Table of Contents

Page Number
I. Introduction 3-4
A. Scope and Limitations 5
B. Objectie of t!e Stud" #
II. $atient%s $rofile &
III. 'ro(t! and )eelopment *
I+. ,ealt! ,istor" and $resent Illness -
+. .edical Orders /0-/1
+I. Laborator" 23aminations /3
+II. )ru4 Stud" /4-/-
+III. Anatom" and $!"siolo4" 10-1/
I5. $at!op!"siolo4" 11
5. ,ealt! Assessment 13-1#
5I. Actual 6ursin4 .ana4ement 1&-1-
5II. )isc!ar4e plannin4 and referral 30
5III. 2aluation and Implications 3/
5I+. Biblio4rap!" 31
1
I. INTRODUCTION
Bronchopneumonia which is also known as lobular pneumonia is one of two
types of bacterial pneumonia as classified by gross anatomic distribution of
consolidation (solidification). In bacterial pneumonia, invasion of the lung parenchyma
by bacteria produces an inflammatory immune response. This response leads to a filling
of the alveolar sacs with exudates. The loss of air space and its replacement with fluid is
called consolidation. In bronchopneumonia, or lobular pneumonia, there are multiple
foci of isolated, acute consolidation, affecting one or more pulmonary lobes.
It should be noted that although these two patterns of pneumonia, lobar and
lobular, are the classic anatomic categories of bacterial pneumonia, in clinical practice
the types are difficult to apply, as the patterns usually overlap. Bronchopneumonia
(lobular) often leads to lobar pneumonia as the infection progresses. The same
organism may cause one type of pneumonia in one patient, and another in a different
patient. rom the clinical standpoint, far more important than distinguishing the
anatomical subtype of pneumonia, is identifying its causative agent and accurately
assessing the extent of the disease.
Bronchopneumonia tends to appear in patches in and around the small airways
and passages. !utward 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.
2
Bronchopneumonia is more common in elderly people, and in association with
other viral respiratory illnesses (bronchitis), and as a complication of those who have
asthma.
#neumonia, including bronchopneumonia is a fairly common illness and it affects
millions of people annually in the $nited %tates. 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 &"ray, may test a
sample of the sputum, may do a 'B' to get a count of the white blood cells in the
blood, may take a '(T scan, and)or may take a pleural fluid culture of the fluid
surrounding the lungs. $pon diagnosis, most people will be treated at home with
antibiotics. If the patient is suffering from dehydration or has a severe case of
bronchopneumonia, he or she may be treated in the hospital where the illness can be
more closely monitored. *ith appropriate treatment, most people recover fully within a
couple weeks. +ery infirm or elderly people who do not get appropriate treatment can
die from bronchopneumonia.
3
A. Scope and Limitation
This case presentation involves a patient named ,oldan, #rincess -elou B,
diagnosed with Bronchopneumonia as supplied by .r. (parece
The scope and limitation of this case study are as follows/
#atient0s history and background
!verview of the disease
#redisposing and precipitating factors of the aforementioned disease
#athophysiology of Bronchopneumonia as the resulting diagnosis.
1ursing and 2edical management administered during the confinement period
.ischarge plan, referrals and recommendations pertinent to the disease
condition
(ssessment of the client from %eptember 34 to %eptember 56 of year 5667,
within hospital premise.
4
B. Objective o! t"e Stud#
This study is conducted by the student of Team 8, 1'2863568 'luster 5 for the
following purposes/
Trace the disease process of the patient
Identify the health care services needed particular to patient0s condition
,ecogni9e the significance of the ordered diagnostic tests in relation to the
patient0s disease condition
ormulate and implement an effective nursing care plan especially designed for
the patient0s problems as identified in the nursing assessment.
Inculcate health teachings and importance of following medication regimen to the
patient
:xplain and elaborate to patient0s significant others the need for encouragement
and support to the patient in the latter0s pursuit of a better health
5
II. PATI$NT%S PRO&IL$
1ame/ Ro'dan( Prince )e'ou B.
(ddress/ P*+ ,a'id( ,iba'abag -a'a#ba'a# Cit#( Bu.idnon
%ex/ &ema'e
%tatus/ C"i'd
Birthday/ )anuar# /( 0112
#lace of Birth/ ,a'id( .iba'abag -a'a#ba'a# Cit# Bu.idnon
(ge/ 2 mont" o'd
1ationality/ &i'ipino
,eligion/ Baptit
ather/ 3uer4in Ro'dan
2other/ N#''e Ro'dan
,ank in the amily5 $'det
1umber of siblings/ 6
.ate of (dmission/ September 66( 0112
Time of admission/ 65/1 pm
#lace of admission/ Bu.idnon Provincia' 7opita'*-a'a#ba'a#
.iagnosis/ Bronc"opneumonia( evere communit# ac8uired
(ttending #hysician/ Dr. Arace'i Aparece
6
III. 9RO:T7 AND D$;$OP-$NT

!ne of the greatest events in life after marriage is to have a child. This was what
2r. (nd 2rs. ;uerwin ,oldan had hoped and prayed for. Their prayers were answered
and on -anuary <, 5667, 2rs. ,oldan gave birth to a healthy baby girl. They named her
#rincess -elou.
