case presentation out put 2

7/29/2019 Case Presentation Out Put 2

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University of La Salette

College of NursingSantiago City

Philippines

BronchopnuemoniaLucas Paguila Medical Clinic Hospital

August 07, 2012

Prepared by:

BSN-3A Bracket C


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Introduction

Bronchopneumonia is an illness of lung, which is caused by different organism likebacteria, 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 to the 6% deaths.Streptococcus pneumoniae (pneumococcus) and Mycoplasma pneumonia both are the common

bacterium, which causes bronchopneumonia in the adults and children.

CAUSESBacteria

Virus

Bacterial pneumonias tend to be the most serious and, in adults, the most common causeof pneumonia. The most common pneumonia-causing bacterium in adults is Streptococcus

pneumonia (pneumococcus).

RISK FACTOR

ElderlyHospitalizationImmobilization

Immune Deficiency

Long Term Illness

Smoking


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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 ofdifferent disease processes ranging from fungal and bacterial infections to cancer.

DIAGNOSTIC TEST

1. ABG is a test done to measure how much oxygen and carbon dioxide is in your blood. It also

looks at the acidity (pH) of the blood. Usually, blood gases look at blood from an artery. In rarer

cases, blood from a vein may be used.

2. CBC

Complete blood count (CBC) test measures the following:

The number of red blood cells (RBCs)The number of white blood cells (WBCs)

The total amount of hemoglobin in the blood

The fraction of the blood composed of red blood cells (hematocrit)

The mean corpuscular volume (MCV) -- the size of the red blood cellsCBC also includes information about the red blood cells that is calculated from the other

measurements:

MCH (mean corpuscular hemoglobin)


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Anatomy and Physiology

Respiratory System:

- Consists of the external nose, the nasal cavity, the Pharynx, the Larynx, the Trachea, theBronchi and the Lungs.

Function:

Gas exchange Filters inspired air Voice production Olfaction Regulate blood pH

Upper Respiratory Tract: (Nose-Larynx)

Nose -the external opening of the Respiratory System-Consist of External nares /nostrils and Nasal Cavities

RESPONSIBILITY:-Rich supply of capillaries warm the inspired air

-Olfactory mucosa

-Respiratory Mucosa


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-Supported by a framework of nine pieces of cartilage (Three individual pieces

and three cartilage pairs ) that area held in place by ligaments and muscles

*Trachea (Wind pipe)-Is a membranous tube consists of connective tissue and smooth Muscle,

Reinforced with 16-20 C shaped pieces of cartilage

-Adult: about 1.4-1.6 cm in diameter and about 10-11 cm long.

*Bronchi

-The trachea divides the left and right main (primary) bronchi each of which

connects to the lung.-The left main bronchus is more horizontal than the right main bronchus because

it displaced by the Heart. Foreign objects that enter the trachea usually logged in

the right main Bronchus; because it is more it is more vertical than the left mainBronchus and therefore more indirect line with the trachea. The trachea is lined

with psuedostratified ciliated columnar epithelium and are supported by C

shaped pieces of cartilage.

*Lungs

-Are the principal organs of respiration.

-Each lung is cone shaped, with its base resting on the diaphragm and its apexextending superiorly to a point about 2.5 centimeters above the clavicle.

-The lung has three lobes: the superior, middle and inferior lobe.

-Includes the Bronchioles, and the alveoli.


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Demographic Data

Name: Pt. Honey Pooh

Gender: Female

Age: 4 y/oBirthdate: December 20, 2007

Birthplace: Ipil, Echague Isabela

Address: Paddad, Alicia, IsabelaReligion: Roman Catholic

Nationality: FilipinoEthnicity: IlocanoAdmission

Date: July 31, 2012

Time: 4:30 pm

Attending Physician: Dra. PaguilaChief Complaint: cough for 3 days, dyspnea, and fever for 1 day

Initial Vital Signs:Temp: 38. 9 C

PR: 148bpm

RR: 48 cpm


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Nursing History

History of Present Illness

According to the patient's mother, the patient was hospitalized at Lucas-Paguila with a

diagnosis of bronchopneumonia on June 26, 2012. Three days prior to admission, the patient

experienced cough & dyspnea. On July 31, 2012 the patient had a fever in the morning so theyadmitted her at Lucas-Paguila Medical hospital at 4:40PM.

