Download - Bronchi Pneumonia
Bronchitis is a respiratory disease in which the mucous membrane in the lungs' bronchial passages becomes inflamed
Table of Contents
Page Number
I. Introduction 3-4
A. Scope and Limitations
5
B. Objective of the Study
6
II. Patients Profile
7III. Growth and Development
8IV. Health History and Present Illness
9V. Medical Orders
10-12VI. Laboratory Examinations
13VII. Drug Study
14-19VIII. Anatomy and Physiology
20-21IX. Pathophysiology
22X. Health Assessment
23-26XI. Actual Nursing Management
27-29
XII. Discharge planning and referral
30XIII. Evaluation and Implications
31XIV. Bibliography
32
I. INTRODUCTION
Bronchopneumonia which is also known as lobular pneumonia is one of two types of bacterial pneumonia as classified by gross anatomic distribution of consolidation (solidification). In bacterial pneumonia, invasion of the lung parenchyma by bacteria produces an inflammatory immune response. This response leads to a filling of the alveolar sacs with exudates. The loss of air space and its replacement with fluid is called consolidation. In bronchopneumonia, or lobular pneumonia, there are multiple foci of isolated, acute consolidation, affecting one or more pulmonary lobes.
It should be noted that although these two patterns of pneumonia, lobar and lobular, are the classic anatomic categories of bacterial pneumonia, in clinical practice the types are difficult to apply, as the patterns usually overlap. Bronchopneumonia (lobular) often leads to lobar pneumonia as the infection progresses. The same organism may cause one type of pneumonia in one patient, and another in a different patient. From the clinical standpoint, far more important than distinguishing the anatomical subtype of pneumonia, is identifying its causative agent and accurately assessing the extent of the disease.
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.
A. Scope and Limitation
This case presentation involves a patient named Roldan, Princess Jelou B, diagnosed with Bronchopneumonia as supplied by Dr. ApareceThe scope and limitation of this case study are as follows:
Patients history and background
Overview of the disease
Predisposing and precipitating factors of the aforementioned disease
Pathophysiology of Bronchopneumonia as the resulting diagnosis.
Nursing and Medical management administered during the confinement period
Discharge plan, referrals and recommendations pertinent to the disease condition
Assessment of the client from September 17 to September 20 of year 2008, within hospital premise.
B. Objectives of the Study
This study is conducted by the student of Team 5, NCM501205 Cluster 2 for the following purposes: Trace the disease process of the patient
Identify the health care services needed particular to patients condition
Recognize the significance of the ordered diagnostic tests in relation to the patients disease condition
Formulate and implement an effective nursing care plan especially designed for the patients problems as identified in the nursing assessment.
Inculcate health teachings and importance of following medication regimen to the patient
Explain and elaborate to patients significant others the need for encouragement and support to the patient in the latters pursuit of a better health
II. PATIENTS PROFILE
Name: Roldan, Princess Jelou B.Address: P-5 Kalid, Kibalabag Malaybalay City, BukidnonSex: FemaleStatus: ChildBirthday: January 3, 2008Place of Birth: Kalid, kibalabag Malaybalay City BukidnonAge: 8 months old
Nationality: Filipino
Religion: Baptist
Father: Querwin RoldanMother: Nylle RoldanRank in the Family: EldestNumber of siblings: 1Date of Admission: September 11, 2008Time of admission: 1:30 pm
Place of admission: Bukidnon Provincial Hospital-Malaybalay Diagnosis: Bronchopneumonia, severe community acquiredAttending Physician: Dr. Araceli ApareceIII. GROWTH AND DEVEOPMENT
One of the greatest events in life after marriage is to have a child. This was what Mr. And Mrs. Querwin Roldan had hoped and prayed for. Their prayers were answered and on January 3, 2008, Mrs. Roldan gave birth to a healthy baby girl. They named her Princess Jelou. The patient is now in 8 months old and according to Sigmund Freud Psychoanalytic Theory, he is now in the oral stage of development in which infants during this age are interested in oral stimulation or pleasure. The infant in this age, suck for enjoyment or for relief of tension as well as nourishment. The child mainly explores the world by using mouth especially the tongue. And because of this, since the port of entry of bacteria is in the mouth, the patient was able to ingest the bacterium that was held from his hand that might be contaminated and placed on his mouth. As a result it precipitated the cause and the development of the disease.IV. HEALTH HISTORY AND PRESENT ILLNESS
