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INTRODUCTION Bronchopneumonia, a community acquired pneumonia, is an acute inflammation of the walls of smaller bronchial tubules with varying amounts of pulmonary consolidation due to spread of the inflammation into peribronchiolar alveoli and the alveolar ducts . Most cases are caused by organisms aspirated from the mouth (Wikipedia.com) . This is a case of a 6 month old male child, TDL, diagnosed with bronchopneumonia. He was admitted at JR Borja’s General Hospital on December 17, 2008 at 12:15pm with chief complaints of cough, fever and respiratory distress. Onset of cough was three days prior to admission which developed to shortness of breath a day prior to admission and fever in the morning on the day prior to admission. Upon assessment, the group found out that the family lives in Gaabucayan Agora near an industrial area. Patient TDL was previously admitted to Sabal Hospital with a diagnosis of Bronchial Asthma last August 2008.

SCOPE & LIMITATION This case presentation only covers the case bronchopneumonia with signs and symptoms manifested in particular with patient TDL. Data gathered and used are based on the assessment conducted on December 17, 2008 and December 18, 2008. Care and interventions for the patient were also limited to the all in all 16 hours duty of the said dates. The lack of ABG or at least a pulse oximeter in the Pediatric ward of the hospital prevented the group to monitor accurately the oxygen saturation and over-all gas exchange of the patient. Culture and Sensitivity Test and Gram Staining were done but results were not released during duty dates so the group has no knowledge of the exact microorganism causing the disease. Based on the signs and symptoms, the group assumed that it is of bacterial origin in constructing the Pathophysiology of the disease.

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General Objectives: The general objectives for conducting this case study are for students to incorporate concepts and enhance knowledge in Maternal and Child Health Nursing and Medical Surgical Nursing to apply the appropriate nursing management for clients with Bronchopneumonia accurately and efficiently. This study also aims to develop the skills that are applied for the care of patients with this condition. At the same time, it allows the students to utilize the different attitudes that were instilled on them, such as on being respectful, patient and empathetic. Specific Objectives: At the end of 2 Hours of case presentation, this case study specifically aims to: a. Define Bronchopneumonia accurately b. Discuss briefly the causative factors that may have precipitated the onset of the condition c. Discuss thoroughly the signs and symptoms manifested by patient d. Discuss the different drugs; indications, mechanism of action, therapeutic effects, adverse effects and contraindications. e. Present accurately the condition of the patient f. Acquire knowledge and understanding of the Pathophysiology of Bronchopneumonia g. Discuss the nursing care plan appropriate in providing care to alleviate the manifestation of the patient’s symptoms h. Identify and provide the health teachings needed for the continuum of care i. Use the nursing care plan as the framework of the patient’s care

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ASSESSMENT TOOL Date of Assessment: December 18, 2008 Client Profile: Name: __Dan Lordy M. Tuzon_______ Age: __6months__ Birthday: __May 24, 2008_ Birthplace: _Cagayan de Oro City_ Address: __Gaabucayan extension, Agora, CDO__ Religion: __Roman Catholic__ Name of parents/guardian__Mrs. Flora Tuzon__ Name of Informant: ___ Mrs. Flora Tuzon ___ Relation to client: __Mother__ Attending Physician:__Dr. Caragos/Perez___ Date of admission: _December 17, 2008 Room/ward #: _1_ No. of days admitted __2__ Chief complaints/ upon admission: __Fever, cough, & difficulty in breathing_“Galisod lagi ug ginhawa akong anak tungod sa iyang ubo…” as verbalized by mother. Medical Diagnosis, if any: __Severe Bronchopneumonia__ Current Medications: Name of drugs Paracetamol (Tempra) Hydrocortisone Combivent Cefuroxime

Dosage 1ml q4h po 30mg q6h ivtt 1neb q6h 250mg q8h ivtt

Indications PRN for fever Corticosteroid Bronchodilator Antibiotic

Past hospitalizations, if any: __October-2008 at Sabal Hospital___ Past treatments, if any: ___mother cannot specify___ I. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN Appearance _Weak____________________________________________________ Grooming _hair properly groomed, clean clothing____________________________ Posture ____not noted_(patient was lying on bed during assessment)____________ Height __Not noted____________________ Weight ___8kg.___________________ H.R. ___168bpm_ R.R __74cpm Temperature __39.7°C_”taas jud kaayo iyang hilanat, mao gidala najud nako siya dri sa hospital_basin magkumbulsyon na” as verbalized by mother___ Immunizations received including date: BCG- May 2008 OPV-June 2008 Hep B-May 2008

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II. NUTRITIONAL METABOLIC PATTERN Skin: Color __Pale and dusky___________ Texture __good skin turgor, warm, (-) _rashes_ Lesions _some scratches on face-- “sige mana dili makambrasan iyang nawong gud”- as verbalized by Mother__ Hair: Color __light brown__________ Texture ____Normal_____ Lesions __None_____________ Nail: Color __Pale________________ Condition Normal capillary refill 3sec Oral mucosa: Teeth __None_________ Condition __inflammed gums_____ Daily food intake: ___Breastfed per demand___________________________________ Food Supplements _None___________________________________________________ Vitamins taken __”naa ni siya vitamins, kadtong Ceelin, pero karon wala na siya makatumar, wala paman sad gud mi ikapalit.”___ III. ELIMINATION PATTERN Bowel habits: Frequency __twice_ Consistency ___Loose and Watery__ Bladder habits: Frequency__5-7 times Amount __100cc__

