POLYTECHNIC COLLEGE OF DAVAO DEL SUR

MacArthur Highway, Digos City

A CASE STUDY OF
Empyema Thoracis, Left secondary to
BPN severe Community Acquired Pneumonia
s/p Chest Thoracostomy Tube

IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS IN
RLE/NCM 103

Presented to
Mr. Sajid S. Uy, RN

1
 Presented by

Radee King R. Corpuz

May, 2009

INTRODUCTION

Pneumonia is an inflammation of the lungs caused by

an infection. It is also called Pneumonitis or
Bronchopneumonia. Pneumonia can be a serious threat to
our health. Although pneumonia is a special concern for
older adults and those with chronic illnesses. It can also
strike and young and healthy people as well. It is a
common illness that affects thousands of people each year

2
in the Philippines, thus, it remains an important cause of
morbidity and mortality in the country.
There are many kinds of pneumonia that range in
seriousness from mild to life-threatening. In infectious
pneumonia, bacteria, viruses, fungi or other organisms
attack the lungs, leading to inflammation that makes it hard
for an individual to breathe. Pneumonia can affect one or
both lungs. In young and healthy individual, early treatment
with antibiotics can cure bacterial pneumonia. The drugs
used to fight pneumonia are determined by the germ
causing pneumonia and the doctors findings.. It is best to
do everything we can to prevent pneumonia, but if one get
sick, recognizing and treating the disease early offers the
best chance for a full recovery.

A case with a diagnosis of Pneumonia may catch

one’s attention, though the disease is just like an ordinary
cough and fever, it can lead to death especially when there
is no immediate intervention done. Since the case is a
toddler, an appropriate care has to be done to promote
faster recovery for the patient. Treating patients with

3
pneumonia is necessary to prevent its spread to others and
make them as another victim of this illness.
Bronchopneumonia is an illness of the lungs 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 6% in mortality rate.
Streptococcus pneumoniae (pneumococcus) and
Mycoplasma pneumoniae both are the common bacterium
which causes bronchopneumonia in the adults and children.

Acute inflammation of the walls of the smaller

bronchial tubes, with varying amounts of pulmonary
consolidation due to spread of the inflammation into
peribronchiolar alveoli and the alveolar ducts; may become
confluent or may be hemorrhagic.
In United States, pneumonia is the most common
cause of death from infectious diseases. It accounts for
almost 66,000 deaths per year and ranks as the seventh
leading cause of death in the United States (Brunner and

4
Suddarth’s Medical-Surgical Textbook, pp
628/pneumonia).
In Philippines, the case of pneumonia is one of leading
cause of mortality and morbidity among Filipinos, 75-85%
of the population acquired the disease and the one affected
the disease are those who are in low income status and the
below poverty line individual. (www.DOH.org/pneumonia)
Our patient Baby C, was 1 year old, living at
Gravahan, Matina Proper, Davao City, was admitted at
Davao Medical Center last March 28, 2009, at 6:37pm,
with chief complain of difficulty of breathing.
According to her mother, she noticed that her baby is
having substernal retraction with rapid shallow breathing
while asleep.
The family immediately took the baby to Davao
Medical Center, and was diagnosed with BPN severe,
Community Acquired Pneumonia.
Weeks after, the doctors suggested for placement of
chest thoracostomy tube, due to the accumulation of pus in
the pleural space.

5
IDENTIFICATION OF THE CASE

A.PERSONAL PROFILE

Name : Baby C
Address : Gravahan, Matina Proper, Davao
City
Age : 1 year
Gender : Female
Civil status : Single
Occupation : none
Admitting Doctor : Dr. Veralou L. Sojor
Admitting Diagnosis : Empyema Thoracis,
Left secondary to
BPN severe Community Acquired
Pneumonia s/p Chest
Thoracostomy Tube

Religion : Roman Catholic

Nationality : Filipino
Educational Attainment: none
Spouse name : Mr. J
Occupation : Mini Store owner

6
 Chief Complaint : Difficulty of breathing,
Dyspnea
Date of admission : March 28, 2009; 6:37pm
B.Background/History
DM HPN CA ASTHMA
Maternal - - - -
Paternal - - - -

The parents of the client both manifest negative (-)

history of the following diseases: DM, Hypertension,
Cancer, Asthma as interviewed.

