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INTRODUCTION
BRONCHOPNEUMONIA
Bronchopneumonia is an illness of lung which is caused by different organism like bacteria, viruses, and fungi and characterized by acute inflammation of the walls of the bronchioles. It is also known as pneumonia. It is common in women and causes to the 6% deaths. Streptococcus pneumoniae (pneumococcus) and Mycoplasma pneumoniae both are the common bacterium which causes bronchopneumonia in the adults and children.
Acute inflammation of the walls of the smaller bronchial tubes, with varying amounts of pulmonary consolidation due to spread of the inflammation into peribronchiolar alveoli and the alveolar ducts; may become confluent or may be hemorrhagic.
CAUSES
Bacteria Virus
Bacterial pneumonias tend to be the most serious and, in adults, the most common cause of pneumonia. The most common pneumonia-causing bacterium in adults is Streptococcus pneumoniae (pneumococcus).
RISK FACTOR
Elderly Hospitalization Immobilization Immune Deficiency Long Term Illness Smoking
SYMPTOMS
Cough with greenish or yellow mucus Fever Chest pain Rapid, shallow breathing Shortness of breath Headache Loss of appetite Fatigue
TREATMENT
Hospitalization Intravenous Antibiotic Therapy Oxygen Therapy Rest
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.
COMPLICATIONS
Empyema
is a condition in which pus and fluid from infected tissue collects in a body cavity. the name comes from the Greek word empyein meaning pus-producing (suppurate).
Pleurisy
is an inflammation of the membrane that surrounds and protects the lungs (the pleura). Inflammation occurs when an infection or damaging agent irritates the pleural surface.
Lung abscess
is an acute or chronic infection of the lung, marked by a localized collection of pus, inflammation, and destruction of tissue. Lung abscess is the end result of a number of different disease processes ranging from fungal and bacterial infections to cancer.
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) MCHC (mean corpuscular hemoglobin concentration)The platelet count is also usually included in the CBC
3. Chest X ray
chest x-ray is an x-ray of the chest, lungs, heart, large arteries, ribs, and diaphragm.
4. Pleural fluid culture
is a test that looks at a sample of fluid from the space around the lungs to find and identify disease-causing organisms.
5. History and Physical Examination6. CT of Chest7. Pleural fluid gram stain8. Sputum gram stain9. Sputum Smear Examination
PREVENTION
Pneumoccoccal Vaccine
The pneumococcal polysaccharide vaccine helps protect against severe infections due to the bacteria Streptococcus pneumoniae. This bacteria frequently causes meningitis and pneumonia in older adults and those with chronic illnesses. The vaccine has not been shown to prevent uncomplicated pneumonia.
Smoking Cessation
Hand washing
ANATOMY & PHYSIOLOGY
A respiratory system functions to allow gas exchange. The gases that are exchanged, the anatomy or structure of the exchange system and the precise physiological uses of the exchanged gases vary depending on the organism. In humans and other mammals, for example, the anatomical features of the respiratory system include airways, lungs, and the respiratory muscles. Molecules of oxygen and carbon
dioxide are passively exchanged, by diffusion, between the gaseous external environment and the blood. This exchange process occurs in the alveolar region of the lungs.
THE NOSE
• Air enters through two openings, the external nares or nostrils.• Just inside each nostril is an expanded vestibule containing coarse hairs.• A midsagittal nasal septum divides the nasal cavity.• The maxillary, nasal, frontal, ethmoid and sphenoid bones form the lateral and
superior walls of the nasal cavity.• The hard and soft palate forms the floor of the cavity. (the posterior part of the soft
palate is the uvula)• The external portion of the nose is composed of cartilage that forms the bridge
and the tip of the nose.• The superior, middle and inferior nasal cochae are bony shelves that project from
the lateral walls of the nasal cavity.• The spaces between the conchae are the meatuses.• Posteriorly the internal nares open into the nasopharynx.
THE PHARYNX
• Is a chamber shared by the digestive and respiratory systems. • It extends between the internal nares and the entrances to the larynx and
esophagus.• A stratified squamous epithelium lines the pharynx. The throat of pharynx is divided in three regions:
1. Upper naso-pharynx2. Middle oropharynx3. Lower laryngopharynx
THE NASOPHARYNX
• Lies superior to the soft palate• Serves a passageway for airflow from nasal cavity• It contains the pharyngeal tonsils ( adenoids) in posterior wall, and the opening of
the eustaquian tubes (auditory tube) THE OROPHARYNX
• Extends front soft palate down to the epiglottis (base of the tongue)• It contains the palatine and lingual tonsils.
