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INTRODUCTION

Bronchopneumonia, a community acquired pneumonia, is an acute inflammation


of the walls of smaller bronchial tubules with varying amounts of pulmonary
consolidation due to spread of the inflammation into peribronchiolar alveoli and the
alveolar ducts . Most cases are caused by organisms aspirated from the mouth
(Wikipedia.com) .

This is a case of a 6 month old male child, TDL, diagnosed with


bronchopneumonia. He was admitted at JR Borja’s General Hospital on December 17,
2008 at 12:15pm with chief complaints of cough, fever and respiratory distress. Onset of
cough was three days prior to admission which developed to shortness of breath a day
prior to admission and fever in the morning on the day prior to admission. Upon
assessment, the group found out that the family lives in Gaabucayan Agora near an
industrial area. Patient TDL was previously admitted to Sabal Hospital with a diagnosis
of Bronchial Asthma last August 2008.
SCOPE & LIMITATION

This case presentation only covers the case bronchopneumonia with signs and
symptoms manifested in particular with patient TDL. Data gathered and used are based
on the assessment conducted on December 17, 2008 and December 18, 2008. Care and
interventions for the patient were also limited to the all in all 16 hours duty of the said
dates. The lack of ABG or at least a pulse oximeter in the Pediatric ward of the hospital
prevented the group to monitor accurately the oxygen saturation and over-all gas
exchange of the patient. Culture and Sensitivity Test and Gram Staining were done but
results were not released during duty dates so the group has no knowledge of the exact
microorganism causing the disease. Based on the signs and symptoms, the group assumed
that it is of bacterial origin in constructing the Pathophysiology of the disease.

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General Objectives:

The general objectives for conducting this case study are for students to
incorporate concepts and enhance knowledge in Maternal and Child Health Nursing and
Medical Surgical Nursing to apply the appropriate nursing management for clients with
Bronchopneumonia accurately and efficiently. This study also aims to develop the skills
that are applied for the care of patients with this condition. At the same time, it allows the
students to utilize the different attitudes that were instilled on them, such as on being
respectful, patient and empathetic.

Specific Objectives:

At the end of 2 Hours of case presentation, this case study specifically aims to:

a. Define Bronchopneumonia accurately


b. Discuss briefly the causative factors that may have precipitated the onset of the
condition
c. Discuss thoroughly the signs and symptoms manifested by patient
d. Discuss the different drugs; indications, mechanism of action, therapeutic effects,
adverse effects and contraindications.
e. Present accurately the condition of the patient
f. Acquire knowledge and understanding of the Pathophysiology of Bronchopneumonia
g. Discuss the nursing care plan appropriate in providing care to alleviate the
manifestation of the patient’s symptoms
h. Identify and provide the health teachings needed for the continuum of care
i. Use the nursing care plan as the framework of the patient’s care

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ASSESSMENT TOOL

Date of Assessment: December 18, 2008


Client Profile:
Name: __Dan Lordy M. Tuzon_______ Age: __6months__
Birthday: __May 24, 2008_ Birthplace: _Cagayan de Oro City_
Address: __Gaabucayan extension, Agora, CDO__
Religion: __Roman Catholic__
Name of parents/guardian__Mrs. Flora Tuzon__
Name of Informant: ___ Mrs. Flora Tuzon ___ Relation to client: __Mother__
Attending Physician:__Dr. Caragos/Perez___
Date of admission: _December 17, 2008 Room/ward #: _1_ No. of days admitted __2__
Chief complaints/ upon admission: __Fever, cough, & difficulty in breathing_“Galisod
lagi ug ginhawa akong anak tungod sa iyang ubo…” as verbalized by mother.
Medical Diagnosis, if any: __Severe Bronchopneumonia__

Current Medications:

Name of drugs Dosage Indications


Paracetamol (Tempra) 1ml q4h po PRN for fever
Hydrocortisone 30mg q6h ivtt Corticosteroid
Combivent 1neb q6h Bronchodilator
Cefuroxime 250mg q8h ivtt Antibiotic

Past hospitalizations, if any: __October-2008 at Sabal Hospital___


Past treatments, if any: ___mother cannot specify___

I. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN

Appearance _Weak____________________________________________________
Grooming _hair properly groomed, clean clothing____________________________
Posture ____not noted_(patient was lying on bed during assessment)____________
Height __Not noted____________________ Weight ___8kg.___________________
H.R. ___168bpm_ R.R __74cpm
Temperature __39.7°C_”taas jud kaayo iyang hilanat, mao gidala najud nako siya dri sa
hospital_basin magkumbulsyon na” as verbalized by mother___

Immunizations received including date:


BCG- May 2008
OPV-June 2008
Hep B-May 2008

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II. NUTRITIONAL METABOLIC PATTERN

Skin: Color __Pale and dusky___________ Texture __good skin turgor, warm, (-)
_rashes_
Lesions _some scratches on face-- “sige mana dili makambrasan iyang nawong
gud”- as verbalized by Mother__
Hair: Color __light brown__________ Texture ____Normal_____
Lesions __None_____________
Nail: Color __Pale________________ Condition Normal capillary refill 3sec
Oral mucosa: Teeth __None_________ Condition __inflammed gums_____
Daily food intake: ___Breastfed per demand___________________________________
Food Supplements _None___________________________________________________
Vitamins taken __”naa ni siya vitamins, kadtong Ceelin, pero karon wala na siya
makatumar, wala paman sad gud mi ikapalit.”___

III. ELIMINATION PATTERN

Bowel habits:
Frequency __twice_ Color __Yellow___
Consistency ___Loose and Watery__ Amount __50cc___
Bladder habits:
Frequency__5-7 times Color __Straw yellow___
Amount __100cc__