Health History
This is a case of a 8 months old, female, Filipino, Baptist, from Purok 5, kalid, Kibalabag, Malaybalay City, Bukidnon, who was admitted for the first time at the Bukidnon Provincial Hospital-Pedia Ward due to complaints of cough and difficulty of breathing. The informant was the mother with 90% reliability.History of Present Illness
A diagnosed case of Bronchopneumonia-severe community acquired. Four days prior to admission, the patient was experiencing cough for a long duration followed by difficulty of breathing. Because of this, her parents were alarmed of his condition and afraid of what bad will happen to her, they decided to take Princess to the hospital for admission dated September 11, 2008 at 1:30 in the afternoon.Family History
There were no known critical diseases in the family. According to the mother, her husband was having some cough. Though her husband wasnt diagnose with what type of disease it was, she thinks that it was the cause that her children was infected with the disease. Personal Health History
According to Mrs. Roldan, her child was having quite for quite a longer time,. She said that she thinks that her children got her cough from their father who had a cough. They were able to have a check-up in their health center and instructed to take herbal medications such as kalabo and gabon.V- Medical Orders
September 11, 2008
Pls. Admit to pedia ward
For immediate intervention
TPR q 4 hours
To identify Pt. conditions
NPO temporarily except meds
To avoid aspiration
CBC, platelet count, U/A, S/E
To identify any deviation
Start IVF D5 0.3% NaCl 500 cc @ 20 gtts/min
For fluid and electrolytes replacements
Pen G 350,000 U IVTT q 6 hours
To prevent infections
PCM drops.8 ml q 4 hours for fever
To decrease body temp.
O2 inhalation 1L/min
Provide O2 consumption
Refer for any unusualities
For immediate intervention
May use ampicillin 300 mg IVTT q 6 hours instead of pen G
Prevent infection, prophylaxis
May resumed feeding if not dyspneic anymore
Providing nutrient
September 12, 2008
Continue meds
For compliance and easy healing
IVTF with D5IMB 500 cc @ SR
Providing adequate F & E consumption
Gentamycin 20 mg IVTT q 12 hours now
prophylaxis
For referral to Dr. Aguirre
For another intervention and consultation
September 13, 2008
Continue meds.
For compliance
Start erythromycin 250 mg/5ml 2.5 ml 3 x a day p.o
Preventing infection in the respiratory tract
Hold feeding once Pt. dyspneic
To prevent aspiration
IVTF D5IMB 500 cc @ 35 gtts/min
For rehydration and adequate consumption
September 14, 2008
Continue meds For compliance and easy healing
IVTF D5IMB 500 cc @ SR Hydration status
September 15, 2008
Start gentamycin 20 mg slow IVTT q 12 hours For prophylaxis Nebulize salbutamol neb q 6 hours To liquefy secretion
IVTF D5IMB 500 cc @ SR To provide adequate F&E replacement
Continue meds For complianceSeptember 16, 2008
Continue meds For compliance
IVTF D5IMB 500 cc @ SR For rehydrationSeptember 17, 2008
Continue meds For complianceSeptember 18, 2008
Home per request-signed by mother For legal purposes Home meds-erytromycin 2.5 ml TID x 7 days Preventing infectionsSeptember 19, 2008
Continue meds For compliance
IVTF D5IMB 500 cc @ SR For rehydrationSeptember 20, 2008
Continue meds For compliance
VI-LABORATORY EXAMINATION
TESTRESULTSNORMAL RANGEIMPLICATION
CBC --(2/1/08) WBC
HGB
HCT
Platelet
Segmenters
lymphocytes
14.7
9.3
27.0
469,000
50
50
5.0-10.0/L
13.7-16.7 g/dl
40.5-49.7 vols %
144,000-372,000
43.4-76.2 %
17.4-46.2 %Infection
Anemia
Anemia
Iron deficiency anemia
Normal
Anemia
VII. DRUG STUDYName of Drug Generic (Brand)Date OrderedClassificationDose/ Frequency/ RouteMechanism of ActionIndication (why drug is ordered)ContraindicationSide EffectNursing Precaution
Ampicillin
Feb. 1, 2008Anti-infective Antibiotic 300 mg IVTT q 6 hoursInhibit cell wall synthesis during bacterial multiplication>For respiratory tract infection
>For GI infection
Contraindicated to hypertensive drugs or other penicillin.
