinent Family History Mr. Gangnam is currently in a cohabitating relationship living with his newly Filipina partner. She doesnt have any family member living with him On his mother side his grandmother died because of unknown causes also with grandfather died of unknown reason. The father and mother of Mr. Gangnam also died of unknown reasons or due to old age. His parents had a total of 4 children and he is the 3 rd eldest; his siblings composed of 2 females and 2 males. His siblings are still alive at present and dont have any known disease condition. Mother Side
Grandfather (Unknown) Grandmother (Unknown)

Father Side
Grandfather (Unknown) Grandmother (Unknown)

Mother (unknown)

Father (unknown)

Sibling 1

Sibling 2

Gangnam Bronchopneumonia Right Lobe

Sibling 3

Broken lines no longer living

Full lines - living IV. History of Past and Present Illness History of Past Illness:

Mr. Gangnam doesnt have any past surgical procedure. He mentioned that he usually had past symptoms of cough, colds, and fever. He usually takes over the counter medication such as Paracetamol, nasal decogensatant and antitusive. But if symptoms worsen, he usually consults to a medical professional. Also he mentioned that he doesnt have any allergies to any substances. On September 4, 2012 he has past admission to SHMC due to shortness of breath and continuous coughing and discharge last September 6, 2012.

History of Present Illness:

4 days prior to admission there is presence of continuous coughing, shortness of breath, presence of loss of appetite and presence of body malaise.

On September 10, 2012 at 8pm Mr. Gangnam was rush to the Emergency room of SHMC due to shortness of breath and continuous coughing. He was initially provided an oxygen inhalation and nebulization to ease the shortness of breath. Also he was given Furosemide ampoule so that to lower down the blood pressure which is 160/70. Mr. Gangnam was somewhat relieved but doctors decided to admit the patient to continuously monitor the condition of patient.

Physical Examination

September 10, 2012 (As lifted from chart) Vital Signs as follows: Temperature: 36.50 C PR: 73 bpm RR: 23cpm BP: 160/70 Weight: 210 lbs HEENT: (+) pink palpebral conjunctiva Chest & Lungs: (+) symmetrical chest expansion, (+) harsh breath sounds Heart: (-) murmur Abdomen: soft, (+) bowel sound

Genitalia: (-) lesions Extremities: (-) edema September 12, 2012 Nurse Patient Interaction General Appearance: Upon the interaction, the patient is irritable and there is presence of loss of energy due to continuous coughing. In addition patient verbalizes shortness of breathing. Vital signs as follows: Temperature: 36.20 C PR: 82 bpm RR: 24 cpm BP: 110/80 Integumentary: a. Skin: with pink palpebral conjunctiva, with good capillary refill time of less than 3 seconds, with good skin turgor b. Hair: black in color, combed, equally distributed, without lice Head and Face: a. Scalp: smooth, no evidence of tenderness, flaking, scaling and redness/open lesions b. Skull: normocephalic, no abnormal depression/elevation c. Face: symmetrical in shape with appropriateness of facial expression, Eyes: a. General: symmetrical, with no presence of lesions b. Eyebrows: equal distribution of hair c. Eyelids and eyelashes: symmetrical in shape, hair is evenly distributed d. Pupils: equal size, Pupil equally round reactive to light and Accommodation( PERRLA) e. Sclerae: white in color, no jaundice Ears: a. General: both symmetrical in shape, same level with outer canthus of the eye, Nose: a. General: not deviated, symmetrical nares, no bleeding, no exudates Mouth and Throat: a. Mouth: no lesion, pinkish gum b. Tongue: no lesions c. Buccal Mucosa: moist, pinkish in color Neck: a. General: no masses Chest: a. General: Symmetrical chest expansion b. Respiration: shallow breathing due to continuous coughing, difficulty of Breathing c. Lungs: with harsh breath sounds Gastrointestinal: a. Abdomen: no distention, with bowel movement, Body Mass index Patients Height: 55

Weight: 210 lbs BMI-34.9 The patients weight is heavily overweight

V.

ANATOMY AND PHYSIOLOGY OF THE RESPIRATORY SYSTEM

Man can survive without food and water for about three days or more , but if he stops breathing for 3 to 5 minutes he will immediately die . From this point the importance of the respiratory tract in our bodies comes. All organs in the human body need oxygen in their metabolism and carbon dioxide to be removed from their tissues as a waste product and the respiratory tract is responsible to perform this function. In this essay we will look at the structure and function of the respiratory tract. The primary function of the respiratory system is gas exchangedelivering oxygen (O2) from the environment to the tissues and removing carbon dioxide (CO2) from the tissues. Generally, the respiratory system acts as a servant to the rest of the body by delivering enough O2 and removing sufficient CO2 for metabolic demands. As O2 demand increases, the body responds with a variety of mechanisms to ensure an adequate supply of O2. These physiologic mechanisms include the unique functions of several cell types in the lung, pulmonary circulation, mechanics of the respiratory system, transport of O2 and CO2 in blood, respiratory gas exchange, and coordination of all of these mechanisms by the respiratory control system. Respiratory System, in anatomy and physiology, organs that deliver oxygen to the circulatory system for transport to all body cells. Oxygen is essential for cells, which use this vital substance to liberate the energy needed for cellular activities. While the intake of oxygen and removal of carbon dioxide are the primary functions of the respiratory system, it plays other important roles in the body. The respiratory system helps regulate the balance of acid and base in tissues, a process crucial for the normal functioning of cells. It protects the body against disease-causing organisms and toxic substances inhaled with air. The respiratory system also houses the cells that detect smell, and assists in the production of sounds for speech. The upper respiratory tract consists of the nose and the pharynx, or throat. The lower respiratory tract includes the larynx, or voice box; the trachea, or windpipe, which splits into two main branches called bronchi; tiny branches of the bronchi called bronchioles; and the lungs, a pair of saclike, spongy organs. The nose, pharynx, larynx, trachea, bronchi, and bronchioles conduct air to and from the lungs. The lungs interact with the circulatory system to deliver

oxygen and remove carbon dioxide. In addition, there are some muscles helping in the respiratory movements which are the intercostal muscles and the diaphragm.

The

upper respiratory tract: 1- The nose and the nasal cavity : The nose forms the visible part of the upper tract which has two external openings (the nostrils). The flow of air from outside of the body to the lungs begins with the nose, which is divided into the left and right nasal passages. The nasal passages are lined with a membrane composed primarily of one layer of flat, closely packed cells called epithelial cells. Each epithelial cell is densely fringed with thousands of microscopic cilia, fingerlike extensions of the cells. Interspersed among the epithelial cells are goblet cells, specialized cells that produce mucus, a sticky, thick, moist fluid that coats the epithelial cells and the cilia. Numerous tiny blood vessels called capillaries lie just under the mucous membrane, near the surface of the nasal passages. While transporting air to the pharynx, the nasal passages play two critical roles: they filter the air to remove potentially disease-causing particles; and they moisten and warm the air to protect the structures in the respiratory system. Moreover , the nasal cavity includes paranasal sinuses which produce mucus, maintain sound and lighten the skull. Coarse hairs found just inside the nostrils of the nose trap airborne particles as they are inhaled. The particles drop down onto the mucous membrane lining the nasal passages. The cilia embedded in the mucous membrane wave constantly, creating a current of mucus that propels the particles out of the nose or downward to the pharynx. In the pharynx, the mucus is swallowed and passed to the stomach, where the particles are destroyed by stomach acid.

In addition to their role in the respiratory system, the nasal passages house cells called olfactory receptors, which are involved in the sense of smell. When chemicals enter the nasal passages, they contact the olfactory receptors. This triggers the receptors to send a signal to the brain, which creates the perception of smell. 2- The pharynx : The pharynx is a muscular tube serving to connect the nasal cavity and the mouth with the lower respiratory tract and the esophagus. the pharynx is lined with a protective mucous membrane and ciliated cells that remove impurities from the air. In addition to serving as an air passage, the pharynx houses the tonsils, lymphatic tissues that contain white blood cells. The white blood cells attack any disease-causing organisms that escape the hairs, cilia, and mucus of the nasal passages and pharynx. The tonsils are strategically located to prevent these organisms from moving further into the body. It is divided into three parts: the nasopharynx, the oropharynx and the laryngopharynx. The lower respiratory tract: 1- The larynx : The larynx, also known as voice box, lies between the pharynx and the trachea. The larynx is made up mainly of cartilages. . It plays a primary role in producing sound; it prevents food and fluid from entering the air passage to cause choking by allowing air to pass from the glottis which closes during swallowing; and its mucous membranes and cilia-bearing cells help filter air. The cilia in the larynx waft airborne particles up toward the pharynx to be swallowed. 2- The trachea : The trachea is a tube beginning from the edge of the larynx and divides into two bronchi which continue into the lungs. The trachea is formed of 15 to 20 C-shaped rings of cartilage. The sturdy cartilage rings hold the trachea open, enabling air to pass freely at all times. The open part of the C-shaped cartilage lies at the back of the trachea, and the ends of the C are connected by muscle tissue. The trachea allows air to pass from the larynx to the bronchi and then to the lungs. The trachea is lined with mucus membranes and with ciliated cells which are responsible for removing dirt particles from air before it enters the lungs. 3- The bronchi : The trachea branches into two tubes, the left and right bronchi, which deliver air to the left and right lungs, respectively. Within the lungs, the bronchi branch into smaller tubes called bronchioles. The bronchi divide into smaller bronchioles which branch in the lungs forming passageways for air. The bronchioles divide many more times in the lungs to create an impressive tree with smaller and smaller branches, some no larger than 0.5 mm (0.02 in) in diameter. These branches dead-end into tiny air sacs called alveoli. The alveoli are the

