TRACE COLLEGETraceville Subdivision, El Danda Street, Los Baos, Laguna

COLLEGE OF NURSINGBachelor of Science in Nursing

In partial fulfillment of the course requirement in

Nursing Care Management 101 with RLE

NURSING CASE STUDYBronchopneumonia

Submitted by:

Date Submitted:

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COLLEGE OF NURSINGBachelor of Science in Nursing

NURSING CASE STUDYBronchopneumonia

After having presented, the Nursing Case Study is hereby approved by the following

Clinical Instructor

Date Submitted:

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CHAPTER 1 INTRODUCTIONLast August 18, 2008, a group of students with eleven members were assigned to Mrs. Aura Venus B. Ramos at Los Baos Doctors Hospital and Medical Center to complete their affiliation and to gain lots of new knowledge, and develop their skills and passion on the field of nursing. Each members of the group were required to submit an individual nursing case study. We have our orientation on the first day of duty and were told that being assigned on the main ward we must expect that each of us will have at least 2 patients everyday. What interests me to take Mr. RRs case to be studied is that I handled him almost for the whole week of my duty. I think, I already established a good nurse-patient relationship with this patient and because of that itll be easier for me to ask information needed for my case study. Another thing is that hes always alone in his room. Nobody among the members of his family is there to take care of him and assist him while staying at the hospital. Through taking him as my case study, I can have the reason to stay longer with him and take care of him. And lastly, it is my first time to handle a patient with bronchopneumonia. This is my chance to gain new information related to geriatric nursing. Im aiming to be a geriatric nurse, hoping to be suitable and deserving to be a nurse with the specialty of taking care of elderly, and Im thankful that almost all my patient, even before, were old aged. Bronchopneumonia is a classification of Pneumonia according to its distribution of inflammation. Pneumonia is the leading cause of morbidity in the Philippines as of year 2004 and the 5th leading cause of mortality in the Philippines as of year 2004 among male and female, and among all ages.

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CHAPTER 2 OBJECTIVES

General Objectives: My general objective is to understand what Bronchopneumonia is. Specific Objectives: Specifically: 1.) To know what causes to have Bronchopneumonia. 2.) To know the anatomy and physiology of the body organ involved in Bronchopneumonia. 3.) To understand the pathophysiology of Bronchopneumonia. 4.) To relate my patient chief complaint on his condition having Bronchopneumonia. 5.) To improve myself on formulating Nursing Care Plans. 6.) To relate the medications and medical procedures done to Mr. RR on his condition of having Bronchopneumonia.

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CHAPTER 3 HEALTH HISTORYi. PATIENTS DATAPatient's Name: Mr. RR Hospital Case No.: 0441208 Address: Timugan, Los Baos, Laguna Birth Date: 09/04/1954 Placeof Birth: San Pablo City, Laguna, Ph Age: 54Y0M Insurance: MedoCare Sex: Male Date & Time Admitted: 09/21/08 06:58pm Ordinal Rank (if pedia patient): n/a Ward/Room No./Bed No.: Rm # *03 Nationality: Filipino Inclusive Date of Confinement: --Civil Status: Married Discaharge Date&Time: --Religion: Catholic Attending Physician: Dr. M, MD Occupation: Pay Collector Educational Background: 3rd Yr Highschool Payment Source for Discharges: Self/Family: Employer/Union (give name): Public Agency (give name): Others (pls. specify): Private Insurance (pls. specify name of insurance company): MedoCare Name of Spouse (if married): Occupation: Teacher Admitted per: Ambulatory: Mrs. NR Educational Attainment: Stretcher: Age: 50 College Graduate Wheelchair:

Level of Consciousness upon Admission: Alert: Oriented: * Drowsy: Lethargic: Chief Complaint/s: Fever with chills Impression/ Admitting Diagnosis: T/C Bronchopneumonia Final Diagnosis: Community-acquired Pneumonia Disoriented: Asleep:

Responds to Verbal: Responds to Pain: Easily Aroused:

Unresponsive: Confused:

