BRONCHOPNEUMONIA

PREPARED BY ,
M. HASEENA
ER DEPT.
DR . AHMAD ABANAMY
HOSPITAL

NURSING CASE STUDY OF A PATIENT

WITH BRONCHOPNEUMONIA
Demographic data
NAME :X
AGE : 9 YEARS
SEX : MALE
NATIONALITY :TURKISH
DATE OF ADMISSION :12/01/13
CHIEF COMPLAINTS :fever,COUGH ,
SOB.
DIAGNOSIS : BRONCHOPNEUMONIA

PHYSICAL ASSESSMENT
:

GENERAL APPEARANCE
Child is looking dull respiratory distress present, wheezing
present, skin is warm to touch
Vital signs:
Temperature : 38.8c
Heart rate : 115 /mnt,
Respiration : 54 b/ mnt nasal flaring present
Blood pressure : 100/ 80 mmHg
Spo2
: 88 % in room air
GENERAL MEASUREMENT
Head circumference 44cm
Chest circumference 28cm
Weight -33kg
Length -110cm

 PHYSICAL ASSESSMENT
SKIN

Normal skin colour

Hair soft and silky
Warm to touch
Nails to end of fingers and often extend
NOSE
Nostrills patent bilaterally
Nasal flaring present
Nasal discharges present

PHYSICAL ASSESSMENT
MOUTH AND THROAT
Uvula midline
Secretion present
Tongue moves freely
Gag reflex present
Teeth is normal in colour
Productive cough present
NECK
Short neck present
Turns side to side easily
No lymph node enlargement present

PHYSICAL ASSESSMENT
CHEST
Bilateral chest movement present
Nipple is symmetrical
Retraction present
Crackles present
Decreased breath sound present
Tachycardia present
ABDOMEN
Soft to palpate
Umbilicus is normal
Bowel sound is normal on auscultation

PHYSICAL ASSESSMENT
GENITALIA
Urinary meatus at tip of glans penis
Palpable testes in scrotum and is normal in shape
Adequate voiding and defecation present
BACK
Spine is intact
No spinal deformity present
EXTREMITIES
Full range of motion present
Ten fingers and ten toes present
Nails are normal in shape and colour

MILESTONES OF
DEVELOPMENT

MILESTONES
GROSS MOTOR

FINE MOTOR

BOOK BASE

PATIENT BASE

Enjoying team games,

eg: foot ball, tennis,
cricket
Are able to swimm
Showing increased
body awareness and
awareness of own
physical skill

MET

Can use adult type

tools such as saws and
hammers
Handwriting become
more legible
Increase writing speed
Writing can occur well
without ruled lines

MET

MILESTONES OF
DEVELOPMENT
TALKING AND
UNDERSTANDING

Use and understand

very complex language

PRESENT

SOCIAL

Able to resolve
problems like fight with
friends and siblings
Ability to understand
others point of view

PRESENT

INTELLECTUAL

Depends on the school

curriculum

IMMUNIZATION STATUS
VACCI
NE

BIRT
H

1MO
S

HEP
B

2MO
S

4MO
S

6MO
S

9MO
S

12M
OS

15M
OS

18MO
S

1923MO
S

23YR
S

46YR
S

RV

DPT

Hib

PCV

IPV

INFLU
ENZA

MMR

VARI
CELL

710YR
S

ABBREVIATION OF
VACCINES

Hep B
RV

: Hepatitis B
: Rotavirus

DPT
HiB
PCV
IPV
MMR
Hep A
MCV 4

: Diphtheria , Pertuses, Tetanus

: Haemophilus influenza type B
: Pneumococcal vaccine
: Inactivated poliovirus
: Measeles, Mumps, Rubella
: Hepatitis A
: Meningococcal virus

PATIENT HISTORY
Past Medical History: patient Xs is known case of bronchial asthma
since
other

childhood.
And he is on medication (nebulization) , and no
treatment .

