bronchopnemonia

7/30/2019 bronchopnemonia

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Bronchopneumonia

(Bronchial pneumonia )

Inflammation of the lungs beginnings inthe terminal bronchioles


2/23

Sources of information : Pts mother, case notes Q,1 year 4 month(2nd child of two siblings),malay girl from

samrahan,Kuching

Comes to A&E Cuddled by his mother,weight: 6.29kg

Mother: housewife(20 y/old)

Father:fisherman(25y/old)

1ST hospitalization(august 2011)

Date of admission:7/12/12(2nd hospitalization)

Past surgical history: none

Allergies: no known allergies to medication, food


3/23

Reasons for hospitalization:

c/o:Fever 5/7, cough 5/7,less active ,rhinorrhea ,vomit x 1 after

milk,tachypneic,poor oral intake

Past medical history:premature @24/52(admitted into NICU and was

intubated),Failure to thrive,chronic lung disease,ROP(resolved by laser

theraphy), resolved bilateral IVH with hydrocephalus

Birth history:SVD,premature baby(24th week),birth weight:695 gram

Immunization history:up to date,given palvizumab(X 4) latest on 21/3/12

Developmental/growth pattern:weight:6.18 kg,able to sit alone,stand with

support,able to call mama,has palmar grasp

Medical Diagnosis:Bronchopneumonia


4/23

Physical examination

General condition: less active, weak,irritable, difficult to approach

Weight:6.18kg(on assessment)

V/sign:temperature:36.5 Celsius(axila),HR:124/min,RR:44/

min,Spo2:97% Oxygen 0.5L/min

Lung examination:Bilateral lung crepitation, rhonchi,subcostal andsubsternum recession.

Chest examination:pectus carinatum(pigeon chest)


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Functional health pattern

Health Perception-Health Management Pattern This is second time admitted

Admitted due to c/o:Fever 5/7, cough 5/7,less active ,rhinorrhea ,vomit x

1 after milk,tachypneic,poor oral intake

Previously well and active playing at home

Child was on MDI ventolin(prn) and beclomethasone (BD) usingaerochamber(mother know how to use)

Nutritional and Metabolic Pattern

Dietary history's:B/F stopped at 3months of age,currently given bottle

feeding 5-6oz ,4-6hly(lactogen),semisolid food(6-9 teaspoon),porridge

Poor intake during sick,coughing during bottle feeding causing vomiting Was supplied with folic acid and multivitamin


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Elimination Pattern

BO X 1-2/day with normal color and consistency of stool,

PU (3-4 X diapers changed) with normal colour urineActivity and exercise pattern

Active playing toys at home,wathcing tv(cartoon)

Bathing time: morning and evening

Sleep-Rest Pattern

No problem of insomnia,Ussually sleep 8pm-6am,sleeping with parents

Day sleeping(11am-2pm) initiates by bottle feeding

Sleep position: knee-chest position(longer),supine(shortly)

Cognitive-Perceptual Pattern

Child alert, responsive,irritable Anxiety,fear to nurse

Sensory-pattern

Hearing ,vision normal, all other sensory intact(touch,taste,smell)


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Coping stress

If child upset and tired/sleepy she will cry more

Role Relationship Pattern

24 taken care by her mother

childs play companion :cousins

Support system:parents

Stay with mother ,father ,grandfather and grand mother

sexuality 2nd child of 2 siblings

Sister 4 years old

Value belief pattern

muslim


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PATHOPHYSIOLOGY

Microorganism enteralveolar Spaces by

dropletinhalation(Etiologic

Agent:bacteria,virus,fungi)

Inflammation

occurs

Alveolar fluidincrease

Ventilationdecreases as

secretion thicken

Bronchopneumonia


9/23

Sign and symptomsCough

Fever

Chest pain

Rapid, shallow breathing

SOB

Headache

Loss of appetiteFatigue(less active)


10/23

Risk factors

Congenital oracquired

immunodeficiencyPREM

Malnutrition andmetabolic

derangement

Intubation andtracheostomy

CNS depression (

inhibit cough andgag reflex)

Viral infection

predisposebacterial infection


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Investigation

Chest X-ray : Right perihilar haziness -connection between the

mediastinum and the pleural cavities meet

Serology laboratory report C- reactive protein : negative ( no inflammation

throughout the body)

Hematology report(abnormal)

a) Full blood count, Hb low(IDA)

b) Differential count

-Monocytes high (attack bacteria or viruses) , Neutrophils low ( infection)

12 lead ECG

Normal reading(To look out for spreading of disease to heart)


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Complication

*Empyema or lung abscesses - cavity containing pus (abscess)forms (antibiotics, narcotic pain medications, and surgical tube

drainage)

*Septic shock. Blood fills the veins and leaks through the walls ofthe capillaries, causing uncontrolled tissue swelling and possiblyorgan failure, which can lead to death (otitis, meningitis, brainabscess, endocarditis)

*Pleuritis. Inflammation of the pleura (narcotic painmedications, nonsteroidal anti-inflammatory medications for pain,or antibiotics). Pleura damage pleurisy, pleural effusion, pleuralempyema.