IV. ACTIVITY-EXERCISE PATTERN

Daily activities: ___”Sa balay raman mi pirmi kay wala man ko nag trabaho, naa ragyud
ko pirmi sa akong mga anak gabantay”, “kada-adlaw gyud ni siya duwaon sa among mga
silingan, tambok man gud siya ug hinga-taw-on mao daghan ganahan magduol niya.” As
verbalized by mother__
Leisure activities: __”kadtong wala pa siya masakit, kiat jud kaayo ni siya, labina inig
mag dula na siya sa iyang ate. Lihok jud ni siya a bata, karon, dili jud, sige ra ug hilak”
As verbalized by mother__
Exercise routine: _”kana amo siyang duwa-duwaon, mao na na silbi iyang exercise,
kusog pud kaayo mag ambak2x maskin dili pa katindog.”As verbalized by mother

V. SLEEP-REST PATTERN

Time of Sleep: _”walay klaro nga oras iyang tulog, sukad pa ni gahapon kadto nagsugod
iyang hangos” As verbalized by mother_”Pero katong wala pa siya nahospital gatulog
nana siya inig alas 8 dayon momata siya mga 6 or 7 sa buntag”._

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Quality: _”Dili lagi na siya makatulog ug tarong tungod kay ga-hangos siya. Pero sa
balay noon kay straight gyud iya katulog”, As verbalized by mother_
Sleep aid/s: __none___

VI. RESPIRATION

Subjective
Dyspnea, related to: Accumulation of secretion in the airway
Cough: Unproductive _“Galisod lagi ug ginhawa akong anak tungod sa iyang ubo…” as
verbalized by mother.
History of: Bronchial Asthma
Use of respiratory aids: Oxygen inhalation via nasal cannula(lpm)
Comments: “gahangos jud siya mag ginhawa, samot na siya galisod ginhawa pag mag
hilaka” as verbalized by mother

Objective
Respiratory: Rate: 74 cpm Depth: Rapid shallow breathing
Use of accessory muscle: (+) chest retractions Nasal flaring: (+)
Breath sounds: Wheeze and crackles noted upon auscultation_

VII. SENSORY-PERCEPTUAL PATTERN

Vision: __Normal______________________ Aid/s for vision: __None____________


Hearing: __ Normal____________________ Aid/s for hearing: ____ None_______
Smell: ___ Normal_____________________

VIII. COGNITIVE PATTERN

Ability to express
_____” dili man siya responsive kaayo inig dulaon karon, lain gyud tingale iyang pamati
kay lihokan mani siya atong wala pa siya masakit”. Another way of expressing the
patient’s needs or problems is through crying which is normal in his age.

IX. ROLE-RELATIONSHIP PATTERN

Ordinal positon of client in the family: __2___________


Primary care giver of client:__Mother- Flora Tuzon____
Other support system of client: _Father______________

LABORATORY RESULTS

CBC

Normal values Indications

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WBC: 12,000 5,000-10,000 Infection
Hemoglobin: 10.0 12.0-16.0gm/dl anemia
Hematocrit: 32.2 37.0-47.0vol% Polycythemia, diarrhea
Platelet: 383,000 150,000-400,000/mm within normal values
(Differential Count)
Granulocyte: 68 43.4-76.2 % within normal values
Lymphocyte: 32 17.4-48.2 % within normal values

CXR
Type of examination: CHEST APL
X-ray report:
Blotchy densities in both lungs , more in the right, Heart, Trachea, Diaphragm,
and sinuses are unremarkable.

Impression: Brochopneumonia, severe

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ANATOMY AND PHYSIOLOGY

The respiratory system consists of all the organs involved in breathing. These
include the nose, pharynx, larynx, trachea, bronchi and lungs. The respiratory system
does two very important things: it brings oxygen into our bodies, which we need for our
cells to live and function properly; and it helps us get rid of carbon dioxide, which is a
waste product of cellular function. The nose, pharynx, larynx, trachea and bronchi all
work like a system of pipes through which the air is funneled down into our lungs. There,
in very small air sacs called alveoli, oxygen is brought into the bloodstream and carbon
dioxide is pushed from the blood out into the air. When something goes wrong with part
of the respiratory system, such as an infection like pneumonia, it makes it harder for us to
get the oxygen we need and to get rid of the waste product carbon dioxide.

Air enters your lungs through a system of pipes called the bronchi. These pipes
start from the bottom of the trachea as the left and right bronchi and branch many times
throughout the lungs, until they eventually form little thin-walled air sacs or bubbles,
known as the alveoli. The alveoli are where the important work of gas exchange takes
place between the air and your blood. Covering each alveolus is a whole network of little
blood vessel called capillaries, which are very small branches of the pulmonary arteries.
It is important that the air in the alveoli and the blood in the capillaries are very close
together, so that oxygen and carbon dioxide can move (or diffuse) between them. So,
when you breathe in, air comes down the trachea and through the bronchi into the alveoli.
This fresh air has lots of oxygen in it, and some of this oxygen will travel across the walls
of the alveoli into your bloodstream. Travelling in the opposite direction is carbon
dioxide, which crosses from the blood in the capillaries into the air in the alveoli and is
then breathed out. In this way, you bring in to your body the oxygen that you need to live,
and get rid of the waste product carbon dioxide.

The lungs are covered by smooth membranes that we call pleurae. The pleurae
have two layers, a 'visceral' layer which sticks closely to the outside surface of your

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lungs, and a 'parietal' layer which lines the inside of your chest wall (ribcage). The
pleurae are important because they help you breathe in and out smoothly, without any
friction. They also make sure that when your ribcage expands on breathing in, your lungs
expand as well to fill the extra space.