The patient is now in 7 months old and according to %igmund reud
#sychoanalytic Theory, he is now in the oral stage of development in which infants
during this age are interested in oral stimulation or pleasure. The infant in this age, suck
for en=oyment or for relief of tension as well as nourishment. The child mainly explores
the world by using mouth especially the tongue. (nd because of this, since the port of
entry of bacteria is in the mouth, the patient was able to ingest the bacterium that was
held from his hand that might be contaminated and placed on his mouth. (s a result it
precipitated the cause and the development of the disease.
7
I;. 7$ALT7 7ISTOR< AND PR$S$NT ILLN$SS
7ea't" 7itor#
This is a case of a 7 months old, female, ilipino, Baptist, from #urok 8, kalid,
>ibalabag, 2alaybalay 'ity, Bukidnon, who was admitted for the first time at the
Bukidnon #rovincial ?ospital"#edia *ard due to complaints of cough and difficulty of
breathing. The informant was the mother with @6A reliability.
7itor# o! Preent I''ne
( diagnosed case of Bronchopneumonia"severe community acBuired. our days
prior to admission, the patient was experiencing cough for a long duration followed by
difficulty of breathing. Because of this, her parents were alarmed of his condition and
afraid of what bad will happen to her, they decided to take #rincess to the hospital for
admission dated %eptember 33, 5667 at 3/<6 in the afternoon.
&ami'# 7itor#
There were no known critical diseases in the family. (ccording to the mother, her
husband was having some cough. Though her husband wasn0t diagnose with what type
of disease it was, she thinks that it was the cause that her children was infected with the
disease.
Perona' 7ea't" 7itor#
(ccording to 2rs. ,oldan, her child was having Buite for Buite a longer time,. %he
said that she thinks that her children got her cough from their father who had a cough.
They were able to have a check"up in their health center and instructed to take herbal
medications such as kalabo and gabon.
8
;* -edica' Order
September 66( 0112
#ls. (dmit to pedia ward
or immediate intervention
T#, B C hours
To identify #t. conditions
1#! temporarily except meds
To avoid aspiration
'B', platelet count, $)(, %):
To identify any deviation
%tart I+ .8 6.<A 1a'l 866 cc D 56 gtts)min
or fluid and electrolytes replacements
#en E <86,666 0$0 I+TT B F hours
To prevent infections
#'2 drops.7 ml B C hours for fever
To decrease body temp.
!5 inhalation 3G)min
#rovide !5 consumption
,efer for any unusualities
or immediate intervention
2ay use ampicillin <66 mg I+TT B F hours instead of pen E
#revent infection, prophylaxis
2ay resumed feeding if not dyspneic anymore
#roviding nutrient
September 60( 0112
'ontinue meds
or compliance and easy healing
I+T with .8I2B 866 cc D %,
9
#roviding adeBuate H : consumption
Eentamycin 56 mg I+TT B 35 hours now
prophylaxis
or referral to .r. (guirre
or another intervention and consultation
September 6/( 0112
'ontinue meds.
or compliance
%tart erythromycin 586 mg)8ml 5.8 ml < x a day p.o
#reventing infection in the respiratory tract
?old feeding once #t. dyspneic
To prevent aspiration
I+T .8I2B 866 cc D <8 gtts)min
or rehydration and adeBuate consumption
September 6=( 0112
'ontinue meds
or compliance and easy healing
I+T .8I2B 866 cc D %,
?ydration status
September 6+( 0112
%tart gentamycin 56 mg slow I+TT B 35 hours
or prophylaxis
1ebuli9e salbutamol I neb B F hours
To liBuefy secretion
I+T .8I2B 866 cc D %,
To provide adeBuate H: replacement
10
'ontinue meds
or compliance
September 6>( 0112
'ontinue meds
or compliance
I+T .8I2B 866 cc D %,
or rehydration
September 6?( 0112
'ontinue meds
or compliance
September 62( 0112
?ome per reBuest"signed by mother
or legal purposes
?ome meds"erytromycin 5.8 ml TI. x 4 days
#reventing infections
September 6@( 0112
'ontinue meds
or compliance
I+T .8I2B 866 cc D %,
or rehydration
September 01( 0112
'ontinue meds
or compliance
11
;I*LABORATOR< $AA-INATION
T$ST R$SULTS NOR-AL
RAN9$
I-PLICATION
CBC ""B0C6C12%D
*B'
?EB
?'T
#latelet
%egmenters
lymphocytes
3C.4
@.<
54.6
CF@,666
86
86
8.6"36.6)G
3<.4"3F.4 g)dl
C6.8"C@.4 vols A
3CC,666"<45,666
C<.C"4F.5 A
34.C"CF.5 A
Infection
(nemia
(nemia
Iron deficiency
anemia
1ormal
(nemia
12
;II. DRU9 STUD<
Name o! Drug
9eneric
BBrandD
Date
Ordered
C'ai!ication DoeC
&re8uenc#
C Route
-ec"anim
o! Action
Indication
B4"#
drug i
orderedD
Contraindication Side $!!ect Nuring
Precaution
(mpicillin eb. 3,
5667
(nti"infective
(ntibiotic
<66 mg
I+TT B F
hours
Inhibit cell
wall
synthesis
during
bacterial
multiplication
Jor
respiratory
tract
infection
Jor EI
infection
'ontraindicated
to hypertensive
drugs or other
penicillin.
