POLYTECHNIC COLLEGE OF DAVAO DEL SUR MacArthur Highway, Digos City

A CASE STUDY OF Empyema Thoracis, Left secondary to BPN severe Community Acquired Pneumonia s/p Chest Thoracostomy Tube

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS IN RLE/NCM 103

Presented to Mr. Sajid S. Uy, RN

Presented by Radee King R. Corpuz

May, 2009

INTRODUCTION

Pneumonia is an inflammation of the lungs caused by an infection. It is also called Pneumonitis or Bronchopneumonia. Pneumonia can be a serious threat to our health. Although pneumonia is a special concern for older adults and those with chronic illnesses. It can also strike and young and healthy people as well. It is a common illness that affects thousands of people each year in the Philippines, thus, it remains an important cause of morbidity and mortality in the country. There are many kinds of pneumonia that range in seriousness from mild to life-threatening. In infectious pneumonia, bacteria, viruses, fungi or other organisms attack the lungs, leading to inflammation that makes it hard for an individual to breathe. Pneumonia can affect one or both lungs. In young and healthy individual, early treatment with antibiotics can cure bacterial pneumonia. The drugs used to fight pneumonia are determined by the germ causing pneumonia and the doctors findings.. It is best to do everything we can to prevent pneumonia, but if one get sick, recognizing and treating the disease early offers the best chance for a full recovery.

A case with a diagnosis of Pneumonia may catch ones attention, though the disease is just like an ordinary cough and fever, it can lead to death especially when there is no immediate intervention done. Since the case is a toddler, an appropriate care has to be done to promote faster recovery for the patient. Treating patients with pneumonia is necessary to prevent its spread to others and make them as another victim of this illness. Bronchopneumonia is an illness of the lungs 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 6% in mortality rate. 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. In United States, pneumonia is the most common cause of death from infectious diseases. It accounts for almost 66,000 deaths per year and ranks as the seventh leading cause of death in the United States (Brunner and Suddarths Medical-Surgical Textbook, pp 628/pneumonia). In Philippines, the case of pneumonia is one of leading cause of mortality and morbidity among Filipinos, 75-85% of the population acquired the disease and the one affected the disease are those who are in low income status and the below poverty line individual. (www.DOH.org/pneumonia) Our patient Baby C, was 1 year old, living at Gravahan, Matina Proper, Davao City, was admitted at Davao Medical Center last March 28, 2009, at 6:37pm, with chief complain of difficulty of breathing. According to her mother, she noticed that her baby is having substernal retraction with rapid shallow breathing while asleep. The family immediately took the baby to Davao Medical Center, and was diagnosed with BPN severe, Community Acquired Pneumonia. Weeks after, the doctors suggested for placement of chest thoracostomy tube, due to the accumulation of pus in the pleural space.

IDENTIFICATION OF THE CASE A. PERSONAL PROFILE Name Address Age Gender Civil status Occupation Admitting Doctor : Baby C : Gravahan, Matina Proper, Davao City : 1 year : Female : Single : none : Dr. Veralou L. Sojor

Admitting Diagnosis : Empyema Thoracis, Left secondary to BPN severe Community Acquired Pneumonia s/p Chest Thoracostomy Tube Religion Nationality Spouse name Occupation Chief Complaint B. Background/History DM Maternal Paternal HPN CA ASTHMA : Roman Catholic : Filipino : Mr. J : Mini Store owner : Difficulty of breathing, Dyspnea

Educational Attainment: none

Date of admission : March 28, 2009; 6:37pm

The parents of the client both manifest negative (-) history of the following diseases: DM, Hypertension, Cancer, Asthma as interviewed.