C. Medical History

According to the medical history of the client,

Baby C had no other diagnosed illness except,
bronchopneumonia, before the patient experienced

7
 episodic fever and cough due to environmental factor.
Baby C. was hospitalized due to persistent cough with
yellowish mucus secretion. Baby C had completed the
immunization process done in there Barangay Health
Center.

D. History of Present Illness

4 days prior to admission, Baby C experienced on
and off high fever, with substernal retraction, rapid
and shallow breathing. With yellowish mucus
secretion present productively.

E. Socio-economic background
The family of baby C was very supportive, they
have provided all her medication. Specially her
medicine and payments for other diagnostic
procedures to be done for her early and faster recovery

8
 DEFINITION OF TERMS

Bradypnea – slower than normal rate (<10

breaths/minute), with normal dept and regular rhythm
(Brunner and Suddart’s Medical-Surgical Textbook, Chpt
21,pp 572)

Dyspnea – distressful sensation of uncomfortable breathing

that may be caused by certain heart conditions(Brunner and
Suddart’s Medical-Surgical Textbook, Chpt 23,pp 625)

Empyema – inflammatory fluid and debris in the pleural

space. It results from an untreated pleural-space infection
that progresses from free-flowing pleural fluid to a complex

9
collection in the pleural space. (Brunner and Suddart’s
Medical-Surgical Textbook, Chpt 23,pp 625)

Hypoxemia – decrease in arterial oxygen tension in the

blood (Brunner and Suddart’s Medical-Surgical Textbook,
Chpt 21,pp 625)

Mycoplasma pneumonia – another type of Community

Acquired Pneumonia (CAP), occurs most often in children
and young adults and is spread by infected respiratory
droplets through person-to-person contact(Brunner and
Suddart’s Medical-Surgical Textbook, Chpt 23,pp 630)

Pleural effusion – abnormal accumulation of fluid in the

pleural space(Brunner and Suddart’s Medical-Surgical
Textbook, Chpt 23,pp 625)

Pleural cavity – the area between the parietal and visceral

pleurae a potential space(Brunner and Suddart’s Medical-
Surgical Textbook, Chpt 23,pp 625)

10
Substernal Retraction – indrawing beneath the
breastbone, commonly manifested to infant and neonate
with respiratory distress(Fundamentals of Nursing, Seventh
Edition, Vital Signs unit VII, pp 507)

Thoracentesis – insertion of a needle into the space to

remove fluid that has accumulated and decrease pressure on
the lung tissue; may also be used diagnostically to identify
potential causes of a pleural effusion(Brunner and
Suddart’s Medical-Surgical Textbook, Chpt 23,pp 625)

Thoracostomy - done to drain fluid, blood, or air from the

space around the lungs(Brunner and Suddart’s Medical-
Surgical Textbook, Chpt 23,pp 625)

11
ANATOMY AND PHYSIOLOGY

12
13
 A respiratory system functions to allow gas
exchange. The gases that are exchanged, the anatomy or
structure of the exchange system and the precise
physiological uses of the exchanged gases vary depending
on the organism.
In humans and other mammals, for example, the
anatomical features of the respiratory system include
airways, lungs, and the respiratory muscles. Molecules of
oxygen and carbon dioxide are passively exchanged, by
diffusion, between the gaseous external environment and
the blood. This exchange process occurs in the alveolar
region of the lungs.

14
 The respiratory system can be conveniently
subdivided into an upper respiratory tract (or conducting
zone) and lower respiratory tract (respiratory zone), trachea
and lungs.
The conducting zone starts with the nares (nostrils) of
the nose, which open into the nasopharynx (nasal cavity).
The primary functions of the nasal passages are to: 1) filter,

15
2) warm, 3) moisten, and 4) provide resonance in speech.
The nasopharnyx opens into the oropharynx (behind the
oral cavity).
The oropharynx leads to the laryngopharynx, and
empties into the larynx (voicebox), which contains the
vocal cords, passing through the glottis, connecting to the
trachea (wind pipe).
The trachea leads down to the thoracic cavity (chest)
where it divides into the right and left "main stem" bronchi.
The subdivision of the bronchus are: primary, secondary,
and tertiary divisions (first, second and third levels). In all,
they divide 16 more times into even smaller bronchioles.
The bronchioles lead to the respiratory zone of the
lungs which consists of respiratory bronchioles, alveolar
ducts and the alveoli, the multi-lobulated sacs in which
most of the gas exchange occurs.Ventilation of the lungs is
carried out by the muscles of respiration.
Ventilation occurs under the control of the autonomic
nervous system from the part of the brain stem, the medulla
oblongata and the pons. This area of the brain forms the
respiration regulatory center, a series of interconnected

