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Case Study

about
Pneumonia with
Bronchial
Asthma
I. Introduction:
 This is a case of a 1 year old child who
was diagnosed Pneumonia with
Bronchial Asthma.
 Definition of Pneumonia

 Definition of Bronchial Asthma

 Etiologic Agent
II. Goals and
Objectives
III. Client’s Profile
A. Socio-demographic data
 Patient X is a 1- year old Filipina female who is living with her family at
Zone 1 Agusan, Cagayan de Oro City. Her religion is Roman Catholic.
She has no allergies reported. Patient has a Pneumonia, Bronchial
Asthma.
 Patient X was admitted last February 9, 2010 at NMMC-P3F3 Pediatric
Respiratory Ward because of having an onset productive cough
associated with fever. With that, patient X was admitted.B.
B. Vital signs
 The patient vital signs are one of the most important data that should be
given a direct attention because it will serve as basis in determining any
risk factors towards the patient. The increase and decreased of the vital
sign of the patient must be monitored in order to determined whether the
patient is at risk or not.
 The patient had the following vital signs upon admission: PR- 165 bpm ;
RR- 68 cpm; and temp- 36.5°C .
IV. Physical Assessment
 Health perception and management pattern (pre-
hospitalization)
 Nutrition-Metabolic Pattern (MGH – still in)
 Elimination pattern (pre-hospitalization)
 Activities of daily living (ADL) (pre-hospitalization)
 Self-perception and self-concept pattern (while confined)
 Activities Tolerance-Exercise pattern (while confined)
 Sleep rest pattern (while confined)
 Cognitive-Perception (while confined)
 Role-Relationship Pattern (while confined)
 Values – Belief Pattern
V. Neurological Assessment
 Appropriate behavior/communication
Crying
 Emotional State
Anxious
 Skin
 General Color
Pallor
 Eyes
 Conjunctiva
Pale
 Mouth
 Lips
Pallor
 Respiratory Status
 Breathing Pattern
Irregular (68 cpm- tachypnea)
 Breath Sounds
Wheezing during expiration
VI. Anatomy and Physiology
 ORGANS OF THE RESPIRATORY
SYSTEM
 THE UPPER RESPIRATORY
 NOSE
 NASAL CAVITY

 PHARYNX

 THE LOWER RESPIRATORY


 LARYNX
 BRONCHIAL TREE

 LUNGS
VII.
PATHOPHYSIOLOGY
OF PNEUMONIA
WITH BRONCHIAL
ASTHMA
VIII. Laboratory Test Results
 Hemoglobin
 11.2g/dl(12.0-16.0)
 Low Hgb suggest an anemia. Anemia can be due to nutritional deficiencies, blood loss,
destruction of blood cells internally, or failure to produce blood in the bone marrow.
 Hematocrit
 35.8%(37.0-47.0)
 Low Hct suggests an anemia.
 MCV
 62.9fL(82.0-98.0)
 Low MCV may indicate microcytic anemia.
 MCH
 19.7pg(27.0-31.0)
 Low MCH may indicate microcytic anemia.
 MCHC
 31.3g/dL(31.5-35.0)
 It is below the normal range but may indicate anemia.
Differential Count
 Lymphocyte
 74.8%(17.4-48.2)
 High lymphocyte compensates to fight the bacteria found in the body.
 Neutrophil
 10.9%(43.4-76.2)
 Low neutrophil indicates that the patient is vulnerable to infection
thus, she may acquire viral and or bacterial acquired condition easily.
 Monocyte
 12.6%(4.5-10.5)
 High monocyte may indicate bacterial infection.
 Eosinophils
 0.4%(1.0 – 3.0)
 It is below normal range that may suggest asthma.
IX. NURSING
CARE PLAN
X. DRUG STUDY

Zinc Sulfate
 Salbutamol

 Cefuroxime

 Ipratropium Bicarbonate

 Paracetamol

 Hydrocortisone
XI. Discharge Planning
 M-edication to take
 E-xercise

 T-reatment

 H-ygiene

 O-ut patient follow up

 D-iet
XII. HEALTH TEACHING
The best way to control this is prevention.
 Teach the family about the management required for the disorder.
 Keep your environment clear of potential allergens.
 Pay attention to the weather and take precautions when you know weather or air pollution conditions
may affect you. You may need to stay indoors or limit your exercise to indoor activities.
 Be smart about exercise.
 Encourage significant others to do chest tapping to facilitate mobilization of secretion.
 Encourage to change patient's position regularly to facilitate drainage and mobilization of secretion.
 Encourage to provide well ventilated area.
 Instruct to give medications at the right route, dose, and time.
 Remind significant others to always assess to patient needs.
 Instruct significant others to keep child always clean and dry.
 Advise to go to the physician if signs and symptoms of pneumonia and bronchial asthma are observed.
 Teach the folks the importance of monitoring the progress and compliance with the treatment regimen.
 Patient needs health promotions activities and health screening.
 Emphasize to the significant others the importance of having regular check-up to know her present
condition.
XIII. LEARNING
EXPERIENCE
THANK
YOU!!!!