C. Medical History According to the medical history of the client, Baby C had no other diagnosed illness except, bronchopneumonia, before the patient experienced episodic fever and cough due to environmental factor. Baby C. was hospitalized due to persistent cough with yellowish mucus secretion. Baby C had completed the immunization process done in there Barangay Health Center. D. History of Present Illness 4 days prior to admission, Baby C experienced on and off high fever, with substernal retraction, rapid and shallow breathing. With yellowish mucus secretion present productively. E. Socio-economic background The family of baby C was very supportive, they have provided all her medication. Specially her medicine and payments for other diagnostic procedures to be done for her early and faster recovery

DEFINITION OF TERMS

Bradypnea slower than normal rate (<10 breaths/minute), with normal dept and regular rhythm (Brunner and Suddarts Medical-Surgical Textbook, Chpt 21,pp 572) Dyspnea distressful sensation of uncomfortable breathing that may be caused by certain heart conditions(Brunner and Suddarts Medical-Surgical Textbook, Chpt 23,pp 625) Empyema inflammatory fluid and debris in the pleural space. It results from an untreated pleural-space infection that progresses from free-flowing pleural fluid to a complex collection in the pleural space. (Brunner and Suddarts MedicalSurgical Textbook, Chpt 23,pp 625) Hypoxemia decrease in arterial oxygen tension in the blood (Brunner and Suddarts Medical-Surgical Textbook, Chpt 21,pp 625) Mycoplasma pneumonia 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(Brunner and Suddarts Medical-Surgical Textbook, Chpt 23,pp 630) Pleural effusion abnormal accumulation of fluid in the pleural space(Brunner and Suddarts Medical-Surgical Textbook, Chpt 23,pp 625) Pleural cavity the area between the parietal and visceral pleurae a potential space(Brunner and Suddarts Medical-Surgical Textbook, Chpt 23,pp 625)

Substernal Retraction indrawing beneath the breastbone, commonly manifested to infant and neonate with respiratory distress(Fundamentals of Nursing, Seventh Edition, Vital Signs unit VII, pp 507) Thoracentesis 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(Brunner and Suddarts Medical-Surgical Textbook, Chpt 23,pp 625) Thoracostomy - done to drain fluid, blood, or air from the space around the lungs(Brunner and Suddarts Medical-Surgical Textbook, Chpt 23,pp 625)

ANATOMY AND 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. 8

The

respiratory system can be conveniently subdivided into an upper respiratory tract (or conducting zone) and lower respiratory tract (respiratory zone), trachea and lungs. The conducting zone starts with the nares (nostrils) of the nose, which open into the nasopharynx (nasal cavity). The primary functions of the nasal passages are to: 1) filter, 2) warm, 3) moisten, and 4) provide resonance in speech. The nasopharnyx opens into the oropharynx (behind the oral cavity).

The oropharynx leads to the laryngopharynx, and empties into the larynx (voicebox), which contains the vocal cords, passing through the glottis, connecting to the trachea (wind pipe). The trachea leads down to the thoracic cavity (chest) where it divides into the right and left "main stem" bronchi. The subdivision of the bronchus are: primary, secondary, and tertiary divisions (first, second and third levels). In all, they divide 16 more times into even smaller bronchioles. The bronchioles lead to the respiratory zone of the lungs which consists of respiratory bronchioles, alveolar ducts and the alveoli, the multi-lobulated sacs in which most of the gas exchange occurs.Ventilation of the lungs is carried out by the muscles of respiration. Ventilation occurs under the control of the autonomic nervous system from the part of the brain stem, the medulla oblongata and the pons. This area of the brain forms the respiration regulatory center, a series of interconnected neurons within the lower and middle brain stem which coordinate respiratory movements. The sections are the pneumotaxic center, the apneustic center, and the dorsal and ventral respiratory groups. This section is especially sensitive during infancy, and the neurons can be destroyed if the infant is dropped or shaken violently. The result can be death due to "shaken baby syndrome. Inhalation is initiated by the diaphragm and supported by the external intercostal muscles. Normal resting respirations are 10 to 18 breaths per minute. Its time period is 2 seconds. During vigorous inhalation (at rates exceeding 35 breaths per minute), or in approaching respiratory failure, accessory muscles of respiration are recruited for support. These consist of sternocleidomastoid, platysma, and the strap muscles of the neck. Inhalation is driven primarily by the diaphragm. When the diaphragm contracts, the ribcage expands and the contents of the abdomen are moved downward. This results in a larger thoracic volume, which in turn causes a decrease in intrathoracic pressure. As the pressure in the chest falls, air moves into the conducting zone. Here, the air is filtered, warmed, and humidified as it flows to the lungs.