Color __Yellow___ Amount __50cc___ Color __Straw yellow___

IV. ACTIVITY-EXERCISE PATTERN Daily activities: ___”Sa balay raman mi pirmi kay wala man ko nag trabaho, naa ragyud ko pirmi sa akong mga anak gabantay”, “kada-adlaw gyud ni siya duwaon sa among mga silingan, tambok man gud siya ug hinga-taw-on mao daghan ganahan magduol niya.” As verbalized by mother__ Leisure activities: __”kadtong wala pa siya masakit, kiat jud kaayo ni siya, labina inig mag dula na siya sa iyang ate. Lihok jud ni siya a bata, karon, dili jud, sige ra ug hilak” As verbalized by mother__ Exercise routine: _”kana amo siyang duwa-duwaon, mao na na silbi iyang exercise, kusog pud kaayo mag ambak2x maskin dili pa katindog.”As verbalized by mother

V. SLEEP-REST PATTERN Time of Sleep: _”walay klaro nga oras iyang tulog, sukad pa ni gahapon kadto nagsugod iyang hangos” As verbalized by mother_”Pero katong wala pa siya nahospital gatulog nana siya inig alas 8 dayon momata siya mga 6 or 7 sa buntag”._

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Quality: _”Dili lagi na siya makatulog ug tarong tungod kay ga-hangos siya. Pero sa balay noon kay straight gyud iya katulog”, As verbalized by mother_ Sleep aid/s: __none___ VI. RESPIRATION Subjective Dyspnea, related to: Accumulation of secretion in the airway Cough: Unproductive _“Galisod lagi ug ginhawa akong anak tungod sa iyang ubo…” as verbalized by mother. History of: Bronchial Asthma Use of respiratory aids: Oxygen inhalation via nasal cannula(lpm) Comments: “gahangos jud siya mag ginhawa, samot na siya galisod ginhawa pag mag hilaka” as verbalized by mother Objective Respiratory: Rate: 74 cpm Depth: Rapid shallow breathing Use of accessory muscle: (+) chest retractions Nasal flaring: (+) Breath sounds: Wheeze and crackles noted upon auscultation_ VII. SENSORY-PERCEPTUAL PATTERN Vision: __Normal______________________ Aid/s for vision: __None____________ Hearing: __ Normal____________________ Aid/s for hearing: ____ None_______ Smell: ___ Normal_____________________ VIII. COGNITIVE PATTERN Ability to express _____” dili man siya responsive kaayo inig dulaon karon, lain gyud tingale iyang pamati kay lihokan mani siya atong wala pa siya masakit”. Another way of expressing the patient’s needs or problems is through crying which is normal in his age. IX. ROLE-RELATIONSHIP PATTERN Ordinal positon of client in the family: __2___________ Primary care giver of client:__Mother- Flora Tuzon____ Other support system of client: _Father______________ LABORATORY RESULTS CBC Normal values

Indications

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WBC: 12,000 Hemoglobin: 10.0 Hematocrit: 32.2 Platelet: 383,000 (Differential Count) Granulocyte: 68 Lymphocyte: 32

5,000-10,000 12.0-16.0gm/dl 37.0-47.0vol% 150,000-400,000/mm 43.4-76.2 % 17.4-48.2 %

Infection anemia Polycythemia, diarrhea within normal values within normal values within normal values

CXR Type of examination: CHEST APL X-ray report: Blotchy densities in both lungs , more in the right, Heart, Trachea, Diaphragm, and sinuses are unremarkable. Impression: Brochopneumonia, severe

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ANATOMY AND PHYSIOLOGY The respiratory system consists of all the organs involved in breathing. These include the nose, pharynx, larynx, trachea, bronchi and lungs. The respiratory system does two very important things: it brings oxygen into our bodies, which we need for our cells to live and function properly; and it helps us get rid of carbon dioxide, which is a waste product of cellular function. The nose, pharynx, larynx, trachea and bronchi all work like a system of pipes through which the air is funneled down into our lungs. There, in very small air sacs called alveoli, oxygen is brought into the bloodstream and carbon dioxide is pushed from the blood out into the air. When something goes wrong with part of the respiratory system, such as an infection like pneumonia, it makes it harder for us to get the oxygen we need and to get rid of the waste product carbon dioxide. Air enters your lungs through a system of pipes called the bronchi. These pipes start from the bottom of the trachea as the left and right bronchi and branch many times throughout the lungs, until they eventually form little thin-walled air sacs or bubbles, known as the alveoli. The alveoli are where the important work of gas exchange takes place between the air and your blood. Covering each alveolus is a whole network of little blood vessel called capillaries, which are very small branches of the pulmonary arteries. It is important that the air in the alveoli and the blood in the capillaries are very close together, so that oxygen and carbon dioxide can move (or diffuse) between them. So, when you breathe in, air comes down the trachea and through the bronchi into the alveoli. This fresh air has lots of oxygen in it, and some of this oxygen will travel across the walls of the alveoli into your bloodstream. Travelling in the opposite direction is carbon dioxide, which crosses from the blood in the capillaries into the air in the alveoli and is then breathed out. In this way, you bring in to your body the oxygen that you need to live, and get rid of the waste product carbon dioxide. The lungs are covered by smooth membranes that we call pleurae. The pleurae have two layers, a 'visceral' layer which sticks closely to the outside surface of your 8

