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CONTENT
NO CONTENT P5AGES
1. APPRECIATION 1-2
3. INTRODUCTION 5-6
6. ASSESSMENT 15-17
7. ADMISSION/ORIENTATION 18-21
9. DEFINITION 27-30
APPRECIATION
First of all,I am grateful to god since I can able to finished my case study on
time.Finally,I manage to complete my book of case study with the same care that I had
given to my patient.Surely not forgetting to thanks all of them that were helpful in my
case study,especially to the Lecturer and Clinical Instructor,Sister Rashidah that always
gave me support in my case study.
Lastly but not least,I would like to thanks to my parents and my lovely friend that
always gave me support and helped me when I need their helped.
LEARNING OBJECTIVES
8. Identify the nursing problems & plan effective nursing intervention to care
for patients with acute Bronchitis.
9. Provide the Health Education for the patient about home care management
INTRODUCTION
For this semester 2,I was posted to Ipoh Specialist Hospital(ISH) for my clinical
posting.So during this clinical posting ,every students in my group (32) had to choose
one case that isn related to the study of Respiratory or Cardiovascular as a case
study.Because of that,I had chosen a case about Bronchitis which is related to the study
of Respiratory Systems.I had chosen this case as my case study because for me it was a
very interesting topic and important to know more about Lower Respiratory Tract(LRT)
when had infected a large number of age group.
In this book,I will also explained about the investigation that is normally required
for this kind of patient and how the doctor diagnosed the disease.At the same time,a few
nursing cares that had to be carried out to the patient.
Bed No : xxx
Reason for admission: Patient complain of high fever for 1 week with
Sputum and feel dizziness and nausea.
Medical history : Migrain since 20 years old
Surgical history : Nil
Family medical history: Nil
Current medication : Own medication
Allergies : Seafood
Diagnosis : Acute Bronchitis
Date admitted : 28 September 2007
Time of admission : 2 pm
PHYSICAL
EXAMINATION
1. Head examination :
• Hair -clean
-no infection such as dandruff.
-normal hair texture.
• Eyes -normal
-use visual aids
-conjunctivae pink
-symmetrical eyes
6 . Back examination :
On that day, 28 September 2007, I did the assessment to my patient when she was
admitted in the ward and there is the finding of the assessment:
INTERVIEW:
Every patient who had admitted to the ward in hospital will be interview by student
nurse or staff nurse. It done because it helps the nurses to plan their nursing report. With
that, we can practicing an carry out the interview skill by taking such as asking question
that we have learn in communication subject. We also can carry out the theory in the
practical. The data that should be collect during interview such as name of patient,
occupation, race, religion, reason of admission, age, sex, and others. We also can carry
collect data during interview such as:
Family History:
Medical History:
Surgical History:
Current Medication:
Allergies:
-Madam Z had allergies to seafood.
3. Bladder:
• Madam Z doesn’t had any problem in pass urine and do not get up
at night to pass urine.
4. Elimination:
• Madam Z have problem to pass motion.
• Madam Z had pass motion 5 day ago.
• Madam Z doesn’t take any medication to pass motion.
6. Mobility:
• Madam Z can ambulate by her self.
7. Personal Hygiene:
• Madam Z always maintains her personal hygiene. She also take
her bath 2 times per day.
8. Communication:
• Madam Z understand well what ever I try to explain about her
any question or procedure that I want to carry out.
• For her vision, she had use visual aid.
• Madam Z can hear well(normal hearing)
9. Skin condition :
• Madam Z have normal skin condition.
ADMISSION
On 28 September 2007 at 2pm,Madam Z admitted to Ipoh Specialist
Hospital(ISH).She was admitted in the 2 floor(level 2),surgical medical ward, single bed,
room 405.On admission, she looks lethargic.
During admission , Madam Z told me that she having high fever and cough for 1
weeks, difficulty in breathing when cough for 1 week, coughing with sputum 2week ago.
Sputum yellowish in color.
Madam Z looks anxious because she worried about her condition. She also had
allergic to seafood.
On admission, Madam Z looks lethargic but her husband was companies her.
Madam Z and her husband give cooperation to me when the assessment was going on.