When you breathe in (inspiration), your muscles need to work to fill your lungs
with air. The diaphragm, a large, sheet-like muscle which stretches across your chest
under the ribcage, does much of this work. At rest, it is shaped like a dome curving up
into your chest. When you breathe in, the diaphragm contracts and flattens out, expanding
the space in your chest and drawing air into your lungs. Other muscles, including the
muscles between your ribs (the intercostal muscles) also help by moving your ribcage in
and out. Breathing out (expiration) does not normally require your muscles to work. This
is because your lungs are very elastic, and when your muscles relax at the end of
inspiration your lungs simply recoil back into their resting position, pushing the air out as
they go.

Each branch of the bronchial tree eventually sub-divides to form very narrow
terminal bronchioles, which terminate in the alveoli. There are many millions of alveoli
in each lung, and these are the areas responsible for gaseous exchange, presenting a
massive surface area for exchange to occur over.

Each alveolus is very closely associated with a network of capillaries containing


deoxygenated blood from the pulmonary artery. The capillary and alveolar walls are very
thin, allowing rapid exchange of gases by passive diffusion along concentration
gradients. CO2 moves into the alveolus as the concentration is much lower in the alveolus
than in the blood, and O2 moves out of the alveolus as the continuous flow of blood
through the capillaries prevents saturation of the blood with O2 and allows maximal
transfer across the membrane.

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Air usually moves into the body through the nose and into the nasal cavity. The nasal
hairs catch and filter foreign substances that may be present in the inhaled air. The air is
warmed and humidified as it passes by blood vessels close to the surface of the epithelial
lining which contains goblet cells that produce mucus to trap dusts, microorganisms,
pollen, and other foreign substances. The epithelial cells of this lining contain cilia—
microscopic, hair-like projections of the cell membrane—which constantly moving and
directing down toward the throat. Air then moves from the nasal cavity into the pharynx
and larynx. The larynx contains the vocal cords and epliglottis, which close during
swallowing to protect the lower respiratory tract from any foreign particles. From the
larynx, air proceeds to the trachea, the main conducting airway into the lungs. The
trachea divides into two main bronchi, which further divides into smaller and smaller
branches. All of these tubes contain mucus-producing goblet cells and cilia to entrap any
particles that may have escaped the upper protective mechanisms. The walls of the
trachea and conducting bronchi are highly sensitive to irritation. When receptors in the
walls are stimulated, a central nervous system reflex is initiated and a cough results. The
cough causes air to be pushed through the bronchial tree under tremendous pressure,
cleaning out any foreign irritant. This reflex, along with the similar sneeze reflex, forces
foreign materials directly out of the system, opening it for more efficient flow of gas.

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Throughout the airways, many macrophage scavengers freely move about the epithelium
and destroy invaders. Mast cells are present in abundance and release histamine,
serotonin, adenosine triphosphate, and other chemicals to ensure a rapid and intense
inflammatory reaction to any cell injury. The end result of these various defense
mechanisms is that the lower respiratory tract is virtually sterile—an important protection
against respiratory infection that could interfere with essential gas exchange.

Gas exchange occurs in the alveoli. In this process, carbon dioxide is lost from the blood
and oxygen is transferred to the blood. The exchange of gases at the alveolar level is
called ventilation. The alveolar sac holds the gas, allowing needed oxygen to diffuse
across the respiratory membrane into the capillary while carbon dioxide, which is more
abundant in the capillary blood, diffuse across the membrane and enters the alveolar sac
to be expired. The respiratory membrane is made up of the capillary endothelium, the
capillary basement membrane, the interstitial space, the alveolar basement membrane, the
alveolar epithelium, and surfactant layer. The sac is able to stay open because the surface
tension of the cells is decreased by the lipoprotein surfactant. Absence of surfactant leads
to alveolar collapse.

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NARRATIVE PATHOPHYSIOLOGY

Bronchopneumonia, also known as lobular pneumonia, is a type of pneumonia


characterized by multiple foci of isolated, acute consolidation, affecting one or more lung
lobes. It is one of two types of bacterial pneumonia as classified according to the gross
anatomic distribution of consolidation (solidification), the other being lobar pneumonia.
Bronchopneumonia is more likely than lobar pneumonia to be associated with
streptococcus. The difference between bronchopneumonia and lobar pneumonia is in the
distribution of consolidation. In lobar pneumonia, consolidation occurs in one entire lobe
while in bronchopneumonia or lobar pneumonia; there are multiple separate acute areas
of consolidation which may affect one or more lobes. It should be noted however, that
although these 2 patterns of pneumonia, lobar or lobular are the classic anatomic
categories of bacterial pneumonia, in clinical practice the types are difficult to apply as
the patterns usually overlap. Bronchopneumonia often leads to lobar pneumonia as the
infection progresses.
The predisposing factors of bronchopneumonia include age, an immature or
altered state of immunity and polluted environment (smoking, noxious gases, etc). The
factors that precipitate this condition include exposure to pathogen and an upper
respiratory tract infection. Bronchopneumonia almost always occur after an upper
respiratory tract infection wherein the pathogen is able to mobilize through the
respiratory defenses due to factors such as inhalation of polluted gasses which may
impair the ability of the cilia to propel pathogens upward. These factors also include
extremes of age in these age brackets has immature or altered state of immunity. Once the
pathogen enters the lower respiratory tract, they infect the airways, starting in the
bronchi, bronchioles, terminal bronchioles and spread to the alveoli. Once the cells of
these structures are injured, they release biochemical mediators of inflammation and the
inflammatory response occurs. Also, once cells in the respiratory mucosa (goblet cells)
become injured they secrete large amounts of mucous which contribute to the pooling or
accumulation of fluid in the airways and alveoli. Biochemical mediators such as
Histamine and Bradykinin cause capillary vasodilatation which increases blood flow to
the area thereby bring also more nutrients. WBC’s such as neutrophils, monocytes, and

