c

This is a case of a 3 year old male child, diagnosed with bronchopneumonia. He was

admitted at Southern Negros Doctor¶s Hospital last July 14, 2010 1:22:14 pm with chief

complaints of cough, fever. Onset of cough was three days prior to admission which developed

to shortness of breathe a day prior to admission and fever in the morning on the day prior to

admission. Upon assessment, the group found out that the family just transferred in Sipalay near

a crowded area.

Group 2 BSN 2 Care and interventions for the patient were also limited to the all in all 24 hours

duty of the said dates. The lack of ABG or at least a pulse oximeter in the Pediatric ward of the

hospital prevented the group to monitor accurately the oxygen saturation and over-all gas

exchange of the patient. Culture and Sensitivity Test and Gram Staining were done but results

were not released during duty dates so the group has no knowledge of the exact microorganism

causing the disease. Based on the signs and symptoms, the group assumed that it is of bacterial

origin in constructing the Pathophysiology of the disease.

Our title signifies a certain precautions but in spite of the warnings it yield, sometimes it has

been neglected by the by passers and law violators. In health, there are some certain precautions

too, failure to do so you might end up on a tragic end. Bronchopneumonia is manifested by a

simple cough and fever but the warn that it yields can cause death on young ones if neglected.

In our world today, we live to the awareness we go after and die at our own expense of

neglecting the ±
.

ð
c 

After an hour of case presentation, the student nurse will be able to present the summary

of the different aspect of the client¶s case in order to promote further consciousness and

awareness of the condition for the promotion of health and prevention of further complications as

equally significant to the client¶s wellness.

  c 
c

After an hour of case presentation, the Group 2 together with the BSN 2 students, clinical

instructors and panelist will be able to:

 c Recognize the main factors that causes the disease

c assessment to gather pertinent data about the client as deemed relevant to the case

c name the major health problem of the client

c present the anatomy and physiology

c Discuss the pathophysiology of the client¶s disease condition

c Present laboratory studies conducted therein

c Present other ideal laboratory studies and their implication to support the diagnosis of the

disease.

c Determine the patient¶s family background, previous medical history and history of

present illness

c Create a plan of care appropriate for the client¶s condition

c Develop certain health assessment in regards with the necessary nursing Procedures

appropriate to the client¶s case.

c Evaluate the efficiency of the nursing care provided according to the nursing care plan

K
 
cK  c

Name: Mr. J. M.

Age: 3 Year old

Address: Sipalay City

Date of birth: March 08¶ 2007

Height: 1 feet and 11 inches

Weight: 15 kg

Place of birth: Bacolod City

Civil Status: Single

Name of Mother: J. L. M.

Name of Father: R. M.

No. of Siblings: 1 A. M. 4 Year Old ; Kindergarten

Religion: Roman Catholic

Citizenship: Filipino

Chief Complaint: Fever and cough

Admission Date: 14 July 2010 @ 1:22:14 pm

Admitting Diagnosis: None

Actual Diagnosis: Bronchopneumonia

Attending Physician: A. N. MD.

Date of Discharge: July 21,2010

i
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c

According to the statement of the patient¶s Mother, it was three months past when they

transferred from bacolod to sipalay. Houses are so very crowded in there present location and

their house was place near at the sea. Since then, her child is used to play with some other kids

outside the streets and she don¶t know what her child is eating together with his new friends.

1 week prior to her child¶s admission, Mr. J. M. loss his apetite and has a whooping cough for

several days.Salbutamol was then aided by her mother as a response to relieve the child¶s

coughing but In hours time, they seek a consultation regarding to the child¶s condition and

ended up admitting in SNDH ( Southern Negros Doctor¶s Hospital). Three days of admission,

Fever occurs it was then diagnosed to be a bronchopnuemonia.

K cc 
ci

c

According to the child¶s Mother, there was no indication of hospitalization in the past years of

the child until just now.



ci

c

There are a several cases of asthma in some relatives of the child¶s maternal side.

The parents of the client both manifest (-) history of the following diseases: DM, Hypertension,

Cancer, Asthma as interviewed.

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c

Patient Folks and Patient Chart.