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During forced inhalation, as when taking a deep breath, the external intercostal muscles and accessory muscles further expand the thoracic cavity. Exhalation is generally a passive process, however active or forced exhalation is achieved by the abdominal and the internal intercostal muscles. The lungs have a natural elasticity; as they recoil from the stretch of inhalation, air flows back out until the pressures in the chest and the atmosphere reach equilibrium. During forced exhalation, as when blowing out a candle, expiratory muscles including the abdominal muscles and internal intercostal muscles, generate abdominal and thoracic pressure, which forces air out of the lungs. The right side of the heart pumps blood from the right ventricle through the pulmonary semilunar valve into the pulmonary trunk. The trunk branches into right and left pulmonary arteries to the pulmonary blood vessels. The vessels generally accompany the airways and also undergo numerous branchings. Once the gas exchange process is complete in the pulmonary capillaries, blood is returned to the left side of the heart through four pulmonary veins, two from each side.

The pulmonary circulation has a very low resistance, due to the short distance within the lungs, compared to the systemic circulation, and for this reason, all the pressures within the pulmonary blood vessels are normally low as compared to the pressure of the systemic circulation loop. Virtually all the body's blood travels through the lungs every minute. The lungs add and remove many chemical messengers from the blood as it flows through pulmonary capillary bed . The fine capillaries also trap blood clots that have formed in systemic veins. The major function of the respiratory system is gas exchange. As gas exchange occurs, the acid-base balance of the body is maintained as part of homeostasis. If proper ventilation is not maintained two opposing conditions

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could occur: 1) respiratory acidosis, a life threatening condition, and 2) respiratory alkalosis. Upon inhalation, gas exchange occurs at the alveoli, the tiny sacs which are the basic functional component of the lungs. The alveolar walls are extremely thin (approx. 0.2 micrometres), and are permeable to gases. The alveoli are lined with pulmonary capillaries, the walls of which are also thin enough to permit gas exchange. All gases diffuse from the alveolar air to the blood in the pulmonary capillaries, as carbon dioxide diffuses in the opposite direction, from capillary blood to alveolar air. At this point, the pulmonary blood is oxygen-rich, and the lungs are holding carbon dioxide. Exhalation follows, thereby ridding the body of the carbon dioxide and completing the cycle of respiration. In an average resting adult, the lungs take up about 250ml of oxygen every minute while excreting about 200ml of carbon dioxide. During an average breath, an adult will exchange from 500 ml to 700 ml of air. This average breath capacity is called tidal volume. The respiratory system lies dormant in the human fetus during pregnancy. At birth, the respiratory system is drained of fluid and cleaned to assure proper functioning of the system. If an infant is born before forty weeks gestational age, the newborn may experience respiratory failure due to the under-developed lungs. This is due to the incomplete development of the alveoli type II cells in the lungs. The infant lungs do not function due to the collapse of the alveoli caused by surface tension of water remaining in the lungs. Surfactant is lacking from the lungs, leading to the condition. This condition may be avoided if the mother is given a series of steroid shots in the final week prior to delivery. The steriods accelerate the development of the type II cells.

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A transverse section of the thorax, showing the contents of the middle and the posterior mediastinum. The pleural and pericardial cavities are exaggerated since normally there is no space between parietal and visceral pleura and between pericardium and heart

In human anatomy, the pleural cavity is the body cavity that surrounds the lungs. The lungs are surrounded by the pleura, a serous membrane which

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folds back upon itself to form a two-layered, membrane structure. The thin space between the two pleural layers is known as the pleural space; it normally contains a small amount of pleural fluid. The outer pleura (parietal pleura) is attached to the chest wall.