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others enter the area through the process of chemotaxis and phagocytosis of pathogens,
and debris occur. However, phagocytes also release endogenous pyrogens which
stimulate the hypothalamus to increase the body temperature causing fever. Another
action of the inflammatory response is increased capillary permeability which causes
capillaries to open up and make it easier for plasma, blood cells (WBC’s) & plasma
proteins to leave the blood stream and enter into the plasma and WBC’s and leak into the
airway and alveoli causing swelling and edema. Thus fluid accumulation is evident in the
bronchi, bronchioles and alveoli which include mucus, and other blood components such
as WBC’s. This fluid is then manifested in the patient as crackles and wheezing which are
breath sounds that indicate fluid in the airways and narrowing of the airways respectively.
The presence of mucus stimulates coughing as to expectorate the liquid in the airways.
While the WBC is detected, as leukocytosis or increase in the number of WBC indicative
of infection. Because of this fluid accumulation in the airway (bronchioles or terminal
bronchioles) and alveoli two things happens. First, the airways are clogged with exudates
and fluids which results to less oxygen reaching the alveoli. His is manifested as
shortness of breath or a feeling of difficulty catching your breath. Second, the alveoli lose
air spaces and solidify because the space which air must occupy is filled with fluids and
exudates (consolidation). This is manifested as dullness during percussion. This results to
decreased lung compliance and recoil; which needs the use of accessory muscles to fully
expand the lungs during breathing manifested as chest retractions. Both these events lead
to decrease oxygen and carbon dioxide exchange in the alveoli (oxygen can’t transfer to
the bloodstream, and carbon dioxide from the bloodstream can’t be expelled from the
body through the lungs). The body compensates the decrease in oxygen that reaches the
alveoli by increasing the respiratory rate to bring more oxygen to the alveoli manifested
as Tachypnea. Because not enough oxygen is transferred to the blood from the alveoli,
the blood will contain less oxygen which is also known as hypoxemia. With hypoxemia,
hypoxia is almost inevitable. Because the blood carries less oxygen, less oxygen is also
delivered to body tissues and organs. This is manifested in the patient as pale and dusky
skin. However, at the beginning of this compromise, the heart compensates by increasing
the heart rate to bring more blood and sufficient oxygen to vital organs and other body
tissues manifested as tachycardia. This condition has complications which are fatal.

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When hypoxia is severe that vital organs and other tissues are almost unoxygenated it
could complicate to multiple organ failure which eventually leads to death.

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MEDICAL MANAGEMENT

Ideal Management

Bronchopneumonia

If the cause is bacterial, the goal is to cure the infection with antibiotics. If the
cause is viral, antibiotics will NOT be effective. In some cases it is difficult to distinguish
between viral and bacterial pneumonia, so antibiotics may be prescribed. Pneumococcal
vaccinations are recommended for individuals in high-risk groups and provide up to 80
percent effectiveness in staving off pneumococcal pneumonia. Influenza vaccinations are
also frequently of use in decreasing one’s susceptibility to pneumonia, since the flu
precedes pneumonia development in many cases.

Unlike lobar pneumonia, in which an entire section or subdivision of the lung may
be inflamed; bronchopneumonia tends to appear in patches in and around the small
airways and passages. Outward clinical symptoms will be similar to those of lobar
pneumonia, however, and can include fever, coughing, chest pain, chest congestion,
chills, difficulty with breathing and blood-streaked mucus that is coughed up. Pneumonia,
including bronchopneumonia is a fairly common illness and it affects millions of people
annually in the United States. The severity of the illness will depend on the type of
bacteria or infection causing the illness, as well as the overall health of the person who
has bronchopneumonia.

In order to diagnosis this illness, a doctor may take a chest X-ray, may test a
sample of the sputum, may do a CBC to get a count of the white blood cells in the blood,
may take a CAT scan, and/or may take a pleural fluid culture of the fluid surrounding the
lungs.

Upon diagnosis, most people will be treated at home with antibiotics. If the
patient is suffering from dehydration or has a severe case of bronchopneumonia, he or she

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may be treated in the hospital where the illness can be more closely monitored. With
appropriate treatment, most people recover fully within a couple weeks. Very infirm or
elderly people who do not get appropriate treatment can die from bronchopneumonia.

Actual Management

Chest X-Ray, urinalysis and hematology had been performed to the patient. Chest
X-Ray is used to help diagnose symptoms such as shortness of breath, bad or persistent
cough, chest pain or injury and fever. Succeeding chest X-Ray was used to evaluate
changes found on the previous X-Ray result. Urinalysis is done to test for the presence of
sodium retention. Hematology is performed to help diagnose the patient’s condition and
to check for presence of infection.

The patient was diagnosed with severe bronchopneumonia, several drugs were
administered to treat this condition, namely: Hydrocortisone, Paracetamol, Cefuroxime
with supportive therapies: Salbutamol and Oxygen inhalation.

Drugs for management of Severe Bronchopneumonia:

Hydrocortisone, classified under corticosteroid, was used to treat severe


inflammation. This decreases inflammation, mainly by stabilizing leukocyte lysosomal
membranes; suppresses immune response; stimulates bone marrow; and influences
protein, fat, and carbohydrate metabolism.

Paracetamol, an antipyretic agent used to treat mild fever. The drug may relieve
fever through central action in the hypothalamic heat regulating center.

Cefuroxime, a cephalosporin agent used to treat lower respiratory tract infection.


It is a second generation cephalosporin that inhibits cell wall synthesis promoting osmotic

17
instability; usually bactericidal; generally well tolerated and side effects are usually
transient.

Other Supportive Therapies:

Salbutamol is a short-acting beta2-adrenergic receptor agonist used for the relief


of bronchospasm in conditions such as asthma and chronic obstructive pulmonary disease
using a nebulizer for the patient. This is used to soften the mucus thus make it easier for
the patient to expectorate cough.