lungs, and a 'parietal' layer which lines the inside of your chest wall (ribcage). The pleurae are important because they help you breathe in and out smoothly, without any friction. They also make sure that when your ribcage expands on breathing in, your lungs expand as well to fill the extra space. When you breathe in (inspiration), your muscles need to work to fill your lungs with air. The diaphragm, a large, sheet-like muscle which stretches across your chest under the ribcage, does much of this work. At rest, it is shaped like a dome curving up into your chest. When you breathe in, the diaphragm contracts and flattens out, expanding the space in your chest and drawing air into your lungs. Other muscles, including the muscles between your ribs (the intercostal muscles) also help by moving your ribcage in and out. Breathing out (expiration) does not normally require your muscles to work. This is because your lungs are very elastic, and when your muscles relax at the end of inspiration your lungs simply recoil back into their resting position, pushing the air out as they go. Each branch of the bronchial tree eventually sub-divides to form very narrow terminal bronchioles, which terminate in the alveoli. There are many millions of alveoli in each lung, and these are the areas responsible for gaseous exchange, presenting a massive surface area for exchange to occur over. Each alveolus is very closely associated with a network of capillaries containing deoxygenated blood from the pulmonary artery. The capillary and alveolar walls are very thin, allowing rapid exchange of gases by passive diffusion along concentration gradients. CO2 moves into the alveolus as the concentration is much lower in the alveolus than in the blood, and O2 moves out of the alveolus as the continuous flow of blood through the capillaries prevents saturation of the blood with O2 and allows maximal transfer across the membrane.

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Air usually moves into the body through the nose and into the nasal cavity. The nasal hairs catch and filter foreign substances that may be present in the inhaled air. The air is warmed and humidified as it passes by blood vessels close to the surface of the epithelial lining which contains goblet cells that produce mucus to trap dusts, microorganisms, pollen, and other foreign substances. The epithelial cells of this lining contain cilia— microscopic, hair-like projections of the cell membrane—which constantly moving and directing down toward the throat. Air then moves from the nasal cavity into the pharynx and larynx. The larynx contains the vocal cords and epliglottis, which close during swallowing to protect the lower respiratory tract from any foreign particles. From the larynx, air proceeds to the trachea, the main conducting airway into the lungs. The trachea divides into two main bronchi, which further divides into smaller and smaller branches. All of these tubes contain mucus-producing goblet cells and cilia to entrap any particles that may have escaped the upper protective mechanisms. The walls of the trachea and conducting bronchi are highly sensitive to irritation. When receptors in the walls are stimulated, a central nervous system reflex is initiated and a cough results. The cough causes air to be pushed through the bronchial tree under tremendous pressure, cleaning out any foreign irritant. This reflex, along with the similar sneeze reflex, forces foreign materials directly out of the system, opening it for more efficient flow of gas.

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Throughout the airways, many macrophage scavengers freely move about the epithelium and destroy invaders. Mast cells are present in abundance and release histamine, serotonin, adenosine triphosphate, and other chemicals to ensure a rapid and intense inflammatory reaction to any cell injury. The end result of these various defense mechanisms is that the lower respiratory tract is virtually sterile—an important protection against respiratory infection that could interfere with essential gas exchange. Gas exchange occurs in the alveoli. In this process, carbon dioxide is lost from the blood and oxygen is transferred to the blood. The exchange of gases at the alveolar level is called ventilation. The alveolar sac holds the gas, allowing needed oxygen to diffuse across the respiratory membrane into the capillary while carbon dioxide, which is more abundant in the capillary blood, diffuse across the membrane and enters the alveolar sac to be expired. The respiratory membrane is made up of the capillary endothelium, the capillary basement membrane, the interstitial space, the alveolar basement membrane, the alveolar epithelium, and surfactant layer. The sac is able to stay open because the surface tension of the cells is decreased by the lipoprotein surfactant. Absence of surfactant leads to alveolar collapse.

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NARRATIVE PATHOPHYSIOLOGY Bronchopneumonia, also known as lobular pneumonia, is a type of pneumonia characterized by multiple foci of isolated, acute consolidation, affecting one or more lung lobes. It is one of two types of bacterial pneumonia as classified according to the gross anatomic distribution of consolidation (solidification), the other being lobar pneumonia. Bronchopneumonia is more likely than lobar pneumonia to be associated with streptococcus. The difference between bronchopneumonia and lobar pneumonia is in the distribution of consolidation. In lobar pneumonia, consolidation occurs in one entire lobe while in bronchopneumonia or lobar pneumonia; there are multiple separate acute areas of consolidation which may affect one or more lobes. It should be noted however, that although these 2 patterns of pneumonia, lobar or lobular are the classic anatomic categories of bacterial pneumonia, in clinical practice the types are difficult to apply as the patterns usually overlap. Bronchopneumonia often leads to lobar pneumonia as the infection progresses. The predisposing factors of bronchopneumonia include age, an immature or altered state of immunity and polluted environment (smoking, noxious gases, etc). The factors that precipitate this condition include exposure to pathogen and an upper respiratory tract infection. Bronchopneumonia almost always occur after an upper respiratory tract infection wherein the pathogen is able to mobilize through the respiratory defenses due to factors such as inhalation of polluted gasses which may impair the ability of the cilia to propel pathogens upward. These factors also include extremes of age in these age brackets has immature or altered state of immunity. Once the pathogen enters the lower respiratory tract, they infect the airways, starting in the bronchi, bronchioles, terminal bronchioles and spread to the alveoli. Once the cells of these structures are injured, they release biochemical mediators of inflammation and the inflammatory response occurs. Also, once cells in the respiratory mucosa (goblet cells) become injured they secrete large amounts of mucous which contribute to the pooling or accumulation of fluid in the airways and alveoli. Biochemical mediators such as Histamine and Bradykinin cause capillary vasodilatation which increases blood flow to the area thereby bring also more nutrients. WBC’s such as neutrophils, monocytes, and

