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INTRODUCTION

a. Overview of the Case

Bronchopneumonia, or bronchial pneumonia, is a type of pneumonia that


originates in the bronchioles of the lungs, which are the smaller ducts of the
bronchial tubes. The contagious infection is caused by a variety of bacteria,
viruses, and other microorganisms.

Infant, toddler and older people can easily acquire this disease. As the
Group B5 rotated in the pedia ward in Bukidnon Provincial Hospita; - Talakag, I
was assigned into a 3 years old patient whose name is Ampoan, Alona Tayaotao
who was diagnosed with Bronchopneumonia. It’s my first time to handle a patient
with a case of bronchopneumonia and it seems to be challenging in my part as a
student nurse. Through this case study I share my knowledge and care to my
patient and at the same time I also gained knowledge from my patient.
b. Objective of the Study

At the end of 2-days (16 hrs) duty, I will be able to bring improvement to
my patient’s health status, impart health teachings and informations to the patient
and to her family, thus enhancing their naked mind regarding to the illness of
their daughter and poor health management. As a part of this objective, my aim
is to provide nursing interventions to the identified health problems affecting the
family and gain their cooperation towards the improvement of their daughter’s
health condition

c. Scope and Limitation of the Study

The NCM501X was assigned in pedia ward of X. The study was directed
to X’s health. The information gather was only limited from the assessment to the
second day of our duty which is done last January 16-18, 2007. Any information
verbalized by the mother and father regarding to their daughter Ampoan, Alona
are included in this study.
In a period of time, the interventions are not to bring patient in a full
recovery but to improve the health status of the patient and to prevent
complications. For the parents are included in this study in the enhancement of
the patient’s health, health teaching is being done as a part of my interventions.
In this way, Dole-out system is being avoided.

II. HEALTH HISTORY


a. Profile of Patient

Name : X

Date Assessed: January 16,2007


Age 3 years old
Sex Female
Date of Birth July 5, 2003
Birth Place X
Nationality Filipino
Religion Roman Catholic
Temperature 39.2˚ C
Pulse rate 80 bpm
Respiratory rate 34 cpm
Blood Pressure No Opportunity
Height: 97 cm
Weight 13 kg

Types of previous illness/ surgery Date

Cough January 13, 2007


Cold January 13, 2007
Fever January 13, 2007
Diarrhea January 15, 2007

Has received blood in the past _____ Yes ___/__ No If yes list dates____
Reactions___ Yes ___ No

Medication Name Dose /Frequency Time of Last dose

Gabon (pabukal) Once a day after supper January 14, 2007

b. Family and Personal Health History

Name : X(Father)

Date Assessed: January 18,2007


Age 32 years old
Sex Male
Date of Birth April 16, 1974
Birth Place X
Nationality Filipino
Religion Roman Catholic
Temperature No Opportunity
Pulse rate No Opportunity
Respiratory rate No Opportunity
Blood Pressure No Opportunity
Height 5’5’’
Weight 51 kg
Educational Attainment High School, Undergraduate
Occupation Farmer
Income P1,500/month

Name : X
(Mother)

Date Assessed: January 17,2007


Age 32 years old
Sex Female
Date of Birth September 25, 1974
Birth Place X
Nationality Filipino
Religion Roman Catholic
Temperature 37.2˚ C
Pulse rate 75 bpm
Respiratory rate 18 cpm
Blood Pressure 110/90 mmHg
Height 4’10”
Weight 44 kg
Educational Attainment Elementary, Undergraduate
Occupation Housewife
Income None

5 Children: All are still dependent on their parents.

NAME AGE EDUC. ATTAINMENT


X 12 Grade Six
X. 8 Grade Two
X 5 -----
X 3 -----
X 1 -----

Health History
Roque, Ampoan

Types of previous illness/ surgery Date

Back ache December 2006

Has received blood in the past _____ Yes ___/__ No If yes list dates____
Reactions___ Yes ___ No

Medication Name Dose /Frequency Time of Last dose

Lana ------- -------

Mr. X is farmer in X. According to Mr. X, he sometimes experienced back


ache due to his daily work, though it is such a hinder, he still continue to work to
earn money and to raise his family. As an intervention he engaged to self
treatment by placing an amount of “Lana” and rubs it to the area where pain is
being identified.
X