THE LARYNGOPHARYNX
The narrow zone between the hyoid bone and the entrance to the esophagus.
THE LARYNX
• Joins the laryngopharynx with the trachea.• It consist of cartilage• It is called the voice box.• The three main cartilage are: thyroid cartilage (Adams’s apple), epiglottis, and the
cricoid cartilage.• Other cartilage is: arytenoids cartilage, corniculate cartilage and the cuneiform
cartilage.• The epiglottis is a piece of elastic cartilages that falls over the opening
( GLOTTIS ) during swallowing to prevent ingested food from entering the respiratory tract.
• The corniculate cartilage are involve the opening and closing of the epiglottis, and in the production of sounds
• Two pairs of folds span the glottal opening. The ventricular folds (false vocal cords) are inelastic but the tension in the vocal cords can be adjusted by voluntary muscle movements.
• During expiration air flowing through the larynx vibrates the vocal cords (true vocal cords) and produces sound waves.
• Coughing and laryngeal spasms are protective reflex that protect the glottis and trachea from objects and irritants.
THE TRACHEA
• Extends from the level of the sixth cerebral vertebra, at the base of the larynx, to the level of the fifth thoracic vertebra.
• is a tubular structure with 4.25 inch length and 1 inch in diameter.• At its caudal limit the trachea divides to form primary bronchi.• Lies anterior to the esophagus.• Along the length of the trachea are 15-20 c-shapes in pieces of hyaline cartilage
(tracheal cartilages)• The tracheal muscle holds the two sides of the c-shaped c• Trachea is lined with pseudo stratified ciliated columnar epithelium. • The trachea branches within the mediastum, forming the left and right bronchi.
(Extra pulmonary bronchi) • Each bronchus enters a lung at groove, The Hilus. • Each bronchus branches into increasingly smaller passageway to conduct air into
the lungs. • The primary bronchi branch into as many secondary bronchi
(Intrapulmonary bronchi) • As there are lobes in each lung
• The smallest passageway is the bronchioles.
THE LUNGS
• is pair of cone shaped organs lining in the pleural cavity.• The apex is the conical top of each lung, and the broad inferior portion is the base.• Each lung has a hilus, a medical slits as the bronchial tubes, vascularization,
lymphatic, and nerves reach the lungs.• Each lining is divided into lobes by deep fissures.
• Right lungs have three lobes and left lungs have two lobes. • Left lung is divided by oblique fissure into superior and inferior lobes. • Right lung is divided into three lobes (superior, middle and inferior) • Superior and middle lobes are separated by a Horizontal fissure and • The Oblique fissure separates Inferior and Middle lobes. THE PLEURAL CAVITIES
• The thoracic cavity is bounded by the ribcage and the muscular diaphragm.• The mediastinum divides the region into TWO PLEURAL CAVITIES. • The pleural cavity is lined with a serous membrane, THE PLEURA.• Parietal pleura line the thoracic wall, diaphragm, and mediastinum.• Visceral pleura cover the surfaces of the lungs.
• The alveolar walls are made of simple squamous pulmonary epithelium. • Scattered among epithelium are surfactant cells that secretes oil coating to prevent the alveoli from sticking together after exhalation. • Also the alveolar walls are macrophages that phagocytes debris or potential pathogens. • Pulmonary capillaries cover the exterior of the alveoli.
DEMOGRAPHIC DATA
Name : Angelee FerrerAddress: : Antonino, Alicia, IsabelaGender : FemaleAge : 1 year oldDate of Birth : August 31, 2007Place of Birth : San Isidro, IsabelaReligion : Roman CatholicNationality: : FilipinoWeight : 7.8 kilos
Admission Data:
Chief Complaint : Body weakness associated with Fever & Cough for 2 daysDate of Admission : September 26, 2008Time of Admission : 02:10 pmMode of Arrival : Cuddled by her motherClinical Diagnosis : BronchopneumoniaAttending Physician : Dra. Mila Paguila
Latest Vital Signs
Temp : 380CPR : 130 bpmRR : 44 cpm
NURSING HISTORY
History of Present Illness
Two days prior to admission, the patient experienced on and off fever associated with cough and colds. She became weak because she cannot eat and sleep well at night. So her mother decided to rushed her to Lucas – Paguila Hospital for medical check up but the attending physician advised the mother for hospitalization of her child for close observation and proper treatment of her illness.
