Saint Marys University School of Health Sciences Bayombong, Nueva Vizcaya

In partial fulfillment Of the requirements in

Nursing Care Management 101

Submitted by: Apryll L Sicam Student

Submitted to: Ms. Erika Medrano, RN Clinical Instructor (RLE)

PERSONAL DATA

Name: Age: Sex: Address: Civil Status: Birth Date: Birth place: Educational attainment: Occupation: Religion: Nationality: Language: Date of admission: Time of admission: Chief complaints: Admitting diagnosis: Final diagnosis: Attending Physician: Ward: Date of discharge: Time of discharge: 8 y/o Male

ILY boy

Labni, Mabuso, Bambang, Nueva Vizcaya Single March 6, 2001 Labni, Mabuso, Bambang, Nueva Vizcaya Elementary undergraduate N/A Roman Catholic Filipino Iloco, Tagalog, September 12, 2009 7:02 am cough for 2 weeks, on and off fever for 1 week, headache, and body weakness Pneumonia with some dehydration Bronchopneumonia Dr. Blanza Pedia ward, room 203 September 14, 2009 4:30 pm

HEALTH HISTORY
CURRENT HEALTH PROBLEM:

Condition started one week ago with on and off fever, anorexia and body weakness. His parents gave him over the counter drugs such as Mefenamic acid and Paracetamol tablet to alleviate the symptoms but the condition still persisted. His parents advised him to absent in school for a while but since the child earns good academic performance, he insisted to go. On September 12, Monday, though not feeling well, insisted to wake up and prepare for school. Just before he steps out of their house, he collapsed that made him brought to NVPH for observation and treatment.
PAST HEALTH PROBLEMS:

The family source of income comes from the fathers side line jobs such as being a carpenter. The family lives in a mountainous area in Mabuso and the child usually walks from their home to reach school. He often experienced cough and colds especially during rainy days because he and his friends usually play in the river first when they are on their way home after school. The boys would take over-the-counter drugs to cure cough and colds. Ily boy had been hospitalized at NVPH when he was 4 y/o due to severe vomiting and diarrhea. The parents would hospitalized him only if the condition stayed for a week or so due to financial constraints.
ACCIDENTS:

He didnt encountered any kind of accidents.

FAMILY RISK FACTORS:

The patients family has a history of weak lungs as been mentioned by his father. Two of their relatives had experienced Pneumonia but none had died due to the disease.
MEDICATION:

He takes over the counter drugs such as Mefenamic acid for pain and Paracetamol tablets for fever

BRIEF DESCRIPTION OF THE DISEASE

Bronchopneumonia -is an illness of lung which is caused by different organism like bacteria, viruses, and fungi , and characterized by acute inflammation of the walls of the bronchioles. It is also known as pneumonia. It is common in women and causes to the 6% deaths. Streptococcus pneumonia and mycoplasma pneumonia both are the common bacterium which causes bronchopneumonia in the adults and children. Acute inflammation of the walls of smaller bronchial tubes, with varying amounts of pulmonary consolidation due to spread of the inflammation into peribronchiolar alveoli and alveolar ducts; may become confluent or may be hemorrhagic. -an inflammation of the terminal bronchi, air-vesicles, and interstitial tissue of a few or many of the lobules. Predisposing factors Some patients are unable to clear their lungs due to medication, old age, physical weakness and pulmonary fibrosis. Patients who are immobile develop retention of secretions; thus, most commonly involves the lower lobes. Cilia not functioning-hereditary dyskinesis, squamous metaplasia, cigarette smoking, gas exposure. Alcohol, tobacco and oxygen therapy interfering with the ability of the alveolar macrophages to kill bacteria. Bacteria grows within secretions collected in the chest. Eg. In chronic bronchitis, cystic fibrosis or an obstructing malignant tumour. Pulmonary edema fluid is a good culture media. Risk factors Are older than 65 Have other health problems, such as chronic obstructive pulmonary disease, heart failure, asthma, diabetes, longterm (chronic) kidney failure, or chronic liver disease. Cannot care for yourself or would not be able to tell anyone if your symptoms got worse. Have severe illness with less oxygen getting to the tissues (hypoxia). Have chest pain caused by inflammation of the lining of the lung (pleurisy) and therefore are not able to cough up mucus effectively and clear the lungs. Are being treated outside a hospital and is not getting better (such as your shortness of breath not improving). Are not able to eat or keep food down so that you need to take fluids through a vein (intravenous). Symptoms of bronchopneumonia Cough with greenish or yellow mucus Fever Chest pain Rapid, shallow breathing Shortness of breath Headache Loss of appetite Fatigue Causes of bronchopneumonia