$se cautiously
with other drug
allergy.
'1%/
lethargy,
sei9ures,
di99iness,
EI/ 1ausea,
vomiting,
diarrhea
%>I1/ #ain
at I+ site
!ther/
hypersensiti
vity
reactions,
over growth
of
nonsuscepti
ble
organism

'heck about
allergy of
penicillin.
Eive drug 3"
5 hours
before or 5"<
after meal.
2onitor
sodium level.
1otify if rash,
fever, chill
develop
14
Name o!
Drug
9eneric
BBrandD
Date
Ordered
C'ai!ication DoeC
&re8uenc#
C Route
-ec"anim
o! Action
Indication
B4"# drug
i orderedD
Contra*
indication
Side $!!ect Nuring
Precaution
Eentamicin
sulfate
eb. 5,
5667
(nti"infective
(ntibiotic
56 mg
I+TT B 35
hours
Inhibit protein
synthesis by
binding
directly to the
ribosomal
subunitKbacteri
cidal.
%erious
infection
caused by
sentsitive
strains of
#seudomon
as
aerruginosa,
:. 'oli,
#roteus.
'ontraindicat
d to
hypertensive
drugs or other
aminoglycosid
e
$se
cautiously in
neonate,
infant,elderly
ang impared
renal function.
'1%/ fever,
headache,
di99iness,
sei9ure,
nunbness
::1T/
blurred
vision,
tinnitus
EI/ 1ausea,
vomiting,
%>I1/ #ain
at I+ site,
rash
!ther/
anaphylaxis
,

:valuate
hearing
before giving
therapy.
2onitor renal
function
*atch for
s)sx of fever,
chill,
increase ?,
15
Name o!
Drug
9eneric
BBrandD
Date
Ordered
C'ai!ication DoeC
&re8uenc#
C Route
-ec"anim
o! Action
Indication
B4"# drug i
orderedD
Contra*
indication
Side $!!ect Nuring
Precaution
#en E eb. 3,
5667
(nti"infective <86,666
mg I+TT B
F
#revent
bacterialcell
wall synthesis
during
replication.
Increase
amoxicillin
effectiveness
by inactivating
betalactamase
s
Gower
respiratory
tract infection
cause by
strain of gram
positive and
gram
negative
organism.
To prevent
pneumonia.
'ontraindic
ated to
hypertensiv
e drugs or
other
penicillin.
$se
cautiously
with other
drug allergy,
especially to
cephalospor
ins,
because of
possible
cross
sensitivity.
'1%/
neurophath
y, sei9ures,
di99iness,
fatigue
EI/ 1ausea,
vomiting,
enterocolitis
!ther/
hypersensiti
vity
reactions,
anaphylaxis
, pain

2onitor #t.
hepatic
function.
%hake well
before
in=ecting
2onitor renal
function
closely.
16
Name o!
Drug
9eneric
BBrandD
Date
Ordered
C'ai!ication DoeC
&re8uenc#
C Route
-ec"anim
o! Action
Indication
B4"# drug i
orderedD
Contra*
indication
Side $!!ect Nuring
Precaution
#aracetamol eb. 3,
5667
1on"opioid
analgesics
and
antipyretics
.rops 6.7
ml B C
hours
Thought to
produce
analgesia by
blocking pain
impulses by
inhibiting
synthesis of
prostaglandins
in the '1% or
other
substances
that sensiti9e
pain receptors
to stimulation.
The drug may
relieve fever
through the
central action
in the
hypothalamic
heat"regulating
center.
$se to relieve
mild to
moderate
pain
It is also used
to bring down
a high
temperature.
'ontraindicate
d to patients
hypersensitive
to drug.
