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. Upper naso-pharynx
2. Middle oropharynx
3. 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 : Angelee Ferrer

Address: : Antonino, Alicia, Isabela
Gender : Female
Age : 1 year old
Date of Birth : August 31, 2007
Place of Birth : San Isidro, Isabela
Religion : Roman Catholic
Nationality: : Filipino
Weight : 7.8 kilos

Admission Data:

Chief Complaint : Body weakness associated with Fever & Cough for 2 days
Date of Admission : September 26, 2008
Time of Admission : 02:10 pm
Mode of Arrival : Cuddled by her mother
Clinical Diagnosis : Bronchopneumonia
Attending Physician : Dra. Mila Paguila

Latest Vital Signs

Temp : 380C
PR : 130 bpm
RR : 44 cpm
 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 METHOD OF FINDINGS INTERPRETATION

ASSESSMENT
Skull Inspection Normocephalic Normal
Palpation Absence of masses Normal
Hair Inspection Curly hair Normal
Face Inspection Smooth but pale Due to fever & colds
looking
Eyes Inspection Pale conjunctiva Due to fever & weakness
Nose Inspection (+) mucus secretion Due to colds
Mouth
Lips Inspection Pale lips Due to fever & colds

Teeth & gums Inspection White teeth Normal

Tongue Inspection Moves freely, no Normal

tenderness
Ears Inspection Color same as facial Normal
skin; symmetrical;
auricle aligned with
outer canthus of eye,
about 10’ from
ventricle
Skin Inspection Smooth Norrmal
Neck Inspection Muscles equal size;
head centered Normal
-Lymph nodes Palpation Not palpable Normal
-Thyroid gland Palpation Lobes may not be
palpated Normal
Thorax Inspection Symmetrical Normal
 Palpation Chest wall intact, no Normal
tenderness
Percussion Dullness Decrease confluent &
pleural effusion
Auscultation Coarse breath sound Air passing through fluid or
(Dry rales) mucus in any air passage

BODY PART METHOD OF FINDINGS INTERPRETATION

ASSESSMENT

Abdomen Inspection Flat abdominal Normal

contour
Auscultation Audible bowel Normal
sounds
Percussion Tympany over the Normal
stomach and gas
filled bowels
Palpation No tenderness Normal
Upper and Lower
extremities Inspection Symmetrical Normal
Palpation (-) Tenderness Normal
 DRUG STUDY

DRUG USES SIDE EFFECTS CONSIDERATIONS

Generic Name: Prophylaxis and Headache, N&V, • When given by

Salbutamol treatment of palpitations, nebulization, use face
bronchospasm d/t Tachycardia, mask or mouthpiece
Brand name: reversible tremor, • Monitor pulmonary
Ventolin proventil obstructive airway bronchospasm status
disease. Inhalation
Classification: solution for acute
Sympathomimetic bronchospasm
attacks. Stimulates
Dosage: beta-II receptor of
½ tsp – tid bronchi leading to
broncho dilation
 DRUG USES SIDE EFFECTS CONSIDERATION

Generic Name: Prophylaxis and Anorexia • Assess for any

Hydrocortisone treatment of N&V allergic reaction
sodium succinate chronic bronchial Lethargy • Monitor v/s, I&O,
asthma, perennial Headache and weight
Brand name; rhinitis, Fever • Avoid alcohol and
A-hydrocort symptomatic Joint pain caffeine
solucortef sarcoidosis Desquamation
Myalgia
Dosage: Weight loss
15 mg – IV q6 Hypotension

Classification:
Corticosteroids

DRUG NAME USES SIDE EFFECTS CONSIDERATION

Generic Name: Analgesics and Rare side effects: Check the time and
Paracetamol antipyretic dosage before
commonly used for Hives; rash; administering.
Brand Name: relief of fever, head Shortness of breath.
Tylenol, Biogesic aches and other Assess for possible
Tempra minor pains and Prolonged & drug reactions.
aches. habitual use may
Route: lead to liver damage
Oral, Rectal or failure.

Dosage:
Q4h/Q6h

Available forms:
Tablet and
suppository

DRUG NAME USES SIDE EFFECTS CONSIDERATION

Generic Name:
Cefuroxime For lower Most common: Asses for possible
respiratory tract Diarrhea/loose S&S of drug
Brand Name: infection due to S. stools, abdominal reaction.
Zinacef, Ceftin pneumoniae, UTI’s pain & N/V
due to e. coli & skin Asses for anemia &
Route: and skin structure renal dysfunction.
IV due to s. aureus
Dosage:
125 mg/q6

Classification:
Cephalosporin,
Second Generation

DRUG NAME USES SIDE EFFECTS CONSIDERATION

Generic Name:
Ceftriaxone For lower Most common: Asses for possible
respiratory tract Diarrhea, rash, S&S of drug
Brand Name: infection due to S. nausea, pain, reaction.
Rocephin pneumoniae, UTI’s induration
due to e. coli & skin tenderness at Asses for GI disease.
Route: and skin structure injection site
IV due to s. aureus Monitor renal
dysfunction.
Dosage:
250 mg

Classification:
Cephalosporin,
Third Generation

DRUG NAME USES SIDE EFFECTS CONSIDERATION

Generic Name:
Ambroxol HCL A mucolytic agent GI side effects like Asses for possible
used in the epigastric pain, S&S of drug
Brand Name: treatment of gastric fullness may reaction.
Bromussyl, respiratory also occur. Rare
Ambolyt disorders associated allergic responses Asses for GI disease.
with viscid or such as eruption,
Route: excessive mucus. It urticaria & Monitor renal
IV is the active angioneurotic dysfunction.
ingredient of link edema may also
Dosage & Strenth Mucosolvan or link occur.
Syrup 30mg/5 ml Mucoangin.
 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 Normal Values

WBC - 2.4 x 10³/UL Hct % Male 40 – 54
RBC 3.32 x 10/UL Female 37 – 47
HGB - 9.0 g/dl Platelet (10³/L) 140 – 440
HCT - 24.4 % Wbc (x10/L) 4.3 – 10.00
MCV - 73.5 fL Gran % 44.2 – 80.2
MCH 36.9 g/dl (x10/L) 2.0 – 8.8
PLT 1.64 x 10³/UL Lymph (10/L) 28 – 48
LYM % + 62.10 % Mono (10/L) 1.2 – 5.3
MXD 8.6 % Hgb 9/dl Male 14 – 18
Neut % -29.3 % Female 12 – 16
Lym # 1.5 x 10³/UL
Neut # .7 x10³/UL
RDW – 5D -34.5 fL
RDW - cl 12.6 %

COURSE IN THE WARD

Doctor’s Order Interpretation

9/26/08 Please admit patient

TPR shift
For CBC/Chest X ray To determine the cause of
fever & cough
D5 .3NaCl 500 cc @ 30
mgtts/min
Cefuroxime 125 mg IV q6 Initial antibiotic
to (-) ANST
Ambroxol drug – 2 ml tid To relieve cough
Salbutamol Syrup ½ tsp tid To relieve cough &
secretion
Paracetamol drops – 1 ml To relieve fever
q4 if 38°c and above

Aerosol q4 To liquefy secretion

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

9/29/08 Continue medicine

D5 .3NaCl 500cc to follow
9/30/08 MGH
Zinnat 125mg bid Medicine to be taken at
Continue other meds home
Ceferinas ½ od
Appetite Plus – 1 tsp od

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: Predisposing Factors:

• Bacteria * Elderly
• Virus * 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 Pleurisy
(collection of pus & liquid (Inflammation of membrane)
From infected tissue)

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.