Bacterial pneumonias tend to be most serious and, in adults, the most common cause of pneumonia. The most common pneumonia-causing bacterium in adults is Streptococcus pneumonia (pneumococcus). -Bronchopneumonia may occur as a complication of some disease. Eg. In children Diphtheria, Measles, whooping cough. In adults Influenza, typhoid and paratyphoid fever etc. -It is often seen in two extremes of life (in infants and old age). -Most bronchopneumonia cases are caused by organisms aspirated from the mouth.

Complications Pulmonary fibrosis Bronchiectasis Lung abscess Emphysema Bacteremia with abscess in other organs Treatment of bronchopneumonia A. Medical treatment 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% effectiveness in staving off pneumococcal pneumonia. Influenza vaccinations are also frequently of use in decreasing ones susceptibility to pneumonia, since the flu precedes pneumonia development in many cases.

ANATOMY AND PHYSIOLOGY

Respiratory System Primary function is to obtain oxygen for use by body's cells & eliminate carbon dioxide that cells produce Includes respiratory airways leading into (& out of) lungs plus the lungs themselves

RESPIRATORY STRUCTURE: Thoracic Cavity Cone-shaped structure containing the conducting system gas exchange system, pleura and mediastinal and pericardial structures. Primary Bronchi the right and left primary bronchi are formed by the division of the trachea

the right primary bronchus is wider, shorter and straighter than the left

Lungs Paired cone-shaped organs lying in the entire thoracic cavity except for the ost central area, the mediastinum. Apex is the narrow superior portion of each lung Base is the broad lung area resting on the diaphragm The surface of each lung is covered with a visceral serosa called the pulmonary or visceral pleura and the walls of the thoracic cavity are lined by the parietal pleura The left lung also contains a concavity, the cardiac notch in which the heart lies; it has 2 lobes and 8 bronchopulmonary segments The right lung is thicker and broader; and contains 3 lobes and 10 bronchopulmonary segments Pleurae Membranes protectively covering each lung and lining the thoracic cavity. Has 2 layers, parietal pleura ( lining the inner surface of the chest wall and covering the costal, diaphragmatic and mediastinal surfaces of the thorax); visceral pleura ( it hugs the contours of the lung tissue including the fissures between the lobes of the lungs) Has a small amount of pleural fluid as lubricant Bronchioles Often referred to as bronchial or respiratory tree the terminal bronchioles is subdivided into small conduits called respiratory bronchioles Diaphragm the major muscle for respiration, innervated by the phrenic nerve The right side is higher than the left because of the space occupied by the liver. The normal excursion of the diaphragm is 1.5 cm, with deep breathing this may increase to 7 or 8 cm. Other muscles for respiration external and internal intercostals muscles parasternal, scalene, sternocleidomastoid, pectoralis muscles

trapezius

and

Respiratory Center located in the brainstem ( medulla oblongata) It is stimulated by an increased concentration of CO2 and to a lesser degree by decreased amounts of O2 in arterial blood. Stimulation of the respiratory center causes an increase in the rate and depth of breathing, thus blowing off excess CO2 and reducing blood acidity. Respiratory Conducting System Upper airway it conducts air to the lower airway, protects it from foreign matter and it warms, filter and humidify the inspired air. Consists of nose, pharynx, epiglottis and larynx Lower airway - also called as the tracheobronchial tree