functional units of the lungs and they form the site of gaseous exchange. The alveoli deliver oxygen to the circulatory system and remove carbon dioxide. Interspersed among the alveoli are numerous macrophages, large white blood cells that patrol the alveoli and remove foreign substances that have not been filtered out earlier. The macrophages are the last line of defense of the respiratory system; their presence helps ensure that the alveoli are protected from infection so that they can carry out their vital role. 4- The lungs: The lungs are located in the thoracic cavity and they are covered with the pleural membranes. The right lung has three lobes, while the left lung has two lobes only. The lungs include the bronchi, the alveoli, connective tissues, blood vessels, lymph vessels and nerves. The lungs are enveloped by a thin layer of mesothelial cells referred to as the pleura. This membrane is analogous to the pericardium, which covers the heart, and the peritoneum, which covers the intraabdominal organs. The "visceral" layer covering the lungs is continuous with the "parietal" layer that covers the inner surface of the chest cavity. These two layers of pleura are separated by a thin layer of fluid, which amounts to less than 10 mL in the normal adult lungs. This fluid contains a population of mesothelial cells and significant concentrations of mucopolysaccharides, which acts as a lubricant for the smooth movement of the pleural layers against one another. Expansion of the chest wall is transmitted to the lung surface through the pleural surface, but this process can be interrupted if air or excess fluid enters the pleural compartment, thereby separating the visceral and parietal layers. The lungs are the part of the respiratory tract responsible for respiration, since the exchange of gases takes place in them. The lungs supply the heart with oxygenated blood through the pulmonary veins and take off the deoxygenated blood through the pulmonary arteries. Moreover, the elastic properties of the lungs enable it to inhale and exhale the air. In addition, the respiratory tract has very important role in maintaining the pH of the body fluids. There are also other functions of the respiratory tract which include coughing, sneezing, crying, laughing, hiccupping and snoring.

VI.

Diagnostic Procedure Diagnostic/Laboratory Procedures Date Ordered Date result/s Complete Blood Count (CBC) DO: 9-1012 DR: 9-1012 CBC provides Indication/s or Purposes Results Normal Values Analysis and Interpretation of Results

valuable information about the blood and blood-forming tissues (especially the bone marrow), as well as other body systems. Abnormal results can indicate the presence of a variety of conditions-including anemia, and patient leukemia, infectionsexperiences of the

sometimes before the symptoms

disease. Measur es the total amount of hemoglobin in the blood to determine the oxygen carrying capacity of the blood. a. Hemoglobin 9-10-12 9-10-12 A decrease number of for hemoglobin severe case, While signifies anemia and hypoxia. 129 (140-175 gm/L) There was a decrease in the result due to bronchopneumonia. Since there was an accumulation of mucus through in the the bronchioles, to a the main inadequate diffusion of oxygen lungs which is bloodstream Hemoglobin happens.

increase hemoglobin signifies dehydration.

component of RBC is responsible for 98.5% of oxygen transported in blood. And when there is inadequate diffusion of oxygen, there is reduction of oxygen that

binds in the hemoglobin which results to the death of the RBCs.

b. Hematocrit

9-10-12 9-10-12

Measures

the 0.36

(0.41-0.50)

There was a decrease in the result die. due to inadequate oxygen. Without oxygen, RBCs

percentage of RBCs in the blood volume. A decrease in the number or size of red cells also decreases the amount of space they hematocrit. Conversely, an occupy, resulting in a lower

increase

in

the

number or size of red cells increases the amount of space they occupy, resulting in a higher hematocrit.

c. WBC

01-25-10 01-25-10

Determine the number of circulating WBCs in the blood. An elevated WBC count occurs in infection, allergy, systemic illness, inflammation, tissue injury, and leukemia. A low WBC count may occur in some viral infections,

15.5

(5-10 x109/L)

The result is elevated indicating an infection as an inflammatory response.

immunodeficiency states, and bone marrow failure. The WBC count provides clues about certain illnesses, and helps physicians monitor a patient's recovery from others. d. RBC 01-25-10 01-25-10 To determine the RBC level in the blood 3.75 (4.2-5.4x1012/L) The result is below the normal range, which indicates that there is a problem with regards to the RBC concentration and oxygen supply of the patient. This is due to the damage in blood cell production. This may also be an indicator the patient for anemia.

e. Lymphocytes

01-25-10

Produces antibodies responsible for

0.58

0.22-0.40

The patients lymphocytes level is increased. An indicative that there

01-25-10

allergic reactions. A decrease in number will signify a decrease in the production of antibodies which results to the inability of the body to fight foreign microorganisms. In an increase of lymphocytes, this indicates that there is an infection within the body. This is a defense mechanism of the body by which the lymphocytes produce antibodies to fight the microorganisms.

is a presence of infection, which is the bodies response to produce an inflammatory response to fight the infection.

f. Platelet count

To evaluate platelet production. When platelets are low, it may take longer for the blood to clot. When platelet counts are too high, unnecessary blood clots may occur.

280

150-400x10 12/L

Platelet count is within normal range that suggests lower chances of bleeding tendencies.

Nursing Responsibilities Prior to Procedure: Explain the procedure to the patient and value of the test for planning patients care. Tell the patient what to expect (especially pain or discomfort) in the procedure. Inform the patients SO that there is no need to restrict fluid intake of the patient prior to the procedure. Ask the patient to relax and do not move as the start of the procedure.

During the Procedure: Perform the procedure using heparin zed capillary tube.

Insert the needle within 45 when penetrating the skin then 15 after the needle has been inserted in the vein. Stabilize the syringe and draw blood carefully.

After the Procedure: Ensure subdermal bleeding has stopped before removing the pressure. If hematoma develops at the venipuncture site, apply warm soaks. If hematoma is large, monitor pulses distal to the venipuncture site. Send the sample to the laboratory immediately. Notify the physician or the laboratory of medications the patient is taking that might affect the results; they may need to be restricted. Document the procedure and findings. Indications Diagnostic/ Laboratory Procedures Arterial blood gas Date Result(s) Date Ordered: Sept. 10, 2012 pH Date Result: Purposes Test measures the acidity (pH) and the levels of oxygen 7.48 7.35-7.45 The patient blood pH is alkalinic and carbon dioxide in the blood from an Date Ordered or Results Normal Values Analysis and Interpretation of results

Sept. 10, 2012

artery. This test is used to check how well the lungs are able oxygen to into move the because of Hydrogen. of decreased excretion

blood and remove carbon dioxide from the blood. His pCO2 level is low thus making it alkalinic indicate pCO2 18mmHg 35-45mmHg and that this she

ishyperventilating.

His PO2 level is increased. Elevated pO2 levels are associated with Increased oxygen levels in the inhaled air His HCO3 is

decreased making the blood acidic

thus PO2 108mmHg 80-100mmHg with

indicating partial

metabolic acidosis compensation.

The patient O2sat is normal.

13.3mEq/L HCO3

22-26mEq/L

The patient SO2 is normal.

O2 sat

99%

97%

SO2 Nursing Responsibilities Prior: Assess the patients knowledge about the test.

96%

>94%

Explain the patient that the test is used to detect an inflammation, infection, and anemia. Tell the patient that a blood sample will be taken. Explain who will perform the venipuncture and when. Explain to the patient that she may feel slight discomfort from the needle puncture and the tourniquet. Inform the patient that she should avoid strenuous exercise for 24 hours before the test.

 If the patient is being treated for an infection, advise her that this test will be repeated to monitor his progress. Notify the laboratory and physician of medications the patient is taking that may affect test results; they may need to be restricted. During: Adhere to standard precaution. Post: Apply direct pressure to the venipuncture site until bleeding stops. If a hematoma develops at the venipuncture site, apply warm soaks. If the hematoma is large, monitor pulses distal to the venipuncture site. Ensure subdermal bleeding has stopped before removing pressure Instruct the patient that she may resume to his medications that were discontinued before the test as ordered.

Diagnostic/Laboratory Procedures

Date Ordered Date result/s

Indication/s or Purposes

Results

Normal Values(Units used in hospital)

Analysis and Interpretation of Results

Chest X-ray

It is done by using a radioactive device. It is usually obtain to determine the size, contour and portion of the heart or lungs. Use to determine the location and size of the heart for the detection of any mediastinal abnormalities and any cardiac disease and assess or demonstrate physiologic

Ill- defined densities are noted in both inner lung zones with paratracheal and hilar nodularities. Heart is not enlarged. Diaphragm is low and flattened. Bony thorax is unremarkable.

