Central Luzon Doctors’ Hospital Educational Institution San Pablo, Tarlac City
In partial fulfillment of the requirements in NCM 102(RLECommunity health Nursing)
A case Study on:
Submitted to: Ma’am Raelyn Benavides RN,MSN Clinical Instructor Submitted by: Baluyot, Janella Baybin, Flori An Corpuz, Tina Jayme, Leh, Luisa Tsina G. Manzano, Ezra D. Rafael, Diana Joy Silverio, Everlasting
INTRODUCTION: Our patient baby K is an eleven month baby who lives at San Pablo, Tarlac City. Baby K was bought to the center together with her parents who complains at cough, colds, and fever for 1 week. She was diagnosed with bronchopneumonia. Bronchopneumonia is an acute inflammation of the smaller bronchial tubes with regular with irregular areas of considilation due to spread of the inflammation into peribronchial cuveoli and the alveoli or dust of the lungs. It is type of pneumonia characterized by an inflammation of the lung generally associated with and following amount with bronchitis. Our group choose this case to acquire knowledge about bronchopneumonia, we would use this knowledge to promote awareness about this sickness, most especially to the people in the community who has a little knowledge about this sickness.
OBJECTIVES: State the present health history of the client. To determine the cephalocaudal assessment obtained from the client. Trace the pathophysiology of the client’s disease Discuss the nature of the nature of the drugs given to the client. Provide the family with therapeutic interventions Outline recommendations based on the case study finding.
Nursing Health History B a. General Description of Client Baby K is 66 cm in height. She appeared to be drowsy in appearance. When she went to the center to consult she was suffering from difficulty of breathing, cough, colds and fever. She was diagnosed with Bronchopneumonia, in additional to that baby K also looked weak. b. Health Perception-Health Management Patterns Baby K’s mother stated that she already had her fever for almost a week. The mother administered tempra to cure her fever. c. Nutritional-Metabolic Pattern The patient is still breast feeding. But due to her sickness baby K lost her appetite. d. Elimination Pattern Because of loss of appetite baby K’s elimination pattern was lessen. She only defecates 1-2 times a day. e. Activity-Exercise Pattern Baby K’s primary activity would be crawling or trying to walk. f. Sleep-Rest Pattern As stated by the mother, Baby K’s sleep pattern is kind of disturbed because of her sickness. g. Cognitive-Perceptual Pattern Baby K has no sensory defect. She communicates through crying and some baby talk. h. Self-Perception – Self-Concept Pattern: i. Role-Relationship Pattern At this point of time, we cant still point out baby K’s role relationship because she is still an infant, though her mother states that she is a behave baby. j. Sexuality-Reproductive Pattern Patient baby K is still a baby she is still in oral stage according to Sigmund Freud’s theory. k. Coping-Stress Tolerance Pattern Baby K’s copes through crying, because she is still an infant. l. Value-Belief Pattern Baby K’s family is Roman Catholic.
Nursing health history A Patient: Baby K Date of Admission: November 19 2012 Ward: Tibag, health center Age: 11 months old Sex: female C/S: single Religion: Roman Catholic I. Chief complaint Cough colds and fever for 1 week. II. Past medical history A. Immunization/tests + BCG +DPT +OPV +HEP B +Measles B. Hospitalizations. Baby k’s first admission was November 19 2012. Upon consultation at Tibag RHU they immediately confined her at Tarlac Provincial Hospital. She stayed at NICU for 5 days and 3 days at pedia ward and was discharged November 16, 2012. C. Injuries NONE D. Transfusions NONE E. Medications suprax. (cefiximine) (zinc sulfate) Diazinc F. Allergies NONE III. Family History Parents Health status Disease or cause of present in the death family Mr. R L D Mrs. M
Social and personal history Birthplace: Tarlac Provincial Hospital Education: N/A Birthday: December 10, 2011 Ethnic background: Pampango Client’s position in the family: Youngest child Residence: San Pablo, Tarlac City Home Environment: Concrete Occupation: N/A Financial Support System: supported by her parents. Habits: none Physical activity: Since baby K is still an infant, her activity are mostly crawling and trying to walk. Brief Description of Average Day: She wakes up early and her siblings play with her. Baby K sleeps at noon and 8pm at night.
