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BRONCHOPNEUMONIA PREPARED BY , M. HASEENA ER DEPT. DR . AHMAD ABANAMY HOSPITALNURSING CASE STUDY OF A PATIENT WITH BRONCHOPNEUMONIADemographic dataNAME :XAGE : 9 YEARSSEX : MALENATIONALITY :TURKISHDATE OF ADMISSION :12/01/13CHIEF COMPLAINTS :fever,COUGH , SOB.DIAGNOSIS : BRONCHOPNEUMONIA

2PHYSICAL ASSESSMENT:GENERAL APPEARANCEChild is looking dull respiratory distress present, wheezing present, skin is warm to touchVital signs: Temperature : 38.8cHeart rate : 115 /mnt, Respiration : 54 b/ mnt nasal flaring presentBlood pressure : 100/ 80 mmHgSpo2 : 88 % in room airGENERAL MEASUREMENTHead circumference 44cmChest circumference 28cmWeight -33kgLength -110cm

3PHYSICAL ASSESSMENT SKIN Normal skin colour Hair soft and silkyWarm to touchNails to end of fingers and often extendNOSE Nostrills patent bilaterallyNasal flaring presentNasal discharges present

PHYSICAL ASSESSMENTMOUTH AND THROATUvula midlineSecretion presentTongue moves freelyGag reflex presentTeeth is normal in colourProductive cough presentNECKShort neck presentTurns side to side easilyNo lymph node enlargement present

CHESTBilateral chest movement presentNipple is symmetricalRetraction presentCrackles presentDecreased breath sound presentTachycardia presentABDOMEN Soft to palpateUmbilicus is normal Bowel sound is normal on auscultation PHYSICAL ASSESSMENTPHYSICAL ASSESSMENTGENITALIAUrinary meatus at tip of glans penisPalpable testes in scrotum and is normal in shapeAdequate voiding and defecation presentBACKSpine is intactNo spinal deformity presentEXTREMITIES Full range of motion presentTen fingers and ten toes presentNails are normal in shape and colour

MILESTONES OF DEVELOPMENT MILESTONESBOOK BASE PATIENT BASEGROSS MOTOR

Enjoying team games, eg: foot ball, tennis, cricketAre able to swimmShowing increased body awareness and awareness of own physical skill

MET FINE MOTOR

Can use adult type tools such as saws and hammersHandwriting become more legible Increase writing speedWriting can occur well without ruled lines

METMILESTONES OF DEVELOPMENTTALKING AND UNDERSTANDINGUse and understand very complex language PRESENTSOCIAL Able to resolve problems like fight with friends and siblingsAbility to understand others point of view PRESENTINTELLECTUAL

Depends on the school curriculum

IMMUNIZATION STATUSVACCINEBIRTH1MOS2MOS4MOS6MOS9MOS12MOS15MOS18MOS19-23MOS2-3YRS4-6YRS7-10YRSHEP B

RV DPT Hib PCV IPV INFLUENZA MMR VARICELLA HEP A MCV 4 ABBREVIATION OF VACCINESHep B : Hepatitis BRV : RotavirusDPT : Diphtheria , Pertuses, TetanusHiB : Haemophilus influenza type BPCV : Pneumococcal vaccineIPV : Inactivated poliovirusMMR : Measeles, Mumps, RubellaHep A : Hepatitis AMCV 4 : Meningococcal virus PATIENT HISTORYPast Medical History: patient Xs is known case of bronchial asthma since childhood. And he is on medication (nebulization) , and no other treatment .Present medical history: patient xs is came to ER Dept due to the complaints of 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 : patient xs has no present and past surgical history

TOPIC PRESENTATIONBronchopneumonia 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 SYSTEMThe 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 NOSEIt 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 PHYSIOLOGYPHARYNX : 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 PHYSIOLOGYTHE 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 CARTILAGEThese are supporting the larynx

ANATOMY AND PHYSIOLOGYTRACHEA 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 . LUNGSThe 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 PHYSIOLOGYThe 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 lungThe costal surface of each lung borders the ribsOn 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 PHASEInspiration 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 BREATHINGEXPIRATION PHASEIt 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 .

