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 cells CBC 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 Examination 6. CT of Chest 7. Pleural fluid gram stain 8. Sputum gram stain 9. 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. 2. 3. Upper naso-pharynx Middle oropharynx 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 Address: Gender Age Date of Birth Place of Birth Religion Nationality: Weight : : : : : : : : : Angelee Ferrer Antonino, Alicia, Isabela Female 1 year old August 31, 2007 San Isidro, Isabela Roman Catholic Filipino 7.8 kilos

Admission Data: Chief Complaint Date of Admission Time of Admission Mode of Arrival Clinical Diagnosis Attending Physician Latest Vital Signs Temp PR RR : : : 380C 130 bpm 44 cpm : : : : : : Body weakness associated with Fever & Cough for 2 days September 26, 2008 02:10 pm Cuddled by her mother Bronchopneumonia Dra. Mila Paguila

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°C RR : 44 cpm PR : 130 bpm General Appearance: The patient is 1 year old female child, weak with fever and cough cuddled by her mother. BODY PART
Skull Hair Face Eyes Nose Mouth Lips Teeth & gums Tongue Ears

METHOD OF ASSESSMENT
Inspection Palpation Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection

FINDINGS
Normocephalic Absence of masses Curly hair Smooth but pale looking Pale conjunctiva (+) mucus secretion Pale lips White teeth Moves freely, no tenderness Color same as facial skin; symmetrical; auricle aligned with outer canthus of eye, about 10’ from ventricle Smooth Muscles equal size; head centered Not palpable Lobes may not be palpated Symmetrical

INTERPRETATION
Normal Normal Normal Due to fever & colds Due to fever & weakness Due to colds Due to fever & colds Normal Normal Normal

Skin Neck -Lymph nodes -Thyroid gland Thorax

Inspection Inspection Palpation Palpation Inspection

Norrmal Normal Normal Normal Normal

Palpation Percussion Auscultation

Chest wall intact, no tenderness Dullness Coarse breath sound (Dry rales)

Normal Decrease confluent & pleural effusion Air passing through fluid or mucus in any air passage

BODY PART Abdomen

METHOD OF ASSESSMENT Inspection Auscultation Percussion Palpation

FINDINGS Flat abdominal contour Audible bowel sounds Tympany over the stomach and gas filled bowels No tenderness Symmetrical (-) Tenderness

INTERPRETATION Normal Normal Normal Normal Normal Normal

Upper and Lower extremities

Inspection Palpation

DRUG STUDY

DRUG Generic Name: Salbutamol Brand name: Ventolin proventil Classification: Sympathomimetic Dosage: ½ tsp – tid

USES 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

SIDE EFFECTS Headache, N&V, palpitations, Tachycardia, tremor, bronchospasm

CONSIDERATIONS • When given by nebulization, use face mask or mouthpiece • Monitor pulmonary status

DRUG Generic Name: Hydrocortisone sodium succinate Brand name; A-hydrocort solucortef Dosage: 15 mg – IV q6 Classification: Corticosteroids

USES Prophylaxis and treatment of chronic bronchial asthma, perennial rhinitis, symptomatic sarcoidosis

SIDE EFFECTS Anorexia N&V Lethargy Headache Fever Joint pain Desquamation Myalgia Weight loss Hypotension

CONSIDERATION • Assess for any allergic reaction • Monitor v/s, I&O, and weight • Avoid alcohol and caffeine

DRUG NAME Generic Name: Paracetamol Brand Name: Tylenol, Biogesic Tempra Route: Oral, Rectal Dosage: Q4h/Q6h Available forms: Tablet and suppository

USES Analgesics and antipyretic commonly used for relief of fever, head aches and other minor pains and aches.

SIDE EFFECTS Rare side effects: Hives; rash; Shortness of breath. Prolonged & habitual use may lead to liver damage or failure.

CONSIDERATION Check the time and dosage before administering. Assess for possible drug reactions.