Ki

c
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c

c
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c

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c
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†c 3 year old baby boy
†c Weigh 15 kilograms
†c Short black hair
†c mucus production noted upon coughing
†c Rapid shallow breathing noted
†c Expressed his self through crying
†c Skin is warm to touch
†c Irritability noted due to his condition

c 
cðc

July 14, 2010

1:22 3:30 am
HR: 156 bpm HR: 160 bpm
 RR: 60 cpm RR: 64 cpm
TEMP: 38.3 °C TEMP: 37.8 °C

5:15 am 8:00 am
HR: 150 bpm HR: 162 bpm
PR: 63 cpm PR: 54 cp
TEMP: 38 °C TEMP: 37.3 °C

11:30am
HR: 149 bpm
RR: 38 cpm
TEMP: 37.5 °C

July 15, 2010

5:00 am 8:30 am
HR: 149 bpm HR: 140 bpm
RR: 40 cpm RR: 33 cpm
TEMP: 37.4 °C TEMP: 36.9 °C

c  ð 

†c Skin: warm to touch, he experience on and off fever, with good skin turgor. Negative
of rashes, sores, and lesions.
†c Hair: Short black and equally distributed.
†c Scalp: there in no lumps and lesion noted upon palpation
†c Nalis: clean and well cut
†c Nail beds: Good capillary refill: (Blanch test of 3-5 seconds)
c
c  
†c The patient can able to expressed his self through crying.
†c Restlessness due to coughing
†c With complaints of headache

c 
†c Eyes- flashy conjunctiva due to fever. Eyelashes present curving outward. No lesions
noted on the eyelid. Pupil equal, round, reactive to light and accommodation.
†c Ears- symmetrical in size and pinna aligned to the outer canthus
†c Nose- Nasal flaring and symmetrical in midline.
†c Throat- there is an obstruction as evidence by a wheezing and crackles.

c K

c
c
†c Use of respiratory aids: None
†c ObjectiveRespiratory: Rate: 74 cpm
†c Depth: Rapid shallow breathing
†c Use of accessory muscle: (+) chest retractions
†c Nasal flaring: (+)
†c Breath sounds: Wheeze and crackles noted upon auscultation

c
ðc

 
c
c
†c Patient has a heart rate of 156-140 beats per minute
†c No edema and swelling noted.
 †c Good capillary refill less than 2sec.

ic ð  

c

c
†c Patient had excessive urination, with minimum of 800cc per diaper
c
c ð
  
c
c
†c Flat abdominal contour, no tenderness or distention.
†c Thorax had dullness of sound due to decrease confluent and pleural effusion.
c
c    
c
†c The patient had normal upper and lower extremities, symmetrical and no
tenderness upon palpation
†c No muscle atrophy noted
†c Weakness of muscle due to fever
†c The patient¶s body is appropriate for his age
†c No lesion and edema noted

c  
c
  c

†c Formula Milk per demand. He only eats meats and ignore vegetables .He loves to eat non
nutritional food value.

Ki


c
  c

c
A.c HEAD

†c Black short hair and slightly thin in volume

†c Hair Equally distributed
†c The size of the head is fairly proportion to the body
†c No mass noted upon inspection and palpation
†c With complaints of headache

B.c FACE

†c There is no presence of abnormalities except for the a facial redness due to high
temperature.

C.c EYES
†c Eyes- flashy conjunctiva due to fever.
†c Eyelashes present curving outward.
†c No lesions noted on the eyelid.
†c Pupil equal, round, reactive to light and accommodatio

D.c NOSE

†c Our patient has nasal flaring, any discharges, any swelling and tenderness noted upon
inspection.

E.c MOUTH
†c The patient had a pallor lips, reddened gums, without front teeth.
†c Thin whitish coating noted in the tongue.
 F.c EARS
†c Symmetrical in size and pinna aligned to the outer canthus
†c There is a slight deafness as evidence by a slow response due to his condition.

G.c NECK/ THROAT

†c Neck is symmetrical no palpable lymph nodes.
†c With head can turned from right to left gradually, but with no resistance due to his
condition.

H.c CHEST
†c (+) chest retractions c
†c There is no rib deformities, nodules, and areas of tenderness
†c Crackle sound heard upon auscultation
†c Slight dull sound heard noted upon percussion
†c Characterized pain in the chest at 3 at the pain scale of 5-1 which is 1 is the most
painful.