Present medical history:

complaints of

patient xs is came to ER Dept due to the

high grade fever, severe cough, since

2 days.
Shortness of breath , poor oral intake since one day.
Seen and examined by our ER Paediatrition,
nebulisation with ventolin, atrovent and pulmicort given. Inj .
hydrocortisone 100mg IV given .But no
improvement so the patient
is admitted to ward for
further conservative management

Surgical history
surgical history

patient xs has no present and past

TOPIC PRESENTATION
Bronchopneumonia is a severe type of
pneumonia that is characterized by
multiple areas of acute and isolated
consolidation that affect one or more
pulmonary lobes. It is one of the most
serious infection in childrens.The
disease assumes alarming proportion if
both the lungs are affected. Great care
has to be taken if the patient suffers
from bronchopneumonia. If it is left
untreated, the outcome may be fatal.

BRONCHOPNEUMONIA IMAGES

BRONCHOPNEUMONIA
IMAGES

CROSS SECTION OF
BRONCHOPNEUMONIA AFFECTED LUNGS

ANATOMY AND PHYSIOLOGY OF

RESPIRATORY SYSTEM

The respiratory system is situated in the thorax, and

is responsible for gaseous exchange between the
circulatory system and the outside world.

RESPIRATORY SYSTEM

RESPIRATORY SYSTEM

ANATOMY AND PHYSIOLOGY

The respiratory system is represented by the
following structures

THE NOSE

It consist of the visible external nose and the internal

nasal cavity. The nasal septum divide the nasal cavity into
right and left sides. Air enters two opening , the external
nares (nostrils and naris ) and pasess into the vestibule
and through passages called meatuses. The bony wall of
the meatus called concha , are formed by the facial bone
( the inferior nasal concha and the ethmoid bone ) . from
the meatuses the air then funnels into left and right
internal nares. Hair , mucus, blood capillaries and cilia
that lines the nasal cavity filter, moisten ,warm and
eliminate debris from the passing air .

ANATOMY AND PHYSIOLOGY

PHARYNX
: The pharynx ( throat ) consist of the following three
region , listed in
order through which incoming air passess
NASOPHARYNX : It receives the incoming air from the two internal
nares , the two auditory tubes that equalize the air pressure in the
middle ear also enter here . the pharyngeal tonsils ( adenoid ) lies
at the back of the nasopharynx.

OROPHARYNX : It receives air from the nasopharynx and food from

the oral cavity , the palatine and lingual tonsils are located here .

LARYNGOPHARYNX : It passess food to the oesophagus and air to

the larynx

ANATOMY AND PHYSIOLOGY

THE LARYNX
: It receives air from the laryngopharynx . it consist of several
piece of cartilage that are joined by membranes and
ligaments .
EPIGLOTTIS
It is the first piece of cartilage of the larynx , is a flexible flap
that covers the glottis . the upper region of the larynx , during
swallowing to prevent the entrance of the food .

THYRIOD CARTILAGE

It protect the front of the larynx , a forward projection of this

cartilage appears as the ADAMS apple ( laryngeal prominence ) .

ANATOMY AND PHYSIOLOGY

The upper vestibular folds ( false vocal cords ) contain muscle

fibres that brings the folds together and allow the breath to be
held during periods of muscular pressure on the thoracic cavity
( eg : straining while defecating , or lifting a heavy object )

The lower vocal folds ( true vocal cords ) contain elastic

ligament that vibrate when skeletal muscle move them into the
path of out going air . various sound including speech are
produced in this manner .

CRICOID CARTILAGE

These are supporting the larynx

ANATOMY AND PHYSIOLOGY

TRACHEA

The trachea ( wind pipe )is a flexible tube about 10-12 cm long and 2.5 cm in
diameter

The mucosa is the inner layer of the trachea contain mucus producing goblet cells
and pseudo stratisfied ciliated epithelium . the movement of the cilia sweeps
debris away from the lungs towards the pharynx .

The submucosa is a layer of areolar connective tissue that surround the mucosa .