Past Medical History
When the patient is four (4) years olds, she was diagnosed of anemia and she was hospitalized then. As she is growing, she sometime experienced fever, cough and colds but manageable and treated with over the counter drugs and sometimes her mother used herbal medicine like lagundi for cough.
Family Medical History
The parents and other member of the family have no known illness. The patient completed her immunization given in the Barangay Health Center.
Daily Activity Pattern
Nutritional Pattern
Prior to admission, the patient daily diet are fish and meat sometimes she eats soup of a vegetable mixed with rice. She drinks a lot of water even after she drinks her milk.
During hospitalization, she cannot eat no solid food intake. She just drinks water and sometimes milk.
Personal Hygiene
Prior to admission, the patient takes a bath and brushes her once a day. And at night before she goes to bed her mother clean her with wet hand towel and change her clothes.
During confinement, the mother cleans her child of wet hand towel and changes her clothes.
Rest and Sleep Pattern
Prior to admission, the patient usually sleeps at around 8:00 pm and wakes up at 7:00 am. During daytime she also sleeps for 2 to 3 hours every afternoon.
During confinement, she sleeps more than her usual sleeping pattern.
Exercise Pattern
Prior to her admission, the patient spends most of her time in playing. During confinement the patient has no physical activity, she sleep most of the time.
Elimination Pattern
Prior to admission, the patient defecates once a day with no particular time. She voids 6 to 8 times a days.
When she was hospitalized, she defecates watery stool for 2 to 3 times. And changed 3 diapers full of urine.
Socio-Cultural Health
Cultural Health
The patient family observes typical Filipino cultural values.
Recreational Pattern
The patient loves to play with her cousins sometime she play alone while watching TV. And she is the joy of the family.
Environmental Pattern
They live a very simple and quite life. Her family lives in her grandfather house, two storey house made of concrete materials. The surrounding is safe and very quite to live in.
Economic Pattern
The patient father is a tricycle driver while the mother is a plain house wife who took care of the patient. According to the mother, income from tricycle is not enough that’s why the patient grandfather is supporting them financially.
Interaction Pattern
The patient is the joy of the family. She is very sweet to her grandparents. And friendly to other child of her age.
Cognitive Pattern
The patient can recognized object and person. She knows already to express what she likes and don’t likes. At her age now, she can recognize some color like red and yellow.
Coping Pattern
The presence of her father and her mother makes everything light for her. She feels safe, happy and smiles a lot when her parents are with her.
PHYSICAL ASSESSMENT
September 26, 2008
Temp: 38°CRR : 44 cpmPR : 130 bpm
General Appearance: The patient is 1 year old female child, weak with fever and cough cuddled by her mother.
BODY PART METHOD OF ASSESSMENT
FINDINGS INTERPRETATION
Skull InspectionPalpation
NormocephalicAbsence of masses
Normal Normal
Hair Inspection Curly hair NormalFace Inspection Smooth but pale
lookingDue to fever & colds
Eyes Inspection Pale conjunctiva Due to fever & weaknessNose Inspection (+) mucus secretion Due to coldsMouth Lips
Teeth & gums
Tongue
Inspection
Inspection
Inspection
Pale lips
White teeth
Moves freely, no tenderness
Due to fever & colds
Normal
Normal
Ears Inspection Color same as facial skin; symmetrical;
auricle aligned with outer canthus of eye,
about 10’ from ventricle
Normal
Skin Inspection Smooth NorrmalNeck
-Lymph nodes -Thyroid gland
Inspection
Palpation Palpation
Muscles equal size; head centered Not palpable
Lobes may not be palpated