I.c UPPER EXTREMITIES/ ARMS

cc
†c Both arms can move freely within range of motion
†c Can perform flexion and extension without any hindrance or pain but with no
resistance
†c There is no presence of edema noted upon palpation

J.c ABDOMEN

†c There is a presence of bowel sound noted upon auscultation

†c No mass noted upon deep palpation
†c Abdominal wall moves posterior in a symmetrical fashion with inspiration

K.c BACK/FLANK

†c There is no abnormal mass noted upon palpation

NURSING HISTORY (GORDON¶S FUNCTIONAL HEALTH PATTERN)

Ä c

 
  

According to the patient¶s Mother her child hates whenever he takes a bath and prefer to play

and swims at the nearby sea. The Mother doesn¶t believe in quack doctors and chooses to have

her own remedy when her child caught a fever such as herbal medicines.

¢ c
  
 

According to the patient¶s Mother, her child used to take vitamins every morning after

breakfast; and her child never eats vegetables and only prefers to eat meats. The patient¶s mother

utters that she feed her child with formula milk per demand.
þ c    

According to the patient¶s mother, her child defecates twice a day with color yellow and

mushy stool just about 50 cc. Her child urination frequency is 5-7 times a day with a straw

yellow color just about 100 cc.

! c Ä
 
 

According to the patient¶s mother, her child daily activity is playing with his group of

friends. Her mother states that she and her child walked every time they¶re going to church due

to lack of transportation and this serves as their exercise routine.

 c — 

According to the patient¶s mother, her child used to obey simple commands such picking up

his toys and other small task appropriate to his age.

According to patient¶s Mother she brought her child to take a nap on 2:00 pm until her child

is disturbed by his coughing. Her child use to take several hours to fall asleep again.

- c þ 
  

There is no sign of abnormalities on the client¶s sensory organs and all his five is senses is quite

responsive towards stimulations.

ð c —  
 

Mr. J.M. 3 years old is not in active in his sexual Reproductive Pattern due to his young age.

The child is 2nd in the cardinal of his family and Mr. J.M. is attached to his mother.

c þ —  

According to the patient¶s Mother, Mr. J.M. is always come home crying and always irritated.
v c  ¢ 

.Mr. J.M. always go to church together with his family and as to what his mother stated, ³We

never forgot to teach her child a good manners according to the good etiquettes and the

importance of own culture.´

Anatomy and Physiology of the c  c

The c   is crucial to every human being. Without it, we would cease to live
outside of the womb. Let us begin by taking a look at the structure of the respiratory system and
how vital it is to life. During inhalation or exhalation air is pulled towards or away from the
lungs, by several cavities, tubes, and openings.

The organs of the respiratory system make sure that oxygen enters our bodies and carbon dioxide
leaves our bodies.

The respiratory tract is the path of air from the nose to the lungs. It is divided into two sections:
 c c and the  c c. Included in the upper respiratory
tract are the   ,  c  , K
,  , and the 
. The lower
respiratory tract consists of the  , 
, 
 , and the 
 .

As air moves along the respiratory tract it is warmed, moistened and filtered.
The 
 flank the heart and great vessels in the chest cavity.



c

1.c 
ið or ventilation

2.c  
c K
, which is the exchange of gases (oxygen and carbon
dioxide) between inhaled air and the blood.
3.c  
c K
, which is the exchange of gases between the blood and
tissue fluids.
4.c 
c K


In addition to these main processes, the respiratory system serves for:

›c ð
ccci, which occurs in coordination with the kidneys, and as

a
›c M!
  
 
›c 
c cc   due to loss of evaporate during expiration

 
c
c
c 
 c


is the exchange of air between the external environment and the alveoli. Air moves
by bulk flow from an area of high pressure to low pressure. All pressures in the respiratory
system are relative to atmospheric pressure (760mmHg at sea level). Air will move in or out of
the lungs depending on the pressure in the alveoli. The body changes the pressure in the alveoli
by changing the volume of the lungs. As volume increases pressure decreases and as volume
decreases pressure increases. There are two phases of ventilation; inspiration and expiration.
During each phase the body changes the lung dimensions to produce a flow of air either in or out
of the lungs.