*Bronchiectasis -airways that are inflamed and easily collapsible(antibiotics and meter dose inhaler salbutamol and bectomethason)

*Reactive airways disease - persistent asthma and treatment givenare meter dose inhaler salbutamol and bectomethason


13/23

NCP

Ineffective airway clearance related accumulation ofsecretion(narrow airway) and inflammation of airwaysecondary to bronchopneumonia evidenced bytacypnea,RR:44,bilateral rhonci,generalized lung

crepitation,substernal and subcostal recession Imbalanced nutrition less than body requirement related to

poor oral intake, loss appetite, and coughing evidenced byweight loss (from 6.29kg -6.18 kg),less active and weak

Parental anxiety related to lack of knowledge about the

disease , prognosis , and treatment evidence by facialexpression and verbalization of worries by parents Risk for nosocomial infection related to hospitalization


14/23

Nursing care plan

Ineffective airway clearance related accumulation of secretion(narrow airway) and

inflammation of airway secondary to bronchopneumonia evidenced by

tacypnea,RR:44,bilateral rhonci,generalized lung crepitation,substernal and

subcostal recession

Goal:patient will not having respiratory distress ,RR within normal range(24-

40),minimal rhonci ,less substernal ,subcostal recession ,coughing and spo2 >95%

within 5 days@20/12/12

Intervention:

1) Assess the RR ,pattern, depth of respiration to identify any sign of respiratorydistress.

2) Position the child in a propped up position to enhance the lung expansion for

effective breathing

3) Administer oxygen 0.5 L/min via nasal prong to prevent respiratory distress

and to ensure patient receive adequate oxygenation to prevent hypoxia

4) Administer MDI sulbutamol 100mcg(2puffs,8hly) as a bronchodilator to prevent

respiratory muscle spasm and beclamethasone 100mcg(2puffs,BD) , SyrupPrednisolone 6mg OD to reduce the inflammation on respiratory tract.


15/23

5) Watch out and explain to the parents about the side effect of sulbutamol and

beclamethasone (eg:tachycardia,headache,N/V,tremors,nasal dryness/irritation)

so parents will understand more and can report as soon if this side effect need anurgent intervention from nurses/doctor.

6) Do suction via nasal when necessary to help remove the secretion out.

7) Encourage caregiver to give more fluid to the child to help moisten the

secretion.

8)Monitor RR,SPO2 level,Breathing pattern,presence of recession duringbreathing after each therapeutic intervention to evaluate the effectiveness of the

intervention

Evaluation:child is comfortable,active with RR :38,less coughing,less rhonchi

and less crepitations on lungs,spo>97% under N/P 0,5L/Min @11 am(21/12/12)


16/23

Imbalanced nutrition less than body requirement related to poor oral intake, lossappetite, and coughing evidenced by weight loss (from 6.29kg -6.18 kg),less activeand weak

Goal: Patient will have balance nutrition ,have good tolerance to oral intake andregain the appetite (11am@18/12/12)

Intervention:1) Assess the progressive of nutritional imbalance by monitoring the daily weight

to initiate a proper management2) Assess the child preferred food so caregiver can prepare food that based on her

choice and she will more tolerate to such kind of food

3) Teach caregiver to give their child to give a small frequent meals ,so that she willmore tolerate and enhance the absorption of the nutrient effectively .4) Teach caregiver to give food when child are relax, not crying ,after enough rest

and dont force child to eat if she refuse to ensure cooperation from the child toeat

5) Provide a pleasant environment during her mealtime eg:music,conversation,be onher side and provide support to enhance her mood to eat

6) Administer Syrup multivitamin 2.5ml OD, Syrup folic acid 1mgOD as a dietary supplement for the child that she need for her growth anddevelopment.