History of Past Illness

According to the patients mother, this is the 4th

time that her daughter has been admitted

to the hospital. The first time that the patient was admitted to the hospital was at the age of 9

months; the patient had a chief complaint of cough and fever. At the age of 1 year and 2 months,the patient was admitted to Lucas-Paguila due to loose bowel movement. She has completed all

her vaccines. The patient has no known food allergies.

Family Health History

The patient has a family health history of asthma, diabetes mellitus, and hypertension.


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Gordon's Functional Health Pattern

PRIOR TO ADMISSION DURING ADMISSION

Health perception - Health

Management Pattern

According to the mother,

the patient has a healthy

body.

The child is unaware of

her condition.

Nutritional - Metabolic

pattern

According to the patients

mother, the patient eatsthree times a day. She eats

fatty foods but also eatsvegetables and fruits likesquash and apple. She

drinks 1 glass of water a

day and 5-10 7-ounce

bottles of milk a day. Shealso drinks soft drinks.

During admission, the

patient does not eatregularly. She only drinks

1/2 glass of water in themorning. During one shift,the patient consumed 1 1/2

bottles of milk.

Elimination Pattern According to the patients

mother, the patientdefecates daily every

noon. The patient urinates4-5 times a day.

The patient did not

defecate since the first dayof her admission. During

the shift, the patienturinated twice.

Activity - Exercise Pattern According to the patientsmother, the patient wakes

The patient was dependenton her mother for her


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Coping Stress Tolerance

Pattern

According to the mother,

the patient has a close

relationship with themother. The mother would

help solve all the problemsthat the patient may have.

The relationship between

the mother and the patient

is still strong. The patienttalks with the mother for

any needs.

Value - Belief Pattern The patient is a RomanCatholic. She was baptized

at Our Lady of Atochia

Church when she was a

year old. According to themother, the patient and

mother prays together

every day.

The mother and patientprays together.


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1st

Physical Assessment

Date: August 01, 2012

Time: 1:00PM

Vital Signs:

Temp: 38. 9 CPR: 148 bpm

RR: 48 cpm

General Appearance: Received patient lying on bed with an ongoing D5 .03 NaCl 500ml regulated at

30ugtts/min hooked at right arm, patent and infusing well.

Mood: responsive, alert, awake

Behavior: acting with appropriate behavior


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Physical Assessment

AREA ASSESSED METHODS FINDINGS INTERPRETATION

1. SKINCOLOR

TEXTURE

TEMPERATURE

MOISTURE

TURGOR

INSPECTION

INSPECTION

ANDPALPATION

PALPATION

PALPATION

PALPATION

Light brown

skin color

Smooth

Normally

warm

Smooth

Snacks back

to previous

state


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COLOR

PUPIL (PERRLA)

INSPECTION

INSPECTION

Pink red

Responds to

pen light

NORMAL

NORMAL

6. EXTERNALAUDITORY CANAL

HEARING INSPECTION Hearing

equally in

both ears

NORMAL

7. NOSESYMMETRY

COLOR

INSPECTION

INSPECTION

Symmetrical

Same color as

the face

NORMAL

NORMAL

8. LIPS AND MOUTH


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12.UPPEREXTREMITIES

SYMMETRY

ROM

INSPECTION

INSPECTION

Symmetrical

(+) Full range

of motion

NORMAL

NORMAL

13.LOWEREXTREMITIES

SIZE

SYMMETRY

ROM

INSPECTION

INSPECTION

INSPECTION

Equal in size

Symmetrical

(+) Full range

of motion

NORMAL

NORMAL

NORMAL


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Laboratory ResultsDate: August 31,2012, 12:05pm

CBC RESULTS NORMAL INTERPRETATION

RBCHct

Hgb

WBC

4.430.35

128

10.9

4-60.4-0.54

130-180

5-10

NORMALNORMAL

NORMAL

NORMAL

DIFFERENTIAL

LymphocytesMonocytes 0.240.06 0.25-.350.03-0.14 NORMAL

BLOOD INDICES

MCV (mean cell volume)