The rhythm of ventilation is also controlled by the "Respiratory Center" which is located largely
in the medulla oblongata of the brain stem. This is part of the autonomic system and as such is
not controlled voluntarily (one can increase or decrease breathing rate voluntarily, but that
involves a different part of the brain). While resting, the respiratory center sends out action
potentials that travel along the phrenic nerves into the diaphragm and the external intercostal
muscles of the rib cage, causing inhalation. Relaxed exhalation occurs between impulses when
the muscles relax. Normal adults have a breathing rate of 12-20 respirations per minute.

 cKc c
c
When one breathes air in at sea level, the inhalation is composed of different gases. These gases
and their quantities are Oxygen which makes up 21%, Nitrogen which is 78%, Carbon Dioxide
with 0.04% and others with significantly smaller portions.

Diagram of the K
.

In the process of breathing, air enters into the nasal cavity through the nostrils and is filtered by
coarse hairs (  ) and mucous that are found there. The vibrissae filter macroparticles,
which are particles of large size. Dust, pollen, smoke, and fine particles are trapped in the
mucous that lines the
 c (hollow spaces within the bones of the skull that warm,
moisten, and filter the air). There are three bony projections inside the nasal cavity. The
 c c
c
c
 c
 . Air passes between these conchae via the nasal
meatuses.


c

During quiet breathing, expiration is normally a passive process and does not require muscles to
work (rather it is the result of the muscles relaxing).


c 



c 
 is the magnitude of the change in lung volume produced by a change in
pulmonary pressure. Compliance can be considered the opposite of stiffness.


c c 
c


c
c

  c
c

c  
c c
c c c c

For the sake of convenience, we will divide the respiratory system in to the upper and lower
respiratory tracts:

 c cc

The upper respiratory tract consists of the nose and the pharynx. Its primary function is to
receive the air from the external environment and filter, warm, and humidify it before it reaches
the delicate lungs where gas exchange will occur.
Air enters through the nostrils of the nose and is partially filtered by the nose hairs, then flows
into the nasal cavity. The nasal cavity is lined with epithelial tissue, containing blood vessels,
which help warm the air; and secrete mucous, which further filters the air. The endothelial lining
of the nasal cavity also contains tiny hairlike projections, called cilia. The p
 serve to transport
dust and other foreign particles, trapped in mucous, to the back of the nasal cavity and to the
pharynx. There the mucus is either coughed out, or swallowed and digested by powerful stomach
acids. After passing through the nasal cavity, the air flows down the pharynx to the larynx.

 c cc

The lower respiratory tract starts with the larynx, and includes the trachea, the two bronchi that
branch from the trachea, and the lungs themselves. This is where gas exchange actually takes
place.

1.c Larynxľ

The larynx (plural larynges), colloquially known as the voice box, is an organ in our neck
involved in protection of the trachea and sound production. The larynx houses the vocal cords,
and is situated just below where the tract of the pharynx splits into the trachea and the esophagus.
The larynx contains two important structures: the epiglottis and the vocal cords.

The epiglottis is a flap of cartilage located at the opening to the larynx. During swallowing, the
larynx (at the epiglottis and at the glottis) closes to prevent swallowed material from entering the
lungs; the larynx is also pulled upwards to assist this process. Stimulation of the larynx by
ingested matter produces a strong cough reflex to protect the lungs. Note: choking occurs when
the epiglottis fails to cover the trachea, and food becomes lodged in our windpipe.

The vocal cords consist of two folds of connective tissue that stretch and vibrate when air passes
through them, causing vocalization. The length the vocal cords are stretched determines what
pitch the sound will have. The strength of expiration from the lungs also contributes to the
loudness of the sound. Our ability to have some voluntary control over the respiratory system
enables us to sing and to speak. In order for the larynx to function and produce sound, we need
air. That is why we canMt talk when weMre swallowing.