After assessment done, I took vital signs as a baseline data. The result was below :
Temperature : 38.50C
Pulse : 76/bpm
Respiration : 22/bpm
Blood pressure :110/85mmHg
ORIENTATION
Purpose of orientation:
Patient unit:
• Visiting hours :
• Meal time :
-Breakfast : 0800-0830 hour
Nose: To filter impurities, humidifier and warmth the inhaled air. We also use it as a
sense of smell.
The pharynx functions as a passage way for the respiratory and digestive tract.
Larynx: Is a cartilaginous epithelium lined structure that connect the pharynx and the
trachea.
It protects the lower airway from foreign substances and facilitates coughing.
Trachea: It mucosa lining contains gland that produce mucus to trap debris.
Examples: The mucosa lining contains gland that produce mucus to trap debris
LOWER RESPIRATORY TRACT
Consist of which contains the pleural, pleural cavity, bronchial, and alveoli.
TRACHEA:
• Also called as windpipe.
• Located in front of the esophagus, beginning at the lower border
of cricoids cartilage of the larynx and extending to the level of
the sixth or seventh thoracic vertebra.
• The trachea is about 4 to 5 inches (12 to 15cm)and 1 inch
(2.5cm) in diameter.
• It contains 16 to 20 C- shaped rings of cartilage joined by
connective tissue.
RIGHT BRONCHUS:
• Wider, shorter and more vertical than the left bronchus and is
therefore the more likely of the two to become obstructed by
inhaled foreign body.
• It is approximately 2.5cm long.
• After entering the right lung at the hilum it divided into three
branches, one to each lobe. Each branch then subdivides into
numerous smaller branches.
LEFT BRONCHUS:
• 5cm long and is narrower than the right.
• After entering the lung at the hilum it divided into two
branches, one to each branch then subdivided into
progressively smaller tubes within the lung substance.
BRONCHIOLES:
• Absence of cartilage, the smooth muscle in the walls of the
bronchioles become thicker and is responsive to autonomic
nerve stimulation and irritation.
• Ciliated columnar mucous membrane changes gradually to
non-ciliated cuboidal-shaped cells in the distal bronchioles.
ALVEOLI:
• The alveoli are surrounded by a network of capillaries.
• The exchanges of gases during respiration take place across
two membranes, the alveolar and capillary membranes.
RIGHT LUNG:
• Divided into three distinct lobes. It is superior, middle and
inferior.
LEFT LUNG:
• It is smaller as the heart is situated left of the midline.
• Divided into only two lobes: superior and inferior
LUNG
ALVEOLI
DEFINITION
Definition 1:
.
(Dictionary of Nursing-Fajar Bakti)
By ELIZABETH A.MARTIN
Definition 2:
An infection of the bronchial tree (tubes that carry air from the mouth and nose to the
lungs. When these tubes get infected, they swell and mucus forms. Mucus is material
that comes up when cough.
(pulmonarychannel.com/acute bronchitis)
Definition 3
An inflammation of the lining of the bronchial tubes ,the commenest disease of the
breathing system which is caused by viruses or bacteria. It is characterized by
coughing the production of mucopurulent sputum and bronchospasm.
Viruses depress normal defense mechanism, enable bacteria to present in the respiratory
tract to multiply.
Causative agent:
• Streptococcus pneumonia.
• Haemophilus influenza
• Streptococcus phyrogenes
• Staphylococcus aureus
Normal Bronchitis
-Bronchial is clear -Bronchial swollen
-More mucus produced
CHRONIC BRONCHITIS
Is a chronic inflammation of the bronchiol mucosa resulted in hyperactivity or the
mucus-secreting glands of the bronchial mucosa in response to prolonged or frequent
recurring irritation.
It develops mostly in middle-aged men who are chronic heavy smokers and may have
a familial predisposition.
• Thickening
• Increase in the number and size of mucous glands
• Oedema
• Reduction in the number of ciliated cells
• Narrowing of bronchioles due to fibrosis following repeated inflammatory
episodes
2. Air pollution.
• Open burning, industrial gases.
3. Allergies.
4. Weather.
5. Hereditary
6. Occupational exposure
• Exposure to chemical fumes and dust.