Use cautiously with other drug allergy.CNS: lethargy, seizures, dizziness,
GI: Nausea, vomiting, diarrhea
SKIN: Pain at IV site
Other: hypersensitivity reactions, over growth of nonsusceptible organism
Check about allergy of penicillin.
Give drug 1-2 hours before or 2-3 after meal.
Monitor sodium level.
Notify if rash, fever, chill develop
Name of Drug Generic (Brand)Date OrderedClassificationDose/ Frequency/ RouteMechanism of ActionIndication (why drug is ordered)Contra-indicationSide EffectNursing Precaution
Gentamicin sulfateFeb. 2, 2008Anti-infective Antibiotic 20 mg IVTT q 12 hoursInhibit protein synthesis by binding directly to the ribosomal subunit;bactericidal.Serious infection caused by sentsitive strains of Pseudomonas aerruginosa, E. Coli, Proteus.
Contraindicatd to hypertensive drugs or other aminoglycoside
Use cautiously in neonate, infant,elderly ang impared renal function.CNS: fever, headache, dizziness, seizure, nunbness
EENT: blurred vision, tinnitus
GI: Nausea, vomiting,
SKIN: Pain at IV site, rash
Other: anaphylaxis,
Evaluate hearing before giving therapy.
Monitor renal function
Watch for s/sx of fever, chill, increase HR
Name of Drug Generic (Brand)Date OrderedClassificationDose/ Frequency/ RouteMechanism of ActionIndication (why drug is ordered)Contra-indicationSide EffectNursing Precaution
Pen GFeb. 1, 2008Anti-infective 350,000 mg IVTT q 6Prevent bacterialcell wall synthesis during replication.
Increase amoxicillin effectiveness by inactivating betalactamases Lower respiratory tract infection cause by strain of gram positive and gram negative organism.
To prevent pneumonia.Contraindicated to hypertensive drugs or other penicillin.
Use cautiously with other drug allergy, especially to cephalosporins, because of possible cross sensitivity.CNS: neurophathy, seizures, dizziness, fatigue
GI: Nausea, vomiting, enterocolitis
Other: hypersensitivity reactions, anaphylaxis, pain
Monitor Pt. hepatic function.
Shake well before injecting
Monitor renal function closely.
Name of Drug Generic (Brand)Date OrderedClassificationDose/ Frequency/ RouteMechanism of ActionIndication (why drug is ordered)Contra-indicationSide EffectNursing Precaution
ParacetamolFeb. 1, 2008Non-opioid analgesics and antipyreticsDrops 0.8 ml q 4 hours Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandins in the CNS or other substances that sensitize pain receptors to stimulation. The drug may relieve fever through the central action in the hypothalamic heat-regulating center.Use to relieve mild to moderate pain
It is also used to bring down a high temperature.Contraindicated to patients hypersensitive to drug.Hemolytic anemia, neutropenia, leulopenia, jaundice, rash, urticaria and hypoglycemia
Use liquid form for children.