Both lung fields are clear, heart is in normal size and configuration.

The results suggest that the patient may have an infection because there were hilar nodularities was noted and of air trapping.

Impression: Bilateral PNU with air trapping.

alterations in the pulmonary circulation. This also aids in the visualization of any fluid accumulation or any infiltrates and secretions in organs like the heart and lungs

Nursing Responsibilities Orient client about the procedure. Accompany clients who are confused, combative or ventilator-dependent. Immobilize the neck for suspected spinal fracture prior to the procedure. Assess the need for sedation. Instruct patient to remove all clothes

Assist patient in wearing the gown Remove all materials that might interfere with the exam example are jewelry Ensure comfortable position for the patient.

PATHOPHYSIOLOGY: Client-centered
Predisposing Factors *age (57 years old) Precipitating Factors *respiratory infection *exposure to certain chemicals, pollutants or cigarette smoke *change in the environment

Airborne pathogen

Virulent microorganism

Acquisition of MO nasopharyngeal airway

MO lodges in the bronchi and bronchioles

Centrifugal spread to alveoli

MO infect type II alveolar cells Multiply in the alveolus and invade alveolar epithelium

Increased WBC 13.2 .5x10 9/L (910-12) Given levofloxacin and

Thickening of the alveolar septa by congested Spread of infection through alveolus to capillaries and leucocytic infiltration alveolus through pores of Kohn

Inflammatory pulmonary response

Consolidation along lobar compartment specifically right Difficulty to expectorate secretions

Vascular congestion

Alveolar edema

Fibrinous Compromise inflammation air exchange Impaired tse Extend to pleural Pleural adhesion

Presence of bacteria and neutrophils Increased neutrophils 0.83 (9-1012) Given levofloxacin and Axera (September 10 to 12, Increased neutrophils, and fibrin

Inflamed and fluid filled alveolar sacs Impaired O2 and CO2 exchange Harsh breathe sounds (September, 10 to 12, 2012) Hazy infiltrate in right lower lobe in CXR (September 10,

Release of chemical mediators

Decreased hgb(129 g/L) (September 10, 12) Decreased hct-

Histamine

Bradykinin

Prostaglandin

Increased capillary permeability

Stimulates goblet cells

Accumulation of secretions Increased fluid shifting to interstitial tissues

Loss of appetite (September 10 to 11, Body malaise (Septembe r 10 to 11, Difficulty of sleeping (September 10 to 11, 2012)

Airflow obstruction Block airflow through bronchi

Difficult to expectorate Secretions Cough reflex (September 10 to 11, 2012) Difflam Lozenges- sept 10-12, 2012 Flumucil 1 sachet- sept 10, 2012 Levopront syrup- sept

DOB (September 10 to 11, 2012)

Duavent MDI- sept 10-12, 2012 Oxygen Therapy and nubulization -sept 10-11, 2012 Benadryl syrup-sept 11-12, 2012

Grunting (September 10 to 11, 2012)

ETIOLOGY

Life begins when a newborn inhales his first breath and ends just when breathing ceases. It is something we constantly do yet we rarely perceive. Respiration virtually affects the whole bodily system. A person can survive for days without food and water but absence of oxygen even for a few minutes would mean death. The vital function paired with breathing defines how a persons life could be at stake when damage in the respiratory system occurs. Conversely, it is also through breathing that a person can acquire infirmity. Bronchopneumonia is an infection of the lung that can be caused by nearly any class of organism known to cause human infections. These include bacteria, amoebae, viruses, fungi, and parasites. Pneumonia is also the most common fatal infection acquired by already hospitalised patients. In developing countries, pneumonia ties with diarrhea as the most common cause of death. Even in nonfatal cases, pneumonia is a significant economic burden on the health care system. Pneumonia may be defined as to its location in the lung or origin of infection. Lobar Pneumonia occurs in one part, or lobe, of the lung while Bronchopneumonia tends to be scattered throughout the lung. As to its origin of infection, pneumonia may be classifed as either Community-Acquired Pneumonia (CAP) or Hospital-Acquired Pneumonia. People with CAP type of pneumonia contracted the infection outside a hospital setting. It is one of the most common infectious diseases. The disease often follows a viral respiratory infection such as the flu. One of the most common causes of bacterial CAP is Streptococcus pneumoniae. Other causes include Haemophilus influenzae, mycoplasma, and Chlamydia. Hospital-Acquired Pneumonia on the other hand is an infection of the lungs contracted during a hospital stay. This type of pneumonia tends to be more serious because hospital patients already have weakened defense mechanisms and the infecting organisms are usually more dangerous than those encountered in the community. Hospital patients are particularly vulnerable to gram-negative bacteria and staphylococci. Hospital-acquired pneumonia is also called nosocomial pneumonia.

PRECIPITATING AND PREDISPOSING FACTORS (Client-centered): PREDISPOSING FACTORS Age Bronchopneumonia prevalence is increased in very young persons and very old persons because of airway responsiveness and lower levels of lung function. Two thirds of all bronchopnemonia cases are diagnosed before the patient is aged 18 years. Approximately half of all children diagnosed with bronchopneumonia have a decrease or disappearance of symptoms by early adulthood. The present age of Gangnam which is 57 years old may indicate her risk of acquiring BPN PRECIPITATING FACTORS Respiratory infection Presence of microorganisms stimulates an inflammatory response that results in influx of leukocytes in the lung parenchyma. Chemical mediators are released and cause various responses this is due to airway hypersensitivity, bronchospasm and increased mucus production results. Gangnam had already experienced cough for the past 2 weeks until present Exposure to certain chemicals, pollutants or cigarette smoke The risk of developing some uncommon types of Pneumonia may be increased if the patient lives near an agriculture, construction areas or certain industrial chemicals or animals. Exposure to air pollution, toxic fumes and cigarette smoke can also contribute lung inflammation, which makes it harder for the lungs to clear themselves. Cold weather Cold air causes the airways to constrict. When bronchoconstriction occurs, the airways narrow, allowing less air to pass in and out of the bronchial tubes. This triggers an asthma attack due to the stimulation of the pathway that causes bronchoconstriction.

Signs and Symptoms: Dyspnea Dyspnea, also known as difficulty of breathing, is one of the triad symptoms of bronchopneumonia. It is caused by the decreased airway resistance during bronchopneumonia attack. This is due to three factors. First is bronchospasm which is brought about by chemical mediators as well as autonomic stimulation. Second is mucosal edema or swelling which is caused by the progressive increase of fluid leakage secondary to increased vascular permeability. Third is mucus buildup or mucus plug formation which is due to parasympathetic stimulation as well as by the action of leukotriene. Presence of Adventitious lung sounds Presence of abnormal breath sounds is due to accumulation of secretions in the alveolar sac, which traps air producing theses distinct sounds. Wheezing is one of the triad symptoms of bronchopneumonia. This sound is characteristic of a very small airway. Due to bronchospasm, mucus plug, and mucosal edema, the lumen of the bronchi is reduced to a very small diameter. Air struggles to pass by this constricted pathway and this causes the sound heard. This may be heard during expiration and inspiration. Rales / Crackles is due to the accumulation of secretions by bradykinin responsible for the stimulation of goblet cells in producing mucosal secretions. Cough Coughing is the last triad symptom of bronchopneumonia. It is a natural reflex of the body that is facilitated by the abdominal muscles and the diaphragm. This reflex is triggered by an obstruction in the lower respiratory tract. During an asthma attack, there is mucus buildup and this obstructs the airway. The body compensates by coughing, in an effort to expel the mucus or the obstruction. Sputum is usually mucoid and clear but may be yellow in the presence of an infection. Body Weakness

This is due to the physical exertion brought about by compensatory mechanisms through breathing. Tachypnea This is due to the stimulation of the respiratory center (medulla oblongata and pons) by decreased pH of the blood secondary to hypercapnia/hypercarbia detected by the chemoreceptors. The body compensates by increasing the rate of air exchange between the lungs and the atmosphere to release the accumulated carbon dioxide which releases H ions that cause the pH decrease. Expiration is prolonged to facilitate more carbon dioxide expiration. Elevated White Blood Cells Increased in number of leukocytes is brought about by the presence of bacterial infection in the body. HEALTH PROMOTION AND PREVENTIVE ASPECTS OF THE DISEASE The goals for successful management of bronchopneumonia outlined in the 2002 US National Heart, Lung, and Blood Institute publication. Achieve and maintain control of symptoms. Prevent bronchopneumonia exacerbations. Maintain pulmonary function as close to normal levels as possible. Avoid adverse effects from bronchopneumonia medications. Prevent the development of irreversible airflow limitation. Prevent bronchopneumonia mortality.

Prevention Another essential component in the treatment of bronchopneumonia is the control of factors contributing to bronchopneumonia severity.