Normal Normal
Normal Thorax Inspection Symmetrical Normal
Palpation
Percussion
Auscultation
Chest wall intact, no tendernessDullness
Coarse breath sound(Dry rales)
Normal
Decrease confluent & pleural effusion
Air passing through fluid or mucus in any air passage
BODY PART METHOD OF ASSESSMENT
FINDINGS INTERPRETATION
Abdomen Inspection
Auscultation
Percussion
Palpation
Flat abdominal contour
Audible bowel sounds
Tympany over the stomach and gas
filled bowelsNo tenderness
Normal
Normal
Normal
NormalUpper and Lower extremities Inspection
Palpation Symmetrical
(-) TendernessNormalNormal
DRUG STUDY
DRUG USES SIDE EFFECTS CONSIDERATIONS
Generic Name:Salbutamol
Brand name:Ventolin proventil
Classification:Sympathomimetic
Dosage: ½ tsp – tid
Prophylaxis and treatment of bronchospasm d/t reversible obstructive airway disease. Inhalation solution for acute bronchospasm attacks. Stimulates beta-II receptor of bronchi leading to broncho dilation
Headache, N&V, palpitations, Tachycardia, tremor, bronchospasm
When given by nebulization, use face mask or mouthpiece Monitor pulmonary status
DRUG USES SIDE EFFECTS CONSIDERATION
Generic Name:Hydrocortisone sodium succinate
Brand name;A-hydrocort solucortef
Prophylaxis and treatment of chronic bronchial asthma, perennial rhinitis, symptomatic sarcoidosis
AnorexiaN&VLethargyHeadacheFeverJoint painDesquamation
Assess for any allergic reaction Monitor v/s, I&O, and weight Avoid alcohol and caffeine
Dosage: 15 mg – IV q6
Classification:Corticosteroids
MyalgiaWeight lossHypotension
DRUG NAME USES SIDE EFFECTS CONSIDERATIONGeneric Name:Paracetamol
Brand Name:Tylenol, BiogesicTempra
Route: Oral, Rectal
Dosage: Q4h/Q6h
Available forms:Tablet and suppository
Analgesics and antipyretic commonly used for relief of fever, head aches and other minor pains and aches.
Rare side effects:
Hives; rash;Shortness of breath.
Prolonged & habitual use may lead to liver damage or failure.
Check the time and dosage before administering.
Assess for possible drug reactions.
DRUG NAME USES SIDE EFFECTS CONSIDERATIONGeneric Name:Cefuroxime
Brand Name:Zinacef, Ceftin
Route: IV
Dosage: 125 mg/q6
Classification:
For lower respiratory tract infection due to S. pneumoniae, UTI’s due to e. coli & skin and skin structure due to s. aureus
Most common:Diarrhea/loose stools, abdominal pain & N/V
Asses for possible S&S of drug reaction.
Asses for anemia & renal dysfunction.
Cephalosporin, Second Generation
DRUG NAME USES SIDE EFFECTS CONSIDERATIONGeneric Name:Ceftriaxone
Brand Name:Rocephin
Route: IV
Dosage: 250 mg
Classification:Cephalosporin, Third Generation
For lower respiratory tract infection due to S. pneumoniae, UTI’s due to e. coli & skin and skin structure due to s. aureus
Most common:Diarrhea, rash, nausea, pain, induration tenderness at injection site
Asses for possible S&S of drug reaction.
Asses for GI disease.
Monitor renal dysfunction.
DRUG NAME USES SIDE EFFECTS CONSIDERATIONGeneric Name:Ambroxol HCL
Brand Name:Bromussyl, Ambolyt
Route: IV
Dosage & StrenthSyrup 30mg/5 ml
A mucolytic agent used in the treatment of respiratory disorders associated with viscid or excessive mucus. It is the active ingredient of link Mucosolvan or link Mucoangin.
GI side effects like epigastric pain, gastric fullness may also occur. Rare allergic responses such as eruption, urticaria & angioneurotic edema may also occur.
Asses for possible S&S of drug reaction.
Asses for GI disease.
Monitor renal dysfunction.
LABORATORY TEST
Radiology Result
Findings: Chest Ap and Lat
Chief Complain: Cough
Examination reveals hazy infiltrates at the lower lung.Haziness with nodular densities is seen in both para – tracheal and perihilar spaces.Heart and great vessels are within normal size and configuration.Bony thorax is intact.Both sinuses and diaphragms are normal.Other chest structures are not remarkable.