The inner pleura (visceral pleura) covers the lungs and adjoining structures, i.e. blood vessels, bronchi and nerves. The parietal pleura is highly sensitive to pain; the visceral pleura is not, due to its lack of sensory innervation. The pleural cavity, with its associated pleurae, aids optimal functioning of the lungs during respiration. The pleurae are coated with lubricating pleural fluid which allows the pleurae to slide effortlessly against each other during ventilation. Surface tension of the pleural fluid also leads to close apposition of the lung surfaces with the chest wall. This physical relationship allows for optimal inflation of the alveoli during respiration. Movements of the chest wall, particularly during heavy breathing, are coupled to movements of the lungs since the closely opposed chest wall transmits pressures to the visceral pleural surface and, hence, to the lung itself.

ETIOLOGY AND SYMPTOMATOLOGY

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Etiology
Ideal Predisposing Factor Actual Justification Specifically 6 months and above children has low immune system, that cant resist any bacterial infection, such as airborne transmission. Our patient is, 1 year old baby girl and she acquires the said disease in their community The family of the pt owned a little sari-sari store, which is the source of the familys income and which is situated near the road, as interviewed the client was often baby sited at their store Daily activities of an individual can be a causal factor of the disease. Playing is the common activity at a very young age (1y/o). This individual is not conscious of the environment. The patient common food intake are rice, hotdogs, eggs, chocolates, candies, sometimes fruits ( banana ), combination of breast and formula milk. Such as exposure to certain viruses and foods early in life, may trigger the autoimmune response. Our patient is living in a poor environment, because theyve live in a dusty place where near the highway, where many vehicle passed by. Vehicular smoke and dust particles can be the carrier of the bacteria, viruses.

Age

(+)

Exposure (living) Precipitating Factors Daily Activities

(+)

(+)

Diet

(+)

Mycoplasma pneumonae and environmental factors

(+)

Symptomatology

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Ideal

Actual

Justification
The bronchioles contain submuscosal gland, which produce mucus that covers the inside lining of the airways. Infected bronchioles produce greenish or yellow mucus secretions. On and Off high fever, cause by infection in the body, invaded by specific viruses or bacteria, our body produces body defenses in order to fight. Caused by infection in the lining of the airway Presence of foreign pathogens, and fluid accumulation in the airway lining may cause slow breathing pattern, depth and rhythm Accumulation on the lining of airway, presence of mucus secretion and pathogenic bacteria invades in the body Due to compensatory mechanism such as low immune response, any infection due to a disease will result to the loss of appetite

Cough with greenish or yellow mucus

(-)

Fever
(+)

Chest pain

(-)

Bradypnea

(+)

Shortness of breath

(+)

Loss of appetite
(+)

(poor feeding)

COMPLICATION 16

Empyema is 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. Empyema most commonly occurs in the setting of bacterial pneumonia. About 20-60% of all cases of pneumonia are associated with parapneumonic effusion. With appropriate antibiotic therapy, parapneumonic effusions most often resolve without complications, and they are of little clinical significance. The resulting infection and inflammatory response can proceed until adhesive bands form. The infected fluid becomes loculated pus in the pleural space. Pleurisy is an inflammation of both layers of the pleurae (parietal and visceral). Pleurisy may develop in conjunction with pneumonia or an upper respiratory tract infection, TB, or collagen disease: after trauma to the chest, pulmonary infarction, or PE; in patients with primary or metastatic cancer; and after thoracostomy. The parietal pleura has nerve endings; the visceral pleura does not. When the inflamed pleural membranes rub together during respiration.