?emolytic
anemia,
neutropenia
, leulopenia,
=aundice,
rash,
urticaria
and
hypoglycem
ia
$se liBuid
form for
children.
or child,
don0t exceed
8 doses in 5C
hours.
Be aware in
calculating
daily dose
17
Name o!
Drug
9eneric
BBrandD
Date
Ordered
C'ai!ication DoeC
&re8uenc#
C Route
-ec"anim
o! Action
Indication
B4"# drug i
orderedD
Contra*
indication
Side $!!ect Nuring
Precaution
%albutamol eb. 5,
5667
Bronchodilator I neb B F
hours
Bronchodilato
r.
%albutamol is a
L"adrenergic
stimulant which
has a highly
selective action
on the
receptors in
bronchial
muscle and in
therapeutic
dosesK it has
little or no
action on the
cardiac
receptors.
To prevent or
treat
bronchospas
m in #t. with
reversible
obstructive
airway
disease.
Treatment of
acute severe
asthma and
in routine
management
of chronic
bronchospas
m
'ontraindic
ated to
hypertensiv
e drugs or
its
ingredients.
$se
cautiously
with '+
disorder,
hyperthyroid
ism, or .2.
'1%/
tremor,
nervousnes
s,
di99iness,
weakness,
headache
'+/
tachycardia,
palpitation,
hypertensio
n
::1T/ .ry
and irritated
nose and
throat,
nasal
congestion,
hoarseness
EI/
heartburn,
1ausea,
vomiting,
anorexia
!ther/
hypersensiti
vity
reactions,
2onitor
patient
routinely
Take
freBuent vital
signs to note
side effects.
Ereat care is
needed in
patients with
cardiovascul
ar disease
eg, ischemic
heart
disease,
arrhythmia or
tachycardia,
hypertension
18
Name o!
Drug
9eneric
BBrandD
Date
Ordered
C'ai!ication DoeC
&re8uenc#
C Route
-ec"anim o!
Action
Indication
B4"# drug i
orderedD
Contra*
indication
Side $!!ect Nuring
Precaution
:rythromycin eb. <,
5667
2acrolide (nti
Infective
586
mg)8ml 5.8
ml TI. #.!
Inhibits
bacterial
protein
synthesis by
binding to the
86% subunit of
the ribosome.
Bacteristatic or
bactericidal,
depending on
concentration
2ild to
moderate
skin and soft
tissue
infection
'ontraindic
ated in
pregnant
patients and
those
hypertensiv
e to drug or
other
macrolides.
'1%/ fever
'+/ vein,
irritation
::1T/
hearing
loss,
blurred
vision
EI/
abdominal
pain and
cramping,
nausea H
vomiting
%>I1/
urticaria,
rash and
ec9ema,
dermatitis
!btain urine
specimen for
sulture and
sensitivity
tests before
giving first
dose and
instruct
patient to
report
adverse
reactions
especially
nausea,
abdominal
pain,
vomiting and
fever.
19
;III. ANATO-< E PAT7OP7<SIOLO9<
The lungs are located in the chest on either side of the heart. They are
surrounded and protected by the ribcage. The left lung is a little smaller than the right
lung because it shares space in the left side of the chest with the heart. :ach lung is
divided into sections (lobes). The right lung has three sections or lobes, including the/
(3) ,ight upper lobe, which takes up the top third of the right lungK (5) ,ight middle lobe,
which is the smallest of the three lobes and shaped like a triangleK (<) ,ight lower lobe,
which is the largest of the three.
The ma=or fissure separates the right lower lobe from the right middle and upper
lobes. The left lung is shaped slightly differently than the right. It has only two lobes " the
left upper lobe and the left lower lobe.
!ur lungs are the main organs of the respiratory system. The lungs are located
inside the upper part of our chest on either side of the heart, and they are protected by
the ribcage. The breastbone (sternum) is at the center front of the chest, and the spine
is at the center of the back of the chest.
The inside of the chest cavity and the outside of the lungs are covered by the
pleura, a slippery membrane that allows the lungs to move smoothly as they fill up with
and empty out air when we inhale and exhale. 1ormally, there is a small amount of
lubricating fluid between the two layers of the pleura. This helps the lungs glide inside
the chest as they change si9e and shape during breathing.
20
*ith each breath, our lungs are filled with air that comes into our body through
the nose or mouth. It flows down the throat (pharynx) and through the voice box
(larynx). ( small flap of tissue (epiglottis) covers the entrance to the larynx, and it
automatically closes when we swallow to prevent food or liBuids from getting into our
airways.
!ur largest airway is the windpipe (trachea), which is between three"and"a"half
and six inches long and a little over half an inch in diameter. It brings air to the chest,
where it branches into two smaller airways/ the left and right bronchi, which lead to the
left and right lungs.