1.c Trachea
2.c Bronchi
3.c Lungs

c
c c
 c
Diagram of the 


The cKc
 is the first portion we come to, it then branches off into the
c 
c
,  
c c
, then to the 
 which
have little cartilage and are lined by simple cuboidal epithelium (See fig. 1). The bronchi are
lined by pseudostratified columnar epithelium. Objects will likely lodge here at the junction of
the Carina and the Right Primary Bronchus because of the vertical structure. Items have a
tendency to fall in it, where as the Left Primary Bronchus has more of a curve to it which would
make it hard to have things lodge there.
 K

cc  c

 
 c c

Bronchopneumonia; Community-acquired pneumonia

 

c cK



c

Pneumonia is a respiratory condition in which there is inflammation of the lung.

Community-acquired pneumonia refers to pneumonia in people who have not recently been in
the hospital or another health care facility (nursing home, rehabilitation facility).

 c

 c
c c 

c

Pneumonia is a common illness that affects millions of people each year in the United States.
Germs called bacteria, viruses, and fungi may cause pneumonia.

Ways you can get pneumonia include:

›c Bacteria and viruses living in your nose, sinuses, or mouth may spread to your lungs.
›c You may breathe some of these germs directly into your lungs.
›c You breathe in (inhale) food, liquids, vomit, or secretions from the mouth into your lungs

Pneumonia caused by bacteria tends to be the most serious. In adults, bacteria are the most
common cause of pneumonia.
 ›c The most common pneumonia-causing germ in adults is ppp 
(pneumococcus).
›c Atypical pneumonia, often called walking pneumonia, is caused by bacteria such as
D 


, p
 , and


 .
›c Kp  p pneumonia is sometimes seen in people whose immune system is
impaired (due to AIDS or certain medications that suppress the immune system).
›c 
ppp, 

p
, ppp,   
    , 
 

 , or 
 
 are other bacteria that
can cause pneumonia.
›c Tuberculosis can cause pneumonia in some people, especially those with a weak immune
system.

K
  c

Acute lower respiratory infection, primarily pneumonia, is the leading cause of childhood

death in developing countries, resulting in an estimated four million deaths annually. The two

leading causes of pneumonia in developing countries are ppp and


 
) The current strategy to reduce pneumonia deaths is by appropriate case

management, which focuses on early detection and treatment of pneumonia.

The case management strategy has been a moderate success as demonstrated in several

intervention trials) but such a programme may be difficult to sustain outside a trial setting,

especially in areas with poor access to basic health care. The increasing incidence of

antimicrobial resistance in the pathogens causing pneumonia may further limit its use in the

future. Cotrimoxazole resistance in pneumococci is being increasingly recognized in some

developing countries. In an area of high prevalence of cotrimoxazole resistance in Pakistan, high

rates of treatment failure with cotrimoxazole in patients with severe pneumonia and bacteraemic

pneumonia were observed in comparison to amoxycillin; in patients where pneumococci were

isolated no treatment failures were seen with amoxycillin whereas there was a 28% failure rate

with cotrimoxazole.
 c

Many organisms cause community-acquired pneumonia, including bacteria, viruses, and fungi.
Pathogens vary by patient age and other factors but the relative importance of each as a cause of
community-acquired pneumonia is uncertain, because most patients do not undergo thorough
testing, and because even with testing, specific agents are identified in < 50% of cases.

4 mo to 4 yr - S. pneumoniae, viruses (RSV, parainfluenza viruses, influenza viruses, adenovirus,

rhinovirus, metapneumovirus), Mycoplasma pneumoniae (in older children), group A strepto

K
iKi
ð
c
Precipitating factors Daily
Predisposing factors Age (very Activities
young) Environment
Exposure (living) Diet

Pathological Entry (inhalation) of organism: Bacteria or Viruses

 

 
  




°
  

 




 




 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.
 
 


 

 
 


 


 cc c

ƒc 
ccslower than normal rate (<10 breaths/minute), with normal dept and

regular rhythm

ƒc c 
 ± distressful sensation of uncomfortable breathing that may be caused by

certain heart conditions

ƒc c  c± inflammatory fluid and debris in the pleural space. It results from an

untreated pleural-space infection that progress from free-flowing pleural fluid to a

complex collection in the pleural space.