For child, dont exceed 5 doses in 24 hours.
Be aware in calculating daily dose
Name of Drug Generic (Brand)Date OrderedClassificationDose/ Frequency/ RouteMechanism of ActionIndication (why drug is ordered)Contra-indicationSide EffectNursing Precaution
SalbutamolFeb. 2, 2008Bronchodilator neb q 6 hoursBronchodilator.
Salbutamol is a -adrenergic stimulant which has a highly selective action on the receptors in bronchial muscle and in therapeutic doses; it has little or no action on the cardiac receptors.To prevent or treat bronchospasm in Pt. with reversible obstructive airway disease.
Treatment of acute severe asthma and in routine management of chronic bronchospasm
Contraindicated to hypertensive drugs or its ingredients.
Use cautiously with CV disorder, hyperthyroidism, or DM.CNS: tremor, nervousness, dizziness, weakness, headache
CV: tachycardia, palpitation, hypertension
EENT: Dry and irritated nose and throat, nasal congestion, hoarseness
GI: heartburn, Nausea, vomiting, anorexia
Other: hypersensitivity reactions, Monitor patient routinely
Take frequent vital signs to note side effects.
Great care is needed in patients with cardiovascular disease eg, ischemic heart disease, arrhythmia or tachycardia, hypertension
Name of Drug Generic (Brand)Date OrderedClassificationDose/ Frequency/ RouteMechanism of ActionIndication (why drug is ordered)Contra-indicationSide EffectNursing Precaution
ErythromycinFeb. 3, 2008Macrolide Anti Infective250 mg/5ml 2.5 ml TID P.OInhibits bacterial protein synthesis by binding to the 50S subunit of the ribosome. Bacteristatic or bactericidal, depending on concentrationMild to moderate skin and soft tissue infectionContraindicated in pregnant patients and those hypertensive to drug or other macrolides.CNS: fever
CV: vein, irritation
EENT: hearing loss, blurred vision
GI: abdominal pain and cramping, nausea & vomiting
SKIN: urticaria, rash and eczema, dermatitis
Obtain urine specimen for sulture and sensitivity tests before giving first dose and instruct patient to report adverse reactions especially nausea, abdominal pain, vomiting and fever.
VIII. ANATOMY & PATHOPHYSIOLOGY
The lungs are located in the chest on either side of the heart. They are surrounded and protected by the ribcage. The left lung is a little smaller than the right lung because it shares space in the left side of the chest with the heart. Each lung is divided into sections (lobes). The right lung has three sections or lobes, including the: (1) Right upper lobe, which takes up the top third of the right lung; (2) Right middle lobe, which is the smallest of the three lobes and shaped like a triangle; (3) Right lower lobe, which is the largest of the three.The major fissure separates the right lower lobe from the right middle and upper lobes. The left lung is shaped slightly differently than the right. It has only two lobes - the left upper lobe and the left lower lobe. Our lungs are the main organs of the respiratory system. The lungs are located inside the upper part of our chest on either side of the heart, and they are protected by the ribcage. The breastbone (sternum) is at the center front of the chest, and the spine is at the center of the back of the chest. The inside of the chest cavity and the outside of the lungs are covered by the pleura, a slippery membrane that allows the lungs to move smoothly as they fill up with and empty out air when we inhale and exhale. Normally, there is a small amount of lubricating fluid between the two layers of the pleura. This helps the lungs glide inside the chest as they change size and shape during breathing. With each breath, our lungs are filled with air that comes into our body through the nose or mouth. It flows down the throat (pharynx) and through the voice box (larynx). A small flap of tissue (epiglottis) covers the entrance to the larynx, and it automatically closes when we swallow to prevent food or liquids from getting into our airways. Our largest airway is the windpipe (trachea), which is between three-and-a-half and six inches long and a little over half an inch in diameter. It brings air to the chest, where it branches into two smaller airways: the left and right bronchi, which lead to the left and right lungs. The bronchi themselves divide many times into smaller and smaller airways (bronchioles). Because the pattern of these increasingly smaller passages looks like an upside-down tree, this part of the system is sometimes called the bronchial tree. The airways are held open by flexible, fibrous connective tissue called cartilage. Circular airway muscles can make the airways wider or narrower. The smallest bronchiole is only half a millimeter across. At the end of each bronchiole are clusters of air sacs called alveoli. Each air sac is surrounded by a dense network of tiny blood vessels (capillaries). The extremely thin barrier between the air and the blood allows the blood to pick up oxygen and release carbon dioxide into the alveoli. IX. PATHOPHYSIOLOGYBronchoneumonia refers toa type of pneumonia that is localized, often to the bronchioles and surrounding alveoli.
