BRONCHOPNEUMONIA

POLYTECHNIC COLLEGE OF DAVAO DEL SURMacArthur Highway, Digos City

A CASE STUDY OF Empyema Thoracis, Left secondary to

BPN severe Community Acquired Pneumonias/p Chest Thoracostomy Tube

IN PARTIAL FULFILLMENTOF 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

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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,

7

bronchopneumonia, before the patient experienced

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

9

that progresses from free-flowing pleural fluid to a complex

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,

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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

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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,

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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

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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.

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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.

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ETIOLOGY AND SYMPTOMATOLOGY

Etiology

Ideal Actual JustificationPredisposing Factor

Age (+)

Specifically 6 months and above children has low immune system, that can’t resist any bacterial infection, such as airborne transmission. Our patient is, 1 year old baby girl and she acquires the said disease in their community

Exposure (living)

(+)

The family of the pt owned a little “sari-sari” store, which is the source of the family’s income and which is situated near the road, as interviewed the client was often baby sited at their store

Precipitating FactorsDaily

Activities(+) Daily activities of an

individual can be a causal factor of the disease. Playing is the common activity at a very young age (1y/o). This individual is

25

not conscious of the environment.

Diet (+)

The patient common food intake are rice, hotdogs, eggs, chocolates, candies, sometimes fruits ( banana ), combination of breast and formula milk.

Mycoplasma pneumonae

and environmental

factors

(+)

Such as exposure to certain viruses and foods early in life, may trigger the autoimmune response. Our patient is living in a poor environment, because they’ve live in a dusty place where near the highway, where many vehicle passed by. Vehicular smoke and dust particles can be the carrier of the bacteria, viruses.

26

Symptomatology

Ideal Actual Justification

Cough with greenish or

yellow mucus(-)

The bronchioles contain submuscosal gland, which produce mucus that covers the inside lining of the airways. Infected bronchioles produce greenish or yellow mucus secretions.

Fever(+)

On and Off high fever, cause by infection in the 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

Bradypnea (+)

Presence of foreign pathogens, and fluid accumulation in the airway lining may cause slow breathing pattern, depth and rhythm

Shortness of breath

(+)

Accumulation on the lining of airway, presence of mucus secretion and pathogenic bacteria invades in the body

Loss of appetite

(poor feeding)(+)

Due to compensatory mechanism such as low immune response, any infection due to a disease will result to the loss of appetite

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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 factorsAge (very young)Gender Exposure (living)

Pathological Entry (inhalation)of organism: Bacteria or Viruses

Precipitating factorsDaily ActivitiesEnvironmentDiet

Occurrence of localized inflammation

Mucus production

Bacteria invades alveolar cellin the lungs

Bronchopneumonia

Pulmonary Edema

Manifested by wheezing

Diminished surfactant productionFormation of Hyaline membrane

Sign and SymptomsFeverCoughChest painRapid, shallow breathingShortness of breathHeadacheLoss of appetiteFatigue

Airway Obstruction

If disorder is Treated,Normal breathing patternNormal respiratory rate and Breath sounds

If disorderDaily ActivitiesEnvironmentDieturs:EmpyemaLung AbscessPleurisyPericarditis

Chest ThoracostomyChest ThoracostomyTubeTube

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 IIo v/s q 4hr, BF with SAPo CBC, Pt. U/Ao CXR

IVF D5IMB at 20cc/hr Meds:

o Chloramphenicol at IVTT q8hro Paracetamol, PRNo 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 chloramphenicolo Cefuraxime 335mg IVTT q8hrso Amikaxin 75mg IVTT, ODo Decrease Salbutamol Neb, q4

03/31/09 Still for Na+, K+, Ca+, Mg+ Still for LP Review CXR-APL Continue IVF at same rate as ordered

36

Continue Meds:

o Cefutaximeo Amikacino 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 Cefutaximeo Amikacino Paracetamolo 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) Pencillin Mg (D10)