Wash your hands frequently, especially after blowing your nose, going to the bathroom, diapering, and before eating or preparing foods. Don't smoke. Tobacco damages your lung's ability to ward off infection. Vaccines may help prevent pneumonia in children, the elderly, and people with diabetes, asthma, emphysema, HIV, cancer, or other chronic conditions:

Drink plenty of fluids to help loosen secretions and bring up phlegm. Get lots of rest. Control your fever with aspirin or acetaminophen. Aspirin must NOT be given to children.

COMPLICATIONS Pneumonia is more likely to cause complications in older people, smokers and people with heart failure or lung disease, such as COPD. Pneumonia complications may include:

Bacteria in your bloodstream. The smallest airways in your lungs terminate in tiny air sacs called alveoli (al-VEE-o-li), where blood cells exchange carbon dioxide for oxygen. In pneumonia, alveoli contain bacteria that may enter the bloodstream during gas exchange. Infection then spreads through the bloodstream, potentially causing shock and failure of multiple organs. Septic shock. Unchecked bacterial growth in the bloodstream can shut down normal circulation. Blood fills the veins and leaks through the walls of the capillaries, causing uncontrolled tissue swelling and possibly organ failure, which can lead to death. Fluid accumulation and infection around your lungs. Sometimes fluid accumulates between the thin, transparent membrane (pleura) covering your lungs and the membrane that lines the inner surface of your chest wall - a condition known as pleural effusion. When the pleurae around your lungs become inflamed (pleurisy) often as a result of pneumonia fluid can accumulate and may become infected (empyema). Lung abscess. Occasionally a cavity containing pus (abscess) forms within the area affected by pneumonia. Acute respiratory distress syndrome (ARDS). When pneumonia involves most areas of both lungs, breathing is difficult and your body doesn't get enough oxygen. Underlying lung disease of any kind, but especially COPD, makes you more susceptible to AR

V. THE PATIENT AND HIS CARE

A. Medical Management a.) IVF, Nebulization

Medical Management / Treatment

Date Ordered / Date Performed / Date Changed / Date Discontinued

General Description

Indications / Purposes

Client's response to the treatment

D5 0.3 NaCL

Date Ordered: January 25, 2010

D5

0.3

NaCL that

is

a To correct electrolyte The client responded is imbalances by and well to the treatment as brought evidenced by the client increased did not manifest signs in body administration of IVF. above

solution

considered hypertonic if dehydration not introduced inside the about

Date Performed: January 25, 2010

body but hypotonic once metabolic rate by an of dehydration after the inside the body. It has increase less osmolality than temperature

serum (i.e., it has less normal limits. sodium ion concentration than serum.) It dilutes the serum which

Date Discontinued: January 29, 2010

decreases

serum

osmolality. Water is then pulled from the vascular compartment interstitial the interstitial its into the fluid fluid is

compartment. Then, as diluted, osmolality

decreases which draws water into the adjacent cells. It can be helpful when the cells are dehydrated.

Nursing Responsibilities:

1. Before the procedure Before administering and starting the IV line of the patient, identify the patient and explain the procedure to the SO to gain trust and cooperation. Check the orders of the doctor for IV solution.

Prepare the equipments. Clean the site of insertion.

2. During the procedure Check for the patency of the IV line. Regulate the IVF. Monitor patients hydration. Become alert from fluid overload.

3. After the procedure Instruct patients SO to report signs of fluid overload such as DOB. Check the IV infusion for infiltration, pain, phlebitis and other complications of IV therapy. Monitor site of swelling

Medical Management / Treatment

Date Ordered / Date Performed / Date Changed / Date Discontinued

General Description

Indications / Purposes

Client's response to the treatment

Nebulization

Date Ordered: January It 26, 2010

is

method

of To prevent or treat The client responded bronchospasm, to well to the treatment as

administering

medications

through loosen secretions, and evidenced open

by

the

the inhaled route. It is to Date Performed: particles medications deeper passage of into the of

narrowed loosening of secretions in the lungs of the patient and being able to expectorate it readily.

used to disperse fine airways. January 26, 2010

respiratory tract where absorption occurs. Date Discontinued:

January 27, 2010

Nursing Responsibilities:

1. Before the procedure Obtain baseline assessment of patients respiratory status. Prepare all the equipments necessary. Explain the procedure and indication or medication. Ensure correct delivery of the prescribed medication.

2. During the procedure Place the client in a high- fowlers position. Place mouthpiece near to the mouth and inhale deeply as dose is released. Instruct patients SO to avoid accidentally spraying the inhalant into the eyes of the patient, which may blur vision temporarily.

3. After the procedure

Provide right and accurate documentation.

DRUGS Name of Drug Paracetamol Date ordered, Date Performed, Date Changed DO: 01/25/2010 DP: 01/25/2010 DC: 01/25/2010 (Temp: 38.5C) DO: 01/26/2010 DP: 01/26/2010 DC: 01/26/2010 (Temp: 38.5C) DO: 01/27/2010 DP: 01/27/2010 DC: 01/27/2010 (Temp: 38.3C) DO: 01/27/2010 DP: 01/27/2010 DC: 01/29/2010 Nursing Responsibilities: Before the procedure: Wash hands before preparing medications Route of Administration 77mg IV q4 PRN for fever Indication or Purpose Treatment to fever General Action, Classification Mechanism of Action Antipyretic. Reduces fever by acting directly on the hypothalamic heatregulating center to cause vasodilation and sweating to dissipate heat Clients response to medication There has been a decrease in the patients temperature to normal temperature after continuous administration of the drug.

77 mg IV RTC

Drops 0.5 ml q4h RTC

77 mg IV RTC

Read labels carefully. Check the medication orders if it is complete and legible

During the procedure: Check the drug label three times before administering medications For drops: Make sure that dropper will not touch the mouth of the patient upon administration. For IV route: Check IV site carefully for signs of thrombosis or drug reaction. Clean puncture site before administering drug Med card/KARDEX should include the date the medications was ordered and the last date

After the procedure: Dispose used syringes/ampules properly. Documentation is necessary. Date ordered, Date Performed, Date Changed DO: 01/25/2010 DP: 01/25/2010 DC: 01/26/2010 DO: 01/27/2010 DP: 01/27/2010 DC: 01/29/2010 Route of Administration 385 mg IV q12 -Hold 385 mg IV q12 Indication or Purpose Treatment of infections caused by gram-positive organisms General Action, Classification Mechanism of Action Antibiotic. Bactericidal action against sensitive organisms; inhibits synthesis of bacterial cell wall, causing cell death. Clients response to medication There has been a decrease in the patients temperature to normal temperature after continuous

Name of Drug Ampicillin

administration of the drug. Nursing Responsibilities: Before the procedure: Wash hands before preparing medications Read labels carefully. Check the medication orders if it is complete and legible Arrange patient for sensitivity test to drug

During the procedure: Check the drug label three times before administering medications Assess for patients sensitivity to drug Check IV site carefully for signs of thrombosis or drug reaction Clean puncture site before administering drug Med card/KARDEX should include the date the medications was ordered and the last date

After the procedure: Dispose used syringes/ampules properly. Documentation is necessary.

Name of Drug Gentamicin Sulfate

Date ordered, Date Performed, Date Changed DO: 01/25/2010 DP: 01/25/2010 DC: 01/26/2010 DO: 01/27/2010 DP: 01/27/2010 DC: 01/29/2010

Route of Administration 20 mg IV q12 -Hold 20 mg IV q12

Indication or Purpose Serious infections when causative organisms are not known.

General Action, Classification Mechanism of Action Aminoglycoside. Bactericidal: inhibits protein synthesis in susceptible strains of gram-negative bacteria; appears to disrupt functional integrity of bacterial cell membrane, causing cell death.

Clients response to medication There has been a decrease in the patients temperature to normal temperature after continuous administration of the drug.

Nursing Responsibilities: Before the procedure: Wash hands before preparing medications Read labels carefully. Check the medication orders if it is complete and legible Arrange patient for sensitivity test to drug

During the procedure: Check the drug label three times before administering medications Assess for patients sensitivity to drug

Check IV site carefully for signs of thrombosis or drug reaction Clean puncture site before administering drug Med card/KARDEX should include the date the medications was ordered and the last date

After the procedure: Ensure patients adequate hydration before, during and after therapy. Dispose used syringes/ampules properly. Documentation is necessary. Date ordered, Date Performed, Date Changed DO: 01/25/2010 DP: 01/25/2010 DC: 01/25/2010 DO: 01/25/2010 DP: 01/25/2010 DC: 01/27/2010 Route of Administration 1 suppository stat Indication or Purpose Muscle relaxant: adjunct for relief of reflex skeletal muscle spasm due to local pathology. General Action, Classification Mechanism of Action Skeletal muscle relaxant; Anxiolytic. May act in spinal cord and at supraspinal sites to produce skeletal muscle relaxation. Clients response to medication Active seizure episode was treated after administration of suppose tory.