16
neurons within the lower and middle brain stem which
coordinate respiratory movements.
The sections are the pneumotaxic center, the apneustic
center, and the dorsal and ventral respiratory groups. This
section is especially sensitive during infancy, and the
neurons can be destroyed if the infant is dropped or shaken
violently. The result can be death due to "shaken baby
syndrome.”
Inhalation is initiated by the diaphragm and supported
by the external intercostal muscles. Normal resting
respirations are 10 to 18 breaths per minute. Its time period
is 2 seconds. During vigorous inhalation (at rates exceeding
35 breaths per minute), or in approaching respiratory
failure, accessory muscles of respiration are recruited for
support. These consist of sternocleidomastoid, platysma,
and the strap muscles of the neck.
Inhalation is driven primarily by the diaphragm. When
the diaphragm contracts, the ribcage expands and the
contents of the abdomen are moved downward. This results
in a larger thoracic volume, which in turn causes a decrease
in intrathoracic pressure. As the pressure in the chest falls,

17
air moves into the conducting zone. Here, the air is filtered,
warmed, and humidified as it flows to the lungs.
During forced inhalation, as when taking a deep
breath, the external intercostal muscles and accessory
muscles further expand the thoracic cavity.
Exhalation is generally a passive process, however active
or forced exhalation is achieved by the abdominal and the
internal intercostal muscles.
The lungs have a natural elasticity; as they recoil from the
stretch of inhalation, air flows back out until the pressures
in the chest and the atmosphere reach equilibrium.
During forced exhalation, as when blowing out a
candle, expiratory muscles including the abdominal
muscles and internal intercostal muscles, generate
abdominal and thoracic pressure, which forces air out of the
lungs.
The right side of the heart pumps blood from the right
ventricle through the pulmonary semilunar valve into the
pulmonary trunk. The trunk branches into right and left
pulmonary arteries to the pulmonary blood vessels. The
vessels generally accompany the airways and also undergo

18
numerous branchings. Once the gas exchange process is
complete in the pulmonary capillaries, blood is returned to
the left side of the heart through four pulmonary veins, two
from each side.

The pulmonary circulation has a very low resistance,

due to the short distance within the lungs, compared to the
systemic circulation, and for this reason, all the pressures
within the pulmonary blood vessels are normally low as
compared to the pressure of the systemic circulation loop.
Virtually all the body's blood travels through the lungs
every minute. The lungs add and remove many chemical
messengers from the blood as it flows through pulmonary
capillary bed . The fine capillaries also trap blood clots that
have formed in systemic veins.
The major function of the respiratory system is gas
exchange. As gas exchange occurs, the acid-base balance of
the body is maintained as part of homeostasis. If proper
ventilation is not maintained two opposing conditions could

19
occur: 1) respiratory acidosis, a life threatening condition,
and 2) respiratory alkalosis.
Upon inhalation, gas exchange occurs at the alveoli,
the tiny sacs which are the basic functional component of
the lungs. The alveolar walls are extremely thin (approx.
0.2 micrometres), and are permeable to gases. The alveoli
are lined with pulmonary capillaries, the walls of which are
also thin enough to permit gas exchange. All gases diffuse
from the alveolar air to the blood in the pulmonary
capillaries, as carbon dioxide diffuses in the opposite
direction, from capillary blood to alveolar air. At this point,
the pulmonary blood is oxygen-rich, and the lungs are
holding carbon dioxide. Exhalation follows, thereby ridding
the body of the carbon dioxide and completing the cycle of
respiration.
In an average resting adult, the lungs take up about
250ml of oxygen every minute while excreting about
200ml of carbon dioxide. During an average breath, an
adult will exchange from 500 ml to 700 ml of air. This
average breath capacity is called tidal volume.

20
 The respiratory system lies dormant in the human
fetus during pregnancy. At birth, the respiratory system is
drained of fluid and cleaned to assure proper functioning of
the system. If an infant is born before forty weeks
gestational age, the newborn may experience respiratory
failure due to the under-developed lungs.
This is due to the incomplete development of the
alveoli type II cells in the lungs. The infant lungs do not
function due to the collapse of the alveoli caused by surface
tension of water remaining in the lungs. Surfactant is
lacking from the lungs, leading to the condition. This
condition may be avoided if the mother is given a series of
steroid shots in the final week prior to delivery. The
steriods accelerate the development of the type II cells.