IV. Review of system: General Description: Weight Loss: + Night sweats: Anorexia: Fatigue: + Weakness: + Skin: Itch: + Rash: Lesion: Bruising: Bleeding: Color Change: slightly pale Eyes: normal Vision: Diplopia: Blurring: Excessive Tearing: Ears: normal Earaches: Hearing Loss: Discharge: Tinnitus: Nose: Nasal flaring: + Obstruction: Epistaxis: Discharge:
Throat and Mouth: Sore Throat: Bleeding Gums: Tooth Aches: Decay: Cough: + Sputumum : greenish to yellowish Neck: Swelling: Dysphagia: + Others: Extremities: normal Joint pains: Edema: Varicose Veins: Stiffness: Claudication: Deformities: Neurologic System: Headache: + Dizziness: Memory Loss: Fainting: Numbness: Tingling: Paralysis: Paresis: Seizures: Mental Health: Anxiety: + Sexual Problem: Depression: Fears: Insomnia: Breast: Lumps: Discharge: Pain: Bleeding: Cardiovascular: Chest pain: Palpitation: Dyspnea on exertion: + Edema: PND: Orthopnea:
Others: Gastrointestinal System: Food Tolerance: Heartburn: Nausea: Jaundice: Vomiting: Pain: Bloating: Excessive Gas: Constipation: Change in BM: Melena: Genitourinary System: Dysuria: Nocturia: Retention: Polyuria: Dribbling: Hematuria: Flank pain: Male: Penile Discharge: Lesions: Testicular pains: Others: Female: Menarche: Old LMP: Cycle: CVS: Chest pain: Palpitation: + Dyspnea on Exertion: Edema: PND: Orthopnea: Others:
GIT: Food tolerance: Heartburn: Nausea: Vomiting: Pain: Bloating: Excessive Gas: Constipation: Change in BM: Melena: GU: Dysuria: Nocturia: Retention: Polyuria: Dribbling: Hematuria: Flank pain: Male: Penile Discharge: Lesions: Testicular Pain: Others: Female: Menarche Others: Extremities: Joints Pain: Varicose Veins: Claudicatio: Edema : Stiffness : Deformities : Neuro : Headache : + Dizziness : Memory loss : Fainting : Numbness tingling : Paralysis : Presis : Seizures : Others :
Mental Health Status : Anxiety : + Depression : Insomia : Sexual Problems
ANATOMY AND PHYSIOLOGY OF RESPIRATORY SYSTEM
The Nose - Responsible in smelling something. It has two openings called nostrils; the air enters the nasal passages through the nostrils. The air that you breathe must be cleaned before reaching the lungs of the person. - Cilia are a tiny hair that is responsible for protecting a person from germs. The cilia filter the smaller particles of dust and dirt. - Mucous membrane is a moist tissue lining in the nose that also catches particles of dirt. It also warms and moistens the incoming air. There is also tiny blood vessel that also warm and moisten the passing air inside the nose. The Pharynx - The clean air travels from the nasal passages to the pharynx, It is located at the back of the throat. Divided into two tubes: - Esophagus is the tube that connects the pharynx with the stomach. It carries food, liquids and saliva from your mouth to the stomach. - Trachea or windpipe is a bony tube portion of the respiratory tract that connects the larynx with the bronchial parts of the lungs. Epiglottis is the flap cartilage located at the bottom of the pharynx. It opens and closes the trachea. It prevents the food from going to the trachea by closing it
during swallowing. The epiglottis is open to allow the flow of air in the breathing process most of the time. The Larynx - From the pharynx, the clean air moves down to the larynx. - The Larynx or voice box is located between the pharynx and the trachea. Humans use the larynx to breathe, talk, and swallow. - The larynx contains the vocal cords that vibrate when air passes through them. The Trachea or Windpipe - The trachea, or windpipe, is a bony tube portion of the respiratory tract that connects the larynx with the bronchial parts of the lungs that about 13 centimeters long. - The inner wall of the trachea is also lined with cilia. The cilia catch the dust particles that reach the windpipe. The dust particles are then pushed out and up toward the throat and mouth for expulsion. This is why one coughs or sneezes just because of the dirt gets into the upper respiratory tract. The lower end of the trachea branches into two large tubes called the bronchi. The Lungs - The Lungs are the organs of respiration (in-charge for breathing). The left bronchus leads to the left lung while the right bronchus leads to the right lung. Each bronchus divides into smaller tubes called bronchial rami. The bronchial rami branches off further into smaller tubes calledbronchial tubes or bronchioles. At the ends of these bronchioles are the tiny air sacs calledalveoli. - The bronchioles and alveoli look like the branches of a tree. Bronchi is the biggest branches that arecovered by cilia and a thin film of mucus. Dust and pollen are trapped by the mucus before they reach the alveoli. - Each of the lungs has 300 million alveoli. Alveolus is surrounded by tiny blood vessels called capillaries. These are the smallest of blood vessels that help to distribute oxygenated blood from the arteries to the tissues and to feed deoxygenated blood from the tissues back to the veins.