Types of previous illness/ surgery Date

Cough December 2006


Cold December 2006
Has received blood in the past _____ Yes ___/__ No If yes list dates____
Reactions___ Yes ___ No

Medication Name Dose /Frequency Time of Last dose

Neozep 550 mg BID P.O. -------

Last December 2006, Mrs. X experienced common cough and cold and
had taken Neozep to get rid of such illness. According to Mrs. X, she got this
illness due to the cold weather they have experienced last December 2006. As a
treatment, MsX had taken Neozep 550 mg twice a day.

c. History of Present Illness

Based on my interview with Mrs. X X regarding to her daughter’s illness,


she said that no one in their family and relatives had experienced pneumonia and
other respiratory problem, the most common illness that they only experienced
are cough, cold and fever. She told me that, she found X to be playful with his
brother and sister during the first and second week of this month but recently
three days before X’s admission she found her daughter weak and experiencing
fever and start to experienced dyspnea. The only thing that she suspected
regarding to the illness is the bad weather they experienced during the past few
days.

d. Chief Complain
X fourth child of MrX and Mrs. X who was admitted last January 16, 2007
with a chief complain of cough and dry and experienced cold, fever, and
diarrhea, five days prior to admission.

III. DEVELOPMENTAL DATA

Infancy
According to Erickson, the central crisis at this stage is trust vs. mistrust.
Resolution at this stage determines how the person approaches subsequent
developmental stages. During the first year of life, infant depend on their parents
for physiologic needs. Fulfillment for this need is required for the infant to develop
a basic sense of trust.
As for my patient, according to her mother during her infancy period she
always demand for an attention, she would really cry whenever she is being held
by other person. She also manifest sucking reflex.

Early childhood
According to Freud’s theory this age represents the anal phase of
development when rectum and anus are the especially significant areas of the
body. This is the toilet training stage.
Aside from her mother, Alona is being trained by her father, older brothers
and sister on when and where to defecate. Based on my interview to the client’s
mother, my patient is not properly trained. Though Alona give signs to her
parents that she wants to defecate and able to identify where is the proper place
to defecate but still she sometimes can’t help to defecate in her underwear.
IV. MEDICAL MANAGEMENT

a. Medical Orders and Rationale

Date Doctor’s Order Rationale

January 16, 2007 > Obtain consent >To obtain patient’s


approval if there is an
instance that the patient
should be undergone to
an operation and the
hospital will not be held
liable for any
circumstances to come.

> Laboratory: >To determine presence


Hematology of microbes,
the type of organisms in
the blood and the
antibiotic used in which
the organism is sensitive.

> D5LR 500 cc at > For fluid replacement


40 mgtts./min.

> Diet as Tolerated > To maintain patient’s


nutritional status.

Date Doctor’s Order Rationale

>Medications: > Reduction of fever/


- Paracetamol Drop body temperature.
1.2 ml QID P.O.

- Cefuroxime > Serious infections of


250 mg every 8 hrs IVTT the lower respiratory
ANST (-) tract.

- Salbutamol > Inhalation used as


1 neb every 6 hrs quick relief agent for
acute bronchospasm and
for prevention of exercise
induced bronchitis
spasm.

> Place patient in semi- > Allow proper breathing


fowler’s position

> For fluid replacement


January 17, 2007 >IVTF: > D5LR 500 cc at
40 mgtts./min.

>Same meds order > Reduction of fever/


body temperature.

- Serious infections of the


lower respiratory tract.

- Inhalation used as quick


relief agent for acute
bronchospasm and for
prevention of exercise
induced bronchitis
spasm.

> Diet as Tolerated > To maintain patient’s


nutritional status.

> Maintain bed rest > Prevent over


exhaustion and reduce
oxygen consumption.
DRUG STUDY
Name of Patient: Ampoan, Alona

Generic name Brand Date Classification Dose/ Mechanism Specific Contra- Side Nursing
of Ordered Name Ordered Frequency/ of Action Indication indication Effects/ Precautions
Drug Route Toxic
Effects
Paracetamol Biogesi 1/16/07 Anti-pyretic Drop 1.2 ml Inhibits the Reduction Contraindicate Skin: -assess
c QID P.O. synthesis of of fever/ d in patients rash, patient
the body hypersensitive urticari temperature
prostaglandin temperatur to drug a before and
s that may e during
serve as GI: therapy
mediators of Hepatic -be alert for
pain and failure adverse
fever primarily reactions
in the CNS. GU: and drug
Renal interaction
failure -give liquid
form to
children
-warn pt.
that high
doses or
unsupervise
d long-term
use can
cause liver
damage.
DRUG STUDY
Name of Patient: Ampoan, Alona