Predisposing Factors
Precipitating Factors
Age
Presence of MVGender
Immunosuppresed condition
Target Organ: Lungs
Patients pulmonary defense is weak related to
clinical condition
Bacteria enters the lungs and replication occurs
and triggers pulmonary Inflammation
Immune system tries to response to presence of bacteria,
Stimulating Hypothalamus for thermal regulation
while immune system releases antibodies
Antibodies (macrophages) combat the bacteria present
In the lungs
Exudates gradually accumulate into the lungs
resulted from death of bacteria and macrophages
Irritation of the mucous membrane causing inflammation
Of the bronchial walls
Exudate fluid fills in the alveolar air spaces and
invade alveolar septa
Poor oxygen exchange within the lungs causing
Lung parenchymal dysfunction.
Multi-organs Involved
Heart, Brain, GIT
Complication
Acute Respiratory FailureX. NURSING SYSTEM REVIEW CHART
Name: Roldan, Princess Jelou Date: September 17, 2008Vital Signs:
Pulse:145bpm BP: not assessed Resp: 38 cpm Temp: 36.7C Height: not assessed Weight:not assessed
EENT:
[] impaired vision [] blind
[] pain [] reddened [] drainage
[] gums [] hard of hearing [] deaf
[] burning [] edema [] lesion [] teeth
Assess eyes, ears, nose
throat for abnormality [x] no problem
RESP.
[] asymmetric [x] tachypnea
[] apnea [] rales [x] cough [] barrel chest
[] bradypnea [] shallow [] rhonchi
[x] Sputum [] diminished [] dyspnea
[] orthopnea [] labored [] wheezing
[] pain [] cyanotic
Assess resp. rate, rhythm, depth, pattern,
breath sounds, comfort [] no problem
CARDIO VASCULAR
[] arrhythmia [] tachycardia [] numbness
[] diminishes pulses [] edema [x ]fatigue
[] irregular [] bradycardia [] murmur
[] tingling [] absent pulses [] pain
Assess heart sounds, rate, rhythm, pulse, blood
Pressure, circulation, fluid retention, comfort
[] no problem
GASTRO INTESTINAL TRACT
[] obese [] distention [] mass
[] constipation [] rigidly [] pain
Assess abdomen, bowel habits, swallowing,
Bowel sounds, comfort [] no problem
GENITO-URINARY
[] pain [] urine color [] vaginal bleeding
[] hematuria [] discharge [] nocturia
Assess urine freq., control color, odor, comfort,
GYN bleeding, discharge [x] no problem
NEURO
[] paralysis [] stuporous [] unsteady [] seizures
[] lethargic [] comatose [x] vertigo [] tremors
[] confused [] vision [] grip
Assess motor function, sensation, LOC, strength,
Grip, gait, coordination, orientation, speech
[] no problem
MUSCULOSKELITAL and SKIN
[] appliance [] stiffness [] itching [] petechiae
[] hot [] drainage [] prosthesis [] swelling
[] lesion [] poor turgor [] cool [] deformity
[] wound [] rash [] skin color [] flushed
[] atrophy [] pain [] ecchymosis
[] diaphoretic [] moist
NURSING SYSTEM REVIEW CHART
Name: Roldan, Princess Jelou Date: September 18, 2008Vital Signs:
Pulse:145bpm BP: not assessed Resp: 38 cpm Temp: 36.7C Height: not assessed Weight:not assessed
EENT:
[] impaired vision [] blind
[] pain [] reddened [] drainage
[] gums [] hard of hearing [] deaf
[] burning [] edema [] lesion [] teeth
Assess eyes, ears, nose
throat for abnormality [x] no problem
RESP.