MCH (mean corpuscularhemoglobin)MCHC (Mean Cell

Hemoglobin Concentration)

79.5

28.9

36.4

86-110

26-38

31-37

NORMAL

NORMAL


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Pathophysiology

Predisposing Factors Etiologic Agent Precipitating Factors- Age - Streptococcus pneumonia - immunocompromise

- Sex - Staphylococcus aureus - underlying lung disease- Escherichia coli - alcoholism

-Mycoplasma pneumonia - malnutrition

- altered consciousness

Aspiration of microorganism

Adherence to alveolar

macrophages; exposure of cell

wall components


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Pathophysiology

Aspiration of oropharyngeal secretions is the most common route of lower respiratorytract infection; thus the nasopharynx and oropharynx constitute the first line of defense for most

infectious agents. Another route of infection is through the inhalation of microorganisms thathave been released into the air when an infected individual coughs, sneezes, or talks, or form

aerosolized water, such as that from contaminated respiratory therapy equipment. In healthy

individuals, pathogens that reach the lungs are expelled or held in check by mechanisms of self-

defense (First line: Physical, Mechanical, and Biochemical Barriers, Second line: InflammatoryResponse, Immunity, cough reflex, mucociliary clearance). If a microorganism gets past the

upper airway defense mechanisms, the next line of defense is the alveolar macrophage. Thisphagocyte is capable of removing most infectious agents without setting off significantinflammatory or immune responses. However, if the microorganism is virulent or present in large

enough numbers, it can overwhelm the alveolar macrophage and result in a full-scale activation

of the bodys defense mechanism, including the release of multiple inflammatory mediators,

cellular infiltration, and immune activation. These inflammatory mediators and immunecomplexes can damage bronchial mucous membranes and alveolocapillary membranes, causing

the acini (cluster of cells that resembles a many-lobed "berry"; the berry-shaped termination of

an exocrine gland, where the secretion is produced, is acinar in form, as is the alveolar saccontaining multiple alveoli in the lungs) and terminal bronchioles to fill with infectious debris

and exudate. In addition, some microorganisms release toxins from their cell walls that can cause

further lung damage. The accumulation of exudate in the acinus leads to dyspnea and to V/Q

mismatching and hypoxemia. The immune response includes complement activation and theproduction of antibodies which are crucial for opsonizing the encapsulated bacterium


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Course in the Ward

Date Doctors Order

July 31, 2012

4:35pm

- Admit to ROC- V/S q 4- For CBC- D5 0.3 NaCl 500 ml at 30 ggts/min- Paracetamol 120 mg q 4h for T- 38 C-

Hydrocortisone 25 mg IV q 8- Aerosol with salbutamol- Cefuroxime 250mg IV q 6 ANST- Oxygen at 2-36 for dyspnea- Refer for any signs and symptoms


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Nursing Care Plan


ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: none

Objective:

RestlessnessProductive cough

(+) Rhonchi on rightlower lobe


RR: 48 cpm

Risk for

ineffective airwayclearance r/taccumulation of

tracheobronchialsecretions

After 3-4 hours of

nursing intervention,the patient will be ableto maintain patent

airway clearance AEBreduction of congestion

with breath soundsclear

Monitor V/s Elevate HOB and

encourage frequent

positioning

Auscultate breathsounds and assessair movement

Keep back dry andloosen clothingand teach deep

breathing andcoughing exercises

Instruct the motherto increase fluid

intake

Provide adequaterest periods

Givebronchodilators as

ordered Administer oxygen

therapy and othermedications as

ordered

For baseline data Ventilation to different

lung segment

To ascertain status andnote progress

To promote comfortand adequateventilation and promote

pulmonary hygiene

To liquefy secretions

Rest will preventfatigue and decrease

oxygen demands

To clear airway whensecretions are blocking

the airway To increase oxygen

saturation

After 3-4 hours of

nursing intervention,the patientmaintained a patent

airway AEB areduction of

congestion withclear breath sounds.