Generic Brand Date Classification Dose/ Mechanism Specific Contra- Side Nursing
name of Name Ordered Frequency/ of Action Indication indication Effects/ Precautions
Ordered Route Toxic
Drug Effects

Cefuroxime _____ 1/16/07 Cephalospori 250 mg Inhibits cell Serious Contraindicate CV: Obtain
ns every 8 hrs wall synthesis infections d in patient Phlebiti specimen for
IVTT ANST promoting of the lower hypersensitive s, culture and
(-) osmotic respiratory drug or other Throm sensitivity
instability tract. cephalosporins bophle test before
usually . bitis giving first
bactericidal. dose.
GI:
colitis,
nausea
,
anorexi
a,
vomitin
g,
diarrhe
a

SKIN:
urticari
a, pain,
indurati
on

Other:
Serum
sicknes
s
DRUG STUDY
Name of Patient: Ampoan, Alona

Generic Brand Date Classification Dose/ Mechanism Specific Contra- Side Nursing
name of Name Ordered Frequency/ of Action Indication indication Effects/ Precautions
Ordered Route Toxic
Drug Effects

Salbutamol Salbuta 1-16-07 Therapeutic 1 neb every Relax Inhalation Hypersensitivity CNS: Use
mol broncho – 6 hrs bronchial, used as to adrenergic Nervou cautiously in
proventil dilators uterine, quick amines. sness, cardiac
pharmacologi vascular relief restles disease
c adrenergics smooth agent for sness, hypertension
muscle by acute tremors ,
stimulating bronchos , hyperthyroidi
beta 2 pasm and headac sm,
receptors for he, diabetes,
preventio insomn glaucoma.
n of ia
exercise
induced CV:
bronchitis chest
spasm pain,
palpitat
ions

GI:
Nause
a,
vomitin
g
V. PATHOPHYSIOLOGY W/ ANATOMY AND PHYSIOLOGY

DEFINITION: A contagious infection of the lungs. This type of pneumonia is


localized mainly in the smaller branches of the bronchial tubes called
bronchioles.

Predisposing Factors: Precipitating Factors:


 Poor sanitized environment  Pseudomonas aeruginosa and
 Malnutrition Klebsiella, Staphylococcus
 Age aureus, Haemophilus influenzae,
 Exposure to noxious gases. Staphylococcus pneumoniae
 Enteric gram-netgative bacilli,
fungi, and viruses

Aspiration of If defense mechanism Pathogens thrives in


microorganisms in is weak, possibility of the bronchus of the
lower respiratory tract having pneumonia lungs
could be acquired

As a defense From one area of Inflammation on the


mechanism, the body bronchus, it spreads area of bronchus
reacts by causing within the bronchus to interferes with the
inflammation lung parenchyma. proper diffusion of
Which means bronchus oxygen and CO2
is constricted

With the interference BRONCHOPNEUMONIA Complications:


of air exchange, Signs and Symptoms: Respiratory Acidosis
patient experiences - coughing,
poor oxygenation - chest pains,
- fever, blood-streaked
due to under - sputum,
ventilated area of - chills,
the lungs - dyspnea
- fatigue
VI. NURSING SYSTEM REVIEW
CHART
Name: X_______________________ Date: January 16, 2007____________
Vital Signs:
Pulse: ________ BP: ________ Temp: ________ Height: _________ Weight: ________
EENT:
� Impaired vision � blind
� pain � reddened � drainage
� gums � hard of hearing � deaf
� burning � edema � lesion � teeth
Asses eyes, ears, nose
Throat for abnormality � no problem
RESP.
�asymmetric � tachypnea
� apnea � rales � cough � barrel chest
� bradypnea � shallow � rhonchi
� sputum � diminished � dyspnea
� orthopnea � labored � wheezing
� pain � cyanotic
Asses resp. rate, rhythm, depth, pattern
breath sounds, comfort � no problem
CARDIO VASCULAR
� arrhythmia � tachycardia � numbness
� diminished pulses � edema � fatigue
� irregular � bradycardia � murmur
� tingling � absent pulses � pain
Assess heart sounds, rate, rhythm, pulse, blood
pressure, etc., fluid retention, comfort
� no problem
GASTRO INTESTINAL TRACT
� obese � distention � mass
� dysphagia � rigidity � pain
Asses abdomen, bowel habits, swallowing,
bowel sounds, comfort � no problem
GENITO-URINARY and GYNE
� pain � urine color � vaginal bleeding
� hematuria � discharge � nocturia
Assess urine freq., control, color, odor, comfort/
Gyn-bleeding, discharge � no problem
NEURO
� paralysis � stuporous � unsteady � seizures
� lethargic � comatose � vertigo � tremors
� confused � vision � grip
Assess motor function, sensation, LOC, strength,
grip, galt, coordination, orientation, speech.
� no problem
MUSCULOSKELETAL 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
Asses mobility, motion, galt, alignment, joint function
/skin color, texture, turgor, integrity � no problem