21
A transverse section of the thorax, showing the contents of
the middle and the posterior mediastinum. The pleural and
pericardial cavities are exaggerated since normally there is

22
no space between parietal and visceral pleura and between
pericardium and heart

In human anatomy, the pleural cavity is the body

cavity that surrounds the lungs. The lungs are surrounded
by the pleura, a serous membrane which folds back upon
itself to form a two-layered, membrane structure. The thin
space between the two pleural layers is known as the
pleural space; it normally contains a small amount of
pleural fluid. The outer pleura (parietal pleura) is attached
to the chest wall.

The inner pleura (visceral pleura) covers the lungs and

adjoining structures, i.e. blood vessels, bronchi and nerves.
The parietal pleura is highly sensitive to pain; the visceral
pleura is not, due to its lack of sensory innervation.
The pleural cavity, with its associated pleurae, aids
optimal functioning of the lungs during respiration. The

23
pleurae are coated with lubricating pleural fluid which
allows the pleurae to slide effortlessly against each other
during ventilation. Surface tension of the pleural fluid also
leads to close apposition of the lung surfaces with the chest
wall. This physical relationship allows for optimal inflation
of the alveoli during respiration. Movements of the chest
wall, particularly during heavy breathing, are coupled to
movements of the lungs since the closely opposed chest
wall transmits pressures to the visceral pleural surface and,
hence, to the lung itself.

24
 ETIOLOGY AND SYMPTOMATOLOGY

Etiology

Ideal Actual Justification

Predisposing Factor
Specifically 6 months
and above children has low
immune system, that can’t
resist any bacterial
infection, such as airborne
Age (+)
transmission.
Our patient is, 1 year
old baby girl and she
acquires the said disease in
their community
The family of the pt owned
a little “sari-sari” store,
which is the source of the
Exposure family’s income and which
(+)
(living) is situated near the road, as
interviewed the client was
often baby sited at their
store
Precipitating Factors
Daily (+) Daily activities of an
Activities individual can be a causal
factor of the disease.
Playing is the common
activity at a very young age
(1y/o). This individual is not

25
 conscious of the
environment.
The patient common
food intake are rice,
Diet hotdogs, eggs, chocolates,
(+) candies, sometimes fruits
( banana ), combination of
breast and formula milk.
Such as exposure to
certain viruses and foods
early in life, may trigger the
autoimmune response.
Mycoplasma Our patient is living in
pneumonae a poor environment,
and (+) because they’ve live in a
environmental dusty place where near the
factors highway, where many
vehicle passed by.
Vehicular smoke and dust
particles can be the carrier
of the bacteria, viruses.

26
Symptomatology

Ideal Actual Justification

The bronchioles
contain
submuscosal
gland, which
Cough with produce mucus
greenish or that covers the
yellow mucus (-)
inside lining of the
airways. Infected
bronchioles
produce greenish
or yellow mucus
secretions.
On and Off high
fever, cause by
infection in the
Fever body, invaded by
(+) specific viruses or
bacteria, our body
produces body
defenses in order
to fight.
Chest pain (-) Caused by
infection in the

27
 lining of the
airway
Presence of
foreign
pathogens, and
fluid accumulation
Bradypnea (+) in the airway
lining may cause
slow breathing
pattern, depth and
rhythm
Accumulation on
the lining of
airway, presence
Shortness of
(+) of mucus secretion
breath
and pathogenic
bacteria invades in
the body
Due to
compensatory
mechanism such
Loss of appetite as low immune
(+) response, any
(poor feeding) infection due to a
disease will result
to the loss of
appetite

28
 COMPLICATION

Empyema
is inflammatory fluid and debris in the pleural space.
It results from an untreated pleural-space infection that
progress from free-flowing pleural fluid to a complex
collection in the pleural space.
Empyema most commonly occurs in the setting of
bacterial pneumonia. About 20-60% of all cases of
pneumonia are associated with parapneumonic effusion.
With appropriate antibiotic therapy, parapneumonic
effusions most often resolve without complications, and
they are of little clinical significance. The resulting
infection and inflammatory response can proceed until
adhesive bands form. The infected fluid becomes loculated
pus in the pleural space.

