bronchopneumonia_cs

8/9/2019 BronchoPneumonia_CS

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INTRODUCTION

a. Overview of the Case

Bronchopneumonia, or bronchial pneumonia, is a type of pneumonia that

originates in the bronchioles of the lungs, which are the smaller ducts of the

bronchial tubes. The contagious infection is caused by a variety of bacteria,

viruses, and other microorganisms.

Infant, toddler and older people can easily acquire this disease. As the

Group B5 rotated in the pedia ward in Bukidnon Provincial Hospita; - Talakag, I

was assigned into a 3 years old patient whose name is Ampoan, Alona Tayaotao

who was diagnosed with Bronchopneumonia. Its my first time to handle a patient

with a case of bronchopneumonia and it seems to be challenging in my part as a

student nurse. Through this case study I share my knowledge and care to my

patient and at the same time I also gained knowledge from my patient.
http://www.microscopyu.com/galleries/pathology/bronchopneumonialarge.html


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b. Objective of the Study

At the end of 2-days (16 hrs) duty, I will be able to bring improvement to

my patients health status, impart health teachings and informations to the patient

and to her family, thus enhancing their naked mind regarding to the illness of

their daughter and poor health management. As a part of this objective, my aim

is to provide nursing interventions to the identified health problems affecting the

family and gain their cooperation towards the improvement of their daughters

health condition

c. Scope and Limitation of the Study

The NCM501X was assigned in pedia ward of X. The study was directed

to Xs health. The information gather was only limited from the assessment to the

second day of our duty which is done last January 16-18, 2007. Any information

verbalized by the mother and father regarding to their daughter Ampoan, Alona

are included in this study.

In a period of time, the interventions are not to bring patient in a full

recovery but to improve the health status of the patient and to preventcomplications. For the parents are included in this study in the enhancement of

the patients health, health teaching is being done as a part of my interventions.

In this way, Dole-out system is being avoided.

II. HEALTH HISTORY


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a. Profile of Patient

Name : X

Date Assessed: January 16,2007Age 3 years oldSex FemaleDate of Birth July 5, 2003Birth Place XNationality FilipinoReligion Roman CatholicTemperature 39.2 CPulse rate 80 bpmRespiratory rate 34 cpm

Blood Pressure No OpportunityHeight: 97 cmWeight 13 kg

Types of previous illness/ surgery Date

Cough January 13, 2007Cold January 13, 2007Fever January 13, 2007Diarrhea January 15, 2007

Has received blood in the past _____ Yes ___/__ No If yes list dates____

Reactions___ Yes ___ No

Medication Name Dose /Frequency Time of Last dose

Gabon (pabukal) Once a day after supper January 14, 2007

b. Family and Personal Health History

Name : X(Father)

Date Assessed: January 18,2007


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Age 32 years oldSex MaleDate of Birth April 16, 1974Birth Place XNationality Filipino

Religion Roman CatholicTemperature No OpportunityPulse rate No OpportunityRespiratory rate No OpportunityBlood Pressure No OpportunityHeight 55Weight 51 kgEducational Attainment High School, UndergraduateOccupation FarmerIncome P1,500/month

Name : X(Mother)

Date Assessed: January 17,2007Age 32 years oldSex FemaleDate of Birth September 25, 1974Birth Place XNationality FilipinoReligion Roman CatholicTemperature 37.2 CPulse rate 75 bpmRespiratory rate 18 cpmBlood Pressure 110/90 mmHgHeight 410Weight 44 kgEducational Attainment Elementary, UndergraduateOccupation HousewifeIncome None

5 Children: All are still dependent on their parents.

NAME AGE EDUC. ATTAINMENT


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X 12 Grade Six

X. 8 Grade Two

X 5 -----

X 3 -----

X 1 -----

Health HistoryRoque, Ampoan


Back ache December 2006




Lana ------- -------

Mr. X is farmer in X. According to Mr. X, he sometimes experienced back

ache due to his daily work, though it is such a hinder, he still continue to work to

earn money and to raise his family. As an intervention he engaged to self

treatment by placing an amount of Lana and rubs it to the area where pain is

being identified.