Place an (X) in the area of abnormality. Comment at the


space provided. Indicate the location of the problem in
the figure if appropriate, using (x)
VII. IDEAL NURSING MANAGEMENT
Name of Patient: Ampoan, Alona

Cues Nursing Objective Intervention Rationale Evaluation


Diagnosis
Subjective : Ineffective airway At the end of 30 1. Place patient in semi- 1. To allow patient At the end of 30
As verbalized clearance related minutes the client fowler’s position. to breath properly minutes the client
by the patient’s to bronchial will display absence was able to display
mother inflammation as of dyspnea and feel 2. For absence of
“Maghilaka jud ni evidenced by relax. 2. Instruct patient or its mobilization and dyspnea and felt
siya basta dyspnea grimace watcher to change in expectoration of relax.
maglisod na og and fatigue. position frequently. secretions.
ginhawa.”
3. Decrease the
3. Increase fluid intake. viscosity of
Objectives : secretions.
1. Dyspnea
2. Facial 4. Prevent over
grimace 4. Advice patient to exhaustion and
3. Fatigue maintain bed rest. reduce oxygen
consumption.

5. Treatment of
5. Administer choice penicillin
cephalosporin. resistant
streptococcal

IDEAL NURSING MANAGEMENT


Name of Patient: Ampoan, Alona

Cues Nursing Objective Intervention Rationale Evaluation


Diagnosis
Subjective : Activity At the end of 30 1. Assist patient to 1. To promote At the end of 30
“Gahangoson intolerance minutes the client assume comfortable relaxation. minutes the client
akong anak og related to will display a position for rest/sleep. was able display an
dali maski dari imbalance measurable increase in
lang siya mag between oxygen increase in 2. Assist w/ self-care 2. Helps balance tolerance to activity
lihok-lihok sa supply and tolerance to activity activity as necessary. oxygen supply with absence of
katre” as demand as with absence of and demand and excessive fatigue.
verbalized by the evidenced by excessive fatigue. minimize
patient’s mother fatigue. exhaustion.

Objectives : 3. Instruct parents to 3. To promote


1. Fatigue clean and fix patient’s comfort during
2. Exhaustion bed. rest.

4. Advice the parents to 4. Reduces stress


engage patient in and excess
diversional activities as stimulation and to
appropriate like telling promote rest.
stories.

5. Administer Oxygen 5. To provide


therapy. adequate oxygen.

IDEAL NURSING MANAGEMENT


Name of Patient: Ampoan, Alona

Cues Nursing Objective Intervention Rationale Evaluation


Diagnosis
Subjective : Hyperthermia At the end of 30 1. Perform tepid sponge 1. To reduce At the end of 30
As verbalized related to illness minutes the bath. fever. minutes the client’s
by the patient’s as evidenced by patient’s temperature
mother, “duha na flushed skin and temperature will 2. Offer cool glass of 2. To prevent decreased and
ni kaadlaw ang warm to touch. decrease. water or increase fluid thirst and minimized signs of
iyang hilanat.” intake. dehydration. fever.

Objectives : 3. Add bed 3. To minimize


1. Flushed linens/blanket. patient from
skin chilling and to
2. Temp. maintain near
39.2˚C normal body
3. Chill temperature.

4. Instruct client to 4. To prevent


maintain bed rest. increase of
metabolic rate.