37

04/19/09 Cloxalline (D13-

14) Pencillin Mg

(D10)04/20/09

Cloxalline (D14) Pencillin Mg

(D11)04/22/09

Cloxalline (D15) Pencillin Mg

(D12)04/23-24/09

Cloxalline (D13) Pencillin Mg

(D11)

04/25/09 Cloxalline (D14) Pencillin Mg

(D12) Rpt CXR –APL Insert CTT

04/26/09 Retained CTT Drained every

shift04/27/09

D5IMB at 45cc/hr

Meds:o Pencillin

Mg (D13)o Cloxacilline

(D15)

Laboratory

38

Hematology

Test ResultNormal Values

Clinical Significance

Remarks

CBC+Plt Hemoglobin – H 3.5

F: 1.86-2.48mmol/L

Obstructive Pulmonary dse, Failure of oxygenation

-increased-

Hematocrit – .50

F: 0.37-0.47

dehydrated-increased-

RBC – H 6.59

F: 4.2-5.4

Pulmonary disease

-increased-

WBC – H 4.52

5.0-10.0

Overwhelming viral infection

-decreased-

Neutrophil – L 48

55-75 Viral infection -decreased-

Lymphocytes –26

20-40% - normal range-

Monocytes – 4

2-10 -normal range-

Eosinophil – 4

1-8 -normal range-

Basophil – 0 0-1 -normal range-

Platelet count – 200,000/cu mm

-normal range-

39

Laboratory Chemistry

Test ResultNormal

Values

Clinical

significanceRemarks

Na+144.0

0

135-

145mmol/L

-normal

range-

K+ H 5.9 3.5-5mmol/LTissue

breakdown-increased-

Ca+ 2.502.15-2.55

mmol/L

-normal

range-

Serum

Mg+

H

1.42

0.62-

0.95mmol/L

Excess

ingestion of

Mg+-

containing

antacids

-increased-

Laboratory

40

ABG

Test ResultNormal

Values

Clinical

significanceRemarks

pH 7.42 7.35-7.45 -normal range-

pCO2 41.6 35-45 -normal range-

HCO3 27.6 22.0-27.0Depressed

respiration-increased-

O2 Sat 98.2% 80-100% -normal range-

Cf CO2 28.6 23.0-30.0 -normal range-

PO2 74.0 80-100

Chronic

obstructive

lung

disease

-decreased-

41

MEDICAL MANAGEMENT

Ideal Management

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.

42

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

NURSING ASSESSMENT

Physical Assessment

Neurological

48

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.

Mouth/Tongue/Teeth/ Speech

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

gums, with distant teeth. And the patient had a slurred

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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

Patient has an O2 Sat of 98%, heart rate of 90bpm,

and and blood pressure reading of 80/50, pulse rate was

50

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

Changes in chest x-ray findings

52

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

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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.

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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

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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.

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

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on the duration the doctor ordered for the total recovery of

the patient. Patient with Bronchopneumonia severe

Community Acquired Pneumonia needs to have deep

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

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

T- oxygen therapy, for maintenance

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 JustificationDuration of Illness

-

Duration of illness is good since the condition occur and she was given ample treatment.

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Onset of Illness -

At the onset of illness, the patient experienced poor respiration (DOB)

Compliance to Medication -

Patient can afford to sustain the needed laboratory exams and the feasibility of having the condition

Family Support

-

The family members supported the patient both financially and emotionally.

Environment

-

The hospital setting is 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 Factors

-

The patient manifested all the factors that may lead to Bronchopneumonia sev, CAP which urged the family and the health provider to set-up the proper action

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Percentage

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

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studying the disease which could lead us into successful

research.

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.

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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

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complied study as their reference for research; this will also give them good examples on nursing managements, and nursing diagnoses, 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

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REFERENCES

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

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wikipedia.org/wiki/Pleural cavity

www.medicinenet.com/Bronchopneumonia/

article.htm

www.who.int/topics/bronchopneumonia

www.DOH.org/bronchopneumonia_prevalence

www.vetmed.wsu.edu/ClientEd/diabetes

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