29
Pleurisy

is an inflammation of both layers of the pleurae

(parietal and visceral). Pleurisy may develop in conjunction
with pneumonia or an upper respiratory tract infection, TB,
or collagen disease: after trauma to the chest, pulmonary
infarction, or PE; in patients with primary or metastatic
cancer; and after thoracostomy. The parietal pleura has
nerve endings; the visceral pleura does not. When the
inflamed pleural membranes rub together during
respiration.

Lung abscess

is an acute or chronic infection of the lung, marked by

a localized collection of pus, inflammation, and destruction
of tissue. Lung abscess is the end result of a number of
different disease processes ranging from fungal and
bacterial infections to cancer.

30
Pericarditis

Refers to an inflammation of the pericardium, the

membranous sac enveloping the heart. It may be a primary
illness or it may develop during various medical and
surgical disorders. One of the cause of pericardits, is
disorders of adjacent structures: myocardial infarction,
dissecting aneurysm, pleural and pulomonary disease
(pneumonia)

31
PATHOPHYSIOLOGY

32
 Predisposing factors Precipitating factors
Age (very young) Daily Activities
Gender Environment
Exposure (living) Diet

Pathological Entry (inhalation)

of organism: Bacteria or Viruses

Occurrence of localized inflammation

Mucus production Manifested by wheezing

Diminished surfactant Bacteria invades alveolar cell

production in the lungs
Formation of
Hyaline membrane

Bronchopneumonia Sign and Symptoms

Fever
Cough
Airway Pulmonary Edema Chest pain
Obstruction Rapid, shallow breathing
Shortness of breath
Headache
Loss of appetite
Fatigue

Chest Thoracostomy
Tube

If disorderDaily Activities If disorder is Treated,

Environment Normal breathing pattern
Diet Normal respiratory rate and
urs: Breath sounds
Empyema
Lung Abscess
Pleurisy
Pericarditis

33
 Etiologic agents gain entry into the respiratory tract
through either inhalation or aspiration of secretions. The
pathogen creates a localized inflammatory reaction on the
airway mucosa that results in swelling and increased mucus
production. Significant inflammation and obstruction may
result in wheezing.
As entering the pathogen in the body compensatory
mechanism: body line of defense such as cilia, whipping
motion that propels mucus and foreign substances away
from the lungs toward the lungs, for expectoration. As
more pathological microorganism into the respiratory tract,
cilia may injure in some way, the escalator or the whipping
mechanism may have less effective.
The bacteria or viruses as progressively entering into
the lungs, it may reach to alveolar cell, type II cells lose
their structural integrity and surfactant production is
diminished, a hyaline membrane forms, and pulmonary
edema develops.
Accumulation of mononuclear cells in the submucosa
and perivascular space, resulting in partial obstruction of

34
the airway. They clinically manifest as wheezing and
crackles.
Hematogenous spread of bacteria from an extra-
pulmonary infection site—bacteria from another infected
site can be carried in the blood to the lungs
Resulting from these infections causes the lungs to
become stiff and less distensible, thereby decreasing tidal
volume. The patient must increase his respiratory rate to
maintain adequate ventialtion

MEDICAL MANAGEMENT

Under Dr. Veralou L. Sojor, M.D

03/28/09

35
  Admit patient at IMCU transferred to SVIX
under blue level II
o v/s q 4hr, BF with SAP
o CBC, Pt. U/A
o CXR
 IVF D5IMB at 20cc/hr
 Meds:
o Chloramphenicol at IVTT q8hr
o Paracetamol, PRN
o Salbutamol Nebuli

03/29/09

 Ff up CBC
 Ff U/A
 Ff up CXR
03/30/09
 For ABG, CBC, PC and U/A
 Continue IVF at same rate
 Continue Meds
o Start chloramphenicol
o Cefuraxime 335mg IVTT q8hrs
o Amikaxin 75mg IVTT, OD
o Decrease Salbutamol Neb, q4

03/31/09
 Still for Na+, K+, Ca+, Mg+
 Still for LP
 Review CXR-APL

36
 Continue IVF at same rate as ordered

 Continue Meds:
o Cefutaxime
o Amikacin
o Paracetamol

04/01/09
 V/S q4 with O2 Sat
 Still for NPO
 LP done, place pt on bed flat x4hrs
04/02/09
 Rpt CXR-APL today
 Ff up CSF analysis, GS/CS
 Ff up sugar and protein
 Continue Meds:
o Cefutaxime
o Amikacin
o Paracetamol
o Cloxacilline