ƒc ci c decrease in arterial oxygen tension in the blood

ƒc  c

 ± another type of Community Acquired Pneumonia (CAP),

occurs most often in children and young adults and is spread by infected respiratory

droplets through person-to-person contact

ƒc cK c  
± abnormal accumulation of fluid in the pleural space

ƒc cK c ± the area between the parietal and visceral pleurae a potential space

ƒc   
ccc 
± indrawing beneath the breastbone, commonly manifested to

infant and neonate with respiratory distress

ƒc c
  ± insertion of a needle into the space to remove fluid that has

accumulated and decrease pressure on the lung tissue; may also be used diagnostically

to identify potential causes of a pleural effusion

ƒc c c- done to drain fluid, blood, or air from the space around the lungs

c
X-Ray Report

X- Ray no: 10-1664

Date: July 16, 2010

Examination: Chest PA & Lat.

Opacity seen on left lung which leads to consolidation with normal

vascular heart and great vessel are within normal in size pattern and

configuration.

Other chest structures are unremarkable.

IMPRESSION: > Lung revealed evidence of 




Hematology Report Date: 07-18-10

CBC (Complete Blood Count)

TEST NORMAL VALUES RESULT

Hematocrit 35.0-50.0% 33.0

Hemoglobin 12.0-16.5 g/dl 11.0

White cell count 5,000-10,000mm 3,600

Platelet count 150,000-400,000/mm 275,000

Segmenters 55-65% 42

Lymphocytes 25-35% 58

Blood Type B´ RH type(+)

DISCHARGE PLANNING

Objectives:This plan aims to continue treatment and care for client by involving significant
others to participate in plan of care.Treatment:

Instruct the patient¶s mother to continue talking all the medications prescribed by the physician
and return to hospital for follow-up.

Asses mother¶s understanding of treatment regimen as well as concerns of fear

 i
ð cK
ðc



c cc
 c

cð

ccc
c
I.c  


Èc The medication of the patient is very important to continue depending on the duration

that the doctor ordered for the total recovery of the patient.

Vc Cefuroxime (Zinnat 125 mg. suspension ) 1 ½ teaspoon 2x a day for four days.

Vc Salbutamol syrup 1 teaspoon 3x a day 7 am 2pm 8pm

Vc Montelukast ( kasteur ) 4 mg/ tablet 1 tablet at bedtime

Vc Inhalation:

Vc ½ nebule Budesomide + 1 nebule Comsivent + ( salbutamol pondropism) 2x a day

for 5 days

c  
c

Èc Patient with Bronchopneumonia needs to have deep breathing exercise for lung

expansion and clearing for progressive normal breathing pattern and have adequate rest

periods.

Vc The parents of the client advise to establish ROM for their child.

Vc Promote physical activities that establish breathing exercise pattern.

c 
 
c

Èc The client must relax in order to recover his present condition and instructed

significant others for minimal exposure to an open environment such as dusty and smoky

area, which airborne microorganisms are present that can be a high risk factor that may

cause severity of her condition.

Vc Increase fluid intake

Vc Proper rest at appropriate time

Vc Boost immune system by giving the child vitamins

 c i
ð 
c

Èc It is also important to maintain proper hygiene to prevent further infection.

Significant others of the patient instructed that the toddlers should be bathe everyday.

Vc Always change the clothes to a clean one

Vc Always aid the child to cut the finger nails

c cK
 c i K

c

Èc Follow up check up on July 28, 2010, Wednesday 2pm at OPD of Southern Negros

Doctor¶s Hospital.

Vc Regular consultation to the physician can be factor for recovery to assess and monitor

his condition

c  
c

Èc The diet of the patient is also a factor for fast recovery. Encouraged to eat

nutritious foods intended for respiratory problem patient, the family of the patient plays

a big role for the fast recovery

Vc The mother instructed to encourage her child to eat vegetable especially those

green leafy vegetables

Vc Avoid to let her child eat street food like processed foods
 OUTLINE

I.c Introduction

II.c Objectives: General and Specific

III.c Patient Profile

IV.c Physical Assessment

By System

Cephalocaudal

V.c Nursing History

(Gordon¶s Functional Health Pattern)

VI.c Anatomy and Physiology

VII.c Overview of the Disease

VIII.cEtiology and Pathophysiology

IX.c Laboratory Results

X.c Drug Study

XI.c Nursing Care plan

XII.c Discharge Plan