The adventitia is the outermost layer of the trachea . it consist of areolar

connective tissue .
LUNGS
The lungs are a pair of cone shaped bodies that occupy the thorax , the
mediastenum , the cavity containing the heart , separate the two lungs . left and
right divided by the fissure into two and three lobes . each lobe is further divide
d into lobules with terminal bronchioles . blood vessels , lymphatic vessels and
nerves penetrate each lobe .

ANATOMY AND PHYSIOLOGY

The lungs are the sites for gaseous exchange, and are situated
within the thoracic cavity. They occupy 5% of the body volume in
mammals when relaxed., and their elastic nature allow them to
expand and contract with the process of inspiration and expiration.

Pleura is a double layered membarane consisting of an inner

pulmonary ( visceral ) pleura which surround each lung . the
narrow space between the two membarane is the pleural cavity is
filled with pleural fluid , a lubricant secreted by the pleura .
Each lung has the following superficial features
The apex and the base identify the top and bottom of the lung
The costal surface of each lung borders the ribs
On the medial ( mediastenal surface ) where each lung faces the
other lung , the bronchi , blood vessels, and lymphatic vessels
enter the lungs at the hilus .

ANATOMY AND PHYSIOLOGY

The primary bronchi are two tubes that branch from the trachea
to the left
and right lungs .
Inside the lungs , each primary bronchus divides
repeatedly into branches of secondary
( lobar )
bronchi , tertiary
( segmental ) bronchi , and numerous bronchioles , including terminal
bronchioles and respiratory bronchioles . the wall of the primary bronchi is
constructed like the trachea , but as the branches of the tree get smaller .
the cartilaginous rings and the mucosa are replaced by smooth muscle .

ALVEOLAR DUCTS
These are the final branches of the bronchial tree . each alveolar ducts has
enlarged bubble like swelling along its length . each bubble is called alveolus
. some adjacent alveoli are connected by alveolar pores .

The respiratory membrane consist of the alveolar and capillary walls . gas
exchange occurs across these membarane .

ANATOMY AND PHYSIOLOGY

The characteristics are

TYPE 1 CELLS : are thin , squamous epithelial cells that constitute the alveolar
wall . oxygen diffusion occurs across these cells .

TYPE 2 CELLS : These are cuboidal epithelial cells that are interspersed among
type 1 cells . it will secrete pulmonary surfactant that reduce the surface
tension of the moisture that cover the alveolar walls . a reduction in surface
tension permit oxygen to diffuse more easly into moisture . a lower surface
tension also prevent the moisture on opposite wall of an alveolus , alveolar
duct from cohering and causing the airway to collapse .

ALVEOLAR MACROPHAGE
Alveolar macrophage cells ( dust cells ) wanders among the other cells of the
alveolar wall , removing debris and micro organisam . a dense network of
capillaries surround each alveolus . the capillary wall consist of endothelial cell
surrounded by a thin basement membarane . the basement membarane of the
alveolus and the capillary are often so close that they fuse .

MECHANISM OF BREATHING
Breathing occurs when the contraction or relaxation of muscle around
the lungs changes the total volume of air within the air passages ,
( bronchi , bronchioles ) inside the lungs . when the volume of the
lungs changes , the pressure of the air in the lungs also changes . if
the pressure is greater in the lungs than out side the lungs , the air
rushes out . if the opposite occurs , the air rushes in .

INSPIRATION PHASE
Inspiration occurs when the inspiratory muscle that is the diaphragm
and the external intercostals muscle contract , the contraction of the
diaphragm causes an increase in the size of the thoracic cavity , while
contraction of the external inter costal muscle elevate the ribs and
sternum . thus both muscle causes the lungs to expand , increasing
the volume of their internal air passages . in response the air
pressure inside the lungs decreases below that of air outside the body
. because gases moves from region of high pressure to low pressure ,
air rush into the lungs .