04/17-24/09
 D5IMB at 45cc/hr
 Meds:
o Cloxacilline (D12)
o Pencillin Mg (D9)
o V/S q4hr
04/18/09
 Cloxalline (D12-13)

37
  Pencillin Mg (D10)

04/19/09
 Cloxalline (D13- 04/25/09
14)  Cloxalline (D14)
 Pencillin Mg  Pencillin Mg
(D10) (D12)
04/20/09  Rpt CXR –APL
 Cloxalline (D14)  Insert CTT
 Pencillin Mg
(D11) 04/26/09
04/22/09  Retained CTT
 Cloxalline (D15)  Drained every
 Pencillin Mg shift
(D12) 04/27/09
04/23-24/09  D5IMB at
 Cloxalline (D13) 45cc/hr
 Pencillin Mg  Meds:
(D11) o Pencillin
Mg (D13)
o Cloxacilline
(D15)

38
 Laboratory
Hematology

Norma
Clinical
Test Result l Remarks
Significance
Values
CBC+Plt Hemoglobin F: Obstructive
– 1.86- Pulmonary dse,
H 3.5 2.48 Failure of -increased-
mmol/ oxygenation
L
Hematocrit – F: dehydrated
.50 0.37- -increased-
0.47
RBC – H F: 4.2- Pulmonary
-increased-
6.59 5.4 disease
WBC – H 5.0- Overwhelming -decreased-
4.52 10.0 viral infection
Neutrophil – 55-75 Viral infection -decreased-
L 48
Lymphocytes 20- - normal
–26 40% range-
Monocytes – 2-10 -normal
4 range-
Eosinophil – 1-8 -normal
4 range-
Basophil – 0 0-1 -normal
range-
Platelet -normal

39
 count –
200,000/cu range-
mm

Laboratory
Chemistry

Resul Normal Clinical

Test Remarks
t Values significance
144.0 135- -normal
Na+
0 145mmol/L range-
Tissue
K+ H 5.9 3.5-5mmol/L -increased-
breakdown
2.15-2.55 -normal
Ca+ 2.50
mmol/L range-
Excess
ingestion of
Serum H 0.62-
Mg+- -increased-
Mg+ 1.42 0.95mmol/L
containing
antacids

40
Laboratory
ABG

Clinical
Normal
Test Result significanc Remarks
Values
e
-normal
pH 7.42 7.35-7.45
range-
-normal
pCO2 41.6 35-45
range-
Depressed
HCO3 27.6 22.0-27.0 -increased-
respiration
-normal
O2 Sat 98.2% 80-100%
range-
-normal
Cf CO2 28.6 23.0-30.0
range-
Chronic
obstructive
PO2 74.0 80-100 -decreased-
lung
disease

41
 MEDICAL MANAGEMENT

Ideal Management

42
• Antibiotics are prescribed based in Gram stain
results and antibiotic guidelines (resistance patterns,
risk factors, etiology must be considered).
Combination therapy may also be used.
• Supportive treatment includes hydration,
antipyretics, antihistamines, or nasal decongestants.
• Bed rest is recommended until infection shows
signs of clearing
• Oxygen therapy is given for hypoxemia
• Respiratory support includes endotracheal
intubation, high inspiratory oxygen concentrations,
and mechanical ventilation
• Treatment of atelectasis, pleural effusion, shock,
respiratory failure, or superinfection is instituted, if
needed
• For groups at high risk for community-acquired
pneumonia, pneumococcal vaccination is advised
• Increased fluid intake to thin viscous and tenacious
secretions

43
44
45
46
47
48
 NURSING ASSESSMENT

Physical Assessment

Neurological

The patient had a GCS score of 11, she can able to

express self through crying and understand given by her
mother, patient is able to interact person-to-person.

Eye/Vision

Our patient, have pale conjunctiva due to high grade

fever and generalized weakness upon admission

Ears/Hearing

Our patient doesn’t have hearing problem, no

discharges, symmetrical, no swelling and tenderness. Can
respond normal voice tone

Nose

Our patient doesn’t have nasal problem, no

discharges, no swelling and tenderness noted upon
inspection and, uniform in color.

49
Mouth/Tongue/Teeth/ Speech

The patient’s had a crack and pallor lips, reddened

gums, with distant teeth. And the patient had a slurred
speech. Tongue is slightly pale.