GOAL MET


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Subjective: none

Objective:

Restlessness(+) Rhonchi on right

lower lobe


RR: 48 cpm

Risk for impaired

Gas Exchange r/tinflammation of

airways and

accumulation ofsputum affecting

O2 and O2transport

After 4-5 hours of nursing

intervention, the patient willdemonstrate improvement

in gas exchange AEB a

decrease in respiratory rateto normal (22-34 cpm)

Monitor V/S Observe color of skin,

mucous and nail beds

Elevate HOB andencourage frequent

position changes Encourage deep

breathing andcoughing exercises

Keep back dry andloosen clothing

Provide adequate restperiods

Instruct mother toincrease fluid intake

of the child

Administer oxygentherapy as ordered

For baseline data To note in any

changes of the

status of your gasexchange

To facilitate thediaphragm

To promote goodpulmonary

hygiene

To promotecomfort and

adequate

ventilation Rest will preventfatigue anddecrease oxygen

demands formetabolic

demands

To liquefysecretions

To increaseoxygen saturation

After 4-5 hours of

nursing intervention, thepatients respiratory rate

decreased to 42 cpm

GOAL NOT MET


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Subjective: none

Objective:

Warm to touch

Body weaknessLack of appetite

V/S:

Temp: 38. 9 C

PR: 148 bpmRR: 48 cpm

Hyperthermia r/tinflammatory process

After 30 minutes to 1hour of nursing

intervention, the

temperature of the pt.will decrease from

38.9C to at least 37.5C

Establish rapport Monitor V/s Perform TSB

Promote surfacecooling by means

of undressing

Encourage fluidintake

Maintain patentairway and

provide blanket

Maintain bed restand adequate rest

periods

Administerantipyretics asordered

To gain trust For baseline data TSB promotes

heat loss throughevaporation and

conduction To provide

comfort and

prevent chills

To supportcirculating

volume and tissueperfusion

To promotepatients safety

and to avoidchills

To reducemetabolic

demands andoxygen

consumption

To decreasecirculating

pyrogens

After 30 minutes to 1hour nursing

intervention, the

temperature decreasedfrom 38.9 C to 37.8 C

GOAL PARTIALLYMET


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Date: August 01, 2012ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:

Objective:

(+) Rhonchi in rightlower lobeProductive cough

RestlessnessCough

Tachypnea

V/S:Temp: 38. 9 C

PR: 148 bpmRR: 48 cpm

Risk for infection r/t

suppressed inflammatoryresponse

At the end of the shift,

the patient will be freefrom possible spread of

infection.

Monitor V/S Encourage the

mother to

perform goodhand-washingtechniques

Encourageadequate rest

periods

Stress theimportance ofincreasing the

childs nutritionalintake

Instruct mother toprovide goodhygiene for thechild

Instruct mother toprovide adequate

safe drinkingmilk/water for the

child

Instruct mother tokeep the childwarm and to

provide a blanket

To establishbaseline data

To reduce spreador acquisition of

infection

To enhance fastrecovery and

regain strength

Good nutritionintake canstrengthen the

bodys immunesystem

To prevent entryof microbes

To prevent GIdisturbance

To avoid chillsand to prevent thechild from having

a fever

At the end of the shift,

the patient has been freefrom possible spread of

infection.

GOAL MET.


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Subjective:

Objective:

Lack of appetite

Lack of interest to foodoffered

Risk for imbalancednutrition r/t decrease

nutrient absorption

At the end of theshift, the patient

will consume at

least 65% of thefood offered

Monitor vital signs Assess for difficulty of

swallowing and the

ability to swallow

Encourage familymembers to prepare

food of patientspreferences- develop

meal plan with thepatient

Ask the mother to jointhe child during meal

time

Instruct client to avoidcaffeinated beverages

Promote adequate andtimely fluid intake bylimiting fluids 30

minutes prior to meal

Encourage small butfrequent feedings

Instruct the client to eata bland diet, low in

roughage, avoiding hot,spicy, or very acidic

foods

To have baseline data Can be factors that

can affect ingestion

and causative ofaltered nutrition

To maintain adequatecaloric intake

To meet thenutritional needs of

the client

It stimulates gastricmotility

To reduce possibilityof early satiety

May reduce fatigueand thus enhanceintake while

preventing gastricdistention

This reduces thestress on the

gastrointestinal tract

The patient only ate 50%of foods offered.