Oxygen inhalation, another supportive therapy, is the administration of Oxygen as


a therapeutic modality. Oxygen therapy benefits the patient by increasing the supply of
oxygen to the lungs and thereby increasing the availability of oxygen to the body tissues.

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DOCTOR’S ORDERS

Date Doctor’s Order


December 17, 2008 > please admit under the service of Dr. Dy
> secure consent to care
> problem: SOB
> condition: fair
> allergies: none
> diet: NPO if dyspneic (RR≥50cpm)
> TPR q6 hours. I & O every shift
> start with D5 0.3% NaCl 500cc at 35cc/hr
> labs CBC with V/A
CXR – APL
> meds
• Hydrocortisone 80mg loading dose
now then 30 mg q6 hours
• Combivent q6 hours
> refer to Dr. Dy for further orders
Dr. Caragos
> PCM 100mg/ml
December 18, 2008 > O2 @ 2L/min
> start cefuroxime 250mg IVTT q8h ANST
> may give pcm supp 125mg suppository
(opigesic) per rectum now
> IVF follow-up D5IMB 500cc at same
rate
> pcm 80mg very slow IVTT q4h for temp
38°c ↑

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Drug name Classification Drug dose Mech. Of Indication Contraindication Adverse Nursing
Action Effects Considerations
Generic Analgesic, 1ml q4h po Exact Commonly Active Early : • Check
name: antipyretic. mechanism used for relief alcoholism, liver Anorexia, the
Paracetamol unknown, but of fever, disease or viral nausea, time
appears to headaches, hepatitis diaphoresis, and
Brand name: inhibit and other (increase risk general dosage
Tylenol, prostaglandin minor pains hepatotoxicity.) weakness before
Biogesic, synthesis in and aches. with in first admini
Tempra CNS and, to a 12-24 hours. stering.
lesser extent, • Assess
by blocking Later: for
pain impulse Vomiting, possibl
through right upper e drug
peripheral quadrant reactio
action. Acts tenderness; ns.
centrally on elevated liver • Assess
hypothalamic function tests for
heat- with in 48-72 clinical
regulating hours after improv
center, ingestion. ement
producing and
peripheral relief
vasodilatation of
(skin pain,
erythema, fever.
sweating, heat Therap
loss). eutic
blood
serum
level:
10-30
mcg/m
l;
toxic
serum20
level :
>200m
cg/ml.
21
Drug name Classification Drug dose Mech. Of Indication Contraindication Adverse Nursing
Action Effects Considerations
Generic Cephalosporin, 250mg Binds to For lower History of Antibiotic- • Assess for
name: second q8h ivtt bacterial respiratory hypersensitivity associated possible
Cefuroxime generation membranes. tract to colitis( severe signs and
Inhibits infection due cephalosporins, abdominal symptoms
Brand name: synthesis of to S. anaphylactic pain, of drug
Zinacef, bacterial cell pneumoniae, reaction to tenderness; reaction.
Ceftin wall. UTI’s due to penicillins. fever; watery, • Assess for
Bactericidal. E. coli and severe anemia and
skin infection diarrhea), other renal
due to S. superinfections dysfunctio
aureus. may result from n.
altered • Assess
bacterial moth for
balance. white
Nephrotoxicity patches on
may occur, mucus
especially with membranes
preexisting , tongue.
renal disease. Monitor
Severe bowel
hypersensitivity activity/sto
reaction( severe ol
pruritus, consistency
angioedema, carefully;
bronchospasm, mild GI
anaphylaxis), effects may
particularly in be
patients with tolerable,
history of but
allergies, increasing
especially severity
penicillin. may
indicate
onset of
antibiotic-
associated
colitis.
Monitor I
& O, renal22
function
reports for
nephrotoxi
Drug name Classification Drug dose Mech. Of Indication Contraindication Adverse Effects Nursing
Action Considerations
Generic name: Cortico- 30mg q6h Suppress Inflammatory Contraindicated Seizures, headache, • Admi-
Hydrocortison steroids ivtt inflammatio disorders, with fungal hypotension, shock, nister
e n and the adrenal infections, hypertension, thin. drug as
normal cortical amebiasis, Fragile skin, prescri
insufficiency
Brand name: immune hepatitis B, petechiae, bed
Cortef, response. It vaccinia or ecchymoses, • Dosage
Hydrocortone replaces varicella, purpura, decrease reducti
endogenous antibiotic- carbohydrates ons
cortisol in resistant intolerance, sodium may
deficiency infections, and fluid retention, create
states. It also immuno- hypersensetivity adrenal
has potent suppression reactions, muscle insuffic
mineralocort weakness, iency,
icoid immunosuppression repot
(sodium- immed
retaining) iately
activity for any
abnor
malitie
s
• Take
with
meals

23
Name of Drug Classification Dosage/ Date Ordered Indication Action Side-effects Nursing
Frequency Consideration

Combivent Sympathomimetic 1neb q6h 12/18/08 Prophylaxis Stimulates beta- Headache, >When given
nebule agent and treatment II receptor o Palpitation, by
of bronchi leading Tachycardia, nebulization,
bronchospasm to Tremor, use face mask
d/t reversible bronchodilation Bronchospasm or mouth piece
obstructive
airway disease >Monitor
pulmonary
status

>Use
Combivent
exactly as it
was prescribed.
Do not use the
medication in
larger amounts,
or use it for
longer than
recommended
by the doctor.