Throat/Neck

Neck is symmetrical with head, can turned head from

right to left gradually, but with resistance, no palpable
lymph nodes

Respiratory System

Patient use accessory muscle in order to breathe

normally, presence of wheezes and rales is heard upon
auscultation and in normal hearing, with respiratory rate
of 48cpm

Circulatory/Cardiovascular

50
 Patient has an O2 Sat of 98%, heart rate of 90bpm,
and and blood pressure reading of 80/50, pulse rate was
130bpm with skipping beats. No edema, swelling, good
capillary refill less than 3secs.

Gastrointestinal

Flat abdominal contour, audible bowel sound, no

tenderness or distention. Thorax had dullness of sound due
to decrease confluent and pleural effusion

Genitourinary

Patient had excessive urination, with minimum of

800cc per diaper

Muscoloskeletal

The patient had normal upper and lower extremeties,

symmetrical and no tenderness,

Integumentary

The patien’st skin was warm to touch,with

temperature of 38°C , febrile,with good skin turgor

51
 NURSING MANAGEMENT

NURSING ASSESSMENT AND DIAGNOSIS

• Assess for fever, chills night sweats, pleuritic-type

pain, fatigue, tachypnea, use of accessory muscle,
bradycardia or relative bradycardia, coughing, and
purulent sputum, and auscultate breath sounds for
consolidation
• Note changes in temperature, pulse; amount, odor, and
color of secretions; and breath sounds
• Frequency and severity of cough
• Degree of tachypnea or shortness of breath

52
 • Changes in chest x-ray findings
• Assess the characteristic of drained pus from the lungs
of the patient.
• Assess for complication, including continuing or
recurring fever, failure to resolve, atelectasis, pleural
effusion, cardiac complication, and superinfection
• Encourage bronchial hygiene, such as increased fluid
intake and directed coughing to remove secretions.
• Put patient into moderate high back rest for lung
expansion and clearing, and to cough effectively and
prevent retention of mucopurulent sputum,

NURSING THEORIES

Florence Nightingale

53
Her Notes on Nursing emphasized that a clean
environment, warmth, ventilation, sunlight, and a quiet
environment lead to good health.

Reaction: a non-stimulating environment is essential

especially for our patient, in a way that it promotes faster
recovery on our patient through minimizing external and
stressful stimuli such as limiting visitors during resting
periods that may worsen the situation of our client.

Virginia Henderson

Virginia Henderson defined nursing as "assisting

individuals to gain independence in relation to the
performance of activities contributing to health or its
recovery"

Hildegard Peplau

Hildegard Peplau used the term, psychodynamic nursing, to

describe the dynamic relationship between a nurse and a
patient. She identified nursing roles of the nurse and in our
case this three roles fitted us for our client:
• Counseling Role - working with the patient on current

problems
• Teaching Role - offering information and helping the

patient learn

54
Reaction: As a nursing student, we had many roles to
perform to our patient.
One of these roles is being a councilor. As a councilor, it is
our duty to lessen if not alleviate the client’s problem.

55
56
57
58
59
60
61
62
 HEALTH TEACHINGS

PRIMARY
1. Instruct the SO to have patient an oxygen therapy for
continuous normal breathing, and or breathing exercise

2. Instruct the SO to kept the patient away in open place such

as in road where their store located and dusty place, to
prevent inhalation of airborne microorganisms

3. Instruct the SO to maintain the patient proper diet that she

can tolerate, such as fruits, to help promote wellness.

4. Advice the SO to monitor patient’s fluid intake or adequate

hydration, to help her body re-hydrate to prevent fluid
imbalance.

5. Instruct SO to assist patient in performinf self-hygience

activities she cannot tolerate, to help her maintain her
activities of daily living.

6. Encourage SO to perform self care activities within her

level of own ability

7. Assist patient to perform as much as possible and then to

call for assistance. Collaborate with patient for progressive
activity before and after schedule activity.

63
SECONDARY

1. Administer medications regularly as ordered by the

physician

2. Advice SO to the patient to have proper nutrition to

enhance immune system

TERTIARY

1. Instruct SO to comply patient’s medication regimen

2. Discuss the importance of having a regular check-

up with his physician, with the mother or with the
parents.