GOAL NOT MET.


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Drug Study

DRUG NAME ACTION INDICATION CONTRAINDICATION SIDE EFFECTS NSG.

CONSIDERATION

Generic Name:

Hydrocortisone

Classification:Adrenal Cortical steroid

CorticosteroidGlucocorticoid

Therapeutic Class:Hormone

Enters target cells and

binds to cytoplasmicreceptor; initiates manycomplex reactions that are

responsible for itsanti-inflammatory,

immunosuppressive(glucocorticoid), and salt-

retaining

(mineralocorticoid)actions. Some actions

maybe undesirable,depending on drug use

-Replacement therapy in

adrenal corticalinsufficiency-Allergic states

Severeorincapacitating allergic

conditions-Hematologic disorders

-Ulcerative colitis

-Allergy to any component

of the drug-Fungal infections-Amebiasis

-Hepatitis B-Vaccinia or varicella

-Antibiotic-Resistant infections

-Immunosuppression

CNS:

Vertigo, headache,paresthesias, insomnia,seizures, psychosis

CV:Hypotension,shock,HPN

and heart failuresecondary to fluid

retention,

thromboembolism,thrombophlebitis, fat

embolism, cardiacarrhythmias

Dermatologic:Thin, fragile skin,

petechiae, ecchymosis,

purpura, striae,

subcutaneous fat atrophy

EENT:Cataracts, glaucoma,increased IOP

Endocrine:Amenorrhea, irregular

mens, growth retardation,decreased carbohydrate

tolerance and DM,cushingoid state, HPA

suppression systemic,

Before

- Assessforcontraindications.- Assess body weight,

skincolor, V/S,urinalysis, serum

electrolytes, X-rays, CBC.- Arrange for increased

dosage when patient is

subject to unusual stress.- Do not give live

vaccines withimmunosuppressive

dosesofhydrocortisone.- Observe the 15 rightsof drug administration.

During- Give daily before 9amto mimic normal peak

diurnalcorticosteroidlevels.

- Space multiple dosesevenly throughout the

day.- Use minimal doses for

minimal duration tominimize adverse

effects.


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hyperglycemia

GI:Peptic or esophagealulcer, pancreatitis,

abdominal distention,nausea, vomiting,

increased appetite and

weight gainHematologic:

Na and fluid retention,

hypocalcemia, increasedblood sugar, increased

serum cholesterol,decreased T3 and T4

levels

Hypersensitivity:Anaphylactoidorhypersensitivity

reactions

Musculoskeletal:Muscle weakness, steroidmyopathy and loss of

muscle mass,osteoporosis, spontaneous

fractures

Other:Immunosuppression,aggravation or masking

ofinfections, impairedwound healing

- Do not give IMinjections if patient has

thrombocytopenicpurpura.

- Taper doses whendiscontinuing high-dose

orlong-term therapy.

After

- Monitor client for at

least 30minutes.- Educate client on the

sideeffects ofthemedication and what to

expect.- Instruct client to report

pain at injection site.- Instruct client to take

drug exactly as

prescribed.- Dispose ofusedmaterials properly.

- Document that drughas been given


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DRUG NAME ACTION INDICATION CONTRAINDICATION SIDE EFFECTS NSG.CONSIDERATION

Generic Name:

Cefuroxime

Classification: antibioticCephalosporin

Dosage: 250 mg PO bid

Route: oral

Bactericidal: inhibits

synthesis of bacterial cellwall, causing cell death.

Acute bacterial maxillary

sinusitis caused bystreptococcus pyrogens.

Lower respiratoryinfections caused by

streptococcus

pneumonia, H. influenza

Contraindicated with

allergy to cephalosporinsand penicillins.

Use cautiously with renalfailure, lactation,

pregnancy

CNS: headache,

dizziness, lethargy,paresthiasis.

GI: nausea and

vomiting, diarrhea,anorexia, abdominal

pain, flatulence.