DRUG NAME Generic Name: Cefuroxime Brand Name: Zinacef, Ceftin Route: IV

USES For lower respiratory tract infection due to S. pneumoniae, UTI’s due to e. coli & skin and skin structure due to s. aureus

SIDE EFFECTS Most common: Diarrhea/loose stools, abdominal pain & N/V

CONSIDERATION Asses for possible S&S of drug reaction. Asses for anemia & renal dysfunction.

Dosage: 125 mg/q6 Classification: Cephalosporin, Second Generation

DRUG NAME Generic Name: Ceftriaxone Brand Name: Rocephin Route: IV Dosage: 250 mg Classification: Cephalosporin, Third Generation

USES For lower respiratory tract infection due to S. pneumoniae, UTI’s due to e. coli & skin and skin structure due to s. aureus

SIDE EFFECTS Most common: Diarrhea, rash, nausea, pain, induration tenderness at injection site

CONSIDERATION Asses for possible S&S of drug reaction. Asses for GI disease. Monitor renal dysfunction.

DRUG NAME Generic Name: Ambroxol HCL Brand Name: Bromussyl, Ambolyt Route: IV Dosage & Strenth Syrup 30mg/5 ml

USES 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.

SIDE EFFECTS GI side effects like epigastric pain, gastric fullness may also occur. Rare allergic responses such as eruption, urticaria & angioneurotic edema may also occur.

CONSIDERATION 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 lung 2) Primary Koch’s infection Complete Blood Count Result - 2.4 x 10³/UL 3.32 x 10/UL - 9.0 g/dl - 24.4 % - 73.5 fL 36.9 g/dl 1.64 x 10³/UL Normal Values 40 – 54 37 – 47 140 – 440 4.3 – 10.00 44.2 – 80.2 2.0 – 8.8 28 – 48

WBC RBC HGB HCT MCV MCH PLT

Hct % Platelet (10³/L) Wbc (x10/L) Gran % (x10/L) Lymph (10/L)

Male Female

LYM % MXD Neut % Lym # Neut # RDW – 5D RDW - cl

+ 62.10 % 8.6 % -29.3 % 1.5 x 10³/UL .7 x10³/UL -34.5 fL 12.6 %

Mono (10/L) Hgb 9/dl

Male Female

1.2 – 5.3 14 – 18 12 – 16

COURSE IN THE WARD

Doctor’s Order 9/26/08 Please admit patient TPR shift For CBC/Chest X ray D5 .3NaCl 500 cc @ 30 mgtts/min Cefuroxime 125 mg IV q6 to (-) ANST Ambroxol drug – 2 ml tid Salbutamol Syrup ½ tsp tid Paracetamol drops – 1 ml q4 if 38°c and above Aerosol q4 Refer for possible s/s. 9/28/08 Discontinue Cefuroxime Cefriaxasone 250 IV q 8 Hydrocortisone 15 mg IV q8 Furosemide 5 mg IV stat D5 IMB – 500 cc to follow Continue medicine D5 .3NaCl 500cc to follow

Interpretation

To determine the cause of fever & cough Initial antibiotic To relieve cough To relieve cough & secretion To relieve fever To liquefy secretion

9/29/08

9/30/08

MGH Zinnat 125mg bid Continue other meds Ceferinas ½ od Appetite Plus – 1 tsp od

Medicine to be taken at home

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 SALETTE NURSING DEPARTMENT
Related Learning Experience Lucas – Paguila Hospital Alicia, Isabela

BRONCHOPNEUMONIA
Case Study

Submitted By: LENY DE VERA RENOLO BSN – 3H Group A

Submitted to: MS. VERAMAY CANDO

Clinical Instructor

PATHOPHYSIOLOGY
Etiologic Agent: • Bacteria • Virus Predisposing Factors: * Elderly * Hospitalization * Immobilization * Immune Deficiency * Long Term Illness * Smoking Microorganism enter alveolar Spaces by droplet inhalation ↓ Inflammation occurs ↓ Alveolar fluid increase ↓ Ventilation decreases as secretion thicken ↓ Bronchopneumonia

Empyema (collection of pus & liquid From infected tissue)

Pleurisy (Inflammation of membrane)

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.

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