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NURSING CARE PLAN: 1

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CUES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective: Ineffective Short term: Independent Short- term:
“ airway After 30 minute of - to detect early
_“Galisod lagi ug clearance intervention, the patient will: 1. assess RR signs of After 30
ginhawa akong anak related to a) demonstrate an RR of every 4 hours compromise minutes, the
tungod sa iyang tracheobronchial 50-60cpm,reduced 2. increase fluid patient
ubo…” as verbalized inflammation cough, and irritability intake to at - hydration can help demonstrates
by mother. and presence of the family will: least liquefy viscous the ff:
secretions b) verbalize 3. position secretions &
understanding of cause appropriate improve secretion
(s) and therapeutic (head of bed clearance
management elevated) and
discourage -to prevent The family
use of vomiting with verbalized:
oilbased aspiration into lungs
Long term:’ products
Objective: After 2 days intervention, around nose. -to ascertain status
 tachypnea the patient will: 4. perform & note progress Long-term:
 ineffective a) demonstrate percussion
cough noted absence, improved and vibration -to improve After 2 days of
 crackles and of congestion with every 4 hours respiratory function interventions
wheezing breath sounds 5. avoid supine the patient
noted upon clear, respiration position for -to stimulate cough demonstrates
auscultation noiseless, extended & clear airways minimal breath
 irritability improved 0xygen periods sounds, regular
 rapid shallow exchange. 6. encourage -to enhance rate & depth of
breathing sitting, lateral mobilization of respiration.
prone and secretions that
 cyanosis
upright interfere with
position oxygenation
7. auscultate
breath sounds -to enhance lung
and assess air expansion &
movement ventilation

Dependent
1. give
bronchodilat 26
ors as
ordered
2. suction as needed.
NURSING CARE PLAN: 2

27
CUES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective: Short-term: Independent: Short-term:

“gahangos jud Ineffective After 4 hours of 1. Auscultate chest  To evaluate After 15 mins.
siya mag Breathing intervention, patient will presence/charact Of intervention,
ginhawa, samot Pattern r/t have adequate er of breath the patient
na siya galisod collection of oxygenation. sounds/secretion manifested
ginhawa pag secretions in s. absence of
mag hilaka” as airway 2. Position patient  To promote ease dyspnea with RR
verbalized by properly. Elevate of maximum of 50-60 cpm
mother patient by placing respiration. with minimal
small pillow under wheezing,
Objective: his head. crackles, and
3. Limit visitors and  To decrease irritability.
 Tachypnea maintain a calm anxiety. Anxiety
RR: 74cpm attitude/voice can cause baby Long-term:
 Dyspneic Long-term: when dealing with to cry thus
 Wheeze and the infant adding factors After 16hours of
crackles After 16hours of that contribute to intervention,
noted upon intervention, Patient will difficulty in Patient
auscultation establish a breathing established a
 Irritability normal/effective 4. Instruct mother not  To prevent normal/effective
 Rapid respiratory pattern as to feed baby if aspiration respiratory
shallow evidenced by RR of 50-60 dyspneic pattern as
breathing cpm and absence of evidenced by RR
wheezing, crackles, Dependent: of 50-60 cpm
 (+) chest
dyspnea, and irritability. and absence of
retractions
5. Administer oxygen  To provide wheezing,
 (+) nasal as prescribed by crackles,
flaring adequate
physician oxygenation dyspnea, and
6. Administer irritability
 To treat and
prescribed
manage any
medications
other underlying
causes.
7. Assist with
nebulization of  Facilitates
Combivent nebule liquefaction and
removal of
secretions. And
causes
bronchodilation. 28
NURSING CARE PLAN: 3

29
CUES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective: Impaired gas Short term: Independent Short term
exchange After 4 hours of 1.) Monitor  Manifestations After 4 hours of
_“Galisod lagi related to intervention, the family respiratory rate, of respiratory intervention, the
ug ginhawa altered oxygen will: depth and scale distress are family:
akong anak supply  Verbalize dependent a.) Verbaliz
tungod sa understanding of on/and ed
iyang ubo…” causative factors indicative of understa
as verbalized and appropriate the degree of nding of
by mother. intervention lung causativ
involvement e factors
Long Term: and underlying such as
After 1 week of general health inhaled
Objective: intervention, the patient status. bacteria
 Irritabil will: and
ity (+)  Demonstrate 2.) Observe color of  To note appropri
 Abnor improved skin, mucous respiratory ate
mal ventilation and membranes and compromise intervent
Skin adequate nail beds, noting ions
Color: oxygenation of presence of such as
Pale & tissues manifested peripheral medicati
Dusky by absence of cyanosis on
 Tachyp symptoms of complia
nea w/ respiratory distress 3.) Elevate head of  To maintain nce and
RR= such as irritability, bed/position airway and adequate
74cpm pale skin, client enhance gas breastfee
 Tachyc tachypnea and appropriately exchange ding
ardia tachycardia Long term
HR= 4.) Change patient’s  To mobilize After 1 week of
168 position at least secretions and intervention, the
every 2 hours allow serration patient:
of all lung a.) Demonst
fields rated
improve
5.) Instruct mother  This mobilizes d
to feed the baby secretions. I & ventilati
per demand. O is essential on and
Record intake to monitor adequate
and output fluid status oxygena
tion of
6.) Encourage tissues30
 Helps limit O2
adequate rest. as
meds/consump
Promote manifest
NURSING CARE PLAN: 4