DISCHARGE PLAN

When the doctor noted that the patient is for discharge

it is very important to continue the medication depending
on the duration the doctor ordered for the total recovery of
the patient. Patient with Bronchopneumonia severe
Community Acquired Pneumonia needs to have deep

64
breathing exercise for lung expansion and clearing for
progressive normal breathing pattern and have adequate
rest periods. It is also important to maintain proper hygiene
to prevent further infection.
The client must relax in order to recover her present
condition and instructed significant others for minimal
exposure, to an open environment such as dusty and smoky
area, which airborne microorganisms are present that can
be a high risk factor that may cause severity of her
condition. The diet of the patient is also a factor for fast
recovery. Encouraged to eat nutritious foods intended for
respiratory problem patient, the family of the patient plays
a big role for the fast recovery.
Regular consultation to the physician can be factor for
recovery to assess and monitor her condition

M- advice SO not to skip patient’s medication that the

doctor ordered

E- instruct SO, keep away the patient in smoky area or

dusty environment

T- oxygen therapy, for maintenance

65
H- separate utensils for the patient and other personal
things that will be use for the whole family

O- provide SO information about how to control or prevent

the spread of the disease, present on your patient

D- encourage patient to eat nutritious food such as

vegetable and fruits especially those that contains
vitamin C

S- provide emotional support and provide care for the

mother

PROGNOSIS

Good Poor Justification

Duration of Duration of illness is
Illness good since the condition
-
occur and she was given
ample treatment.
Onset of At the onset of illness,
Illness - the patient experienced
poor respiration (DOB)
Compliance - Patient can afford to

66
to sustain the needed
Medication laboratory exams and the
feasibility of having the
condition
Family The family members
Support supported the patient
-
both financially and
emotionally.
Environmen The hospital setting is
t not well ventilated and
- may promote for further
infection of the patient’s
current situation.
Age Patient is 1 year old
therefore she has a good
chance of recovering for
-
her immune system is
still generating in the
process of development.
Precipitating The patient manifested
Factors all the factors that may
lead to
Bronchopneumonia sev,
-
CAP which urged the
family and the health
provider to set-up the
proper action

Percentage

67
 Good: 4/7x100=42.85/43%
Poor: 3/7x100= 57.14/57%

Overall Prognosis
The prognosis is good, because the duration of illness,
compliance of medication, family support and age are the
contributing factors that result to have a good prognosis

EVALUATION

Through our hardship in preparing for this research,

as we try to interact and communicate to our patient and

her family in a good manner for us to gather the specific

and accurate data that we needed that could help us in

studying the disease which could lead us into successful

research.

68
 The patient’s condition is in recovery period as she

had already undergone medication therapy for her

present condition, which thereby prevented occurrence

of complications. They are financially capable in

sustaining such respiratory condition and the medications

after. Her mother is the one taking good care of her in

throughout her hospitalization, giving emotional and

moral support.

69
 IMPLICATION

Nursing Practice

- this can be used as a guide for practice by other

nurses. They may get many relevant ideas in
giving proper care and interventions to patients
with related illness or those who have the same
illness (BPN severe with Community Acquired
Pneumonia)

Nursing Education

- this study may serve as a helpful learning tool

for student nurses. They may utilize this
complied study as their reference for research;
this will also give them good examples on
nursing managements, and nursing diagnoses,

70
 which will be a very useful guide when they
will be making their own Nursing Care Plans.

Nursing Research

- students may use this compilation as their guide

for research. This will hand them good views and
factual ideas which will be very essential for their
added learning on knowledge for BPN severe
with Community Acquired Pneumonia

REFERENCES

71
• Medical-Surgical, Brunner and Suddart 11th Ed,

Respiratory function and Gas Exchange/pneumonia,

pp 628-631

• Medical-Surgical, Brunner and Suddart 11th Ed,

Diagnostic Test and Results, pp 2148-2152

• Handbook for Medical-Surgical Nursing, 11th Ed,

Management for Respiratory function,pneumonia,

pp665-668

• www.americanthoracicsociety.com/ thoracostomy

• http://www.springerpub.com/prod.aspx?

prod_id=72628

• wikipedia.org/wiki/Pneumonia

• wikipedia.org/wiki/Pleural cavity

72
• www.medicinenet.com/Bronchopneumonia/article.ht

• www.who.int/topics/bronchopneumonia

• www.DOH.org/bronchopneumonia_prevalence

• www.vetmed.wsu.edu/ClientEd/diabetes

73