X


Cough December 2006Cold December 2006


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Neozep 550 mg BID P.O. -------

Last December 2006, Mrs. X experienced common cough and cold and

had taken Neozep to get rid of such illness. According to Mrs. X, she got this

illness due to the cold weather they have experienced last December 2006. As a

treatment, MsX had taken Neozep 550 mg twice a day.

c. History of Present Illness

Based on my interview with Mrs. X X regarding to her daughters illness,

she said that no one in their family and relatives had experienced pneumonia andother respiratory problem, the most common illness that they only experienced

are cough, cold and fever. She told me that, she found X to be playful with his

brother and sister during the first and second week of this month but recently

three days before Xs admission she found her daughter weak and experiencing

fever and start to experienced dyspnea. The only thing that she suspected


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regarding to the illness is the bad weather they experienced during the past few

days.

d. Chief Complain

X fourth child of MrX and Mrs. X who was admitted last January 16, 2007

with a chief complain of cough and dry and experienced cold, fever, and

diarrhea, five days prior to admission.

III. DEVELOPMENTAL DATA

X

Infancy

According to Erickson, the central crisis at this stage is trust vs. mistrust.

Resolution at this stage determines how the person approaches subsequent

developmental stages. During the first year of life, infant depend on their parents

for physiologic needs. Fulfillment for this need is required for the infant to develop

a basic sense of trust.

As for my patient, according to her mother during her infancy period she

always demand for an attention, she would really cry whenever she is being held

by other person. She also manifest sucking reflex.

Early childhood

According to Freuds theory this age represents the anal phase of

development when rectum and anus are the especially significant areas of the

body. This is the toilet training stage.Aside from her mother, Alona is being trained by her father, older brothers

and sister on when and where to defecate. Based on my interview to the clients

mother, my patient is not properly trained. Though Alona give signs to her

parents that she wants to defecate and able to identify where is the proper place

to defecate but still she sometimes cant help to defecate in her underwear.


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IV. MEDICAL MANAGEMENT

a. Medical Orders and Rationale

Date Doctors Order Rationale

January 16, 2007 > Obtain consent

> Laboratory:Hematology

> D5LR 500 cc at40 mgtts./min.

> Diet as Tolerated

>To obtain patientsapproval if there is aninstance that the patientshould be undergone toan operation and thehospital will not be heldliable for anycircumstances to come.

>To determine presenceof microbes,the type of organisms inthe blood and theantibiotic used in whichthe organism is sensitive.

> For fluid replacement

> To maintain patientsnutritional status.

Date Doctors Order Rationale

>Medications:- Paracetamol Drop

1.2 ml QID P.O.

- Cefuroxime250 mg every 8 hrs IVTTANST (-)

- Salbutamol

> Reduction of fever/body temperature.

> Serious infections ofthe lower respiratorytract.

> Inhalation used as


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January 17, 2007

1 neb every 6 hrs

> Place patient in semi-fowlers position

>IVTF: > D5LR 500 cc at40 mgtts./min.

>Same meds order

> Diet as Tolerated

> Maintain bed rest

quick relief agent foracute bronchospasm andfor prevention of exerciseinduced bronchitisspasm.

> Allow proper breathing

> For fluid replacement

> Reduction of fever/body temperature.

- Serious infections of thelower respiratory tract.

- Inhalation used as quickrelief agent for acutebronchospasm and forprevention of exerciseinduced bronchitisspasm.

> To maintain patients

nutritional status.

> Prevent overexhaustion and reduceoxygen consumption.


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DRUG STUDY

Name of Patient: Ampoan, Alona

Generic name

of OrderedDrug

Brand

Name

Date

Ordered

Classification Dose/

Frequency/Route

Mechanism

of Action

Specific

Indication

Contra-

indication

Side

Effects/Toxic

Effects

Nursing

Precaution

Paracetamol Biogesic

1/16/07 Anti-pyretic Drop 1.2 mlQID P.O.

Inhibits thesynthesis oftheprostaglandins that mayserve asmediators ofpain andfever primarilyin the CNS.