The bronchi themselves divide many times into smaller and smaller airways
(bronchioles). Because the pattern of these increasingly smaller passages looks like an
upside"down tree, this part of the system is sometimes called the bronchial tree. The
airways are held open by flexible, fibrous connective tissue called cartilage. 'ircular
airway muscles can make the airways wider or narrower. The smallest bronchiole is
only half a millimeter across.
(t the end of each bronchiole are clusters of air sacs called alveoli. :ach air sac
is surrounded by a dense network of tiny blood vessels (capillaries). The extremely thin
barrier between the air and the blood allows the blood to pick up oxygen and release
carbon dioxide into the alveoli.
21
IA. PAT7OP7<SIOLO9<
Bronc"o neumonia F refers to a type of pneumonia that is localized, often to the
bronchioles and surrounding alveoli.
Predipoing &actor Precipitating &actor
Age Preence o! -;
9ender Immunouppreed condition
Target !rgan/ Lung
#atient0s pulmonary defense is weak related to
clinical condition
Bacteria enters the lungs and replication occurs
and triggers pulmonary Inflammation
Immune system tries to response to presence of bacteria,
%timulating ?ypothalamus for thermal regulation
while immune system releases antibodies
(ntibodies (macrophages) combat the bacteria present
In the lungs
:xudates gradually accumulate into the lungs
resulted from death of bacteria and macrophages
Irritation of the mucous membrane causing inflammation
!f the bronchial walls
:xudate fluid fills in the alveolar air spaces and
invade alveolar septa
#oor oxygen exchange within the lungs causing
Gung parenchymal dysfunction.
-u'ti*organ Invo'ved
?eart, Brain, EIT
Comp'ication
Acute ,espiratory ailure
%)%x
%ore throat
Intermittent
cough
ever
'hilling
%)%x
#roductive
'ough
ever
Gabored
Breathing
22
5. 678SI6' S9ST2. 82+I2: C,A8T
Name: Roldan, Princess Jelou Date: e!tem"er 17, 2008
#ital i$ns:
Pulse: 145"!m %P: not assessed Res!: 38 c!m &em!: 36'7 ( ) *ei$+t: not assessed ,ei$+t:not
assessed
226T:
-. im!aired /ision -. "lind
-. !ain -. reddened -. draina$e
-. $ums -. +ard o0 +earin$ -. dea0
-. "urnin$ -. edema -. lesion -. teet+
1ssess e2es, ears, nose
t+roat 0or a"normalit2 -3. no !ro"lem
82S$'
-. as2mmetric -3. tac+2!nea
-. a!nea -. rales -3. cou$+ -. "arrel c+est
-. "rad2!nea -. s+allo4 -. r+onc+i
-3. !utum -. diminis+ed -. d2s!nea
-. ort+o!nea -. la"ored -. 4+ee5in$
-. !ain -. c2anotic
1ssess res!' rate, r+2t+m, de!t+, !attern,
"reat+ sounds, com0ort -. no !ro"lem
CA8)IO +ASC7LA8
-. arr+2t+mia -. tac+2cardia -. num"ness
-. diminis+es !ulses -. edema -3 .0ati$ue
-. irre$ular -. "rad2cardia -. murmur
-. tin$lin$ -. a"sent !ulses -. !ain
1ssess +eart sounds, rate, r+2t+m, !ulse, "lood
Pressure, circulation, 0luid retention, com0ort
-. no !ro"lem
'AST8O I6T2STI6AL T8ACT
-. o"ese -. distention -. mass
-. consti!ation -. ri$idl2 -. !ain
1ssess a"domen, "o4el +a"its, s4allo4in$,
%o4el sounds, com0ort -. no !ro"lem
'26ITO-78I6A89
-. !ain -. urine color -. /a$inal "leedin$
-. +ematuria -. disc+ar$e -. nocturia
1ssess urine 0re6', control color, odor, com0ort,
78N "leedin$, disc+ar$e -3. no !ro"lem
6278O
-. !aral2sis -. stu!orous -. unstead2 -. sei5ures
-. let+ar$ic -. comatose -3. /erti$o -. tremors
-. con0used -. /ision -. $ri!