Alteration in net bacterial lung resistance caused by either: -Decreased bactericidal ability of the alveolar macrophages -Extreme virulence of the bacteria -Increased susceptibility of host to infection
Stage of congestion: Engorgement of alveolar spaces with fluid and hemorrhagic exudates
Proliferation and rapid spread of organism through the lobe
Acute inflammation occurs that causes excess water and plasma proteins go to the dependent areas of the lower lobes
Consolidation of leukocytes and fibrin within the affected area
RBCs, fibrin, and polymorphonuclear leukocytes infiltrate the alveoli
Containment of the bacteria within the segments of pulmonary lobes by cellular recruitment
Stage of red hepatization: Coagulation of exudates occurs resulting to the red appearance of the affected lung
Stage of gray hepatization: The decrease in number of RBC in the exudates is replaced by neutrophils; which infiltrate the alveoli making the lung tissue to be solid and grayish in color
PHYSICAL EXAMINATION General Survey: Height: 66 cm. Weight: 7.2 kg. Skin: Color: Slightly pale State of Hydration: Good
Turgor: Decreased skin turgor Bruises: None
Eyes: Sclera: Moist Pupils: Pupils Equally Reactive to Light and Accommodation VITAL SIGNS: Capillary Refill: 1-2 secs. Urine Output: 4 diapers a day DATE/ TIME 12-04-12
CR (bpm) 122
RR (cpm) 25
TEMP. (C) 36.8
BODY POSITION AND ALIGNMENT: Supine
Others: Sitting at parent’s lap Alignment:
MENTAL ACUITY: Oriented
Others: Disoriented Incoherent Inappropriately Responsive
SENSORY/MOTOR RESTRICTIONS: Amputation Hearing Disorder
EMOTIONAL STATUS: Apprehensive
OTHER HEALTH RELATED PATTERNS: Fatigue
ENVIRONMENT: Room Temperature: Adequate
SAFETY: Violations of safety measures: Bed has no side rails ACTIVITIES OF DAILY LIVING: CANNOT PERFORM: Feeding
PHYSICAL EXAMINATION FINDINGS SKIN Slightly pale in color Warm and Dry HEAD/ SKULL Skull is round ( normocephalic and symmetric, with frontal parietal and occipital prominences). Smooth skull contour, non tender and free from masses and depression. Head circumference: 42 cm. FACE Symmetric facial features and movements. EYES With white, moist, and glossy sclera. Iris are equal in size and pupils are rounded, both eyes are symmetrically responsive to light, coordinated and moved with parallel alignment. Conjunctivas are slightly thinned. Cornea is transparent, smooth and moist. Iris and pupil are round and uniform in color. EARS Ears are of equal sizes and similar in appearance Non tender upon palpation NOSE AND SINUSES Asymmetric and tender. Mucosa is pink. MOUTH AND PHARYNX Lips in net position, no lesions Pink and dry lips. Pink and moist gums. The dorsal and ventral portion of the tongue were both smooth Pink and smooth soft palate and hard palate NECK Muscles are symmetrical, head centered. Coordinated and smooth movements with no discomfort.