Name of Drug Diazepam

2.3 mg SIVP PRN for seizure

Nursing Responsibilities:

Before the procedure: Wash hands before preparing medications Read labels carefully. Check the medication orders if it is complete and legible Assess for allergy to drug and drug composition

During the procedure: Check the drug label three times before administering medications Wear clean gloves when doing the procedure. Insert suppository in rectum and retain for 15 to 20 minutes. Carefully monitor PR, RR, and BP during IV administration Dispose used equipment properly. Documentation is necessary. Date ordered, Date Performed, Date Changed DO: 01/26/2010 DP: 01/26/2010 DC: 01/29/2010 Route of Administration neb + 0.5 ml NSS q6h General Action, Classification Mechanism of Action Treatment for Bronchodilator. bronchospasm Relaxes muscles in and dyspnea the airways and Indication or Purpose Clients response to medication The patient manifested relief and ease in

After the procedure:

Name of Drug

Salbutamol

inhalation Nursing Responsibilities: Before the procedure: Wash hands before preparing medications

experienced by the patient.

increase air flow to the lungs.

breathing.

Know the reason for which the client is receiving the medication

During the procedure: Check the drug label three times before administering medications Position patient to sit upright during nebulization

After the procedure: Clean nebulizer canister after use. Dispose used equipment properly. Documentation is necessary.

c) Diet Type of Diet NPO (if dyspneic) Date Ordered Date Started Date Changed DO: 01/25/2010 DS: 01/25/2010 DC: 01/27/2010 General Description A diet to withhold oral food and fluids from a patient for various reasons Indication/ Purposes To prevent the risk for aspiration of patient due to difficulty of breathing Specific Food/s Taken None Clients response/ reaction to diet The patients SO complied and the patient was able to tolerate the diet.

Nursing Responsibilities: Before the Procedure: Check doctors order Remind the patient that he should not take anything per orem.

During the Procedure:

May wet the lips with the use of cotton to prevent cracking of lips and to alleviate thirst. Monitor intake and output

After the Procedure: Check doctors order for the next prescribed diet c.) diet Type of Diet Milk feeding with strict aspiration precaution Date Ordered Date Started Date Changed DO: 01/26/2010 DS: 01/26/2010 DC: 01/29/2010 General Description Breastfeeding is where the infant is fed with breast milk directly from the breast of the mother rather than from a baby bottle or other container. This is always available whenever the baby is hungry. This is done by sucking the nipples of the mother properly. Also, the mother Indication/ Purposes This is given to the baby to supply the nutritional supplement for the baby. Also, to prevent aspiration. Strict aspiration precaution prevents fluid from entering in the respiratory tract. Specific Food/s Taken Breast milk Clients response/ reaction to diet The client tolerated the milk of the mother and did not experience diarrhea. Also, the client did not demonstrate any signs of aspiration.

must observe for signs of aspiration Nursing Responsibilities: Before the procedure: Explain the importance and purpose of the prescribed diet. Emphasize strict compliance on the diet regimen. Instructed SO to position the patient in high or semi-fowlers position to avoid aspiration. The mother must always perform hand washing and proper hygiene. Clean the nipples before breastfeeding.

During the procedure: Assist the mother if necessary in the feeding especially in moving position. Let the baby suck the whole areola.

After the procedure: Continue diet prescribed Advice the mother to clean her nipples before and after breastfeeding without soap

d) Activity ACTIVITY Type of activity Bed Rest Date ordered Date started Date changed DO: 01/25/2010 General Description Supine position on bed or semi-fowler to high-fowlers position. Indications or Purposes To decrease workload of the body and to conserve energy Clients response or reaction to activity The patient was able to conserve energy and unnecessary fatigue was minimized.

Nursing Responsibilities: BEFORE Verify doctor's order. Explain the necessary activity to the SO and the reason for such order.

DURING Ensure patients safety. Assess patients comfort.

AFTER Inform the SO of the specific activities that patient is contraindicated. Document as necessary

Nursing Management 1. Nursing Care Plan Problem # 1: Ineffective Airway Clearance r/t bronchial inflammation and retained secretions in the bronchi. Assessment S> O: The >DOB >Rales manifested: Nursing Diagnosis Ineffective airway patient bronchial Scientific Explanation Bronchopneumonia refer Objectives Short term: of Intervention s >Establish Outcomes >To gain the Short term: trust and The SO shall cooperation of have the patient and verbalized his SO. >Monitor and >To understanding of the health obtain teachings given and baseline data. Rationale Expected

s to a type of pneumonia After the bronchioles signs may and nursing

2-3 rapport.

clearance r/t that is localized, often to hours inflammation surrounding and retained Clinical which secretions in pulmonary

alveoli. interventions include the SO shall lead to understanding record VS. congestion verbalize

>Nasal Flaring the bronchi.

>productive, ineffective cough >Weakness >Restlessness >Increase respiratory rate (63 cpm) >PR: 190 bpm The patient in

inflammation bronchioles result to effectively secretions respiratory leads to

of that inability from tract

the of the health may teachings to given the behaviors which improve >note for the >this quality, pattern depth Long term: The shall respirations, patient flaring use muscles rate, indicate and effectiveness of of may of clearance. airway clear demonstrate to >auscultated and the lungs >to presence adventitious breath sounds

shall

have to

determine demonstrated of behaviors improve airway clearance.

the

patients airway

manifestation ineffective clearance.

patients Long term: The shall reduction congestion with patient have of

breathing of pattern. of

may manifest: >Cyanosis >use accessory muscles breathing for of

have nostrils, DOB, of accessory for

demonstrated

demonstrated reduction congestion with sounds clear, respiration noiseless, improved

breath

breath breathing. >Assess patients condition. >To DOB maintain

sounds clear, respiration relieve noiseless, and to improved oxygen

oxygen exchange, secretions will be mobilized, >Provide airway will be health maintained and free secretions. of elevation HOB >Stress need changing position every 2 hours. >Provide health teachings keep environment allergen free of

adequate

and exchange, secretions will be mobilized,

patent airway. >To further

promote airway will be lung maintained and free of secretions.

teachings like expansion.

the >to

facilitate of

in drainage secretions.

>To further

prevent

to aggravation of the patients condition.

like feather pillows smoke.

dust, or

>Instruct SO >To to fluid intake >Provide health teachings provide opportunities for rest. >Promote pleasant environment conducive to rest. >To to

liquefy

increase secretions.

>To prevent or lessen fatigue.

promote

faster recovery.

>encourage increase oral intake cardiac reserve. >encourage SO observe hygiene

>

To

loosen

in the secretions fluid and enable the to

within patient expectorate them. >to

the limits of readily

prevent

to colonization of bacteria in the serves portal when expectorating secretions. as of a exit

frequent oral oral cavity as it

>Encourage restrictive

>

this

may

SO to avoid aggravate DOB

clothing when dressing patient >Teach proper bronchial tapping stress importance >Instruct SO >To to put patient in an upright position when feeding. >Perform >to prevent of prevent and its SO >to loosen the

secretions

the aspiration

suctioning of drying secretions or secretions.

initiate humidified oxygen therapy >Administer due medications. >To means therapy. promote by of

wellness

Pharmaceutical

Problem # 2: Ineffective Breathing Patient r/t airway obstruction. NURSING DIAGNOSIS Ineffective S= O= the patient manifested Breathing Pattern r/t airway obstruction NURSING OBJECTIVES INTERVENTIONS Short Term: After 4 hours of Nursing interventions the patient will establish a >Monitor and Record VS >To obtain baseline data for further comparison EXPECTED OUTCOME Short Term: The patient shall have established a normal respiratory

ASSESSMENT

SCIENTIFIC EXPLANATION Ineffective breathing pattern as inspiration or expiration that does not

RATIONALE

>Weakness >Restlessness >Poor appetite >With nasal flaring >Poor skin turgor >DOB >cough >RR: 63 bpm The patient may manifest: >Cyanosis >Diaphoresis >Altered chest excursion >use of accessory muscles.

provide adequate respiration. It is due to accumulation in the lungs that will occlude the alveoli which in turn may lead to bronchospasm because of the release of histamine that causes narrowing of the blood vessels. This will increase the resistance where the air passage is decreased that is why air and blood couldnt pass through it and there may

normal respiratory pattern AEB absence of tachypnea Long Term: After 4 days of Nursing Interventions the pt will be free from alterations in respiratory pattern AEB normal range of respiratory rate is obtained

>Assess general condition

>To note for any abnormalities and underlying complications >To identify causes of breathing impairment

pattern AEB absence of tachypnea Long Term: The pt shall have been free from alterations in respiratory pattern AEB normal range of respiratory rate is obtained

>Determine presence of factors/physical condition as related to her condition >Note rate and depth of respiration and type of breathing pattern

>To determine any irregularities in the breathing pattern

>Auscultate breath sounds and assess for air movement >Elevate head of

>To ascertain status and note progress >To take

be decrease exchange of gases in the lungs or may lead to DOB then nasal flaring. Due to pt.s present diagnosis, she has decreased protein and caloric reserves in the body. There may be decreased strength and immunity to combat microorganisms and there is an ed risk for acquiring different diseases esp. in the respiratory system.

bed, changing of position every 2 hours

advantage of gravity decreasing pressure on the diaphragm and enhancing drainage of secretions >To liquefy secretions, to immune system and to replace and replenish the body with protein and calories to regain health >To promote wellness >To prevent chilling leading to

>Instruct SO to OFI, foods rich in Vit. C and CHON as ordered by the physician or if patient is dyspneic or placed in NPO temporarily.