Functions: Conduction of air through the many branches of airways to the alveolar level. Mucociliary clearance Production of pulmonary surfactant. Lung Parenchyma the working area of the lung tissue consisting of millions of alveolar units It is the passage and exchange of molecular oxygen and carbon dioxide from the pulmonary capillaries and alveoli. Protective mechanisms for normal respiration Mucus blanket Cilia Macrophages Surfactant Cough Reflex bronchoconstriction Physiology of Respiration Respiration- exchange of CO2 and O2 within the lungs, between the cells and their environment and in intracellular metabolism Pulmonary Ventilation- a process by which gases are exchanged between the external environment and alveoli External Respiration- the exchange of gas between the air in the alveoli and the blood within the pulmonary capillaries Respiratory Gas Transport- O2 and CO2 must be transported to and from the lungs and tissue cells of the body via the bloodstream Internal Respiration- exchange of O2 and CO2 at the tissue- cellular level Mechanics of Breathing Inspiration- is initiated by contraction of the diaphragm and external intercostals Expiration- a passive process and does not require muscles to work Elastic properties of the Lung and Chest Wall - permit expansion during inspiration and return to resting volume during expiration - Elastic Recoil- the tendency of the lungs to return to the resting state after inspiration - Normal elastic recoil- permits passive expiration, eliminating the need for major muscles of expiration. Compliance- the measure of lung and chest wall distensibility It is the volume change per unit of pressure change Airway Resistance- is determined by the length, radius and crosssectional area of the airways and density, viscosity and velocity of the gas Work of Breathing- is determined by the muscular effort required for ventilation Normal breath sounds:

Bronchial: heard over the trachea on the anterior chest wall during both inspiration and expiration. They are loud, highpitcehd and hollow or harsh sounding as if air is passing thru a tube. Vesicular: heard in most peripheral parts of the lungs, lowpitched, soft, swishing sounds and are best heard during inspiration. Bronchovesicular: heard over the trachea, mainstem bronchi and right posterior chest and between the scapulae. They are louder and higher-pitched than vesicular sounds and softer and lower pitched than bronchial sounds. Both heard during inspiration and expiration. Pulmonary Circulation facilitates gas exchange delivers nutrients to lung tissues acts as a reservoir for the left ventricle serves as a filtering system that removes clot, air and other debris from the circulation Gas Transport the delivery of O2 to the cells of the body and the removal of CO2

PATHOPHYSIOLOGY

Etiology: >S. Aureus >Streptococcal pneumonia fluids

Precipitating factors: >Productive cough >Improper hygiene >aspiration of food, and On vomitus >inhalation of toxic, smoke, Dust or gasses >age

Invasion of infectious agents in the airway mucosal lining of the URT Irritation Sneeze and cough reflex Endogenous pyrogens Released by phagocytes Stimulates hypothalamus capillary refill Inflammatory response blood components migrate to Area of infection lungpenetrates the lower respiratory tract (alveoli and bronchioles)

Altered lungs function Increase in temperature Decrease compliance collects around And vital capacity Fever exchange If reaches maximal thermal increase DOB And unattended use of accessory muscle

edema exudates fluid the alveolar wall reduce gas

-nasal flaring Convulsion -rapid, shallow breathing

LABORATORY FINDINGS
Complete Blood Count Hgb Hct RBC Plt WBC Neutrophil Lymphocyt e Monocyte 1.2 x 10^9 L Eosiniphil 1.0 x 10^9 L Basophil 0.1 x 10^9 L MCH 25.6 pg MVC 78 fL MCHC 32.78 g/L Widals test= negative Urinalysis September 13,2009 September 12, 2009 13.2 g/dL 40.2 L 5.16 x 10^12 L 401 x 10^9 L 16.6 x 10^9 L 12 x 10^9 L 2.3 x 10^9 L September 14, 2009 13.4 40.9 5.18 477 29.9 21.7 6.0 1.9 0.0 0.3 25.9 78.9 32.76 Reference rage 13.5-17 40-54 4.7-6.1 150-450 5-10 5-7.5 2-7.5 1.00-4.00 0.20-1.00 0.00-0.50 27-31 82-95 32-36

Color Glucose Character WBC/HPF RBC/HPP Chest X-Ray APL

Yellow Negative Clear 0-1 0-1

Epith cells SG A-urates PO4 pH Mucus threads

ocs 1.015 Rare 5-0 rare

September 14, 2009

Results: Reticulonodular and hazed densities are seen at both inner to mid lung zones and retrocardiac areas Minimal nodular densities are seen at both paratracheal and aerihilar areas The cardiac silhouette is within normal limits Other chest and visualized osseous structures are unremarkable Impression: Bronchopneumonia Concomitant Kochs infection not ruled out

COURSE IN THE WARD

September 12,2009 Shift: 12am-8am Doctors Order IVF:D5LR 1L Lab: CBC request and forwarded Meds: Salbutamol 1neb q 8hours Procedure: None Days in Hosp.: 1 Assessment: Patient admitted at 7:02am v/s: T-36., BP-100/70mmHg