[] asymmetric [x] tachypnea
[] apnea [] rales [x] cough [] barrel chest
[] bradypnea [] shallow [] rhonchi
[x] Sputum [] diminished [] dyspnea
[] orthopnea [] labored [] wheezing
[] pain [] cyanotic
Assess resp. rate, rhythm, depth, pattern,
breath sounds, comfort [] no problem
CARDIO VASCULAR
[] arrhythmia [] tachycardia [] numbness
[] diminishes pulses [] edema [x ]fatigue
[] irregular [] bradycardia [] murmur
[] tingling [] absent pulses [] pain
Assess heart sounds, rate, rhythm, pulse, blood
Pressure, circulation, fluid retention, comfort
[] no problem
GASTRO INTESTINAL TRACT
[] obese [] distention [] mass
[] constipation [] rigidly [] pain
Assess abdomen, bowel habits, swallowing,
Bowel sounds, comfort [] no problem
GENITO-URINARY
[] pain [] urine color [] vaginal bleeding
[] hematuria [] discharge [] nocturia
Assess urine freq., control color, odor, comfort,
GYN bleeding, discharge [x] no problem
NEURO
[] paralysis [] stuporous [] unsteady [] seizures
[] lethargic [] comatose [x] vertigo [] tremors
[] confused [] vision [] grip
Assess motor function, sensation, LOC, strength,
Grip, gait, coordination, orientation, speech
[] no problem
MUSCULOSKELITAL and SKIN
[] appliance [] stiffness [] itching [] petechiae
[] hot [] drainage [] prosthesis [] swelling
[] lesion [] poor turgor [] cool [] deformity
[] wound [] rash [] skin color [] flushed
[] atrophy [] pain [] ecchymosis
[] diaphoretic [] moist
Nursing Assessment II
Subjective Objective
COMMUNICATION:
[] Hearing Loss Comments: Makadungog
[] Visual Changes ug motan-aw man sya kung [x] Denied tawagon iya pangalan, as
verbalized by the patients mother
[] Glasses [] Languages
[] Contact Lens [] Hearing Aide
R L
Pupil Size: 2mm [] Speech Dificulties
Reaction: Both Pupils are equally round and are reactive to light accommodation.
OXYGENATION:
[x] Dyspnea Comments:Ga lisod siya[]Smoking og ginhawa usahay ,asHistory: verbalized by the mother.None
[x] Cough
[x] Sputum
[] DeniedResp. [x] Regular [] Irregular
Describe: equal lung expansionR: Crackles present
L: Crackles present
CIRCULATION:
[] Chest Pain Comments: dli paman ni sya
[] Leg Pain kstorya kung sakit,as As verbalized by the patients[] Numbness of mother Extremitries
[x] Denied
Heart Rhythm [] Regular [x] Irregular
Ankle Edema: None
Pulse: Car. Rad. DP Fem*
R: + + + NOT ASSESSED
L: + + + NOT ASSESSED
Comments: All pulses are present and palpable.