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ii. PAST HEALTH HISTORY Mr. RR verbalized that its been a long time since he was confined in the hospital, and he can remember it. He is conscious about his health. He has no allergy to any foods or other stuffs. He never smoked. He occasionally drinks alcoholic beverages but not to the point that hell get drunk. He never had undergone any surgery. iii. PRESENT HEALTH HISTORY Two days prior to admission, he developed productive cough of whitish sputum followed by low grade fever. He took Carbocisteine (Solmux) and Paracetamol (Biogesic), but because symptoms persist, he consulted his doctor and was abruptly admitted. iv. ADMISSION HISTORY The patient was admitted last September 21, 2008 around 6:58 pm with the chief complaint of fever with chills. He was admitted under the service of Dr. M, MD with the admitting impression of To Consider Bronchopneumonia. Consent for admission was secured. The doctor ordered administration of Intravenous Fluid D5LRS 1 L x 10o and to follow with D5NM 1 L x 10o. The doctor also ordered to monitor his Vital Signs every 4o and record it. His diet was Diet as Tolerated (DAT). The doctor also ordered for the Laboratory Results of CBC, Urinalysis, Na, K, CXR-PA, RBS, BUN, and Crea with administration of the following drugs: Paracetamol 500mg/tab 1 tab every 4o PRN for To > 37.8 oC, Sinecod Forte 1 tab TID, Nebulize with Venolin 1 neb TID, Levofloxacin 500mg/tab 1 tab OD am. v. GENOGRAM On the genogram of Mr. RR, youll noticed that most members of the family have hypertension and died because of cardiac arrest. Mr. RRs mother is the only one among the members of the family with weak lungs, and the only disease associated with my pts diagnosis Bronchopneumonia.

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Grandfather R

Grandmother R

? ? Grandfather R

Grandfather N

Grandmother N

?

? ? Mother R

?

BR,

PR,

SR,

Legends: ? - unknown - cardiac disease - deceased

RR, 54

(Wife) NR, 48

MR, 18

- weak lungs- female - male

NR, 14 DR, 12

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CHAPTER 4 PHYSICAL ASSESSMENTI General Survey Patients mobility was limited, with slow onset and speaks slowly. She is conscious but looks drowsy and very weak on the first two days of my care. Dress appropriately on the condition of her room (specifically the room temperature): wearing sleeveless blouse and doesnt have any unnecessary/unpleasant odor. On the next two days of my care, the patient shows alertness on answering. But I noticed that hes always lonely and he verbalized boredom. Vital Signs results are: Temperature: 36 oC Pulse Rate: 80 bmp Respiratory Rate: 20 cpm Blood Pressure: 100/70 mmHg II Skin, Hair and Nails The color of his hair is black. His skin is smooth, intact and warm to touch without any rashes, bruises nor cuts. His nails are intact, cut, clean and with three seconds capillary perfusion. III Head, Neck and Lymph Nodes Facial expressions show grimace. Neck and lymph nodes palpation is not done. IV Nose and Sinuses No secretions in the nose noted but the patient verbalized V Mouth and Throat Lips look pale in color. Patient verbalized itchiness on throat and difficulty on clearing his throat. The patient uses dentures. Teeth are clean with whitish color. VI Eyes Assessment not done. VII Ears Assessment not done.This is a property of College of Nursing TRACE College. No part of this manuscript may be reproduced or transmitted in any form or by any means. Please obtain permission from the College of Nursing TRACE College.

VIII

Respiratory System Upon auscultation, I heard a breathe sound that sounds like scratching a stainless steel. It is near on the sound of the breath sound crackles. Percussion was not done. Use of accessory muscles while coughing was noted. The patient verbalized that he sometimes feels difficulty on breathing.

IX Cardiovascular System He is not hypertensive with BP of 100/70 mmHg during our shift. The patient doesnt feel any chest pain during my shift. Upon auscultation, Heart Rate was X Breasts Assessment not done. XI Gastro-Intestinal System Patient shows loss of appetite. He eats small amount of food. He defecated twice during my whole week of care. XII Urinary System Patients urinated twice. Amount of urine depends on the amount of fluid intake. XIII Reproductive System Assessment not done. XIV Nervous System Assessment not done. XV Musculoskeletal System Patient is but shows weakness on doing activities like walking and changing positions. XVI XVII Immune and Hematologic System Endocrine System Assessment not done.