Reductionof fever/bodytemperature

Contraindicated in patientshypersensitiveto drug

Skin:rash,urticaria

GI:Hepaticfailure

GU:Renalfailure

-assesspatienttemperaturbefore andduringtherapy-be alert foradversereactionsand druginteraction-give liquidform to

children-warn pt.that highdoses orunsupervisd long-termuse cancause liver

damage.


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DRUG STUDY


Generic

name ofOrdered

Drug

Brand

Name

Date

Ordered

Classification Dose/

Frequency/Route

Mechanism

of Action

Specific

Indication

Contra-

indication

Side

Effects/Toxic

Effects

Nursing

Precaution

Cefuroxime _____ 1/16/07 Cephalosporins

250 mgevery 8 hrsIVTT ANST(-)

Inhibits cellwall synthesispromotingosmoticinstabilityusuallybactericidal.

Seriousinfectionsof the lowerrespiratorytract.

Contraindicated in patienthypersensitivedrug or othercephalosporins.

CV:Phlebitis,Thrombophlebitis

GI:colitis,nausea,anorexia,vomiting,diarrhea

SKIN:urticaria, pain,indurati

Obtainspecimen fculture ansensitivitytest befogiving firdose.


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on

Other:Serumsicknes

s


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DRUG STUDY


Genericname ofOrdered

Drug

BrandName

DateOrdered

Classification Dose/Frequency/

Route

Mechanismof Action

SpecificIndication

Contra-indication

SideEffects/Toxic

Effects

NursingPrecaution

Salbutamol Salbutamolproventil

1-16-07 Therapeuticbroncho

dilatorspharmacologic adrenergics

1 neb every6 hrs

Relaxbronchial,uterine,vascularsmoothmuscle bystimulatingbeta 2receptors

Inhalationused asquickreliefagent foracutebronchospasm andforprevention of

exerciseinducedbronchitisspasm

Hypersensitivityto adrenergicamines.

CNS:Nervousness,restlessness,tremors,headache,insomnia

CV:chestpain,palpitations

GI:Nausea,vomitin

Usecautiously cardiacdiseasehypertensio,hyperthyroism,diabetes,glaucoma.


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g


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V. PATHOPHYSIOLOGY W/ ANATOMY AND PHYSIOLOGY

DEFINITION: A contagious infection of the lungs. This type of pneumonia islocalized mainly in the smaller branches of the bronchial tubes called

bronchioles.

Predisposing Factors: Poor sanitized environment

Malnutrition

Age

Exposure to noxious gases.

Precipitating Factors: Pseudomonas aeruginosa and

Klebsiella, Staphylococcusaureus, Haemophilus influenzae,Staphylococcus pneumoniae

Enteric gram-netgative bacilli,fungi, and viruses

Aspiration ofmicroorganisms inlower respiratory tract

If defense mechanismis weak, possibility ofhaving pneumoniacould be acquired

Pathogens thrives inthe bronchus of thelungs

As a defensemechanism, the body

reacts by causinginflammation

Inflammation on thearea of bronchus

interferes with theproper diffusion ofoxygen and CO2

From one area ofbronchus, it spreads

within the bronchus tolung parenchyma.Which means bronchusis constricted

With the interferenceof air exchange,patient experiences

poor oxygenationdue to underventilated area ofthe lungs

BRONCHOPNEUMONIASigns and Symptoms:

- coughing,- chest pains,- fever, blood-streaked- sputum,- chills,- dyspnea- fatigue

Complications:Respiratory Acidosis


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EENT: Impaired vision blind pain reddened drainage gums hard of hearing deaf burning edema lesion teethAsses eyes, ears, noseThroat for abnormality no problemRESP.asymmetric tachypnea apnea rales cough barrel chest bradypnea shallow rhonchi sputum diminished dyspnea orthopnea labored wheezing pain cyanotic