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others enter the area through the process of chemotaxis and phagocytosis of pathogens, and debris occur. However, phagocytes also release endogenous pyrogens which stimulate the hypothalamus to increase the body temperature causing fever. Another action of the inflammatory response is increased capillary permeability which causes capillaries to open up and make it easier for plasma, blood cells (WBC’s) & plasma proteins to leave the blood stream and enter into the plasma and WBC’s and leak into the airway and alveoli causing swelling and edema. Thus fluid accumulation is evident in the bronchi, bronchioles and alveoli which include mucus, and other blood components such as WBC’s. This fluid is then manifested in the patient as crackles and wheezing which are breath sounds that indicate fluid in the airways and narrowing of the airways respectively. The presence of mucus stimulates coughing as to expectorate the liquid in the airways. While the WBC is detected, as leukocytosis or increase in the number of WBC indicative of infection. Because of this fluid accumulation in the airway (bronchioles or terminal bronchioles) and alveoli two things happens. First, the airways are clogged with exudates and fluids which results to less oxygen reaching the alveoli. His is manifested as shortness of breath or a feeling of difficulty catching your breath. Second, the alveoli lose air spaces and solidify because the space which air must occupy is filled with fluids and exudates (consolidation). This is manifested as dullness during percussion. This results to decreased lung compliance and recoil; which needs the use of accessory muscles to fully expand the lungs during breathing manifested as chest retractions. Both these events lead to decrease oxygen and carbon dioxide exchange in the alveoli (oxygen can’t transfer to the bloodstream, and carbon dioxide from the bloodstream can’t be expelled from the body through the lungs). The body compensates the decrease in oxygen that reaches the alveoli by increasing the respiratory rate to bring more oxygen to the alveoli manifested as Tachypnea. Because not enough oxygen is transferred to the blood from the alveoli, the blood will contain less oxygen which is also known as hypoxemia. With hypoxemia, hypoxia is almost inevitable. Because the blood carries less oxygen, less oxygen is also delivered to body tissues and organs. This is manifested in the patient as pale and dusky skin. However, at the beginning of this compromise, the heart compensates by increasing the heart rate to bring more blood and sufficient oxygen to vital organs and other body tissues manifested as tachycardia. This condition has complications which are fatal.

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When hypoxia is severe that vital organs and other tissues are almost unoxygenated it could complicate to multiple organ failure which eventually leads to death.

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MEDICAL MANAGEMENT Ideal Management Bronchopneumonia If the cause is bacterial, the goal is to cure the infection with antibiotics. If the cause is viral, antibiotics will NOT be effective. In some cases it is difficult to distinguish between viral and bacterial pneumonia, so antibiotics may be prescribed. Pneumococcal vaccinations are recommended for individuals in high-risk groups and provide up to 80 percent effectiveness in staving off pneumococcal pneumonia. Influenza vaccinations are also frequently of use in decreasing one’s susceptibility to pneumonia, since the flu precedes pneumonia development in many cases. Unlike lobar pneumonia, in which an entire section or subdivision of the lung may be inflamed; bronchopneumonia tends to appear in patches in and around the small airways and passages. Outward clinical symptoms will be similar to those of lobar pneumonia, however, and can include fever, coughing, chest pain, chest congestion, chills, difficulty with breathing and blood-streaked mucus that is coughed up. Pneumonia, including bronchopneumonia is a fairly common illness and it affects millions of people annually in the United States. The severity of the illness will depend on the type of bacteria or infection causing the illness, as well as the overall health of the person who has bronchopneumonia. In order to diagnosis this illness, a doctor may take a chest X-ray, may test a sample of the sputum, may do a CBC to get a count of the white blood cells in the blood, may take a CAT scan, and/or may take a pleural fluid culture of the fluid surrounding the lungs. Upon diagnosis, most people will be treated at home with antibiotics. If the patient is suffering from dehydration or has a severe case of bronchopneumonia, he or she

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may be treated in the hospital where the illness can be more closely monitored. With appropriate treatment, most people recover fully within a couple weeks. Very infirm or elderly people who do not get appropriate treatment can die from bronchopneumonia.

Actual Management Chest X-Ray, urinalysis and hematology had been performed to the patient. Chest X-Ray is used to help diagnose symptoms such as shortness of breath, bad or persistent cough, chest pain or injury and fever. Succeeding chest X-Ray was used to evaluate changes found on the previous X-Ray result. Urinalysis is done to test for the presence of sodium retention. Hematology is performed to help diagnose the patient’s condition and to check for presence of infection. The patient was diagnosed with severe bronchopneumonia, several drugs were administered to treat this condition, namely: Hydrocortisone, Paracetamol, Cefuroxime with supportive therapies: Salbutamol and Oxygen inhalation. Drugs for management of Severe Bronchopneumonia: Hydrocortisone, classified under corticosteroid, was used to treat severe inflammation. This decreases inflammation, mainly by stabilizing leukocyte lysosomal membranes; suppresses immune response; stimulates bone marrow; and influences protein, fat, and carbohydrate metabolism. Paracetamol, an antipyretic agent used to treat mild fever. The drug may relieve fever through central action in the hypothalamic heat regulating center. Cefuroxime, a cephalosporin agent used to treat lower respiratory tract infection. It is a second generation cephalosporin that inhibits cell wall synthesis promoting osmotic

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instability; usually bactericidal; generally well tolerated and side effects are usually transient. Other Supportive Therapies: Salbutamol is a short-acting beta2-adrenergic receptor agonist used for the relief of bronchospasm in conditions such as asthma and chronic obstructive pulmonary disease using a nebulizer for the patient. This is used to soften the mucus thus make it easier for the patient to expectorate cough. Oxygen inhalation, another supportive therapy, is the administration of Oxygen as a therapeutic modality. Oxygen therapy benefits the patient by increasing the supply of oxygen to the lungs and thereby increasing the availability of oxygen to the body tissues.