* If applicable
NUTRITION:
Diet : breastfeeding per demand[] N [] V Comments: kusog man xa[] Recent Change mo dede as verbalized by
Weight, Appetite the patients mother
[] Swallowing Difficulty
[x] Denied [] Dentures [x] None
Full Partial With PatientUpper [] [] []
Lower [] [] []
ELIMINATION:
Usual Bowel Pattern [] Urinary Frequency
2 x / day 4-5x/day
[] Constipation Remedy [] Urgency
None [] Dysuria
Date of Last BM [] Hematuria
Sept 17, 2008 [] Incontinence
[] Diarrhea Character [] Polyuria
N/A [] Foley in Place
[x] DeniedComments: Bowel sounds Bowel Sounds: Upon auscultation was Normal
normal, Abdominaldistention
Present [] Yes [x] No
*Urine(Color, Consistency, Odor)
N/A
MGT. OF HEALTH & ILLNESS:
[] Alcohol [x] Denied
(amount, frequency)
[] SBE Last Pap Smear: N/A
LMP: N/A
Briefly describe the patients ability to follow treatment (diet, meds, etc.) for chronic health problems (if present)
The patient who is diagnose with bronchopneumonia wasnt able to follow the prescribed treatment ordered for him due to lack of financial resources.
SKIN INTEGRITY:
[x] Dry Comments: uga kau iyang panit, as verbalized
[] Itching by the pts. mother[] Other
[] Denied
[x] Dry [] Cold [x] Pale
[] Flushed [] Warm
[] Moist [] Cyanotic
Rashes, Ulcers, Decubitus (describe size, location and drainage). The patient does not have rashes, ulcers, or decubitus present.
ACTIVITY/SAFETY
[] Convulsion Comments: dli paman xa[] Dizziness makalakaw-lakaw, as[] Limited Motion
of Joints verbalized by the pts mother.
Limitation in
ability to
[x] Ambulate
[x] Bathe self
[] Other
[] Denied[x] LOC and orientation: The patient is conscious and responsiveGait: [] Walker [] Cane [] Other
[] Steady [] Unsteady
[x] Sensory and motor losses in the face or extremities: None[x] ROM Limitations: None
COMFORT/SLEEP/AWAKE:
[] Pain Comments: cge xa mata mata
(Location, pagkatulog sa gabie,as verba- Frequency, lized by the pts. mother Remedies)
[] Nocturia
[x] Sleep Difficulties
[] Denied[] Facial Grimaces
[] Guarding
[] Other signs of pain: no signs of pain[] Siderail release form signed (60+years)
N/A
COPING:
Occupation: childMembers of household: 3 including the patientMost supportive person: Mother.Observed non-verbal behavior: The patient seems to not mind our presence. Readily and honestly questions given to him.
The person and his phone number that can be reached anytime: Not disclosed by the patient.
XI. NURSING CARE PLAN
CUESNURSING DIAGNOSISOBJECTIVENURSING INTERVENTIONRATIONALEEVALUATION
Subjective:
naa lang ghapon iyang ubo as verbalized by the patients mother
Objective:
>productive cough
>crackles upon auscultation
Ineffective airway clearance related to increased mucus production, fatigue, and coughAt the end of 30 min. to an hour of nursing interventions, the patient will be able to effectively clear secretions.1. Position patient in high-Fowlers or semi-Fowlers position.
2. Turn patient every 2 hours and prn.
3. Perform chest percussion and postural drainage as warranted.
4. encouraged increase in fluid intake
5. Administer bronchodilators as ordered.
1. Promotes maximal lung expansion.
2. Reposition promotes drainage of pulmonary secretions and enhances ventilation to decrease potential atelectasis.
3. Mobilizes secretions and facilitates ventilation of all lung field
4. to help loosen up secretions
5. Promotes relaxation of bronchial smooth muscle to decrease spasm, dilates airways to improve ventilation, and maximizes air exchange.
At the end of our nursing interventions the patient was able to maintain patent airway
NURSING CARE PLAN
CUESNURSING DIAGNOSISOBJECTIVENURSING INTERVENTIONRATIONALEEVALUATION
Subjective:
wla na gyud mi kwarta na ikapalit, dli nami gapautangon dnha sa pharmacy as verbalized by the patients mother.