MECHANISM OF BREATHING
EXPIRATION PHASE
It occurs when the diaphragm and external intercostals
muscle relax . in response , the elastic fibres in lung
tissue cause the lung to recoil to their original
volume . the pressure of the air inside the lungs then
increases above the air pressure out the body and
air rushes out .

ETIOLOGY
Bronchopneumonia is caused by viruses, bacteria , fungi protozoa and myco plasma

Bacteria

Streptococcus
Staphylococcus
Hemophilus influenza
Klebsella

Virus
legionella pneumonia

Fungi
candida albicans

Other predisposing factors include:

common in hospitalized patients
its occur as a complication of some other diseases , eg: in children diphtheria,
measles, and whooping cough
In adults- influenza, typhoid and paratyphoid fever
its caused by organism aspirated from mouth

SIGNS & SYMPTOMS

BOOK BASE

PATIENT MANIFESTATION

HIGH GRADE FEVER

FEVER 38.8 C

COUGH W/ MUCUS

PRESENT

CHEST PAIN

MILD CHEST PAIN PRESENT

FATIGUE

PRESENT

IRRITABILITY

NOT PRESENT

DECREASED APETITE

PRESENT

DECREASED BREATH SOUND

PRESENT

HEADACHE

ABSENT

SIGNS AND SYMPTOMS

High grade fever
Any body temperature that goes above 37 c is considered as fever . in
bronchopneumoniamfever may be he symptoms for having the disease, especially if
it is accompanied by other symptoms such as cold , cough and difficulty of breathing

Frequent and excessive coughing accompanied by mucus

Cough is a natural reaction of the body to the presence of certain elements that may
irritate the throat. However if coughing may become pesistant and accompanied by
mucus , then its a sign of something more serious than normal coughing. A person
with bronchopneumonia experience frequent and excessive coughing sometime
accompanied by mucus.

Chest pain
The persons experience difficulty of breathing and also sensation of not getting
enough air , as a result the person gasping for air frequently
Fatigue
Irritability
Decreased apetite
Decreased breath sound on auscultation
Headache

PATHOPHYSIOLOGY
When bacteria infect the pulmonary lobes, the
lungs produce mucus that fills the alveolar
sacs. this will cause a condition known as
consolidation, which occurs when the lungs
fill with mucus, lead to reduce in air space.
This reduction in air space makes breathing
difficulty causing shortness of breath and
labored or shallow breathing

PATHOPHYSIOLOGY
VIRUS ENTER THE RESPIRATORY TRACT
INFLAMMATION
ACCUMULATION OF BRONCHIAL SECRETION

ALVEOLI COLLAPSE
NARROWING OF AIRWAYS

SOB & DOB

BRONCHOPNEUMONIA

INTERVENTIONS
Perform comprehensive assessment
Auscultate breath sound , noting areas
of decreased or absent ventilation
remove secretions by encouraging
coughing
Regulate fluid intake to optimize fluid
balance and liquefy secretions
Administer oxygen if hypoxemic
Administer medication as prescribed

DIAGNOSIS
Auscultation of breathing
pattern
Chest xray
CBC, Sputum culture , creactive protein

INVESTIGATIONS
TEST
C- REACTIVE PROTEIN
WBC
SODIUM
POTASSIUM

PATIENT VALUE

NORMAL
VALUE

POSITIVE

NEGATIVE

15.62uL
135mmol/L

4.23-9.07uL
135150mmol/L

3.6mmol/L

3.5-5.0
mmol/L

CHLORIDE

103mmol/L

9811mmol/L

TREATMENT
Advise to drink plenty of fluid
Enough rest
Elevate the head of the bed to
minimize respiratory effort
Administer oxygen, if needed
Use antibiotics as prescribe
Antipyretics as ordered

COMPLICATIONS
Pleural damage leads to pleural
effusion, pleural empyema
Cardiovascular disease
Respiratory deficiency
Acute renal insufficiency in dehydration
Septic distribution of the pneumonia
agents through the blood with the
development of otitis, meningitis, brain
abscess, endo carditis