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DOCTOR’S ORDERS Date December 17, 2008

Doctor’s Order > please admit under the service of Dr. Dy > secure consent to care > problem: SOB > condition: fair > allergies: none > diet: NPO if dyspneic (RR≥50cpm) > TPR q6 hours. I & O every shift > start with D5 0.3% NaCl 500cc at 35cc/hr > labs CBC with V/A CXR – APL > meds •

Hydrocortisone 80mg loading dose now then 30 mg q6 hours

•

Combivent q6 hours

> refer to Dr. Dy for further orders Dr. Caragos > PCM 100mg/ml December 18, 2008

> O2 @ 2L/min > start cefuroxime 250mg IVTT q8h ANST > may give pcm supp 125mg suppository (opigesic) per rectum now > IVF follow-up D5IMB 500cc at same rate > pcm 80mg very slow IVTT q4h for temp 38°c ↑

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Drug name

Classification

Drug dose

Generic name: Paracetamol

Analgesic, antipyretic.

1ml q4h po

Brand name: Tylenol, Biogesic, Tempra

Mech. Of Action Exact mechanism unknown, but appears to inhibit prostaglandin synthesis in CNS and, to a lesser extent, by blocking pain impulse through peripheral action. Acts centrally on hypothalamic heatregulating center, producing peripheral vasodilatation (skin erythema, sweating, heat loss).

Indication Commonly used for relief of fever, headaches, and other minor pains and aches.

Contraindication Adverse Effects Active Early : alcoholism, liver Anorexia, disease or viral nausea, hepatitis diaphoresis, (increase risk general hepatotoxicity.) weakness with in first 12-24 hours. Later: Vomiting, right upper quadrant tenderness; elevated liver function tests with in 48-72 hours after ingestion.

Nursing Considerations • Check the time and dosage before admini stering. • Assess for possibl e drug reactio ns. • Assess for clinical improv ement and relief of pain, fever. Therap eutic blood serum level: 10-30 mcg/m l; toxic serum20 level : >200m cg/ml.

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Drug name

Classification

Generic name: Cefuroxime

Cephalosporin, 250mg second q8h ivtt generation

Brand name: Zinacef, Ceftin

Drug dose

Mech. Of Action Binds to bacterial membranes. Inhibits synthesis of bacterial cell wall. Bactericidal.

Indication

Contraindication Adverse Nursing Effects Considerations For lower History of Antibiotic• Assess for respiratory hypersensitivity associated possible tract to colitis( severe signs and infection due cephalosporins, abdominal symptoms to S. anaphylactic pain, of drug pneumoniae, reaction to tenderness; reaction. UTI’s due to penicillins. fever; watery, • Assess for E. coli and severe anemia and skin infection diarrhea), other renal due to S. superinfections dysfunctio aureus. may result from n. altered • Assess bacterial moth for balance. white Nephrotoxicity patches on may occur, mucus especially with membranes preexisting , tongue. renal disease. Monitor Severe bowel hypersensitivity activity/sto reaction( severe ol pruritus, consistency angioedema, carefully; bronchospasm, mild GI anaphylaxis), effects may particularly in be patients with tolerable, history of but allergies, increasing especially severity penicillin. may indicate onset of antibioticassociated colitis. Monitor I & O, renal 22 function reports for nephrotoxi

Drug name

Classification

Drug dose

Generic name: Hydrocortison e

Corticosteroids

30mg q6h ivtt

Brand name: Cortef, Hydrocortone

Mech. Of Action Suppress inflammatio n and the normal immune response. It replaces endogenous cortisol in deficiency states. It also has potent mineralocort icoid (sodiumretaining) activity

Indication

Contraindication Adverse Effects

Nursing Considerations Seizures, headache, • Admihypotension, shock, nister hypertension, thin. drug as Fragile skin, prescri petechiae, bed ecchymoses, • Dosage purpura, decrease reducti carbohydrates ons intolerance, sodium may and fluid retention, create hypersensetivity adrenal reactions, muscle insuffic weakness, iency, immunosuppression repot immed iately for any abnor malitie s • Take with meals

Inflammatory disorders, adrenal cortical insufficiency

Contraindicated with fungal infections, amebiasis, hepatitis B, vaccinia or varicella, antibioticresistant infections, immunosuppression

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Name of Drug

Classification

Dosage/ Frequency

Date Ordered

Indication

Action

Side-effects

Nursing Consideration

Combivent nebule

Sympathomimetic agent

1neb q6h

12/18/08

Prophylaxis and treatment of bronchospasm d/t reversible obstructive airway disease

Stimulates betaII receptor o bronchi leading to bronchodilation

Headache, Palpitation, Tachycardia, Tremor, Bronchospasm

>When given by nebulization, use face mask or mouth piece >Monitor pulmonary status >Use Combivent exactly as it was prescribed. Do not use the medication in larger amounts, or use it for longer than recommended by the doctor.

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NURSING CARE PLAN: 1

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CUES Subjective: “ _“Galisod lagi ug ginhawa akong anak tungod sa iyang ubo…” as verbalized by mother.

