Capitol Medical Center Colleges

Case Study

On

Acute Bronchitis

Submitted by:

Panganiban, Clark David C

Submitted to:

Ms. Jocelyn Amlog RN MAN

 January 26, 2011

I. PATIENT’S PROFILE

Name: Patient X

Age: 1 y.o.

Sex: Male

Address: Q.C.

Birthday: February 1, 2010

Birthplace: Q.C.

Civil Status: Single

Religion: Roman Catholic

Citizenship: Filipino
 Occupation:

Date of Admission: January 15 2010

II. CHIEF COMPLAINT

2 days of fever with cough and cold, 37.6 °C

III. PRESENT HEALTH HISTORY

• 3 days prior to admission the patient has fever with cough and cold.

Physical Assessment

REVIEW OF SYSTEM PHYSICAL EXAMINATION

A.General / Overall health status > received patient conscious, awake and coherent
lying on bed

> with IVF of D5LR 500ml @ 30gtts/min infusing

well

> RR = 34 cpm

> PR = 138 bpm

 > Temp = 37.6°C
> (+) weakness

> (+) productive cough

L. Respiratory > Inspection

- use of accessory muscles in breathing

- (-) noisy breathing

- (+) shallow respirations

- RR = 34 cpm

- (+) cough

- (+) productive cough

> Palpation

- bilateral chest expansion

> Auscultation

- (+) crackles

Q. Musculoskeletal > Inspection

- (+) weakness

- (+) limitation of motion

- (-) deformities
IV. LABORATORY FINDINGS

a. Urinalysis

Actual Findings Actual Findings

Color Yellow Red Blood Cells 0-2 HPF
Transparency Clear Bacteria Negative
Specific Gravity 1.010 Epithelial Cells Rare
Ph 8.0 Mucus Threads Negative
Albumin Negative Amorphous Urates Moderate
Sugar Negative Calcium Oxalates Negative
White Blood Cells 1.3 HPF

b. Hematology

Actual Findings Normal Range Interpretation

Hemoglobin 12.8 Female: 12-16 Decrease in hemoglobin
Male: 13-18 is a sign anemia, or
Child: 14-26 excessive fluid intake
Hematocrit 38 Female: 36 - 57 Decreased hematocrit is
Male: 40 – 54 a sign of anemia.
White Blood Cells 4.0 x 10^9/L 5-10 x 10^9/L Decreases no. of WBC is
a sign of infection
Red Blood Cells 4.7 x 10^12/L 4 – 6.0 x 10^12/L Client’s finding is within
normal range.
Platelet Count 201 x 100^g/L 150 – 400 x 100^g/L Client’s finding is within
normal range
Monocytes - 0.02 – 0.04 Decreased no. may be a
sign of infection
Eosinophils - 0.02 - 0.05 Decreases no. may be a
sign of infection
Lymphocytes 0.41 0.25 – 0.35 Increased no. is a sign of
infection.
V. ANATOMY

o Respiratory System

A respiratory system's function is to allow gas exchange. The

space between the alveoli and the capillaries, 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.

Breathing is an active process - requiring the contraction of

skeletal muscles. The primary muscles of respiration include the
external intercostal muscles (located between the ribs) and the
diaphragm (a sheet of muscle located between the thoracic &
abdominal cavities).
 VI. PATHOPHYSIOLOGY

Noxious Viruses
Predisposing factors
Gases

Inhalation When inhaled, viruses and noxious gases enters the

respiratory tract

Increased mucous Initial respiratory response of the body

production
Because of increased mucous production airway is
Narrowing of airway
narrowed

Increased no. of goblet

Bronchial walls is thickened
cells
Flow of air is altered because of blockage of increase
Airflow obstruction
mucous

Contributing factor that thickens blood vessels in the lungs

Cigarette
smoking
Macrophages destroys foreign particles including bacteria
Altered function of and viruses
alveolar macrophages

BRONCHITIS
 Because of the absence of macrophages infectious
microorganisms is free to enter the body
Increased susceptibility
of respiratory infection
When infection reach the bronchial walls

Prolonged infection of the respiratory system may lead to

pneumonia
Pneumonia

VII. DISCHARGE PLANNING

HEALTH PROMOTION STRATEGY
• MEDICATION • Write the exact time and instruction when to
take the medication and how to take the
medication.
• Emphasize to the significant others the
importance of taking medications as prescribed.
• ENVIRONMENT • Advise significant others for having a frequent
hand washing to prevent transmission of
bacteria to the susceptible patient.
• TREATMENT • Advise significant others to follow the drug
regimen of the patient
• HEALTH TEACHING • Encourage client to practice general hygiene to
prevent infection
• FOLLOW-UP CARE • Remind when will they come back and
 provide a copy of schedule of the doctor,
room and how they visit for follow-up check
up
• DIET • Lecture patient and care giver regarding the
diet