>Provide rest periods such >Keep back dry

further complications >Change soiled linens and clothing, as necessary >For continuous relaxation and to reduce allergens

>To loosen >Do bronchial up secretions tapping after each nebulisation >To prevent cross >Perform proper contamination disposal of secretions if any >To give immediate >Refer to Clinical action to the Instructor then to actual NOD for presence problems of respiratory distress >To maintain hydration and prevent air embolism

>Regulate IVF

>To aid in >Administer expectorants as removing needed and secretions in the lung and ordered regain health

Problem # 3:Hyperthermia Assessment S: O: The >Warm touch skin >Flushed skin >Irritability patient to manifested: Nursing Diagnosis Hyperthermia Scientific Explanation Bronchopneumonia Short term: is a type of After hours by nursing of interventions temperature or of the client acute the one pneumonia characterized multiple isolated, consolidation, affecting more foci Objectives Interventions >Monitor of >Assess clients condition. clients means conduction. Rationale Expected Outcomes obtain Short term: The temperature of >To reduce the the client shall have of from 38.5C to 37C. temperature by decreased

and >To

2-3 take V/S

baseline data.

pulmonary shall

>Weakness >Restlessness >temperature of 38.5C >RR: 63 cpm

lobes. lungs to the

The decrease 38.5C >Identify underlying cause. and to 37C. infection Long term: by After 2-3 days >Note of nursing chronological and a age of client.

>To factors.

assess

inflammation of the from bronchioles is due caused microorganism

contributing

>Children more susceptible

are Long term: The to shall client have a

The

patient

which can lead to intervention the manifestation of maintain but temperature

heatstroke and maintained may not act on core symptoms of temperature within hyperthermia. >To

may manifest: >Dehydration >Seizure >Increase in respiratory rate >Tachycardia

patients the client shall developmental

hyperthermia which core is the response body invasion microorganisms. to often, necessarily part of within normal defensive range and the >Auscultate of the SO behaviors monitor promote normal temperature will breath sound. to and >Perform TSB. the demonstrate

normal

range and the evaluate SO shall have of demonstrated to and may monitor promote normal >To reduce the temperature of clients temperature by the client. presence that

breath sounds behaviors indicate DOB

of the client.

promoting surface cooling. >Provide loose >To and comfortable clothing volume tissue perfusion. >Recommend discuss >To reduce support and

circulating

bed rest and metabolic/ the oxygen importance of demands. adequate fluid intake.

>Give

health >To

promote and

teachings

on wellness

the ways on prevent

how to protect increase the client from body further like clothing restriction activity >Administer replacement fluids electrolytes and OFI >Administer antipyretic drugs ordered >To increase and >To heat temperature. proper and of

in

prevent

dehydration.

decrease of

temperature by as means therapy. Pharmaceutical

Problem # 4: Impaired Gas Exchange related to impairment of alveolar-capillary diffusion secondary to retained secretions (pneumonia) Nursing Diagnosis Impaired gas exchange related to impairment of alveolarcapillary diffusion secondary to retained secretions (pneumonia) Scientific Explanation The process of the exchange of O2 & CO2 occurs in the alveolarcapillary membrane area. The relationship between ventilation and perfusion affects the efficiency of gas exchange. Pneumonia offsets the balance between the airflow and blood flow therefore causing impaired gas exchange. The changes in the alveoli impairs ventilation and Desired Outcome Short-term: The patients SO will be able to verbalize understanding of condition and therapeutic regimen after 4 hours of nursing intervention Long-term: The patient will improve ventilation and adequate oxygenation of tissues after 5 days of nursing interventions

Assessment S: O: the patient manifested: -low hgb count (107) -low hct count (.32) -cold to touch extremities -irritability -tachypnea (63 cpm) -tachycardia (190bpm) -grunting -shallow breathing The patient may manifest: -use of accessory muscle in breathing

Objective Short-term: After 4 hrs of nursing interventions the patients SO will be able to verbalize understanding of condition and therapeutic regimen Long-term: After 5 days of nursing interventions, the patient will improve ventilation and adequate oxygenation of tissues

Interventions

Rationale

-Note -To evaluate respiratory degree of rate, depth, use compromise of accessory muscles -Note -To assess for effectiveness of respiratory cough insufficiency mechanism -Elevate head of bed / position client appropriately -Encourage frequent position changes -To maintain airway

-To promote optimal chest expansion and drainage of secretions

-Encourage SO -To preserve to have patient energy supply

-cyanosis -capillary refill longer than 3 seconds

the altered blood flow brought about by the changes in the capillaries leads to ventilation without perfusion which in the end leads to impairment of gas exchange

in bed rest and minimize activities -Instruct patients SO to increase oral fluid intake of the patient -Keep environment allergen / pollutant free -Administer medications as ordered -To mobilize secretions -To reduce irritant effect of dust and chemicals in airways -To treat underlying conditions using pharmacological methods

Problem # 5: Ineffective Tissue Perfusion related to impaired transport of oxygen Assessment S: O: the patient manifested: -low hgb count Nursing Diagnosis Ineffective tissue perfusion related to Scientific Explanation Due to the impairment of gas exchange, some parts of Objective Short-term: After 4 hrs of nursing interventions Interventions -Encourage quiet, restful atmosphere Rationale -to conserve energy/lower tissue oxygen demands Desired Outcome Short-term: The patients SO shall have verbalized

(107) -low hct count (.32) -cold to touch extremities -irritability -tachypnea (63 cpm) -tachycardia (190bpm) -weakness The patient may manifest: -pallor -use of accessory muscle in breathing -cyanosis -capillary refill longer than 3 seconds -decreased peripheral pulses -decreased urine output

impaired transport of oxygen

the body do not receive adequate amount of oxygen. This causes the patient to experience tachypnea as a result of compensation to oxygen deprivation. The oxygen being supplied in the body is not enough due to the low levels of hemoglobin which is responsible for the oxygenation of tissues thus leading to ineffective tissue perfusion

the patients SO will be able to verbalize understanding of condition and therapy regimen Long-term: After 5 days of nursing interventions the patient will have an increase in perfusion as individually appropriate

-Encourage SO to loose and comfortable clothing - Place patients head in neutral position

-To enhance venous return

-To increase gravitational blood flow

understanding of condition and therapy regimen after 4 hours of nursing interventions Long-term: The patient will have an increase in perfusion as individually appropriate after 5 days of nursing interventions

- Instruct -To increase hgb patients SO to count feed patient with foods rich in iron such as organ meat -Instruct pts SO to increase foods rich in Vitamin C such as citrus fruits -Promote adequate bed rest - Attend needs -to increase resistance against infection,

-To promote wellness -To promote health

-Regulate IVF as ordered -Reinforce milkfeeding as ordered -Administer meds as ordered Problem # 6: Risk for Deficient Fluid Volume r/t fever and rapid RR Assessment S: O: the >Pallor >Sunken anterior fontanel >Sunken Nursing Diagnosis Risk deficient Scientific Explanation Objectives Short term: of >assess mucous

-To maintain hydration -to prevent occurrence of aspiration -To promote recovery

Interventions

Rationale

Expected Outcomes

for Bronchopneumonia refer

>Monitor and >To 2-3 record VS. data. skin >to signs DHN

obtain Short term: The SO shall have verbalized note understanding of on the health teachings given prevent to or

s to a type of pneumonia After bronchioles and nursing

baseline

fluid volume that is localized, often to hours patient r/t fever and the respiratory rate. surrounding alveoli. The interventions and increase in verbalize

may manifest: rapid

symptoms include fever the SO shall turgor, respiratory rate that could understanding loss with could give rise teachings membrane, capillary refill

lead to insensible water on the health skin perfusion,

reduce the risk

eyeball >Poor turgor >dry skin and mucous membrane >decreased capillary refill time skin

to

the

problem

fluid given prevent reduce risk volume. Long term: of

to time or electrolyte the balance. of >Assess condition.

and

of

deficient

volume deficit.

fluid volume. the >To identify aggravating factors. Long term: The SO shall

deficient fluid clients

>Monitor and >to measure have input and demonstrated determine if behaviors and fluid loss is lifestyle equal intake >instruct to to to changes prevent to the volume

After 2-3 days record interventions the SO shall demonstrate behaviors and lifestyle changes prevent fluid deficit.

nursing and output

occurrence of SO >to decrease fluid deficit. provide metabolic

the adequate rest demands >To >Instruct to SO maximize of provide intake

occurrence of periods volume

increase fluid fluids. intake to the client between meals. >To prevent >Establish needs replacement schedule. occurrence or receiving adequate amounts fluids time. at particular of a individual fluid of deficit by like offering fluids