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GORDONS FUNCTIONAL HEALTH PATTERN A. HEALTH PERCEPTION HEALTH MANAGEMENT PATTERN Whenever he is sick he buy OTC drugs, then if symptoms persists, thats the time hell go to his doctor and have check-up. B. NUTRITIONAL METABOLIC PATTERN He eats whatever he wants to eat. He loves to eat fatty foods. He verbalized that hes not eating street foods. C. ELIMINATION PATTERN In the span of my whole week of care, the patient defecated twice and urinated twice everyday. The amount of urine depends on the amount of his fluid intake. D. ACTIVITY EXERCISE PATTERN Before admitted in the hospital, he works as a pay collector and his work is associated with traveling thats why he is at risk to develop bronchopneumonia because of the pollution he encountered every time he travels. He verbalized that he do not exercise. E. SLEEP REST PATTERN Before admitted, he sleeps early. He verbalized that after watching news, around 7pm and awakes early around 4am. F. COGNITIVE PERCEPTUAL PATTERN The patient is conscious but shows loneliness and boredom. Coherent and answers my questions directly. G. SELF PERCEPTION PATTERN/SELF CONCEPT PATTERN The patient is conscious but shows loneliness and boredom. H. ROLE RELATIONSHIP PATTERN He verbalized that all the members of the family were close with each other. And hes happy with how his relationship with his family goes. I. SEXUALLY REPRODUCTIVE PATTERN

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Not asked. J. COPING STRESS TOLERANCE PATTERN Whenever hes bored or sad, he takes rest and sleeps. He is not that fond of watching TV. K. VALUES/BELIEF PATTERN Their whole family religion is Catholic. They do not believe in hilot and faith healers.

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CHAPTER 5 DEFINITION OF COMPLETE MEDICAL DIAGNOSISBronchopneumonia is a type of pneumonia that is characterized by an inflammation of the lung generally associated with, and following a bout with bronchitis. This is really a specific type of pneumonia that is localized in the bronchioles and surrounding alveoli. This article provides a general overview of this condition, including symptoms and treatment options for those who have been diagnosed with bronchopneumonia. The most common pneumonia-causing bacterium in adults is Streptococcus pneumoniae (pneumococcus) Symptoms of bronchopneumonia: Cough with greenish or yellow mucus; Fever; chest pain; Rapid, shallow breathing; Shortness of breath; Headache; Loss of appetite; fatigue Treatment of 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 ones 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. Bronchopneumonia is more common in elderly people, and in association with other viral respiratory illnesses (bronchitis), and as a complication of those who have asthma. 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 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.

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CHAPTER 6 ANATOMY AND PHYSIOLOGY Lungs: The Bronchioles

The Lungs are the principal organs of respiration. Each lung is cone-shaped, with its base resting on the diaphragm and its apex extending superiorly to a point about 2.5 cm above the clavicle. The right lung has three lobes called the superior, middle and inferior lobes. The left lung has two lobes called the superior and inferior lobes. The lobes of the lungs are separated by deep, prominent fissures on the surface of the lung. Each lobe is divided into bronchopulmonary segments separated from one another by connective tissue septa, but these separations are not visible as surface fissures. There are nine bronchopulmonary segments in the left lung and ten in the right lung. The main bronchi branch many times to form the tracheobronchial tree. Each main bronchus divides into lobar bronchi as they enter their respective lungs. The lobar (secondary) bronchi, two in he left lung and three in the right lung, conduct air to each lobe. The lobar bronchi in turn give rise to segmental (tertiary) bronchi, which extend to the bronchopulmonary segments of the lungs. The bronchi continue to branch many times, finally giving rise to bronchioles. The bronchioles also subdivide numerous times to give rise to terminal bronchioles, which then subdivide into respiratory bronchioles. Each respiratory bronchiole subdivides to form alveolar ducts, which are like long, branching hallways with many open doorways. The doorways open into alveoli, which are small airThis is a property of College of Nursing TRACE College. No part of this manuscript may be reproduced or transmitted in any form or by any means. Please obtain permission from the College of Nursing TRACE College.

sacs. The alveoli become so numerous that the alveolar duct wall is little more than a succession of alveoli. The alveolar ducts end as two or three alveolar sacs, which are chambers connected to two or more alveoli. There are about three million alveoli in the lungs. The bronchioles are very small airways that extend from the bronchi to the alveoli. The bronchioles are made up of smooth muscle cells and are smaller than 1 millimeter in diameter. The bronchioles do not have glands or cartilage. The epithelial cells of the bronchioles are cuboidal in shape.