THORAX/ RESPIRATORY With rapid and shallow respirations noted Use of accessory muscles noted with respiratory rate of 25cycles/min. Chest move in or retract during inhalation Productive cough noted Pursed- lip breathing noted Crackles heard over both lower lobes Rales heard on late inspiration Bronchial breath sounds heard over lung periphery Chest circumference: 49 cm. ABDOMEN Paler than skin color, no rashes and lesions Flat in contour Soft and non tender Chest circumference: 43 cm. UPPER AND LOWER EXTREMITIES Texture is uniform. Peripheral pulses were strong and palpable. Radial pulse is 103 beats per minute. NAILS Slightly soft, white nails Capillary refill of 1 second OTHER HEALTH RELATED PROBLEMS: NONE
Nursing Care Plan Assessme nt Subjective : -“hindi siya makahing a”as verbalized by the mother -feeling breathless Objective: -nasal flaring -altered chest excursion decreased inspiratory /expiratory pressure
Ineffective breathing pattern r/t excessive mucous production
There is an obstruction of the airway due to too much production of secretions and where there is a inadequate ventilation that alter in depth and rate of breathing
After 3 hours of proper nursing interventio n the patient will be able to establish effective respiratory pattern
Provide adequate rest periods
to limit fatigue and conserve energy for manage ment of respirato ry distress
After 3 hours of proper nursing interventi on the client was able to establish effective breathing pattern
administer oxygen at lowest concentratio n as indicated suction airway as needed
to clear secretion s
administer analgesic as promote prescribed deeper respirati on and maintain cough emergency equipment when in ventilator accessible support location might be needed
Nursing Diagnosi s
“Iyak siya ng iyak, parang masakit yung lalamunan niya” as verbalized by the mother. O: observed evidenced of pain, Expressive behavior: crying
Acute pain related to persiste nt cough
Cough occurs when there is irritation of the throat and it is cause by an unknown etiology or known etiology. It is categorize by productive or unproductive .
After 1 hour of nursing intervention the client’s mother wil report that pain is relieved and the child will relax.
Asses for referred pain as appropriate
observe nonverbal cues/pain behaviors
To help determine possibility of underlying condition or organ Observatio ns May not be congruent with verbal reports or may be only indicator present when client is unable to verbalize.
After 1 hour of nursing interventio n the patient’s mother verbalized that her child is at ease and pain free
Prevent comfort measures.
to promote nonpharma cological pain manageme nt
Instruct or encourage use of relaxation techniques such as focused breathing. Suggest parent to be present during procedures encourage bed rest periods
To distract attention and reduce tension.
To comfort child
to prevent fatigue
ASSESSMENT s>”nahihirapang huminga ang anak ko”as verbalized by her mother.
O> Restlessness with nasal flaring >Warm, flushed skin. >minimal colorless nasal secretion. > tachycardia >irritability >cough
NURSING DIAGNOSIS Ineffective airway clearance related to accumulation of tracheo bronchial secreation.
SCIENTIFIC EXPLANATION Mucus is produced at all times by the membranes lining the air passages. When the membranes are irritated or inflamed, excess mucus is produced and it will retain in tracheobronchial tree. The inflammation and increased in secretions block the airways making it difficult for the person to maintain a patent airway. In order to expel excessive secretions, cough reflex will be stimulated.
PLANNING After 3-4 hours of nursing intervention the patients will be able to demonstrate improve airway clearance
NURSING INTERVENTION >Monitor and record vital signs >Assess patient’s condition. >Elevate head of bed and encourage frequent position changes.
> Keep back dry and loosen clothing >Auscultate breath sounds and assess air movement . >Monitor child for feeding intolerance and abdominal distention >Instruct the patient to provide an increased fluid intake for the child > Instruct the patient to provide adequate rest periods for the child > Give expectorants and bronchodilators as ordered. >Administer oxygen therapy and other medications as ordered.
RATIONALE >To obtain baseline data
>To know the patient’s general condition >To promote maximal inspiration, enhance expectoration of secretions in order to improve ventilation >To promote comfort and adequate ventilation >To ascertain status and to note progress
>To avoid compromising the airway To help liquefy the secretions To help liquefy the secretions
> Rest will prevent fatigue and decrease oxygen demands for metabolic demands > To clear airway when secretions are blocking the airway
> indicated to increase oxygen saturation.
EVALU ATION After 3-4 hours of NI, pt. shall have Demonst rated improve airway clearance
Drug study Drug Cefixime Brand name: Suprax
Contraindication Hypersensitivity to cephalosporin
Side Effect Diarrhea
Head ache or Dizziness
Adverse effect Abnormal thinking
Nursing Responsibilities Adequate fluid intake
Maintain a well balanced diet while taking this medicine.
Take the medicine as prescribed by the doctor.