Objective:  tachypnea  ineffective cough noted  crackles and wheezing noted upon auscultation  irritability  rapid shallow breathing  cyanosis

NURSING OBJECTIVES DIAGNOSIS Ineffective Short term: airway After 30 minute of clearance intervention, the patient will: related to a) demonstrate an RR of tracheobronchial 50-60cpm,reduced inflammation cough, and irritability and presence of the family will: secretions b) verbalize understanding of cause (s) and therapeutic management

Long term:’ After 2 days intervention, the patient will: a) demonstrate absence, improved of congestion with breath sounds clear, respiration noiseless, improved 0xygen exchange.

INTERVENTIONS

RATIONALE

Independent 1. assess RR every 4 hours 2. increase fluid intake to at least 3. position appropriate (head of bed elevated) and discourage use of oilbased products around nose. 4. perform percussion and vibration every 4 hours 5. avoid supine position for extended periods 6. encourage sitting, lateral prone and upright position 7. auscultate breath sounds and assess air movement Dependent 1. give bronchodilat ors as ordered 2. suction as needed.

EVALUATION Short- term:

- to detect early signs of compromise - hydration can help liquefy viscous secretions & improve secretion clearance

After 30 minutes, the patient demonstrates the ff:

-to prevent The family vomiting with verbalized: aspiration into lungs -to ascertain status & note progress -to improve respiratory function -to stimulate cough & clear airways -to enhance mobilization of secretions that interfere with oxygenation

Long-term: After 2 days of interventions the patient demonstrates minimal breath sounds, regular rate & depth of respiration.

-to enhance lung expansion & ventilation

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NURSING CARE PLAN: 2

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CUES

NURSING DIAGNOSIS

Subjective: “gahangos jud siya mag ginhawa, samot na siya galisod ginhawa pag mag hilaka” as verbalized by mother

OBJECTIVES Short-term:

Ineffective Breathing Pattern r/t collection of secretions in airway

After 4 hours of intervention, patient will have adequate oxygenation.

Objective:  Tachypnea RR: 74cpm  Dyspneic  Wheeze and crackles noted upon auscultation  Irritability  Rapid shallow breathing  (+) chest retractions  (+) nasal flaring

Long-term: After 16hours of intervention, Patient will establish a normal/effective respiratory pattern as evidenced by RR of 50-60 cpm and absence of wheezing, crackles, dyspnea, and irritability.

INTERVENTIONS

RATIONALE

Independent: 1. Auscultate chest

2. Position patient properly. Elevate patient by placing small pillow under his head. 3. Limit visitors and maintain a calm attitude/voice when dealing with the infant

4. Instruct mother not to feed baby if dyspneic

Short-term:  To evaluate presence/charact er of breath sounds/secretion s.  To promote ease of maximum respiration.  To decrease anxiety. Anxiety can cause baby to cry thus adding factors that contribute to difficulty in breathing  To prevent aspiration

Dependent: 5. Administer oxygen as prescribed by physician 6. Administer prescribed medications 7. Assist with nebulization of Combivent nebule

EVALUATION

 To provide adequate oxygenation  To treat and manage any other underlying causes.  Facilitates liquefaction and removal of secretions. And causes bronchodilation.

After 15 mins. Of intervention, the patient manifested absence of dyspnea with RR of 50-60 cpm with minimal wheezing, crackles, and irritability. Long-term: After 16hours of intervention, Patient established a normal/effective respiratory pattern as evidenced by RR of 50-60 cpm and absence of wheezing, crackles, dyspnea, and irritability

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NURSING CARE PLAN: 3

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CUES Subjective: _“Galisod lagi ug ginhawa akong anak tungod sa iyang ubo…” as verbalized by mother.

Objective:  Irritabil ity (+)  Abnor mal Skin Color: Pale & Dusky  Tachyp nea w/ RR= 74cpm  Tachyc ardia HR= 168

NURSING DIAGNOSIS Impaired gas exchange related to altered oxygen supply

OBJECTIVES

INTERVENTIONS

Short term: Independent After 4 hours of 1.) Monitor intervention, the family respiratory rate, will: depth and scale  Verbalize understanding of causative factors and appropriate intervention Long Term: After 1 week of intervention, the patient will:  Demonstrate improved ventilation and adequate oxygenation of tissues manifested by absence of symptoms of respiratory distress such as irritability, pale skin, tachypnea and tachycardia

2.) Observe color of

skin, mucous membranes and nail beds, noting presence of peripheral cyanosis

RATIONALE  Manifestations of respiratory distress are dependent on/and indicative of the degree of lung involvement and underlying general health status.  To note respiratory compromise

3.) Elevate head of bed/position client appropriately

 To maintain airway and enhance gas exchange

4.) Change patient’s position at least every 2 hours

 To mobilize secretions and allow serration of all lung fields

5.) Instruct mother to feed the baby per demand. Record intake and output

 This mobilizes secretions. I & O is essential to monitor fluid status

6.) Encourage adequate Promote

 Helps limit O2 meds/consump

rest.

EVALUATION Short term After 4 hours of intervention, the family: a.) Verbaliz ed understa nding of causativ e factors such as inhaled bacteria and appropri ate intervent ions such as medicati on complia nce and adequate breastfee ding Long term After 1 week of intervention, the patient: a.) Demonst rated improve d ventilati on and adequate oxygena tion of tissues30 as manifest

NURSING CARE PLAN: 4

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CUES Subjective:

NURSING DIAGNOSIS

OBJECTIVES Short-term:

”taas jud kaayo iyang Hyperthermia After 30 minutes of hilanat, mao gidala r/t Infection nursing intervention, najud nako siya dri sa in the lower patient’s temperature hospital_basin respirator will decrease to magkumbulsyon na” tract approximately 38.0ºC as verbalized by mother Long-term: Objective:  Warm skin  Tachypnea RR: 74cpm  Febrile T: 39.7°C  Tachycardia: HR: 168bpm  WBC: 12,000 (5,000-10,000)

After 8 hours of nursing intervention, patient should maintain core temperature within normal range: 36.8°C to 37.0°C

INTERVENTIONS

RATIONALE

Independent: 1. Do continuous tepid sponge bath. 2. Position patient on semi fowlers and instruct patient to maintain bed rest. 3. Monitor body Temperature.

