NAME: HALLA TARED MR NO: 181038 DIAGNOSIS: BRONCHOPNEUMONIA AGE: 2 YRS OLD GENDER: FEMALE DATE OF ADMISSION: 10/12/12 DATE OF DISCHARGE: 17/12/12
GENERAL ASSESSMENT: Mild respiratory distress present Looks lethargic SKIN: Dry and slightly pale HEAD AND NECK: No deformities found THORAX: Symmetrical in size CARDIOVASCULAR: Tachycardia and tachypnea present GENITOURINARY: Adequate urine output GASTROINTESTINAL: Abdomen is soft, not distended MUSCULOSKELETAL: No deformities noted. No joint or muscle pain noted during examination NEUROLOGY: Growth and development is adequate as per Erikson Psychosocial Stage
PAST MEDICAL HISTORY: NO family history of the bronchial asthma, bronchopneumonia, bronchiolitis. DM No allergic history No previous breathlessness History of gastroenteritis PRESENT MEDICAL HISTORY: Shortness of breath and fever present since 1 day at the time of admission.
PNEUMONIA DEFINITION: Pneumonia is an inflammation of the lung parenchyma cause by various microorganisms including bacteria, mycobacterium, fungi and viruses.
LUNGS: The lungs are paired elastic structures enclosed in the thoracic cage which is an air tight chamber with distensible walls The lungs are enclosed in a serous membrane called pleura. The mediasternum is in the middle of the thorax between the pleural sacs that contains the two lungs and each lung is divided into lobes. There are several divisions of the brochi within each lobe of the lung. The subsegmental brochi then bracnhes into bronchioles which have no cartilage in their wall. The lung is made up about 300 million alveoli.
ALVEOLI – are tiny sacs in the lungs that perform gas exchange.that is the main process of respiration. BRONCHI – is basically an organ from the respiratory system. It acts as an caliber for the airway by conducting air into the lungs. BRONCHIOLES – are smaller airways that send the air on to the inside walls of the lungs.
VIRAL ( cytomegalo virus is the most common) BACTERIAL (streptococcal and staphylococcal pneumonia)
PATHOPHYSIOLOGY ALVEOLAR INFLAMMATION AN EXUDATE INTERFERE WITH DIFFUSION OF O2 AND CO2 WBC, NEUTROPHIL MIGRATES TO ALVEOLI FILLED THE AIR SPACE NORMALLY PARTIAL OCCLUSION OF BRONCHI AND ALVEOLI ALVEOLAR OXYGEN TENSION DECREASED BROCHOSPASM HYPOVENTILATION HYPOXEMIA LOBAR PNEUMONIA BRONCHOPNEUMONIA
◦ Ineffective breathing pattern. ◦ Ineffective airway clearance due to secretion. ◦ Altered nutritional pattern less than body requirement due to less food intake. ◦ Hyperthermia related to infection. ◦ Disturbed sleeping pattern due to cough and breathing difficulty.
Improving airway patency. Promoting rest and conserving energy. Promoting fluid intake and maintaining nutrition Promoting family knowledge Monitoring and preventing potential complications. Promoting home and community based care.
BOOK BASE Antibiotics e.g Ceftriaxone and other Cephalosporins. Ampicillin Supportive measures such IV fluids, antipyretic, humidified O2, hydration PATIENT TREATMENT Treated with injection cefuroxime 500mg IV TID, neb Ventolin, pulmicort, atrovent and syrup adol.
ASSESSMENT NURSING DIAGNOSIS PLANNINGIMPLEMENTATIONRATIONALEEVALUATION CUES/EVIDENCE: SUBJECTIVE: “Patient mother complaints of difficulty in breathing”. OBJECTIVE: Dyspnea SOB Respiratory rate changes Coughing Purulent sputum Ineffective airway clearance related to copious tracheobronchial secretion. Improve airway patency. 1.Provide fowlers position. 2.Maintain a clear airway( suction, CPT) as indicated 3.Administer humidified O2. 4.Provide adequate hydration. 5.Implement nursing measures to reduce pain and anxiety. 6.Administer medications and nebulization as order. 1.Helps good air entry. 2.Retained secretions interfere with gas exchange. 3.Loosen secretion improve ventilation. 4.Thins and loosens pulmonary secretion. Mobilize and loosen secretions. 5. Provide toys, watching TV, etc. 6. Antibiotics reduce infection; nebulization helps soothing and expulsion of secretion (e.g inj. Cefuroxime, neb ventolin and pulmicort). Relieved from breathing difficulty.
ASSESSMENT NURSING DIAGNOSIS PLANNINGIMPLEMENTATIONRATIONALEEVALUATION CUES/EVIDENCE: SUBJECTIVE: “Patient’s mother complaints baby having temperature”. OBJECTIVE: Fever Tachypnea Chills Fatigue Weakness Hyperthermia related to infection (Bronchopneumoni a) Patient will relieve from: Fever Tachypnea Chills Fatigue 1.Remove excessive clothing. 2.Provide tipid sponge bath. 3.Encourage increase fluid intake. 4.Administer iv fluids. 5.Administer antipyretic (e.g syrup adol, rofenac suppository as per order). 1.Excessive clothing may increase temperature. 2.High temperature causes coagulation of cell protein and cell die. High temperature leads to brain damage. 3.To prevent dehydration due to tachypnea and fever. 4.To maintain electrolyte imbalance. 5.To reduce body temperature. Fever reduced.
ASSESSMENT NURSING DIAGNOSIS PLANNINGIMPLEMENTATIONRATIONALEEVALUATION CUES/EVIDENCE: SUBJECTIVE: “Mother told baby is not taking orally well”. OBJECTIVE: Dehydrated Fatigue Drowsy Rapid respiratory rate Fluid Volume Deficit Related To Fever and Rapid Respiratory Rate Proper maintenance of fluid volume and adequate nutrition. 1.Encourage increase fluid intake. 2.Give nutritionally enrich drinks with more taste. Enrich with with electrolyte (e.g. Gatorade). 3.Administer IV fluids (e.g dextrose in normal saline glucose) as per doctors order. 4.Provide rest with calm and quiet environment. 1.Rapid repiratory rate leads to insensible fluid loss during exhalation. 2.To avoid dehydration. 3.May helps to provide fluids, calories and electrolytes. 4.To maintain electrolytes imbalance. Patient is hydrated.
Encourage mother to continue full course of antibiotics. Advise to increase activities gradually after fever subsides. Encourage follow up chest x-ray. Increase steam inhalation. Keep away from allergic substances. Review principles of adequate nutrition and rest. Recommended influenza vaccine (pneumovac) to all patients at risk. Refer patient for home care to facilitate adherence to therapeutic regimen as indicated.
Patient relieved from signs and symptoms. Discharged medications syrup Zinnat 125mg (6ml) BID. Neb ventolin 0.3ml + 2ml nss and neb pulmicort 0.5ml. Review after one week.
BRUNNER AND SUDDARTHS. TEXT BOOK FOR MEDDICAL – SURGICAL NURSING 12 TH EDITION. LIPPINCOTT MANUAL OF NURSING PRACTICE 9 TH EDITION