HEMATOLOGIC:bone marrow depression(WBC, decreased

platelets, decreasehematocrit.)

HYPERSENSITIVITY: Ranging rush to fever to

anaphylaxis: serum

sickness reaction.

Assessment:

History: hepatic andrenal impairment,

lactation, pregnancy.

Physical: Skin Status,culture of affected area.

Oral Drug:

Give oral drug with food

to decrease GI upset andenhance absorption.

Discontinue ifhypersensitivity

occurred.

Parenteral Drug:

Report severe diarrhea,difficulty of breathing,unusual tiredness or

fatigue, pain at injection

site


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DRUG NAME ACTION INDICATION CONTRAINDICATION SIDE EFFECTS NSG.

CONSIDERATION

Generic

Name: SalbutamolSulfate AlbuterolSulfate

Brand

Name: AccuNeb,Airomir, Proventil,

Proventil HFA, ProventilRepetabs, Ventolin,

Ventolin HFA, VentolinObstetric Injection,

Ventolin Rotacaps,

Volmax, VoSpire ER

Available

Forms: Capsules forinhalation: 200mcgInjection: 1 mg /ml Solution forinhalation: 0.083%,

0.5%, 0.63 mg / ml, 1.25mg / 3 ml Syrup: 2 mg /5 ml Tablets: 2 mg, 4mg Tablets (extended-release): 4 mg, 8 mg

Relaxes bronchial,

uterine, and vascularsmooth muscle by

stimulating beta2

receptors.

* To prevent or treat

bronchospasm in patientswith reversible

obstructive airway

disease * To prevent exercise-

induced bronchospasm * Acute asthma * Symptom relief duringmaintenance therapy of

asthma and otherconditions with

reversible or irreversibleairways obstruction

(including COPD and

bronchitis)

* Contraindicated in

patients hypersensitive to

drug or its ingredients. * Use with caution in

patients with CV

disorders (includingcoronary insufficiency

and hypertension),hyperthyroidism,

diabetes mellitus, and

those who are unusuallyresponsive to

adrenergics * Use extended-releasetablets cautiously in

patients with GI

narrowing.

. CNS: tremor,

nervousness, dizziness,insomnia, headache,

hyperactivity, weakness,

CNS stimulation,

malaise CV: tachycardia,

palpitations,

hypertension EENT: dry and irritatednose and throat with

inhaled form, nasalcongestion, epistaxis,

hoarseness GI: heartburn, nausea,vomiting, anorexia,altered taste, increased

appetite

* Drug may

decrease sensitivityof spirometry used

for diagnosis of

asthma.* When switching

from regular toextended-release

tablets, keep inmind that a regular

2 mg tablet every 6hours is equivalent

to an extended-release 4 mg tablet

every 12 hours.* Syrup may etaken by children as

young as age 2; itcontains no alcohol

or sugar.* Rarely, erythema

multiforme orStevens-Johnson

Syndrome has beenlinked to use of

syrup in children.


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DRUG NAME ACTION INDICATION CONTRAINDICATION SIDE EFFECTS NSG.CONSIDERATION

Generic Name:

Paracetamol

Brand Name:

Classification:

Analgesic, Anti pyretics

Dose: 1ampFrequency: for PRN

meds q 4-6 hours

Route: oral

Indicated in conditions

like Ear pain, Headache,Malaise, Migraine, mild

to moderate pain, Pain,

Post-vaccine reaction,Short bowel syndrome,

Toothache.

Paracetamol exhibits

analgesic action byperipheral blockage pain

impulse generation. It

produces antipyresis byinhibiting the

hypothalamic heat-regulating center. Its

weak anti-inflammatoryactivity is related to

inhibition ofprostaglandin synthesis

in the CNS

Contraindicated in

conditions like

hypersensitivity

Nausea, allergic reaction,

skin rashes, acute renaltubular, necrosis.

Potentially fatal: Liverdamage

If sensitivity reaction

occurs, discontinue useof paracetamol

If pain persist more than10 days and arthritic and

rheumatic conditionaffecting children,

immediately consult

physician.

case presentation out put 2

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