Short-term: Temperature is decreased through evaporation and conduction. To reduce oxygen consumption/metabolic demands

After 30 minutes of nursing intervention, patient’s temperature decreased from 39.7°C to 38.6ºC Long-term:

High fever greatly increases Metabolic demands and Oxygen consumption and alters cellular To prevent dehydration

4. Monitor and record all sources of fluid loss such as urine , vomiting and diarrhea 5. Wash hands and teach other caregivers to wash hands before contact with patient and between procedures with patient 6. Limit visitors

EVALUATION

After 8 hours of nursing intervention, patient maintained core temperature within normal range from 36.8ºC- 37.0ºC

To reduce the risk of transmitting pathogens from one area of the body to another and prevent further infection This reduces the number of organisms in patient’s environment and restricts visitation by individuals with any type of infection to reduce the transmission of

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NURSING CARE PLAN:

CUES

Risk Factors: •

• •

Inadequate primary defenses particularly decrease in ciliary action Immnosuppressi on Presence of existing infection

NURSING DIAGNOSIS

Risk for Infection (spread)

OBJECTIVES

5

IMPLEMENTATION

Short term: Independent: At the end of 4 hours 1. Apply nursing intervention, the appropriate mother will be able to: therapy for elevated temp. • Verbalize (antipyretics, understanding of TSB, cold the risk factors therapy) for her child 2. Stress proper • Identify hand hygiene interventions to prevent or reduce risk of infection 3. Maintain a germ• The patient will free environment be afebrile Long term: At the end of 2 days of nursing intervention,

4. Emphasize

RATIONALE

EVALUATION

At the end of 4 hours nursing interventions, the mother: • Verbalized understand ing of the risk factors 2. To prevent for her transfer of child microorganisms • Identified 3. To prevent interventio spread of ns that will microorganisms prevent or from reduce the environment to risk of patient infection 4. To prevent 1. To reduce body temp to normal level

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the mother/SO will be necessity of able to: taking antivirals/antibio • demonstrate tics, as directed techniques, (dosage & length lifestyle changes of therapy) to promote safe Dependent: environment. 5. Administer prescribed antimicrobial/ant iviral agents at scheduled time

return of infection & potentiate drugresistant strains

5. To prevent further spread of microorganism in the body

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DISCHARGE PLAN Objectives: This plan aims to continue treatment and care for client by involving significant others to participate in plan of care.

Treatment: •

Instruct the patient’s mother to continue talking all the medications prescribed by the physician and return to hospital for follow-up.

•

Asses mother’s understanding of treatment regimen as well as concerns of fear

Health Teachings: •

Adequate rest and sleep

•

Timing and quantity of medication to be administered

Out Patient Follow-up: •

Instruct family to return to their attending physician for scheduled check-up.

•

Advise family to report to the physician any reoccurrence of dyspnea, and unusual complaints.

•

Encourage family to ask and inquire to the physician if there are unclear of things.

Diet: •

Breastfed per demand PROGNOSIS With treatment, most patients will improve within 2 weeks. Elderly or debilitated

patients may need treatment for longer. If the patient will fail to respond to treatment may

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die from respiratory failure. The doctor will make sure that the chest x-ray becomes normal again after the patient have taken a course of antibiotics. RECOMMENDATION The proponents of this case analysis recommend specific actions and guidelines that should be followed by the patient, his significant others and the healthcare providers such as nurses and student nurses. For the patient’s significant others, the proponents strongly recommend that they should see to it that the patient adheres to the therapeutic regimen as prescribed by the healthcare providers. This includes: medication compliance, not engaging the patient in excessive activity, promoting rest to conserve energy and promoting fluid intake unless contraindicated. Above all this, it is the sole responsibility of the family members to provide emotional, physical and financial support to the patient. For the healthcare providers, especially the nurses and student nurses, they should be aware of the nursing interventions for pediatric patients suffering from Severe Bronchopneumonia. Such as: removal of secretions that interferes with gas exchange, humidification that aids in loosening secretions and improves ventilation, and the administration of oxygen therapy as prescribed. More importantly, they should be equipped with the skills and knowledge in imparting relevant health teachings regarding Pneumonia, its prevention and management to the patient’s significant others. CONCLUSION It is essential to understand the case of the patient at the Pediatric Ward of JR Borja Hospital by studying it in different aspects. The proponents of this case study were able to understand the contributing factors that led to the patients’ condition. Also, the group provided nursing interventions that were relevant and needed by the patient. Furthermore, the understanding of the possible threats or risks that may occur during the disease process is also emphasized. It is therefore vital to assess properly the status of the patient’s condition and its complications. The case “Severe

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Bronchopneumonia” as diagnosed, paved the way for innovative inputs and setting the grounds for new learnings of the group. Above all, regaining the patient’s health was the primordial concern to the medical team including the group of student nurses. APPENDICES GROWTH AND DEVELOPMENT

1. ACCORDING TO PIAGET’S COGNITIVE DEVELOPMENT At par with age: Oral phase The infant’s primary source of satisfaction is the mouth. During assessment, the infant would grab and suck the IV tubing.