PRIORITIZATION OF NURSING PROBLEMS

Ineffective airway clearance related to

accumulation of trachea bronchial
secretion
Hyperthermia related to the inflammatory
process
Impaired gas exchange related to
inflammation of airways and accumulation
of
sputum
Acute pain related to ineffective comfort
measures and inflammation

NURSING HEALTH TEACHING

Follow up the regimen as per order

Frequent hand washing with soap and water
or use hand sanitizer
Advise to have healthy diet and adequate
rest,that will keep the immune system
strong
Advice to cover the mouth while coughing
Follow up to the hospital after finishing the
antibiotic course

NURSING CARE PLAN FOR

BRONCHOPNEUMONIA
ASSESSMENT

NURSING
DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subject :
Difficulty in
breathing

Ineffective airway
clearance related
to accumulation of
tracheobronchial
secretion

After 3- 4 hrs,
patient able to
improve airway
clearance,
reduction of
congestion with
breath sound clear

- Record vital
signs
-Assessment of
breathing pattern
-Advise to drink
plenty fluids
-Elevate head of
bed
-Do suctioning if
necessary

-To obtain baseline

data
-To know the
patient general
condition
-To clear secretion
-To promote
maximxl
inspiration
-To clear airway

After 3-4 hrs

patient shall have
demonstrated
improved airway
clearance,
reduction of
congestion

Objective :
Restlessness with
naslal flaring,
warm flushed
skin ,

ASSESSMENT

NUSING
DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective :
Sleeping
disturbance

Disturbed
sleeping pattern
related to
difficulty of
breathing

After 3-4 hrs of

nursing
intervention he
will be able to
verbalise
understanding of
sleep disturbance

-Monitor vitals
-Encourage to
increase intake of
warm milk for the
child
- Provide a quiet
environment
-Instruct to
elevate head of
the bed
-Oxygen
administration (if
necessary)

-To have a
comparable base
line data
-To promote
comfort and
relaxation
-To promote
comfort for the
child
-To maximize lung
expansion of the
child and
decrease
difficulty of
breathing
-To improve the
o2 saturation

The child shall

have verbalized
understanding of
sleep disturbance

Objective :
Child is restless,
nasal flaring
noted

ASSESSMENT

NUSING
DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective :
Difficulty of
breathing,

Impaired gas
exchange related
to inflammation
of airways

After 4-6 hrs of

nursing
intervention,
patient will be
able to
demonstrate
improvement in
gas exchange

-Monitor and
record vital signs
-Observe color of
skin,mucous
membrane and
nails beds
-Promote
adequate rest
-Keep
environment
allergen freE
-Suction secretion
Prn
-Administer
oxygen as
ordered

-To obtain base

line data
-Cyanosis may
represent
vasoconstrictiono
r the body
response to fever,
chills
-Rest will prevent
fatigue and
decrease oxygen
demand
-To reduce irritant
effects on airway
-To clear airways
-To increase
oxygen saturation

Patient shall
demonstrate
improvement in
gas exchange

Objective :
Presence of
Circum oral
cyanosis
Spo2 = 88% in
room air

ASSESSMENT

NUSING
DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective :
Increased body
temperature
@38.8c

Hyperthermia
related to the
inflammatory
process

After 3 hrs of
nursing
intervention
patient
temperature will
decrease to
normal limit

-Assess patient
condition and
monitor vitals
-perform tepid
sponge bath
-Instruct to
increase fluid
intake
-Maintain patent
airways and
provide blanket
-Provide
antipyretics as
ordered

-To know base line

data
-To promote heat
loss by
evaporation and
conduction
-To support
circulatory
volume and
perfusion
-To promote
patient safety
and reduce chills
-To reduce fever

After 3-4 hrs of

nursing
intervention
patient
temperature shall
have decreased
to normal limits

Objective :
skin is
warm to touch
Vital signs:
Temp :38.8c
PR
:
115/mt
RR
: 54 b/ mt
Spo2 : 88% in
room air

THANK YOU ALL