5. Smoke inhalation
6. Cigarette smoking
PATHOPHYSIOLOGY
↓
Irritation of cells (bronchiol lining tissue)
↓
Inflammation process (vasodilatation)
↓
Edema of bronchial mucosa
↓
Increased mucus production/Thick secretion
↓
Mucus producing goblet cells undergo hypertrophy
↓
Ciliated epithelial cell line the respiratory tract
↓
Ciliary function impaired.
↓
Blocked airway
↓
Bronchitis
CLINICAL MANISFESTATION
• Cough
-May bring up thick white, yellow or greenish color of mucus
• Wheezing
• Dyspnea
• Chest pain
• Malaise
• Fever
• Headache
• Chills
• Hoarseness
• Sore throat
• Rhonchi
• Rales
• Enlarge heart
COMPLICATION
1. Chronic Bronchitis
-bronchial damage, the airways become clogged with
mucus ,bronchospams cannot relieved by bronchodilator
drugs.
2. Pneumonia
-inflammation of the lung cause by bacteria, in which the
alveoli become filled with inflammation cells and the lung
become solid.
3. Asthma
-narrowing of the bronchial airway.
INVESTIGATION
Dr.G
Consultant Nephrologists
2-28,Ipoh Specialist Hospital
Ipoh
SERUM ELECTROLYTES
Sodium 139 mmol/L 135-155
Potassium 3.8 mmol/L 3.5-5.5
Chloride 102 mmol/L 95-111
MEDICATION.
Medication on hospitalization:
• Tablet Azithromycin
• Intravenous Metocloramide
• Tablet PCM
• Intramuscular Voltaran
• Syrup Sedilix
• Dyflam Lonzenges
1 . Tablet Azithromycin
Group: Antibiotics
Route:Orally
Dosage: 500mg
Frequency: Daily
Indication: Lower resp tract infections including bronchitis & pneumonia; skin &
soft tissue infections; acute otitis media; upper resp tract infections
including sinusitis & pharyngitis/tonsillitis.
Route : Intravenous
Dosage :10mg
Frequency: TDS
Route:Orally
Dosage: 1g
Frequency: TDS
Group : Antirheumatic,anti-inflammatory,analgesic.
Date off :-
Dosage :75mg
Route :Orally
Dosage : 10ml
Frequency : TDS
Indication :Relief of dry irritating cough such as those associated with common
cold or upper respiratory tract infections.
Route : Orally
Dosage : 1 tablet
Contraindication : Nil
Time: 1700hour
Goal: Patient will be able to maintain a patent airway within 2 – 3 hours after nursing
intervention given and during hospitalization.
Nursing Intervention:
1. Assess patient general condition such as her breathing pattern, sputum colour,
consistency and amount, respiration rate and sound.
R: As a baseline data for further nursing intervention.
I: I did an assessment to Madam Z such as by counting her respiration rate,
observed her breathing pattern and sound of her breathing.
5. Advice patient to drink a lot of water such as 1.5-2 liter per days.
R: To liquefy secretion and facilitate clearing the phlegm
I :I advised Madam Z to drink a lot of water about 1.5-2 liter per days to keep her
mucus (secretion) thin.
6. Provide mouth gargle (Thymol gargle) to patient.
R: To promote comfort after cough out sputum many time.
I : I ensure Madam Z to gargle her mouth after having cough many times.
Evaluation: Patient able to maintain her clear airway and able to facilitate the removal
of mucus plugs.
Evaluation: Patient able to maintain her clear airway and able to facilitate the removal
of mucus plugs.
Evaluation: Patient able to maintain her clear airway and able to facilitate the removal
of mucus plugs.
Time: 1500hour
Goal: Patient’s cough will be able reduce after 2-3 hours and be more comfort within 3
days after nursing intervention given and during hospitalization.
Nursing Intervention:
5. Encourage patient to drink a lot of plain water especially warm water at least 2 or 3
liters per days
R: To loosen the secretion and to soother the throat.
I: I encourage Madam Z to drink a lot of plain water at least 2 or 3 liter per day to help
loosen the sputum.
9. Inform doctor or nurse in-charge if patient’s still having coughing and the treatment is
not persist.
R :For further treatment.
I :I didn’t inform doctor or nurse in-charged because Madam Z cough are reduce.