1ssess motor 0unction, sensation, 9:), stren$t+,
7ri!, $ait, coordination, orientation, s!eec+
-. no !ro"lem
.7SC7LOS;2LITAL and S;I6
-. a!!liance -. sti00ness -. itc+in$ -. !etec+iae
-. +ot -. draina$e -. !rost+esis -. s4ellin$
-. lesion -. !oor tur$or -. cool -. de0ormit2
-. 4ound -. ras+ -. s;in color -. 0lus+ed
-. atro!+2 -. !ain -. ecc+2mosis
-. dia!+oretic -. moist
Producti/e cou$+
lee!
distur"ance
D5<=%
500cc >
35 $tts?min
)rac;les u!on
auscultation
Dr2 s;in
De!resses
0ontanels
@ati$ue
23
678SI6' S9ST2. 82+I2: C,A8T
Name: Roldan, Princess Jelou Date: e!tem"er 18, 2008
#ital i$ns:
Pulse: 145"!m %P: not assessed Res!: 38 c!m &em!: 36'7 ( ) *ei$+t: not assessed ,ei$+t:not
assessed
226T:
-. im!aired /ision -. "lind
-. !ain -. reddened -. draina$e
-. $ums -. +ard o0 +earin$ -. dea0
-. "urnin$ -. edema -. lesion -. teet+
1ssess e2es, ears, nose
t+roat 0or a"normalit2 -3. no !ro"lem
82S$'
-. as2mmetric -3. tac+2!nea
-. a!nea -. rales -3. cou$+ -. "arrel c+est
-. "rad2!nea -. s+allo4 -. r+onc+i
-3. !utum -. diminis+ed -. d2s!nea
-. ort+o!nea -. la"ored -. 4+ee5in$
-. !ain -. c2anotic
1ssess res!' rate, r+2t+m, de!t+, !attern,
"reat+ sounds, com0ort -. no !ro"lem
CA8)IO +ASC7LA8
-. arr+2t+mia -. tac+2cardia -. num"ness
-. diminis+es !ulses -. edema -3 .0ati$ue
-. irre$ular -. "rad2cardia -. murmur
-. tin$lin$ -. a"sent !ulses -. !ain
1ssess +eart sounds, rate, r+2t+m, !ulse, "lood
Pressure, circulation, 0luid retention, com0ort
-. no !ro"lem
'AST8O I6T2STI6AL T8ACT
-. o"ese -. distention -. mass
-. consti!ation -. ri$idl2 -. !ain
1ssess a"domen, "o4el +a"its, s4allo4in$,
%o4el sounds, com0ort -. no !ro"lem
'26ITO-78I6A89
-. !ain -. urine color -. /a$inal "leedin$
-. +ematuria -. disc+ar$e -. nocturia
1ssess urine 0re6', control color, odor, com0ort,
78N "leedin$, disc+ar$e -3. no !ro"lem
6278O
-. !aral2sis -. stu!orous -. unstead2 -. sei5ures
-. let+ar$ic -. comatose -3. /erti$o -. tremors
-. con0used -. /ision -. $ri!
1ssess motor 0unction, sensation, 9:), stren$t+,
7ri!, $ait, coordination, orientation, s!eec+
-. no !ro"lem
.7SC7LOS;2LITAL and S;I6
-. a!!liance -. sti00ness -. itc+in$ -. !etec+iae
-. +ot -. draina$e -. !rost+esis -. s4ellin$
-. lesion -. !oor tur$or -. cool -. de0ormit2
-. 4ound -. ras+ -. s;in color -. 0lus+ed
-. atro!+2 -. !ain -. ecc+2mosis
-. dia!+oretic -. moist
Producti/e cou$+
lee!
distur"ance
D5<=%
500cc >
35 $tts?min
)rac;les u!on
auscultation
Dr2 s;in
De!ressesed
0ontanels
@ati$ue
24
6ursin4 Assessment II
Subjectie Objectie
CO..76ICATIO6<
-. *earin$ 9oss )omments: A=a;adun$o$
-. #isual )+an$es u$ motanBa4 man s2a ;un$
-3. Denied ta4a$on i2a !an$alanC, as
/er"ali5ed "2 t+e !atients
mot+er

-. 7lasses -. 9an$ua$es
-. )ontact 9ens -. *earin$ 1ide
R 9
Pu!il i5e: 2mm -. !eec+ Di0iculties
Reaction: %ot+ Pu!ils are e6uall2 round and
are reacti/e to li$+t accommodation'
O59'26ATIO6<
-3. D2s!nea )omments:C7a lisod si2a
-.mo;in$ o$ $in+a4a usa+a2C ,as
*istor2: /er"ali5ed "2 t+e mot+er'
None
-3. )ou$+
-3. !utum
-. Denied
Res!' -3. Re$ular -. <rre$ular
Descri"e: e6ual lun$ e3!ansion
R: )rac;les !resent
9: )rac;les !resent
CI8C7LATIO6<
-. )+est Pain )omments: Adli !aman ni s2a
-. 9e$ Pain ;stor2a ;un$ sa;itC,as
1s /er"ali5ed "2 t+e !atients
-. Num"ness o0 mot+er
D3tremitries
-3. Denied
*eart R+2t+m -. Re$ular -3. <rre$ular
1n;le Ddema: None
Pulse: )ar' Rad' DP @emE
R: F F F N:& 1DDD
9: F F F N:& 1DDD
)omments: 1ll !ulses are !resent and
!al!a"le'
E <0 a!!lica"le
67T8ITIO6<
Diet : "reast0eedin$ !er demand
-. N -. # )omments: A;uso$ man 3a
-. Recent )+an$e mo dedeC as /er"ali5ed "2
,ei$+t, 1!!etite t+e !atients mot+er
-. 4allo4in$
Di00icult2

-3. Denied
-. Dentures -3. None
@ull Partial ,it+ Patient
G!!er -. -. -.