31
CUES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective: Short-term: Independent: Short-term:

”taas jud kaayo iyang Hyperthermia After 30 minutes of 1. Do continuous Temperature is After 30 minutes
hilanat, mao gidala r/t Infection nursing intervention, tepid sponge decreased through of nursing
najud nako siya dri sa in the lower patient’s temperature bath. evaporation and intervention,
hospital_basin respirator will decrease to conduction. patient’s
magkumbulsyon na” tract approximately 38.0ºC 2. Position patient To reduce oxygen temperature
as verbalized by on semi fowlers consumption/metabolic decreased from
mother and instruct demands 39.7°C to 38.6ºC
Long-term: patient to
maintain bed Long-term:
After 8 hours of rest.
Objective: nursing intervention, High fever greatly After 8 hours of
 Warm skin patient should maintain 3. Monitor body increases nursing
 Tachypnea core temperature Temperature. Metabolic demands intervention,
RR: 74cpm within normal range: and Oxygen patient
 Febrile 36.8°C to consumption and alters maintained core
T: 39.7°C 37.0°C cellular temperature
 Tachycardia: To prevent dehydration within normal
HR: 168bpm 4. Monitor and range from
 WBC: 12,000 record all 36.8ºC- 37.0ºC
(5,000-10,000) sources of fluid
loss such as
urine , vomiting
and diarrhea
To reduce the risk of
5. Wash hands and transmitting pathogens
teach other from one area of the
caregivers to body to another and
wash hands prevent further
before contact infection
with patient and
between
procedures with This reduces the
patient number of organisms
6. Limit visitors in patient’s
environment and
restricts visitation by
individuals with any
type of infection to 32
reduce the
transmission of
NURSING CARE PLAN: 5

CUES NURSING OBJECTIVES IMPLEMENTATION RATIONALE EVALUATION


DIAGNOSIS

Risk Factors: Risk for Short term: Independent: At the end of 4


Infection At the end of 4 hours 1. Apply 1. To reduce body hours nursing
• Inadequate (spread) nursing intervention, the appropriate temp to normal interventions, the
primary defenses mother will be able to: therapy for level mother:
particularly • Verbalize elevated temp. • Verbalized
decrease in understanding of (antipyretics, understand
ciliary action the risk factors TSB, cold ing of the
• Immnosuppressi for her child therapy) risk factors
on • Identify 2. Stress proper 2. To prevent for her
• Presence of interventions to hand hygiene transfer of child
existing infection prevent or reduce microorganisms • Identified
risk of infection 3. To prevent interventio
• The patient will 3. Maintain a germ- spread of ns that will
be afebrile free environment microorganisms prevent or
from reduce the
Long term: environment to risk of
At the end of 2 days patient infection
of nursing intervention, 4. Emphasize 4. To prevent

33
the mother/SO will be necessity of return of
able to: taking infection &
• demonstrate antivirals/antibio potentiate drug-
techniques, tics, as directed resistant strains
lifestyle changes (dosage & length
to promote safe of therapy)
environment. Dependent:
5. Administer
prescribed 5. To prevent
antimicrobial/ant further spread of
iviral agents at microorganism
scheduled time in the body

34
35
DISCHARGE PLAN

Objectives:
This plan aims to continue treatment and care for client by involving significant
others to participate in plan of care.

Treatment:
• Instruct the patient’s mother to continue talking all the medications prescribed by
the physician and return to hospital for follow-up.
• Asses mother’s understanding of treatment regimen as well as concerns of fear

Health Teachings:
• Adequate rest and sleep
• Timing and quantity of medication to be administered

Out Patient Follow-up:


• Instruct family to return to their attending physician for scheduled check-up.
• Advise family to report to the physician any reoccurrence of dyspnea, and unusual
complaints.
• Encourage family to ask and inquire to the physician if there are unclear of things.

Diet:
• Breastfed per demand

PROGNOSIS

With treatment, most patients will improve within 2 weeks. Elderly or debilitated
patients may need treatment for longer. If the patient will fail to respond to treatment may

36
die from respiratory failure. The doctor will make sure that the chest x-ray becomes
normal again after the patient have taken a course of antibiotics.

RECOMMENDATION

The proponents of this case analysis recommend specific actions and guidelines that
should be followed by the patient, his significant others and the healthcare providers such
as nurses and student nurses.
For the patient’s significant others, the proponents strongly recommend that they
should see to it that the patient adheres to the therapeutic regimen as prescribed by the
healthcare providers. This includes: medication compliance, not engaging the patient in
excessive activity, promoting rest to conserve energy and promoting fluid intake unless
contraindicated. Above all this, it is the sole responsibility of the family members to
provide emotional, physical and financial support to the patient.
For the healthcare providers, especially the nurses and student nurses, they should
be aware of the nursing interventions for pediatric patients suffering from Severe
Bronchopneumonia. Such as: removal of secretions that interferes with gas exchange,
humidification that aids in loosening secretions and improves ventilation, and the
administration of oxygen therapy as prescribed. More importantly, they should be
equipped with the skills and knowledge in imparting relevant health teachings regarding
Pneumonia, its prevention and management to the patient’s significant others.

CONCLUSION

It is essential to understand the case of the patient at the Pediatric Ward of JR


Borja Hospital by studying it in different aspects. The proponents of this case study were
able to understand the contributing factors that led to the patients’ condition. Also, the
group provided nursing interventions that were relevant and needed by the patient.
Furthermore, the understanding of the possible threats or risks that may occur
during the disease process is also emphasized. It is therefore vital to assess properly the
status of the patient’s condition and its complications. The case “Severe

37
Bronchopneumonia” as diagnosed, paved the way for innovative inputs and setting the
grounds for new learnings of the group.
Above all, regaining the patient’s health was the primordial concern to the
medical team including the group of student nurses.

APPENDICES

GROWTH AND DEVELOPMENT

1. ACCORDING TO PIAGET’S COGNITIVE DEVELOPMENT


At par with age: Oral phase

The infant’s primary source of satisfaction is the mouth. During assessment, the
infant would grab and suck the IV tubing.