Asses resp. rate, rhythm, depth, patternbreath sounds, comfort no problemCARDIO VASCULAR arrhythmia tachycardia numbness diminished pulses edema fatigue irregular bradycardia murmur tingling absent pulses painAssess heart sounds, rate, rhythm, pulse, bloodpressure, etc., fluid retention, comfort no problemGASTRO INTESTINAL TRACT obese distention mass dysphagia rigidity painAsses abdomen, bowel habits, swallowing,

bowel sounds, comfort no problemGENITO-URINARY and GYNE pain urine color vaginal bleeding hematuria discharge nocturiaAssess urine freq., control, color, odor, comfort/Gyn-bleeding, discharge no problemNEURO paralysis stuporous unsteady seizures lethargic comatose vertigo tremors confused vision gripAssess motor function, sensation, LOC, strength,grip, galt, coordination, orientation, speech. no problemMUSCULOSKELETAL and SKIN

appliance stiffness itching petechiae hot drainage prosthesis swelling lesion poor turgor cool deformity wound rash skin color flushed atrophy pain ecchymosis diaphoretic moistAsses mobility, motion, galt, alignment, joint function/skin color, texture, turgor, integrity no problem

Place an (X) in the area of abnormality. Comment at thespace provided. Indicate the location of the problem inthe figure if appropriate, using (x)

Name: X_______________________ Date: January 16, 2007____________Vital Signs:Pulse: ________ BP: ________ Temp: ________ Height: _________ Weight: ________

VI. NURSING SYSTEM REVIEW


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VII. IDEAL NURSING MANAGEMENTName of Patient: Ampoan, Alona

Cues NursingDiagnosis

Objective Intervention Rationale Evaluation

Subjective :As verbalized

by the patientsmotherMaghilaka jud nisiya bastamaglisod na ogginhawa.

Objectives :1. Dyspnea2. Facial

grimace3. Fatigue

Ineffective airwayclearance relatedto bronchialinflammation asevidenced bydyspnea grimaceand fatigue.

At the end of 30minutes the clientwill display absenceof dyspnea and feelrelax.

1. Place patient in semi-fowlers position.

2. Instruct patient or itswatcher to change inposition frequently.

3. Increase fluid intake.

4. Advice patient tomaintain bed rest.

5. Administercephalosporin.

1. To allow patientto breath properly

2. Formobilization andexpectoration ofsecretions.

3. Decrease theviscosity ofsecretions.

4. Prevent over

exhaustion andreduce oxygenconsumption.

5. Treatment ofchoice penicillinresistantstreptococcal

At the end of 30minutes the clientwas able to displayabsence ofdyspnea and feltrelax.

IDEAL NURSING MANAGEMENT


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Subjective :

Gahangosonakong anak ogdali maski darilang siya maglihok-lihok sakatre asverbalized by thepatients mother

Objectives :1. Fatigue2. Exhaustion

Activity

intolerancerelated toimbalancebetween oxygensupply anddemand asevidenced byfatigue.

At the end of 30

minutes the clientwill display ameasurableincrease intolerance to activitywith absence ofexcessive fatigue.

1. Assist patient to

assume comfortableposition for rest/sleep.

2. Assist w/ self-careactivity as necessary.

3. Instruct parents toclean and fix patientsbed.

4. Advice the parents toengage patient indiversional activities asappropriate like tellingstories.

5. Administer Oxygentherapy.

1. To promote

relaxation.

2. Helps balanceoxygen supplyand demand andminimizeexhaustion.

3. To promotecomfort duringrest.

4. Reduces stressand excessstimulation and topromote rest.

5. To provideadequate oxygen.

At the end of 30

minutes the clientwas able display anincrease intolerance to activitywith absence ofexcessive fatigue.

IDEAL NURSING MANAGEMENT


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Subjective :

As verbalizedby the patientsmother, duha nani kaadlaw angiyang hilanat.

Objectives :1. Flushed

skin2. Temp.

39.2C3. Chill

Hyperthermia

related to illnessas evidenced byflushed skin andwarm to touch.

At the end of 30

minutes thepatientstemperature willdecrease.

1. Perform tepid sponge

bath.

2. Offer cool glass ofwater or increase fluidintake.

3. Add bedlinens/blanket.

4. Instruct client tomaintain bed rest.

5. Administer anti-pyreticdrug as prescribed.

1. To reduce

fever.

2. To preventthirst anddehydration.

3. To minimizepatient fromchilling and tomaintain nearnormal bodytemperature.

4. To preventincrease ofmetabolic rate.

5. To reduce feverthrough centralaction inhypothalamic heatregulating center.

At the end of 30

minutes the clientstemperaturedecreased andminimized signs offever.