Impression:
1) Pneumonia, right lower lung2) Primary Koch’s infection
Complete Blood Count
Result Normal ValuesWBC - 2.4 x 10³/UL Hct % Male 40 – 54RBC 3.32 x 10/UL Female 37 – 47HGB - 9.0 g/dl Platelet (10³/L) 140 – 440HCT - 24.4 % Wbc (x10/L) 4.3 – 10.00MCV - 73.5 fL Gran % 44.2 – 80.2MCH 36.9 g/dl (x10/L) 2.0 – 8.8PLT 1.64 x 10³/UL Lymph (10/L) 28 – 48LYM % + 62.10 % Mono (10/L) 1.2 – 5.3MXD 8.6 % Hgb 9/dl Male 14 – 18Neut % -29.3 % Female 12 – 16Lym # 1.5 x 10³/UL
Neut # .7 x10³/ULRDW – 5D -34.5 fLRDW - cl 12.6 %
COURSE IN THE WARD
Doctor’s Order Interpretation
9/26/08
9/28/08
9/29/08
9/30/08
Please admit patientTPR shiftFor CBC/Chest X ray
D5 .3NaCl 500 cc @ 30 mgtts/minCefuroxime 125 mg IV q6 to (-) ANSTAmbroxol drug – 2 ml tidSalbutamol Syrup ½ tsp tid
Paracetamol drops – 1 ml q4 if 38°c and above
Aerosol q4Refer for possible s/s.
Discontinue CefuroximeCefriaxasone 250 IV q 8Hydrocortisone 15 mg IV q8Furosemide 5 mg IV statD5 IMB – 500 cc to follow
Continue medicineD5 .3NaCl 500cc to follow
MGHZinnat 125mg bidContinue other medsCeferinas ½ od
To determine the cause of fever & cough
Initial antibiotic
To relieve coughTo relieve cough & secretionTo relieve fever
To liquefy secretion
Medicine to be taken at home
Appetite Plus – 1 tsp od
DISCHARGE PLANNING
1. Instruct SO to continue and complete all the medicines at home.
2. Advise SO to increase the activities gradually.
3. Encourage SO of breathing exercises to promote lung expansion and clearing.
4. The SO must understand the purpose of her medication when and how to take those.
5. Instruct SO to increase fluid intake of the patient.
6. Teach SO the principles of adequate nutrition and rest.
7. Recommend SO of influenza vaccine.
UNIVERSITY OF LA SALETTENURSING DEPARTMENT
Related Learning ExperienceLucas – Paguila Hospital
Alicia, Isabela
BRONCHOPNEUMONIACase Study
Submitted By:
LENY DE VERA RENOLOBSN – 3HGroup A
Submitted to:
MS. VERAMAY CANDOClinical Instructor
PATHOPHYSIOLOGY
Etiologic Agent: Predisposing Factors: Bacteria * Elderly Virus * Hospitalization
* Immobilization * Immune Deficiency * Long Term Illness * Smoking
Microorganism enter alveolarSpaces by droplet inhalation
↓Inflammation occurs
↓Alveolar fluid increase
↓Ventilation decreases as secretion thicken
↓Bronchopneumonia
Empyema Pleurisy(collection of pus & liquid (Inflammation of membrane) From infected tissue)
Lung Abscess(collection of pus, inflammation
& destruction of tissue)
↓Cancer of the lung
↓Death
Pathophysiology:
Inoculation of the respiratory tract by infectious organisms leads to an acute inflammatory response in the host that is typically 1-2 weeks in duration. This inflammatory response differs according to the type of infectious agent present.
Viral Infection These are characterized by the accumulation of mononuclear cells in the submucosa and perivascular space, resulting in partial obstruction of the airway. They clinically manifest as wheezing and crackles.
Disease progresses when the alveolar type II cells lose their structural integrity and surfactant production is diminished, a hyaline membrane forms, and pulmonary edema develops.
Bacterial Infection
The alveoli fill with proteinaceous fluid, which triggers a brisk influx of red blood cells and polymorphonuclear cells (red hepatization) followed by the deposition of fibrin and the degradation of inflammatory cells (gray hepatization).
During resolution, intra - alveolar debris is ingested and removed by the alveolar macrophages. This consolidation leads to decreased air entry and dullness to percussion. Inflammation in the small airways leads to crackles. Wheezing is less common than in viral infections.
Inflammation and pulmonary edema resulting from these infections causes the lungs to become stiff and less distensible, thereby decreasing tidal volume. The patient must increase his respiratory rate to maintain adequate ventilation.