ETIOLOGYBronchopneumonia is caused by viruses, bacteria , fungi protozoa and myco plasma Bacteria Streptococcus StaphylococcusHemophilus influenzaKlebsellaVirus legionella pneumoniaFungi candida albicansOther predisposing factors include:common in hospitalized patientsits occur as a complication of some other diseases , eg: in children diphtheria, measles, and whooping coughIn adults- influenza, typhoid and paratyphoid feverits caused by organism aspirated from mouth

SIGNS & SYMPTOMS

BOOK BASEPATIENT MANIFESTATIONHIGH GRADE FEVERFEVER 38.8 CCOUGH W/ MUCUSPRESENTCHEST PAIN MILD CHEST PAIN PRESENTFATIGUEPRESENTIRRITABILITY NOT PRESENTDECREASED APETITEPRESENTDECREASED BREATH SOUNDPRESENTHEADACHEABSENTSIGNS AND SYMPTOMSHigh grade feverAny 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 breathingFrequent and excessive coughing accompanied by mucusCough 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 frequentlyFatigueIrritabilityDecreased apetiteDecreased breath sound on auscultationHeadache

PATHOPHYSIOLOGYWhen 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

BRONCHOPNEUMONIAINTERVENTIONSPerform comprehensive assessmentAuscultate breath sound , noting areas of decreased or absent ventilationremove secretions by encouraging coughingRegulate fluid intake to optimize fluid balance and liquefy secretionsAdminister oxygen if hypoxemicAdminister medication as prescribedDIAGNOSISAuscultation of breathing patternChest xrayCBC, Sputum culture , c- reactive protein

INVESTIGATIONS TEST PATIENT VALUE NORMAL VALUEC- REACTIVE PROTEIN POSITIVE NEGATIVE WBC 15.62uL 4.23-9.07uL SODIUM 135mmol/L 135-150mmol/L POTASSIUM 3.6mmol/L 3.5-5.0 mmol/L CHLORIDE 103mmol/L 98-11mmol/LTREATMENTAdvise to drink plenty of fluidEnough restElevate the head of the bed to minimize respiratory effortAdminister oxygen, if neededUse antibiotics as prescribeAntipyretics as ordered

COMPLICATIONSPleural damage leads to pleural effusion, pleural empyemaCardiovascular diseaseRespiratory deficiencyAcute renal insufficiency in dehydrationSeptic 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 secretionHyperthermia related to the inflammatory processImpaired gas exchange related to inflammation of airways and accumulation of sputumAcute pain related to ineffective comfort measures and inflammation

NURSING HEALTH TEACHING

Follow up the regimen as per orderFrequent hand washing with soap and water or use hand sanitizerAdvise to have healthy diet and adequate rest,that will keep the immune system strong Advice to cover the mouth while coughingFollow up to the hospital after finishing the antibiotic course

NURSING CARE PLAN FOR BRONCHOPNEUMONIAASSESSMENTNURSING DIAGNOSISPLANNINGINTERVENTIONRATIONALEEVALUATION Subject : Difficulty in breathing

Objective : Restlessness with naslal flaring, warm flushed skin , Ineffective airway clearance related to accumulation of tracheobronchial secretionAfter 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 airwayAfter 3-4 hrs patient shall have demonstrated improved airway clearance, reduction of congestionASSESSMENTNUSING DIAGNOSISPLANNINGINTERVENTIONRATIONALEEVALUATIONSubjective : Sleeping disturbance

Objective : Child is restless, nasal flaring noted Disturbed sleeping pattern related to difficulty of breathingAfter 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 saturationThe child shall have verbalized understanding of sleep disturbanceASSESSMENTNUSING DIAGNOSISPLANNINGINTERVENTIONRATIONALEEVALUATIONSubjective :Difficulty of breathing,

Objective :Presence ofCircum oral cyanosisSpo2 = 88% in room air Impaired gas exchange related to inflammation of airwaysAfter 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 vasoconstrictionor 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 saturationPatient shall demonstrate improvement in gas exchange ASSESSMENTNUSING DIAGNOSISPLANNINGINTERVENTIONRATIONALEEVALUATION Subjective :Increased body temperature @38.8c

Objective : skin is warm to touchVital signs:Temp :38.8cPR : 115/mtRR : 54 b/ mtSpo2 : 88% in room airHyperthermia related to the inflammatory processAfter 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 feverAfter 3-4 hrs of nursing intervention patient temperature shall have decreased to normal limitsTHANK YOU ALL