9o4er -. -. -.
2LI.I6ATIO6<
Gsual %o4el Pattern -. Grinar2 @re6uenc2
2 3 ? da2 4B53?da2
-. )onsti!ation Remed2 -. Gr$enc2
None -. D2suria
Date o0 9ast %= -. *ematuria
e!t 17, 2008 -. <ncontinence
-. Diarr+ea )+aracter -. Pol2uria
N?1 -. @ole2 in Place
-3. Denied
)omments: %o4el sounds %o4el ounds:
G!on auscultation 4as Normal
normal, 1"dominaldistention
Present -. 8es -3. No

EGrineH)olor, )onsistenc2, :dorI
N?1

25
.'T. O= ,2ALT, > ILL62SS<
-. 1lco+ol -3. Denied
Hamount, 0re6uenc2I
-. %D 9ast Pa! mear: N?1
9=P: N?1
%rie0l2 descri"e t+e !atientJs a"ilit2 to 0ollo4
treatment Hdiet, meds, etc'I 0or c+ronic +ealt+
!ro"lems Hi0 !resentI
&+e !atient 4+o is dia$nose 4it+
"ronc+o!neumonia 4asnJt a"le to 0ollo4 t+e
!rescri"ed treatment ordered 0or +im due to
lac; o0 0inancial resources'
S;I6 I6T2'8IT9<
-3. Dr2 )omments:C u$a ;au i2an$
!anitC, as /er"ali5ed
-. <tc+in$ "2 t+e !ts' mot+er

-. :t+er
-. Denied
-3. Dr2 -. )old -3. Pale
-. @lus+ed -. ,arm
-. =oist -. )2anotic
,ashes, $lcers, .ecubitus
(describe si9e, location and
drainage). The patient does not
have rashes, ulcers, or decubitus
present.
ACTI+IT9?SA=2T9
-. )on/ulsion )omments: A dli !aman 3a
-. Di55iness ma;ala;a4Bla;a4C, as
-. 9imited =otion
o0 Joints /er"ali5ed "2 t+e !ts mot+er'

9imitation in
a"ilit2 to
-3. 1m"ulate
-3. %at+e sel0
-. :t+er
-. Denied
-3. 9:) and orientation: &+e !atient is
conscious and res!onsi/e
7ait: -. ,al;er -. )ane -. :t+er
-. tead2 -. Gnstead2
-3. ensor2 and motor losses in t+e 0ace or
e3tremities: None
-3. R:= 9imitations: None
CO.=O8T?SL22$?A:A;2<
-. Pain )omments: Cc$e 3a mata mata
H9ocation, !a$;atulo$ sa $a"ie,Cas /er"aB
@re6uenc2, li5ed "2 t+e !ts' mot+er
RemediesI
-. Nocturia

-3. lee! Di00iculties
-. Denied
-. @acial 7rimaces
-. 7uardin$
-. :t+er si$ns o0 !ain: no si$ns o0 !ain
-. iderail release 0orm si$ned H60F2earsI
N?1
CO$I6'<
:ccu!ation: c+ild
=em"ers o0 +ouse+old: 3 includin$ t+e !atient
=ost su!!orti/e !erson: =ot+er'
:"ser/ed nonB/er"al "e+a/ior: &+e !atient
seems to not mind our !resence' Readil2 and
+onestl2 6uestions $i/en to +im'
&+e !erson and +is !+one num"er t+at can "e
reac+ed an2time: Not disclosed "2 t+e !atient'
26
AI. NURSIN9 CAR$ PLAN
CU$S NURSIN9
DIA9NOSIS
OB)$CTI;$ NURSIN9
INT$R;$NTION
RATIONAL$ $;ALUATION
%ub=ective/
Mnaa lang ghapon
iyang uboN as
verbali9ed by the
patients mother
!b=ective/
Jproductive cough
Jcrackles upon
auscultation
Ine!!ective air4a#
c'earance re'ated
to increaed
mucu
production(
!atigue( and
coug"
(t the end of <6
min. to an hour of
nursing
interventions, the
patient will be
able to effectively
clear secretions.
3. #osition patient in
high"owler0s or semi"
owler0s position.
5. Turn patient every 5
hours and prn.
<. #erform chest
percussion and postural
drainage as warranted.
C. encouraged increase
in fluid intake
8. (dminister
bronchodilators as
ordered.