Evaluation: Patient’s verbalize that her cough has been reduce after 3 hours medication
and nursing intervention given
Evaluation: Patient’s verbalize that her cough has been reduce after 3 hours medication
and nursing intervention given
Evaluation: Patient’s verbalize that her cough has been reduce after 3 hours medication
and nursing intervention given
Evaluation: Patient’s verbalize that her cough has been reduce after 3 hours medication
and nursing intervention given
Evaluation: Patient’s verbalize that her cough has been reduce after medication given
and nursing intervention given to her in 3 days during hospitalization.
Supporting data: Patient told me that her cough has been reduce after 1 week admitted in
the hospitalization.
Date : 28 September 2007.
Time : 1700hour
Goal: Patient body temperature will be reduced after 2 hour medication and nursing
intervention given during hospitalization.
Nursing Intervention:
7. Encourage patient to drink a lot of plain water example 1.5-2 liter per day.
R :To prevent dehydration and reduce patient body temperature.
I :I advised Madam Z to drink a lot of water to prevent dehydration and reduce her
body temperature.
Evaluation: Patient body temperature reduce from 38.50C to 36.90C after 2 hours
medication and nursing intervention given to my patient.
Evaluation: Patient body temperature reduce from 38.50C to 36.90C after nursing
intervention given during hospitalization.
Evaluation: Patient body temperature reduce from 38.50C to 36.90C after nursing
intervention given during hospitalization.
Time: 2100hour.
Supporting data: Patient told me that she can’t sleep because of coughing.
Goal: Patient will be able to sleep atleast 5 hours every night after medication and
nursing intervention given during hospitalization.
Nursing Intervention :
1. Assess patient sleeping pattern by asking the patient such as why she can’t sleep, her of
duration sleep and what is her sleeping time.
R: As baseline data and to plan an appropriate nursing intervention.
I :I asked Madam Z some question such as why she can’t sleep, her duration of
sleep and what is her sleeping time.
4. Encourage patient to drink a lot of warm water such as 1.5 to 2 liter per days
R :To reduce throat irritation.
I :I encouraged Madam Z to drink a lot of warm water such as 1.5 to 2 liter per day to
reduce throat irritation.
Evaluation :Patient able to sleep atleast 5 hours every night after medication and nursing
intervention given during hospitalization.
Evaluation :Patient able to sleep atleast 5 hours every night after medication and nursing
intervention given during hospitalization.
Date :1 October 2007@0900 hours
Evaluation :Patient able to sleep atleast 5 hours every night after medication and nursing
intervention given during hospitalization
Evaluation :Patient able to sleep atleast 5 hours every night after medication and nursing
intervention given during hospitalization
Supporting data :Patient told me that she able to sleep after taken the medication.
Date:7 October 2007.
Time :0900hour.
Nursing Diagnosis: Knowledge deficit regarding disease process and home care
management.
Supporting data :Madam Z asked me about her disease, how it occur and how to prevent
it.
Goal :Patient will gain an understanding about her disease and knew how to prevent it
after 1 or 2 hour nursing intervention given to her and during hospitalization.
Nursing Intervention :
1.Assess patient level of knowledge about her disease such as asking her what she
already knew and what she wanted to knew about her disease.
R :To plan further nursing intervention.
I :I asked my patient what does she wanted to knew about her disease.
6.Advice patient to drink a lot of water such as 1.5 to 2 liter per days.
R :To help and keep the mucus (secretion)thin.
I :I advised Madam Z to drink a lot of plain water such as 1.5 to 2 liter per days.
10.Explain to patient the important of follow up and advice her to come on time.
R :To ensure patient know about the important to follow up and remind her not to
forget the follow up.
11.Advice patient to come and see the doctor whenever she feels the symptom and if
complication occurs.
R :For further treatment.
I :I advise to Madam Z to come to see doctor whenever she feels the symptom and if
she find any complication occurs.
Evaluation :Patient had been made to understand about her disease and how to prevent it
after nursing intervention given to her and during hospitalization.
Supporting data :I asked patient to re-explain what I had explained to her before.
HEALTH EDUCATION
ACUTE BRONCHITIS :
• I had re- explained doctor explanation to Madam Z and her husband about her
disease,how it’s occur, the sign and symptom and other enable them to
understand more about the disease.It is also can helped her able to control and
prevent the disease.