Objectives:
> feelings of tiredness and hopelessness
> depress mood
Ineffective therapeutic management related to lack of financial supportAt the end of 30 minutes of nursing intervention, the patients mother will be encouraged to seek help to other health agencies in order to secure medications.1. Encouraged expression of feelings
2. Provided a therapeutic communication.
3. Discussed the importance of medication compliance
4. Provided alternative ways to gain free medical services.
1. To know what the mother feels towards the situation.
2. To establish trust and rapport.
3. To value the importance of taking the medications.
4. To encourage them to secure medications in other waysAt the end of our nursing intervention, our objective wasnt met because the mother refuse to ask for help to health care agencies.
NURSING CARE PLAN
CUESNURSING DIAGNOSISOBJECTIVENURSING INTERVENTIONSRATIONALEEVALUATION
Subjective:
wala pa man na nko sya gpunasan as verbalized by the patients mother.
Objectives:
foul smell
dirty clothings
wet underwearSelf care deficit related to inability to bathe oneselfAt the end of 30 minutes of nursing intervention, the patients mother will be able to bathe and change her childs clothing1. Wiped the client with wash cloth soaked in soap and water.
2. Changed the patients clothing to a cleaner one.
3. Encouraged the patients mother to changed the soiled linens.
4. Instructed the mother to wash the client everytime that he wets he solied his underwear.1. To promote cleanliness to the client as well as to the mother
2. To promote sense of well being.
3. To promote wellness and cleanliness.
4. To promote wellness and cleanlinessAt the end of 30 minutes, the patients mother was able to follow instructions in maintaining and promoting cleanliness and wellness to the patient.
XII. DISCHARGE PLANNING AND REFERRAL
A. MEDICATIONInstructed the patients mother to take home medications religiously and to report any signs of adverse reactions: erythromycin 2.5 ml three times a day for 7 days
B. EXERCISESEncouraged the patients mother to perform on her child passive range of motion exercises and to perform chest physiotherapy in order to help loosen secretions and promote lung expansion.
C. TREATMENTEncouraged the patients mother to provide adequate rest periods to the client and to observe and promote proper personal hygiene
D. OUTPATIENTEncouraged the patients mother to return to the hospital a week after discharge for a follow-up check-up from Monday to Friday, from 8:00am to 5:00pm for a follow-up check-up.
E. DIETEncouraged the patients mother to provide nutritious foods such as fruits and vegetables and to increase oral intake of fluids.
XIII. EVALUATION AND IMPLICATION
After two days of Hospital visit at the Bukidnon Provincial Hospital Malaybala- Pedia Ward, I was able to achieve the goal in rendering our hospital visit and the bedside care to our patient. I was able to do our nursing interventions as part of our nursing care plan. I can say that the prognosis is good since the disease has been diagnosed and prompted early treatment, but inspite of that there is a problem with the medication compliance because of lack of financial resources. Adequate diet and supplements was encouraged to suffice the daily requirement of the patient.
During the interview and assessment I was able to established trust and rapport with each other and implemented our nursing care as planned. The importance of follow-up check-up examinations and treatment was stressed to the family because of the complications that will brought about of the disease.XIV. BIBLIOGRAPHY
http://en.wikipedia.org/wiki/BronchopneumoniaMedical-Surgical Nursing, 10th Edition by. Smeltzer
S/Sx
Sore throat
Intermittent cough
Fever
Chilling
S/Sx
Productive Cough
Fever
Labored Breathing
Sleep disturbance
Fatigue
Depresses fontanels
D5IMB 500cc @ 35 gtts/min
Productive cough
Crackles upon auscultation
Dry skin
Sleep disturbance
Fatigue
Depressesed fontanels
D5IMB 500cc @ 35 gtts/min
Productive cough
Crackles upon auscultation
Dry skin
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