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Actual Nursing Management

S Kaduha siya nalibang ang akong anak karong buntaga nya

basa-basa iyang tae as verbalized by the patients mother

Mrs. Marilyn Ampoan.O Grimace due to abdominal pain

Pain scaled by 4 in 1-10 scaling

Watery stoolsA Diarrhea related to infection as evidenced by watery stools

and grimaceP Long term: At the end of 1 day, the patients stool will return

to its normal consistency.

Short term: At the end of 30 minutes the patient will be able

to display or verbalize that the pain has decreased.I 1. Promoted bed rest

2. Restarted oral fluid intake gradually

3. Advised patient and parents to eat banana in times of

diarrhea.

4. Instructed parents to clean their food utensils thoroughlyand boil it.

5. Administered intravenous fluids as ordered.

E At the end of 30 minutes the patient was able to display and

verbalized that the pain has decreased.

VIII. REFERRALS AND FOLLOW-UP


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As such Ive told the patients mother and father to immediately consult the

physician or nurse if any unusualities observe to prevent complications. I also

told the parents of my patient to ask some questions to the physician during

doctors round regarding to their daughters illness and advised them to maintain

cleanliness in the area, on the bed and also provide proper hygiene to their

daughter to promote comfort and to enhance wellness.

In times illness or to attain free health service, Ive advised the parents to

visit their nearest Barangay Health Center and have a weekly check-up to

monitor the health status of each family member, thus promoting prevention

rather than cure.

IX. EVALUATION AND COMPLICATIONS

After 2-days of care that was being imparted to the patient, my objectives

were fully met. As what is being said, I was able to managed the condition of my

client and seen some improvement on her health in just few days. Careful

assessment of the clients health status was done. And from such examination,

the clients problems were identified. Interventions were then planned carefully

and were properly addressed to her health problems. After which, her response

and reaction were evaluated and important health teachings for her recovery

were imparted to her mother and father and especially to my patient.

During the second day of our duty, my client was able to display some

improvement regarding to her actions and especially to her breathing. Diarrhea

and fever were no longer present during the last day of my duty. This implies that

the intervention done was effective.

BIBLIOGRAPHY


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Smeltzer.Bare. Textbook on Medical-Surgical Nursing (10th edition) Lippincott-Raven Publisher.Copyright 1996

Wilson, Billie Ann Nurses Drug Guide (vol. 1 & 2) Pearson Education

Inc.,Copyright 2000

Mosbys Pocket Dictionary of Medicine, Nursing and Allied Health (4 th edition)Elsevier(Singapore) PTE LTD> Copyright 2002

Doenges, Marilynn Nursing Care Plans, Guidelines for Individualizing PatientCare(6th edition) F.A Davis Company. Copyright 2000

Kozier. Erb. Blais. Wilkinson. Fundamentals in Nursing (5

th

Edition). Addisonesley Longman Inc. 1998.


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LICEO DE CAGAYAN UNIVERSITYCollege of Nursing

NCM501202A Care Study

XName of Client

Submitted to:

______________________________Name of Faculty

As Partial Requirement for NCM501202

Submitted by:

_______________________________Name of Student

Rating ScaleA. Written WEIGHT RATING

I. INTRODUCTIONa. Overview of the caseb. Objective of the casec. Scope and limitation of the study

5

II. HEALTH HISTORYa. Profile of patientb. Family and personal health historyc. History of Present Illnessd. Chief complain

5

III. DEVELOPMENTAL DATA 5IV. MEDICAL MANAGEMENT

a. Medical Orders and rationaleb. Drug study

20

V. PATHOPHYSIOLOGY W/ ANATOMY ANDPHYSIOLOGY

10

VI. NURSING ASSESSMENT (System Review and Nsg.Assessment II)

10

VII. NURSING MANAGEMENTa. Ideal Nursing Managementb. Actual Nursing Management

30

VIII. REFERRALS AND FOLLOW-UP 5IX. EVALUATION AND COMPLICATIONS 5X. DOCUMENTATION

a. Documentation of evidenced of care for 1 weekrotation

b. Organization/Grammar/Bibliography

5

Total Score 100Equivalent Grade


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