>encourage oral and skin care

>to

prevent

hygiene bacterial colonization in the mouth

and maintain >Discuss the SO to skin integrity the >To provide knowledge of the SO.

risk factors or sufficient potential hypovolemic shock and dehydration. >Encourage maintaining >To ensure of diary of food accurate or fluid intake; picture number voiding forth. the amount of and stools and so and fluid status. problems like on the part

Problem # 7:Risk for Imbalanced Nutrition: less than body requirements related to increased metabolic needs secondary to infectious process. Cues Nursing Diagnosis Scientific Explanation Objectives SHORT TERM: S> O O> Patient may manifest: -loss of weight with inadequate food intake. -pale conjunctiva and mucous membranes. -decreased subcutaneous fat/muscle mass. Nutrition: Imbalanced, less than body requirements related to increased metabolic needs secondary to infectious process. Nutrition: Imbalanced, less than a body requirement occurs when intake of nutrients is insufficient to meet metabolic needs. Due to inflammatory process causing After 4 of nursing intervention, patients SO will verbalize understanding of causative factors and necessary interventions to maintain appropriate weight. -assess weight, body build and activity -Assess patients -to obtain data that may be used for comparison -To evaluate -Monitor VS -To get baseline data -Establish rapport -To gain patients trust and cooperation. After 4 of nursing intervention, patients SO will verbalize understanding of causative factors and necessary interventions to maintain SHORT TERM: Nursing Interventions Rationale Evaluation

depleted energy LONG TERM: reserves, periods of dyspnea and impairment of oxygen and carbon dioxide transport leave little oxygen to meet metabolic needs, The signs and symptoms of infection makes feeding difficult. After 2 weeks of nursing intervention, patient will demonstrate progressive weight gain towards goal.

nutritional status (height and weight)

patients general nutritional state and to obtain baseline weight.

appropriate weight.

LONG TERM:

-obtain nutritional history from SO

-to determine amount and nutritional value of food intake

After 2 weeks of nursing intervention, patient will demonstrate progressive weight gain

-Provide SO with information regarding individual nutritional needs. -monitor weight

-To importance of well-balanced nutritious intake. weight is an indicator of

emphasize the towards goal.

regularly

nutritional status.

-Recommend/ Support hospitalization and instruct SO to seek medical assistance in severe malnutrition/life threatening situation. -To help SO understand the importance of immediate referral to the nearest hospital. -to increase -encourage SO prepare appealing nutritional meals and to promote appetite of the patient when eating.

relaxing and pleasant environment when feeding -Encourage adequate fluid periods -provide increased calorie and CHON in the diet -Reinforce milk feeding -milk serves as the primary source of nutrients of infants. -to prevent DHN -to provide food needed to increase energy

Problem # 8: Disturbed sleeping pattern RT discomforts due to increased nasopharyngeal secretions Cues Nursing Scientific Objectives Interventions Rationale Expected

Diagnosis S= O= the patient manifested: -Restlessness -Nasal Flaring -DOB -nonproductive cough -increased respiratory secretions =the patient may manifest: >lethargy Disturbed sleeping pattern RT discomforts due to increased nasopharyngeal secretions

Explanation A client with bronchopneumoni a has excessive secretions in the tracheobronchial tubes, which induces cough and dyspnea. Coughing is the bodys reflex mechanism to expel the microorganism out. Cough may occur even when a person is sleeping. Dyspnea may awake a person thereby causing interruption on sleep. These symptoms of bronchopneumoni a disturb the clients sleeping pattern. Short term: After 3 hours of nursing intervention, the clients SO will verbalize understanding of appropriate interventions to promote rest and sleep. Long Term: After 2 days of nursing intervention, the clients SO will report improvement >Monitor and record VS >Obtain information from clients SO regarding usual bedtime and number of sleep hours >Provide quite and restful environment >Encourage client SO to cuddle the infant often especially >To prevent >To promote optimal sleep >To promote sleep and warmth >to obtain baseline data >To determine usual sleep pattern

Outcome Short term: After 3 hours of nursing intervention the clients SO shall verbalize understanding of appropriate interventions to promote rest and sleep. Long Term: After 2 days of nursing intervention, the clients SO shall report improvement in sleeping pattern.

in sleeping pattern.

>Provide for injury childs sleep time safety during bedtime

Problem # 9: Activity Intolerance r/t decreased oxygen levels for metabolic demands . Assessment Nursing Diagnosis Scientific Explanation Planning Intervention Rationale Evaluation

S= O= patient manifested: > productive, non-effective cough > nasal discharges, green in color

Activity intolerance r/t decreased oxygen levels for metabolic demands

Inflammation serves as the pulmonary response to the offending organism. The defense mechanism of lungs loses effectiveness thereby allowing

Short term: >After 4 hours of NI, patients SO will demonstrate nonpharmacol ogical techniques to enhance activity

> establish rapport

> to allay anxiety and gain compliance > to obtain baseline data

Short term: After 4 hours of NI, patients SO shall be able to demonstrate nonpharmacolo gical techniques to enhance

> monitor & record v/s

> auscultate

> Ascertain status & note

> adventitious breath sound (rales on both lung field) > irritability > weakness > grunting >DOB >RR: 63 cpm >PR:190 bpm =the patient may manifest: >abnormal heart rate response to activity

organism to penetrate the sterile lower tract where inflammation develops. Disruption of the mechanical defenses of cough & ciliarys motility leads to colonization of lungs & subsequent infection. Depleted energy reserves due to impairment of oxygen & carbon dioxide transport leave little O2 to meet metabolic demands w/c leads to activity intolerance.

intolerance

breath sounds

progress.

activity intolerance

Long term: > After 2 days of NI, patient will be able to demonstrate a decrease in the physiological signs of intolerance and absence of excessive demand for oxygen.

> Observe for signs of respiratory distress

> To assess changes & note complications

Long term: > After 2 days of NI, patient shall be able to demonstrate a decrease in the physiological signs of intolerance and absence of excessive demand for oxygen.

>note presence of factors contributing to fatigue

>fatigue affects the clients actual activity to participate in activities

> stretch bed linens & clear environment >Provide adequate rest periods

> To promote comfort for the patient.

>to prevent overexertion

>encourage to increase oral fluid

>for tissue perfusion & support

intake

circulating volume

> perform bronchial tapping

>to mobilize secretions and aid in expulsion of secretion >to loosen secretions and provide comfort

> provide nebulization as ordered

> Administer drug as ordered

> To provide pharmacologic treatment.

2. Actual SOAPIEs January 26, 2010 S> O>received patient on bed, supine position, asleep. With an ongoing IVF #1 500cc D50.3NaCl @ 150cc level running at 30 gtts/min infusing on right foot. With CRT of <3 seconds, with pink palpebral conjunctiva, with good skin turgor, skin on axial body part is warm to touch, peripheries are cold to touch, with grunting, with non-productive cough, with shallow breathing, with VS taken and recorded as follows: Temp-38.5OC, PR: 190 bpm, RR: 63 cpm A>Hyperthermia P>after 4 hours of nursing interventions, the patients SO will demonstrate behaviors to monitor and promote normothermia such as performing TSB I>established rapport >assessed patients general condition >auscultated for breath sounds >monitored and recorded vital signs >rendered AM care such as diaper change and fixing of bed linens >checked for IVF patency >kept back dry >instructed SO to provide loose and comfortable clothing >instructed SO to place patient on NPO when dyspneic >rendered TSB >provided safety and comfort >encouraged increase OFI of patient to maintain hydration >instructed SO to burp patient after every feeding >regulated IVF to 30gtts/min >due medications given: Paracetamol 77mg IV q4 PRN for fever Ampicillin 385mg IV q12 Gentamycin 20mg IV q12

>needs attended >referred accordingly >seen on rounds by Dr. Yabut with orders made and carried out FTF: D50.3NaCl x 20 gtts/min Follow up CXR results Salbutamol neb neb + 0.5 PNSS q6h Continue present meds RTC Paracetamol IV >changed IVF to #2 D50.3NaCl x 20 gtts/min >IV out at 12:30pm E>Goal met AEB the patients SO demonstration of behaviors to monitor and promote normothermia such as performing TSB January 27, 2010 S> O>received patient on bed, supine position, awake, being breastfed. With CRT of <3 seconds, with pink palpebral conjunctiva, with god skin turgor, skin on axial body part is warm to touch, peripheries are cold to touch, without cyanosis, with non-productive cough, with rales on both lung fields, with DOB, with VS taken and recorded as follows: Temp-38.3OC, PR: 127 bpm, RR: 62 cpm A>Hyperthermia P>after 4 hours of nursing interventions, the patient will have a decrease in body temperature within normal limits/ I>established rapport >assessed patients general condition >auscultated for breath sounds >monitored and recorded vital signs >rendered AM care such as fixing of bed linens and providing adequate ventilation >checked for IVF patency >kept back dry