Nursing Intervention: Consent for admission secured IV insertion Nebulization started Placed on bed comfortably Assessment:

Shift: 8am-4pm Doctors Order IVF:D5LR 1L

Lab: None

Received on bed with D5LR 1L at 980cc level With abdominal pain as claimed 10am, afebrile T= 36.9, PR= 78, RR= 22 11:30am, with complains of headache 2:00pm, afebrile T= 37.1 PR= 80, RR= 23

Meds: Ceftriaxone 1gm q 12hours SIVF ANST(-) Paracetamol 1amp q 4hours TIV prn Salbutamol 1neb q 8hours Procedure: None Shift: 4pm-12am Doctors Order IVF:D5 NM 1L Lab: None

Nursing Intervention: Placed on bed safely and comfortably 3pm, Nebulization Kept rested and undisturbed

Assessment: Received on bed with D5LR 1L at 420cc level With on and off mild abdominal pain as claimed 6:00pm, afebrile T= 37.5, PR= 75, RR= 23 6:45pm, above IVF consumed, follow up D5NM 1L given 10:00pm, afebrile T= 37.5 BP= 100/70 Nursing Intervention: Increase fluid intake emphasize 11pm, nebulization Placed on bed safely and comfortably Kept rested and undisturbed

Meds: Ceftriaxone 1gm q 12hours SIVF ANST(-) Salbutamol 1neb q 6hours Procedure: None

September 13,2009 Shift: 12am-8am Doctors Order IVF:D5NM 1L Lab: Urinalysis

Days in Hosp.: 2 Assessment: Received with IVF of D5NM 1L at 850 level With headache as claimed 2am, T=37, PR= 82, RR=20 On DAT 6am, T=36,9, BP= 100/70mmHg

Meds: Salbutamol 1neb q 8hours Procedure: None Shift: 8am-4pm Doctors Order IVF:D5LR 1L Lab: None

Nursing Intervention: Increase fluid intake 7am, Nebulization Kept rested Assessment: Received on bed with D5LR 1L at 980cc level Still with complain of headache 10am, febrile T= 37.9, PR= 88, RR= 27 2:00pm, afebrile T= 37.3 PR= 56, RR= 22 Nursing Intervention: TSB done Increase the fluid intake 3pm, Nebulization Kept rested and undisturbed

Meds: Ceftriaxone 1gm q 12hours SIVF ANST(-) Paracetamol 1amp q 4hours TIV prn Salbutamol 1neb q 8hours Procedure: None Shift: 4pm-12am Doctors Order IVF:D5 NM 1L Lab: None

Assessment: Received on bed with new D5NM 1L at 700cc level With mild headache as claimed 6:00pm, afebrile T= 37.5, PR= 97, RR= 25 10:00pm, afebrile T= 36.5 BP= 100/70 11:50pm, follow up IVF with another D5NM 1L Nursing Intervention: Increase fluid intake emphasize 11pm, Nebulization Placed on bed safely and comfortably Kept rested and undisturbed

Meds: Ceftriaxone 1gm q 12hours SIVF ANST(-) Paracetamol 1amp q 4hours TIV prn Salbutamol 1neb q 8hours Procedure: None

September 14,2009 Shift: 12am-8am

Days in Hosp.: 3

Doctors Order IVF:D5NM 1L Lab: None

Assessment: Received with IVF of D5NM 1L at 500cc level 2am, T=36.7, PR= 95, RR=24 6am, T=36,5, BP= 90/70mmHg Nursing Intervention: Oral hydration encouraged 7am, Nebulization Kept rested and undisturbed Assessment: Received on bed with D5NM 1L at 150cc level 10am, afebrile T= 36.8, PR= 68, RR= 23 2:00pm, afebrile T= 36.9 BP= 100/70 Home for request (-) headache and abdominal pain 4:30, bill settled and discharged Nursing Intervention: Emphasize oral hydration Encouraged small frequent feedings

Meds: Salbutamol 1neb q 8hours Procedure: None Shift: 8am-4pm Doctors Order IVF:D5LR 1L Lab: Chest X-Ray APL

Meds: Ceftriaxone 1gm q 12hours SIVF ANST(-) Paracetamol 1amp q 4hours TIV prn Procedure: None

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