5. Administer anti-pyretic 5. To reduce fever


drug as prescribed. through central
action in
hypothalamic heat
regulating center.
Actual Nursing Management

S “Kaduha siya nalibang ang akong anak karong buntaga nya


basa-basa iyang tae” as verbalized by the patient’s mother
Mrs. Marilyn Ampoan.
O  Grimace due to abdominal pain
 Pain scaled by 4 in 1-10 scaling
 Watery stools
A Diarrhea related to infection as evidenced by watery stools
and grimace
P Long term: At the end of 1 day, the patient’s stool will return
to its normal consistency.

Short term: At the end of 30 minutes the patient will be able


to display or verbalize that the pain has decreased.
I 1. Promoted bed rest
2. Restarted oral fluid intake gradually
3. Advised patient and parents to eat banana in times of
diarrhea.
4. Instructed parents to clean their food utensils thoroughly
and boil it.
5. Administered intravenous fluids as ordered.

E At the end of 30 minutes the patient was able to display and


verbalized that the pain has decreased.

VIII. REFERRALS AND FOLLOW-UP


As such I’ve told the patient’s mother and father to immediately consult the
physician or nurse if any unusualities observe to prevent complications. I also
told the parents of my patient to ask some questions to the physician during
doctor’s round regarding to their daughter’s illness and advised them to maintain
cleanliness in the area, on the bed and also provide proper hygiene to their
daughter to promote comfort and to enhance wellness.
In times illness or to attain free health service, I’ve advised the parents to
visit their nearest Barangay Health Center and have a weekly check-up to
monitor the health status of each family member, thus promoting prevention
rather than cure.

IX. EVALUATION AND COMPLICATIONS

After 2-days of care that was being imparted to the patient, my objectives
were fully met. As what is being said, I was able to managed the condition of my
client and seen some improvement on her health in just few days. Careful
assessment of the client’s health status was done. And from such examination,
the client’s problems were identified. Interventions were then planned carefully
and were properly addressed to her health problems. After which, her response
and reaction were evaluated and important health teachings for her recovery
were imparted to her mother and father and especially to my patient.
During the second day of our duty, my client was able to display some
improvement regarding to her actions and especially to her breathing. Diarrhea
and fever were no longer present during the last day of my duty. This implies that
the intervention done was effective.

BIBLIOGRAPHY
Smeltzer.Bare. Textbook on Medical-Surgical Nursing (10th edition) Lippincott-
Raven Publisher.Copyright 1996

Wilson, Billie Ann Nurse’s Drug Guide (vol. 1 & 2) Pearson Education
Inc.,Copyright 2000

Mosby’s Pocket Dictionary of Medicine, Nursing and Allied Health (4th edition)
Elsevier(Singapore) PTE LTD> Copyright 2002

Doenges, Marilynn Nursing Care Plans, Guidelines for Individualizing Patient


Care(6th edition) F.A Davis Company. Copyright 2000

Kozier. Erb. Blais. Wilkinson. Fundamentals in Nursing (5th Edition). Addison


esley Longman Inc. 1998.
LICEO DE CAGAYAN UNIVERSITY
College of Nursing

NCM501202
A Care Study

X
Name of Client

Submitted to:

______________________________
Name of Faculty

As Partial Requirement for NCM501202

Submitted by:

_______________________________
Name of Student

Rating Scale
A. Written WEIGHT RATING
I. INTRODUCTION
a. Overview of the case
b. Objective of the case 5
c. Scope and limitation of the study

II. HEALTH HISTORY


a. Profile of patient
b. Family and personal health history 5
c. History of Present Illness
d. Chief complain

III. DEVELOPMENTAL DATA 5


IV. MEDICAL MANAGEMENT 20
a. Medical Orders and rationale
b. Drug study
V. PATHOPHYSIOLOGY W/ ANATOMY AND 10
PHYSIOLOGY
VI. NURSING ASSESSMENT (System Review and Nsg. 10
Assessment II)
VII. NURSING MANAGEMENT 30
a. Ideal Nursing Management
b. Actual Nursing Management
VIII. REFERRALS AND FOLLOW-UP 5
IX. EVALUATION AND COMPLICATIONS 5
X. DOCUMENTATION 5
a. Documentation of evidenced of care for 1 week
rotation
b. Organization/Grammar/Bibliography
Total Score 100
Equivalent Grade