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CHAPTER 7 PATHOPHYSIOLOGYPneumonia: BronchopneumoniaPredisposing Factors Age Work/Job History of weak lungs Without history of pneumococcal vaccination Without history of influenza vaccine in previous years History of being exposed to viral or influenza infection Lifestyle Precipitating Factors Airborne Pathogenic

Inhalation of infectious organism

Infectious organism penetrate airway mucosa Inflammatory response of the lungs

Multiplication of infectious organism in the alveolar spaces WBC migrate to the area of infection

Local capillary leak, edema and exudates

Fluids collect in and around alveoli

Alveolar walls thickenManifests gas exchangeThis is a property of College of Nursing TRACE College. No part of this manuscript may be reproduced or transmitted in any form or by any means. Please obtain permission from the College of Nursing TRACE College.

RBC and fibrin also move into alveoli

Capillary leak spread of infection into the other areas of the lungs

Fibrin and edema of inflammation stiffen the lungsManifests vital capacity

Alveolar collapsedManifests ability of lungs to oxygenate the blood moving through it

Exudates digested by enzymes

Action provides excellent culture media to spread of organism

Clinical Manifestation Fever and chills Plueric Chest Pain Shortness of breath Crackles and wheezes Cough Sputum production Rapid, shallow respirations

IF TREATED

IF NOT TREATED

Diagnostic Exams: COMPLICATIONS: Chest X-ray Hypoxemia Blood/Serologic Exam Ventilatory Failure Treatment: Atelectasis Antimicrobial therapy Pleural Effusion Bronchodilators Pleurisy Deep Breathing and This is a property of College of Nursing TRACE College. No part of this manuscript may be reproduced or transmitted in any form or by any TRACE College. Coughing Exercise obtain permission from the College of Nursing Continued infection despite of means. Please use of antimicrobial therapy Increase Fluid Intake Absolute bedrest

Resolution GOOD PROGNOSIS

Abscess formation

Necrosis of pulmonary tissues

Overwhelming sepsis

Death POOR PROGNOSIS

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CHAPTER 8 LABORATORY AND DIAGNOSTIC EXAMINATIONSNURSING CONSIDERATIONS BEFORE AND AFTER THE PROCEDURES

DATE ORDERED

DIAGNOSTIC EXAMINATIONS WITH DEFINITIONS HEMATOLOGY/CBC the most commonly performed blood test which is a basic evaluation of the cellular components of blood.

NORMAL FINDINGSHemoglobin

ACTUAL RESULTS

CLINICAL SIGNIFICANCE (RATIONALE)Within normal range Within normal range

*08/20/08

13 18 gms Hematocrit 40 - 54 vol % RBC Count 4.5 5.5 M/ml WBC Count 5,000-10,000 cumm Differential WBC Count Segmented Neutrophils: 55 - 65% Lymphocytes: 25 - 35% Monocytes: 3 - 7% Eosinophils: - 5% Basophils: 0 - 3% 0

*12.8 *40 % *4.1 M/ml *8,400/l

AnemiaWithin normal range

*85% *15% *0% *0% *0%---

1. Instruct family about the requirements or instructions 2. Inform the mother/family about the time period before the results will be available. 3. Document teachings. Include the clients responses.

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12/12/2007

Urinalysis the chemical analysis of urine sample

Appearance: Clear Color: straw/amber Odor : aromatic Transparency: Specific Gravity : 1.005 - 1.030 Glucose : negative Casts : none WBC : 0-4 RBC :

Slightly turbid Yellow Not specified Slightly hazy 1.015 NegativeAlbumin-traced;

Urinalysis To measure and detect the level of a variety of substances in the urine.

2 4/cast 1-3