2. ACCORDING TO ERICK ERIKSON’S PSYCHOSOCIAL THEORY At par with age: Secondary circular reaction Under secondary circular reaction, the infant is able to recognize familiar experiences from environment. Patient is able to recognize procedures like auscultating his breath sounds with the use of the stethoscope. The infant was not anxious about it since his past experience with it was not bad. Also, infant enjoys playing peek-a-boo and toys with blinking lights

3. ACCORDING TO FREUD’S PSYCHOSEXUAL THEORY At par with age: Trust vs. Mistrust

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Developmental task is trust versus mistrust. Child is very attached to his primary care giver which is the mother. Cries whenever he sees mother will go to bathroom.

DOCTOR’S ORDERS

Date December 17, 2008

December 18, 2008

Doctor’s Order > please admit under the service of Dr. Dy > secure consent to care > problem: SOB > condition: fair > allergies: none > diet: NPO if dyspneic (RR≥50cpm) > TPR q6 hours. I & O every shift > start with D5 0.3% NaCl 500cc at 35cc/hr > labs CBC with V/A CXR – APL > meds • Hydrocortisone 80mg loading dose now then 30 mg q6 hours • Combivent q6 hours > refer to Dr. Dy for further orders Dr. Caragos > PCM 100mg/ml > O2 @ 2L/min > start cefuroxime 250mg IVTT q8h ANST > may give pcm supp 125mg suppository (opigesic) per rectum now > IVF follow-up D5IMB 500cc at same rate > pcm 80mg very slow IVTT q4h for temp 38°c ↑

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NURSE’S NOTES

Date and Time 12/17/08 (7-3) 12:15pm

1:45pm

2:55pm 12/17/08 (3-11) 3:00pm

Nurse’s Notes > admitted a 6 mos. Old infant, male, brought in by mother due to cough and SOB > awake, weak in appearance > seen & examined by Dr. Caragos with orders carried out > consent to care signed by mother > IVF started & regulated as ordered > for CXR-APL- Done enroute > for U/A > meds prescribed > refered to Dr. Perez with order-meds prescribed > T=38.6°c, RR= 90cpm > refered to Dr. Caragos with order carried out >TSB emphasized; 02 inhalation rendered continuously >placed on MHBR >brought to ward in mother’s arm with IVF & with latest RR: 84 >received from ER per mother’s arm with IVF going >(+)SOB >skin warm to touch >rale >ushered to bed safely >IVF regulated >vital signs taking recorded >O2 inhalation started 40

>NPO-instructed >reminded for Urinalysis TSB done continuously >placed on moderate high back rest 11:00 pm D >with O2 inhalation going on >SOB noted A >IVF regulated well >vital signs taken & recorded >due meds given >reminded for Urinalysis >CXR-APL to follow up result >kept back dry >needs attended >plan of care followed R >endorsed 12/18/08 10:00am (7-3pm shift)

3:00 pm (3-11pm shift)

D>with continuous O2 inhalation >afebrile > HR; 140bpm, RR:48 cpm A>IVF regulated as ordered >vital signs taken and recorded >NPO if dyspneic-mother instructed >on Input & Output regimen >reminded for U/A >CXR-APL- to follow up result >visited by Dr. Perez without orders >needs attended >plan of care followed R>endorsed D> afebrile >with O2 inhalation @2Lpm via nasal cannula >SOB not noted >LBM noted >Temp: 36 ºC, HR: 140bpm, RR: 45cpm A>TPR monitored every 4 hrs >intake and output monitored and recorded >bedside care provided >placed on moderate high back rest >Urinalysis, Gramstain, Culture and sensitivity- to follow up results >due meds given >breastfed with aspiration precaution 41

>health teachings imparted to mother on: a. proper positioning of the IV site b. proper hygiene c. compliance to prescribed medication >kept watched for any unusualities R>endorsed with latest vital signs of: Temp. , HR: , RR:

LABORATORY RESULTS

CBC Normal values

Indications

WBC: 12,000

5,000-10,000

Infection

Hemoglobin: 10.0

12.0-16.0gm/dl

anemia

Hematocrit: 32.2

37.0-47.0vol%

polycythemia;diarrhea

Platelet: 383,000

150,000-400,000/mm

within normal values

Granulocyte: 68

43.4-76.2 %

within normal values

Lymphocyte: 32

17.4-48.2 %

within normal values

(Differential Count)

CXR Type of examination: CHEST APL X-ray report: Blotchy densities in both lungs , more in the right, Heart, Trachea, Diaphragm, and sinuses are unremarkable. Impression: Brochopneumonia, severe

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BIBLIOGRAPHY Bauman, Robert. Microbiology with Dieases by Taxonomy 2nd ed. 2007. Pearson Education, Inc. Black and Hawks. Medical and surgical Nursing 7th ed. 2006 Elsevier and Saunders Doenges, Mariloyn,et.al. Nurse’s Pocket Guide 11th ed.2006. LA. Davis Company Gulanick, meg, et.al.Nursing Care Plans forNewborns and Children- Acute and Critical Care.1992.Mosby- Year Book,Inc. Karch, Amy. Focus on Nursing Pharmacology 3rd ed. 2006. Lippincott William and Wilkins. Kluwer, Wolters. Nursing 2008 Drug Handbook 28th ed.2008. Lippincott Williams and wilkins Luxner, Karla.Delmar’s PEDIATRIC Nursing Care plans 3rd ed,2005. Thomson Delmar Learning

Online Sources: source: medlineplus encyclopedia (online)

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