Evaluation: Child appear energetic, active(willing to play),and regain an appetite toeat


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Intervention:1) Assess the S/S of having anxiety eg:anger,denial ,refuse to answer question

and etc2) Assess their level of anxiety and identify the other potential cause that

make them anxious to carry out appropriate intervention(eg:financialproblem)

3) Assess their level of understanding regarding disease condition, treatment

,prognosis to make sure information to be delivered to them are accordingto their needs

4) Provide and give information about their child condition, treatment andprognosis using simple language(avoid medical jargon) to promoteunderstanding

5) Collaborate and allow parents to participate in decision making andprocedure so they feel less anxious and more cooperative

6) Discuss the choices of treatment with parents ,so they wont feel hopeless

that will worsen their anxiety7) Encourage parents to ask question and reply them with a calm and

unhurried manner so they wont feel helpless Evaluation: Parents have more understanding about their child's condition

,prognosis and treatment as evidenced by ability to explain when beenasked to explain by nurses, appear less anxious and having cheerful facialexpression

Parentral anxiety related to lack of knowledge about the disease , prognosis , andtreatment evidence by facial expression and verbalization of worries by parentsGoal:Parents will feel less anxiety during hospitalization @11am (17/12/12)


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Medical management

A) Syrup erythromycin Ethylsuccinate 140mg BD Actions: Teat upper and lower respiratory tract infections Indication: Bronchopneumonia Cautions: Impaired hepatic function, renal impairment Side effects: Nausea, upper stomach pain, itching, loss of

appetite

Drug interactions: Verapamil , digoxin, oral anticoagulant

B) Syrup folic acid 1mg OD Actions: To treat vitamin deficiencies Indication: As a supplement where a poor dietary intake Cautions: Take with or without food , allergies to contents Side effects: Diarrhea, nausea, itching, dizziness, allergic

reaction Drug interactions: Do not take an antacid within 1 hour

before or 2 hours after you take multivitamins with folicacid/iron syrup


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D) Syrup multivitamin 2.5ml OD Actions: To treat vitamin deficiencies

Indication: As a supplement where a poor dietary intake Cautions: Take with or without food, allergic to the

contents Side effects: Diarrhea, nausea, dizziness Drug interactions: Jaundice, hypercalcaemia

E) Syrup Prednisolone 6mg OD Actions: To treat asthma Indication: Child have asthma Cautions: Take with food, allergic to the contents, eye

disease, heart problems, kidney disease

Side effects: Nausea, headache, dizziness, increasedsweating

Drug interactions: Aspirin, nonsteroidal anti-inflammatory drugs,


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F) IV Augmentin 140mg BD Actions: To treat bacterial infections

Indication: Broncopneumonia Cautions: Blood disorders, kidney problems, liver

disease Side effects: Diarrhea, nausea, itching, dizziness Drug interactions: Probenecid

G) Metered dose inhaler (MDI) Salbutamol 100 mcg 8hourly

Actions: To relieve and prevent bronchospasm Indication: Bronchopneumonia Cautions: Allergy to contents, cardiac arrhythmia

,cardiovascular disorders Side effects: Headache, nausea, dizziness Drug interactions: Do not used with some beta-blockers

(e.g. propranolol) , other bronchodilators (e.g.terbutaline) and digoxin


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H) Metered dose inhaler (MDI) Beclomethasone100 mcg BD

Actions:To treats inflammation Indication: Bronchopneumonia Cautions: Allergic to the contents, heart

problems, stomach problems

Side effects: Headache, nausea, dizziness,upset stomach

Drug interactions: Diltiazem, aspirin

I) Oxygen SaturationKeeps SPO2 > 95 % to prevents hpoxia ( NPO2

0.5l L/min)


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Patients education duringdischarge

-Teach mother and family about importance of hand washing beforetouch the child

-Counsel parents regarding the need to prevent exposure to tobaccosmoke,allergens

-Educate parents about and caution them to look for the signs ofincreasing respiratory distress and to seek medical attention

immediately-Drink plenty of fluids and prevent dehydrated and help loosen mucus intheir lungs.

-Take all prescribed medications. Incomplete medication taken causesbacteria begin to develop drug resistance when they survive forinadequate treatment and continue to multiply and spread.

-Keep all of child follow-up appointments to monitor condition of lungs

-Stay rested and sleep well. Proper rest and enough sleep can helpkeeps immune system strong-Eat a healthy diet. Include plenty of fat-free dairy products,protiens,

fruits, vegetables and whole grains.-Teach mother about the medication (name, how to used, side effect,

cautions) to prevent from wrong medication given


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References

Dorlands Pocket 28th ed Medical Dictionary.(2011).Phildelphia:Elsevier

bronchopnemonia

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