2. ACCORDING TO ERICK ERIKSON’S PSYCHOSOCIAL THEORY


At par with age: Secondary circular reaction

Under secondary circular reaction, the infant is able to recognize familiar


experiences from environment. Patient is able to recognize procedures like
auscultating his breath sounds with the use of the stethoscope. The infant was not
anxious about it since his past experience with it was not bad. Also, infant enjoys
playing peek-a-boo and toys with blinking lights

3. ACCORDING TO FREUD’S PSYCHOSEXUAL THEORY


At par with age: Trust vs. Mistrust

38
Developmental task is trust versus mistrust. Child is very attached to his primary
care giver which is the mother. Cries whenever he sees mother will go to
bathroom.

DOCTOR’S ORDERS

Date Doctor’s Order


December 17, 2008 > please admit under the service of Dr. Dy
> secure consent to care
> problem: SOB
> condition: fair
> allergies: none
> diet: NPO if dyspneic (RR≥50cpm)
> TPR q6 hours. I & O every shift
> start with D5 0.3% NaCl 500cc at 35cc/hr
> labs CBC with V/A
CXR – APL
> meds
• Hydrocortisone 80mg loading dose
now then 30 mg q6 hours
• Combivent q6 hours
> refer to Dr. Dy for further orders
Dr. Caragos
> PCM 100mg/ml
December 18, 2008 > O2 @ 2L/min
> start cefuroxime 250mg IVTT q8h ANST
> may give pcm supp 125mg suppository
(opigesic) per rectum now
> IVF follow-up D5IMB 500cc at same
rate
> pcm 80mg very slow IVTT q4h for temp
38°c ↑

39
NURSE’S NOTES

Date and Time Nurse’s Notes


12/17/08 (7-3)
12:15pm > admitted a 6 mos. Old infant, male,
brought in by mother due to cough and
SOB
> awake, weak in appearance
> seen & examined by Dr. Caragos with
orders carried out
> consent to care signed by mother
> IVF started & regulated as ordered
> for CXR-APL- Done enroute
> for U/A
> meds prescribed
1:45pm > refered to Dr. Perez with order-meds
prescribed
> T=38.6°c, RR= 90cpm
> refered to Dr. Caragos with order carried
out
>TSB emphasized; 02 inhalation rendered
continuously
>placed on MHBR
2:55pm >brought to ward in mother’s arm with IVF
& with latest RR: 84
12/17/08 (3-11)
3:00pm >received from ER per mother’s arm with
IVF going
>(+)SOB
>skin warm to touch
>rale
>ushered to bed safely
>IVF regulated
>vital signs taking recorded
>O2 inhalation started

40
>NPO-instructed
>reminded for Urinalysis
TSB done continuously
>placed on moderate high back rest
11:00 pm
D >with O2 inhalation going on
>SOB noted
A >IVF regulated well
>vital signs taken & recorded
>due meds given
>reminded for Urinalysis
>CXR-APL to follow up result
>kept back dry
>needs attended
>plan of care followed
R >endorsed

12/18/08
10:00am (7-3pm shift) D>with continuous O2 inhalation
>afebrile
> HR; 140bpm, RR:48 cpm
A>IVF regulated as ordered
>vital signs taken and recorded
>NPO if dyspneic-mother instructed
>on Input & Output regimen
>reminded for U/A
>CXR-APL- to follow up result
>visited by Dr. Perez without orders
>needs attended
>plan of care followed
R>endorsed

3:00 pm (3-11pm shift) D> afebrile


>with O2 inhalation @2Lpm via nasal
cannula
>SOB not noted
>LBM noted
>Temp: 36 ºC, HR: 140bpm, RR: 45cpm
A>TPR monitored every 4 hrs
>intake and output monitored and
recorded
>bedside care provided
>placed on moderate high back rest
>Urinalysis, Gramstain, Culture and
sensitivity- to follow up results
>due meds given
>breastfed with aspiration precaution

41
>health teachings imparted to mother on:
a. proper positioning of the IV site
b. proper hygiene
c. compliance to prescribed medication
>kept watched for any unusualities
R>endorsed with latest vital signs of:
Temp. , HR: , RR:

LABORATORY RESULTS

CBC
Normal values Indications
WBC: 12,000 5,000-10,000 Infection
Hemoglobin: 10.0 12.0-16.0gm/dl anemia
Hematocrit: 32.2 37.0-47.0vol% polycythemia;diarrhea
Platelet: 383,000 150,000-400,000/mm within normal values
(Differential Count)
Granulocyte: 68 43.4-76.2 % within normal values
Lymphocyte: 32 17.4-48.2 % within normal values

CXR
Type of examination: CHEST APL
X-ray report:
Blotchy densities in both lungs , more in the right, Heart, Trachea, Diaphragm,
and sinuses are unremarkable.

Impression: Brochopneumonia, severe

42
BIBLIOGRAPHY

Bauman, Robert. Microbiology with Dieases by Taxonomy 2nd ed. 2007. Pearson
Education, Inc.

Black and Hawks. Medical and surgical Nursing 7th ed. 2006 Elsevier and Saunders

Doenges, Mariloyn,et.al. Nurse’s Pocket Guide 11th ed.2006. LA. Davis Company

Gulanick, meg, et.al.Nursing Care Plans forNewborns and Children- Acute and Critical
Care.1992.Mosby- Year Book,Inc.

Karch, Amy. Focus on Nursing Pharmacology 3rd ed. 2006. Lippincott William and
Wilkins.

Kluwer, Wolters. Nursing 2008 Drug Handbook 28th ed.2008. Lippincott Williams and
wilkins

Luxner, Karla.Delmar’s PEDIATRIC Nursing Care plans 3rd ed,2005. Thomson Delmar
Learning

Online Sources:

<http://www.aboutkidshealth.ca/HowTheBodyWorks/Anatomy-of-the-Respiratory-
System.aspx>

<http://www.virtualrespiratorycentre.com/anatomy.asp?sid=18#C1>

source: medlineplus encyclopedia (online)

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