>instructed SO to provide loose and comfortable clothing >rendered TSB >provided safety and comfort >encouraged increase OFI of patient to maintain hydration >encouraged lactating mother t increase intake of foods rich in Iron (e.g. organ meat) and Vitamin C (e.g. citrus fruits) to maintain tissue perfusion and increase immunity of patient >instructed SO to burp patient after every feeding >instructed mother to position patient on upright position when feeding to prevent aspiration >regulated IVF to 30gtts/min >due medications given: Salbutamol neb neb + 0.5 PNSS q6h >needs attended >referred accordingly >seen on rounds by Dr. Bondoc @ 8:30 am with orders made and carried out: Continue meds Continue monitoring FTF: D50.3NaCl x 30 gtts/min Continue nebulization Refer >referred to Dr. Buendia @ 11:45 am with orders made and carried out: Paracetamol drops O.5ml q4h RTC E>Goal partially met AEB decrease in patients body temperature from 38.3 OC to 37.9OC

VI. CLIENTS DAILY PROGRESS IN THE HOSPITAL 1. Clients Daily Progress Chart Days Nursing P r o b l e m s Ineffective airway clearance Ineffective breathing pattern Hyperthermia Impaired gas exchange Ineffective tissue perfusion Risk for deficient fluid volume Risk for Imbalanced Nutrition: less than body requirements Disturbed sleeping pattern Activity Intolerance Vital signs Temperature Pulse Rate Respiratory Rate January 25 (Admission) January 26 January 27 January 28 January 29 (Discharge)

38.5C 168 bpm 54 cpm

38.5C 190 bpm 63 cpm

38.3C 127 bpm 62 cpm

36.9C 102 bpm 36 cpm

36C 118 bpm 34 cpm

Diagnostic/ Laboratory Procedures Complete Blood Count

Hgb =107 WBC=15.5 Hct=0.32 RBC=3.75 Platelet=280 Segmenters=0.42 Lymphocyte=0.5 8 Color= yellow Transparency= slightly turbid pH= 6.0 Specific Gravity= 1.010 Epithelial Cells= (+) Albumin= (-) Sugar= (-) Pus Cells/ HPF= 5-10

Urinalysis

Chest X-Ray Medical Management Drugs Paracetamol

Changed frequency then HOLD (IVO)

Shifted to Oral at 11:30 AM (IVO)

Gentamycin Diazepam Salbutamol Intravenous Fluids Suppository at ER #1 D50.3 NaCl 500 cc x 30 gtts/min

HOLD (IVO)

#2 D50.3 NaCl 500 cc x 20 gtts/min

#3 D50.3 #4 D50.3 NaCl NaCl 500 cc x 500 cc x 20 30 gtts/min gtts/min

Diet NPO dyspneic) (if

Milk Feeding with SAP Activity Bed rest 1. Discharge Planning a) General Condition of Client upon Discharge Upon discharge, the patient is physically well as evidenced by stable vital signs, good skin turgor, and capillary refill time of less than 3 seconds. Information was provided to the SO, which are necessary to maintain wellness. b) METHOD M.E.T.H.O.D Continue medication as instructed by the doctor Co-Amoxiclav (amoxicillin + clavulanic acid) an antiinfective to kill susceptible microorganisms Take 2 ml twice a day for 7 days Teaching points: Patient may take the drug with or without meals Tell the SO of the patient to protect drug from exposure to light Salbutamol + Guaifenesin Syrup Management of airway obstruction. Also used to reduce the viscosity of tenacious sputum & as an expectorant for productive cough. Take 2 ml twice a day for 5 days Teaching points: Patient should take drug with meals May give with meals if GI upset occurs Dispose secretions properly Appetite Plus Syrup #1 - stimulates appetite & enhances wt gain w/ supplementary essential vitamins Take 0.9 ml for one dose Teaching points: Do not exceed recommended daily dose Patient should take drug with meals Do not give with alcohol (e.g., sedatives, analgesics) Patient may resume normal activity Inform SO to limit tremendous activity of patient Provide adequate rest periods Instructed the SO to comply with the therapeutic regimen of

Medication

Exercise Treatment

Health Teachings

Out-Patient Department Diet

the patient. stressed and discussed the importance of compliance to instructions for check-up instructed SO to strictly adhere with the orders for medications of patient Provide safety measures as indicated Instructed SO to have a follow-up check-up of patient on 05 th of February, 2010 at ONA Out Patient Department Pedia. Instructed patients SO to feed patient with nutritious foods Encouraged SO to increase Vitamin C and Protein intake of patient Instructed to increase adequate nutritional intake Instructed to increase oral fluid intake

VII. CONCLUSION and RECOMMENDATION Conclusion and Recommendation As to the conclusion of our study, we were able to meet our objectives. We had built rapport with our patients SO by using therapeutic communication. We have obtained the necessary data for our study. We have performed physical examination, reviewed the laboratory results, and provided interventions to the patients needs. As for our long term goals, we have reviewed the medical condition of the patient, identified precipitating and predisposing factors to the occurrence of the disease condition, reviewed the book-based and patient-based manifestations of the disease, correlated other factors such as relevant data, laboratory results, abnormal findings in the physical assessment, formulated nursing diagnoses and subsequent planning to aid the patients prognosis, evaluated patients response to over-all interventions through the patients daily progress chart, and provided health teachings upon discharge of the patient such as the maintenance of medical managements and measures to prevent reoccurrences or to alleviate aggravating conditions. Pneumonia is an infection of the lung that can be caused by nearly any class of organism known to cause human infections. These include bacteria, amoebae, viruses, fungi, and parasites. Pneumonia is also the most common

fatal infection acquired by already hospitalized patients. A febrile convulsion is a seizure episode associated with a febrile illness in a child between the ages of 5 months and 5 years, that lasts less than 15 minutes. A generalized seizure is one where the child is unconscious and has stiffening of the body and then twitching (convulsing) of both arms and legs. This is what occurs in most children. Early identification of causative factors for the disease condition may help prevent some complications of the disease. Education about the warning symptoms is also important because early recognition may help the patients SO receive treatment and prevent worsening of the disease. Educating the parents/SO with the nature of the disease, signs and symptoms, and preventive measures is a very vital component in combating the disease. Like a student, the SOs need scheduled classes, planned instruction, reading materials which are geared to educational level, demonstrations of procedures and the opportunity to perform these procedures with supervision. Learning is a continuing process and patients are given with the most basic facts regarding bronchopneumonia and benign febrile convulsion. As student nurses, it is recommended to encourage the patients SO to continuously read and learn about their disorder and to keep abreast of new developments in the field. Knowledge and confidence go hand in hand. The more that the family knows about the disease, the easier it will be for them to accept the condition, control the disorder and live a normal productive life. As for student nurses, they are tasked to learn the different interventions that should be given in a client who has bronchopneumonia and benign febrile convulsion in order for them to provide their patients with the necessary care that they need. Studies about the cause and different treatment with regards to this disease do not cease as members of the medical and research fields exert effort to always find ways to alleviate the modes of living of the people. But these have always been a challenge. We may be too young to do such sensitive researches, yet it does not follow that we are excused of the responsibility. We need to provide intensive and good nursing care for our clients. They may be very difficult

to handle but let us not deprive them of the care, respect and compassion that they all deserve. Proper treatment is equated to a best prognosis. With this everyone must exert an effort to combat the progress of this condition through proper and effective information dissemination which entails the prevention of the condition and the need for medical attention for a higher chance of survival, and programs in adjunct to treating this disease. VIII. BIBLIOGRAPHY Book References: Black, J.M. & Hawks, J.H. (2009). Medical-Surgical Nursing: Clinical Management for Positive Outcomes (8th ed.). Singapore: Saunders Elsevier Karch, A.M. (2009). Nursing Drug Guide. Philadelphia: Lippincott Williams & Wilkins. Pilliteri, A. (2007). Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family (5th ed.). Philadelphia: Lippincott Williams & Wilkins. Seeley, R.R., Stephens, T.D., & Tate, P. (2007). Essentials of Anatomy & Physiology (6th ed.). New York: McGraw Hill Internet Sources: Bronchopneumonia Pathophysiology - Signs, Symptoms and Treatment of Bronchopneumonia (n.d.). Retrieved from http://www.total-healthcare.com/man-health/bronchopneumonia.htm Neuman, M.I. (2009). Pediatrics, Pneumonia. Retrieved from http://emedicine.medscape.com/article/803364-overview Panayiotopoulos, C.P. (2005). The Epilepsies: Seizures, Syndromes and Management. Retrieved from NCBI database.

Pneumonia Can Be Prevented Vaccines Can Help (2009). Retrieved from http://www.cdc.gov/Features/Pneumonia/ Slupsky et al. (2009). Fast, Accurate Urine Test for Pneumonia Possible, Study Finds. ScienceDaily. Retrieved from http://www.sciencedaily.com /releases/2009/12/091209093119.htm What is a Febrile Seizure (Convulsion)? (2006). Retrieved from http://www.baby-medical-questions-and-answers.com/febrileseizure.html