• I also gave her a pamphlet of her disease that I had taken from internet to gave
her more knowledge about her disease.
PREVENTION OF ATTACK:
• I asked my patient to maintain cleanliness and hygiene in her office and her
house.
• I asked my patient and her husband to remove dust particles that settle on
furniture,rack and other in her house.
• I asked my patient to avoid direct exposure to air-conditioner and avoid
mingle with people who are smoking in her office.
• I asked my patient to informed her employed to check the air-condition
system.eg:by removing and replace the air-conditioner filter if necessary to
prevent the dissemination of dust and particulate matter in the office.
MEDICATION :
DIET :
• I had reminded my patient the date and the purpose of follow up to ensure
my patient understand and came to hospital for her follow up.
I told my patient to get adequate rest to conserve energy and used of oxygen.
Dr G advised Madam Z to make sure she take and finished all the medication that
has been given and remember to come to hospital for follow up treatment on 14 October
2007.
At the moment,I also gave her a health education to help her to maintain healthy and
avoid to sick.
FOLLOW UP
On 14 October 2007 at 1230 hour,Madam Z comes to hospital for follow up
treatment with Dr G.She came with her husband.
Madam Z looked happy and cheerful.She say she felt comfortable now and her
cough now are reducing.She say thanks to me because I take care of her when she was
admitted in hospital.
Dr G told Madam Z that she do not need to come for further follow up unless she had
any problem related to her condition.Dr G also told Madam Z to come back for treatment
if she felt sick again.
SUMMARY
Madam Z was admitted to Ipoh Specialist Hospital (ISH),in Ipoh,Perak on 28
September at 1400 hour.She came with her husband to the hospital after complaining of
high fever and continuosly coughing for 2 week,difficulty in breathing for 2 days,fell
pain when coughing for 1 week.
Madam Z was suspected as having Bronchitis signs.After all the medical check up
carried out to her,doctor had finally diagnosed her as having Acute Bronchitis.She was
under Doctor G.
During the Admission from Accident and Emergency Department,she was wheeled
in to the ward and accompanied by A&E staff.During that time,her vital signs are :
Temperature :38.50C
Pulse :76/bpm
Respiration :22/bpm
Blood Pressure :110/85mmHg
On that day,Dr G had explained to Madam Z and her parent about Madam z disease
and all of them are able to understand it.In the ward,I also did as Doctor was done and
gave a health education to remind Madam Z and her husband how to take care of herself
and prevent the disease.
After 4 days admitted in the ward,she looks better and healthier than before.She was
discharge on 7 October 2007 around 1230 hour.She was given medication to continue her
treatment at home such as :
Her follow up was on 14 October 2007 at 1230 hour.On that days,she looks cheerful
and more healthier.
CONCLUSION
First of all,I would like to thanks to all those who had helped and guided me in doing
this case study.My patient and her husband gave me a very good cooperation in making
my case study easier.
Before doing my case study,I initially that I could not o this case study because I had
no experience in doing a case study and also difficult to find a case that is related to the
study of Respiratory or Cardiovascular in Ipoh Specialist Hospital(ISH),Perak.But after
all the encouragement given by Clinical Instructor and my lovely friends,I feld more
confident to do and finished my case study.
After finishing doing my case study,I realized that I had learned a lot about taking
care of patient with Bronchitis.I take care of Madam Z from first day of her admission
until she was discharged.I gained information and knowledge about how to take care of
patient with Bronchitis.I also teached my patient about health education for her disease
and how to prevent it.
Lastly,I would like to says thanks again to all those who had helped me and spend
time for me to finished my case study.
REFERENCE
WEBSITE :
1. http://www.yahoo.com.my/bronchitis
2. http://www.msn.com.my/bronchitis
3. http://nlm.nih.gov/medlineplus/bronchitis.html
4. http://pulmonarychannel.com/bronchitis
BOOK :
1.) Anatomy and Physiology in Health and Illness Ross and Wilson,Ninth Edition.
Churchill Livingstone,Anne Waugh and Allison Grant.
3.) Smeltzer S C and Bare B G, (2004), Brunner & Suddarth’s Textbook of Medical
Surgical Nursing, Lippincott Williams and Wilkins.