3. #romotes maximal
lung expansion.
5. ,eposition promotes
drainage of pulmonary
secretions and enhances
ventilation to decrease
potential atelectasis.
<. 2obili9es secretions
and facilitates ventilation
of all lung field
C. to help loosen up
secretions
8. #romotes relaxation of
bronchial smooth muscle
to decrease spasm,
dilates airways to
improve ventilation, and
maximi9es air exchange.
(t the end of our
nursing
interventions the
patient was able
to maintain patent
airway
27
NURSIN9 CAR$ PLAN
CU$S NURSIN9
DIA9NOSIS
OB)$CTI;$ NURSIN9
INT$R;$NTION
RATIONAL$ $;ALUATION
%ub=ective/
Mwla na gyud mi
kwarta na
ikapalit, dli nami
gapautangon
dnha sa
pharmacyN as
verbali9ed by the
patients mother.
!b=ectives/
J feelings of
tiredness and
hopelessness
J depress mood
Ine!!ective
t"erapeutic
management
re'ated to 'ac. o!
!inancia' upport
(t the end of <6
minutes of
nursing
intervention, the
patient0s mother
will be
encouraged to
seek help to
other health
agencies in
order to secure
medications.
3. :ncouraged
expression of feelings
5. #rovided a
therapeutic
communication.
<. .iscussed the
importance of
medication
compliance
C. #rovided
alternative ways to
gain free medical
services.
3. To know what the
mother feels towards
the situation.
5. To establish trust
and rapport.
<. To value the
importance of taking
the medications.
C. To encourage them
to secure medications
in other ways
(t the end of
our nursing
intervention, our
ob=ective wasn0t
met because
the mother
refuse to ask for
help to health
care agencies.
28
NURSIN9 CAR$ PLAN
CU$S NURSIN9
DIA9NOSIS
OB)$CTI;$ NURSIN9
INT$R;$NTIONS
RATIONAL$ $;ALUATION
%ub=ective/
Mwala pa man na
nko sya gpunasanN
as verbali9ed by
the patients
mother.
!b=ectives/
foul smell
dirty
clothings
wet
underwear
Se'! care de!icit
re'ated to inabi'it#
to bat"e onee'!
(t the end of <6
minutes of
nursing
intervention, the
patients mother
will be able to
bathe and change
her child0s
clothing
3. *iped the client with
wash cloth soaked in
soap and water.
5. 'hanged the patients
clothing to a cleaner
one.
<. :ncouraged the
patients mother to
changed the soiled
linens.
C. Instructed the mother
to wash the client
everytime that he wets
he solied his
underwear.
3. To promote
cleanliness to the client
as well as to the mother
5. To promote sense of
well being.
<. To promote wellness
and cleanliness.
C. To promote wellness
and cleanliness
(t the end of <6
minutes, the
patients mother
was able to follow
instructions in
maintaining and
promoting
cleanliness and
wellness to the
patient.
29
AII. DISC7AR9$ PLANNIN9 AND R$&$RRAL
A. -$DICATION
Instructed the patients mother to take home medications
religiously and to report any signs of adverse reactions/
erythromycin 5.8 ml three times a day for 4 days
B. $A$RCIS$S
:ncouraged the patients0 mother to perform on her child
passive range of motion exercises and to perform chest
physiotherapy in order to help loosen secretions and
promote lung expansion.
C. TR$AT-$NT
:ncouraged the patients0 mother to provide adeBuate rest
periods to the client and to observe and promote proper
personal hygiene
D. OUTPATI$NT :ncouraged the patients0 mother to return to the hospital a
week after discharge for a follow"up check"up from
2onday to riday, from 7/66am to 8/66pm for a follow"up
check"up.
$. DI$T :ncouraged the patients mother to provide nutritious
foods such as fruits and vegetables and to increase oral
intake of fluids.
AIII. $;ALUATION AND I-PLICATION
30
(fter two days of ?ospital visit at the Bukidnon #rovincial ?ospital
2alaybala" #edia *ard, I was able to achieve the goal in rendering our hospital
visit and the bedside care to our patient. I was able to do our nursing
interventions as part of our nursing care plan. I can say that the prognosis is
good since the disease has been diagnosed and prompted early treatment, but
inspite of that there is a problem with the medication compliance because of lack
of financial resources. (deBuate diet and supplements was encouraged to suffice
the daily reBuirement of the patient.
.uring the interview and assessment I was able to established trust and
rapport with each other and implemented our nursing care as planned. The
importance of follow"up check"up examinations and treatment was stressed to
the family because of the complications that will brought about of the disease.
AI;. BIBLIO9RAP7<
31
"ttp5CCen.4i.ipedia.orgC4i.iCBronc"opneumonia
2edical"%urgical 1ursing, 36
th
:dition by. %melt9er
32