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. Pericarditis

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Refers to an inflammation of the pericardium, the membranous sac enveloping the heart. It may be a primary illness or it may develop during various medical and surgical disorders. One of the cause of pericardits, is disorders of adjacent structures: myocardial infarction, dissecting aneurysm, pleural and pulomonary disease (pneumonia)

PATHOPHYSIOLOGY

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Predisposing factors Age (very young) Gender Exposure (living)

Precipitating factors Daily Activities Environment Diet

Pathological Entry (inhalation) of organism: Bacteria or Viruses

Occurrence of localized inflammation

Mucus production Bacteria invades alveolar cell in the lungs

Manifested by wheezing

Diminished surfactant production Formation of Hyaline membrane

Bronchopneumonia
Pulmonary Edema

Airway Obstruction

Sign and Symptoms Fever Cough Chest pain Rapid, shallow breathing Shortness of breath Headache Loss of appetite Fatigue

Chest Thoracostomy Tube

If disorderDaily Activities
Environment Diet

urs:
Empyema Lung Abscess Pleurisy Pericarditis

If disorder is Treated, Normal breathing pattern Normal respiratory rate and Breath sounds

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Etiologic agents gain entry into the respiratory tract through either inhalation or aspiration of secretions. The pathogen creates a localized inflammatory reaction on the airway mucosa that results in swelling and increased mucus production. Significant inflammation and obstruction may result in wheezing. As entering the pathogen in the body compensatory mechanism: body line of defense such as cilia, whipping motion that propels mucus and foreign substances away from the lungs toward the lungs, for expectoration. As more pathological microorganism into the respiratory tract, cilia may injure in some way, the escalator or the whipping mechanism may have less effective. The bacteria or viruses as progressively entering into the lungs, it may reach to alveolar cell, type II cells lose their structural integrity and surfactant production is diminished, a hyaline membrane forms, and pulmonary edema develops. Accumulation of mononuclear cells in the submucosa and perivascular space, resulting in partial obstruction of the airway. They clinically manifest as wheezing and crackles. Hematogenous spread of bacteria from an extra-pulmonary infection site bacteria from another infected site can be carried in the blood to the lungs 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 ventialtion

MEDICAL MANAGEMENT Under Dr. Veralou L. Sojor, M.D 20

03/28/09 Admit patient at IMCU transferred to SVIX under blue level II o v/s q 4hr, BF with SAP o CBC, Pt. U/A o CXR IVF D5IMB at 20cc/hr Meds: o Chloramphenicol at IVTT q8hr o Paracetamol, PRN o Salbutamol Nebuli 03/29/09 Ff up CBC Ff U/A Ff up CXR 03/30/09 For ABG, CBC, PC and U/A Continue IVF at same rate Continue Meds o Start chloramphenicol o Cefuraxime 335mg IVTT q8hrs o Amikaxin 75mg IVTT, OD o Decrease Salbutamol Neb, q4 03/31/09 Still for Na+, K+, Ca+, Mg+ Still for LP Review CXR-APL Continue IVF at same rate as ordered Continue Meds: o Cefutaxime o Amikacin o Paracetamol 04/01/09 V/S q4 with O2 Sat Still for NPO LP done, place pt on bed flat x4hrs 04/02/09

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Rpt CXR-APL today Ff up CSF analysis, GS/CS Ff up sugar and protein Continue Meds: o Cefutaxime o Amikacin o Paracetamol o Cloxacilline

04/17-24/09 D5IMB at 45cc/hr Meds: o Cloxacilline (D12) o Pencillin Mg (D9) o V/S q4hr 04/18/09 Cloxalline (D12-13) Pencillin Mg (D10) 04/19/09 Cloxalline (D13-14) Pencillin Mg (D10) 04/20/09 Cloxalline (D14) Pencillin Mg (D11) 04/22/09 Cloxalline (D15) Pencillin Mg (D12) 04/23-24/09 Cloxalline (D13) Pencillin Mg (D11)

04/25/09 04/26/09 Retained CTT Drained every shift 04/27/09 D5IMB at 45cc/hr Meds: o Pencillin (D13) o Cloxacilline (D15) Cloxalline (D14) Pencillin Mg (D12) Rpt CXR APL Insert CTT

Mg

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Laboratory Hematology
Test CBC+Plt Result Hemoglobin H 3.5 Hematocrit .50 RBC H 6.59 WBC H 4.52 Neutrophil L 48 Lymphocytes 26 Monocytes 4 Eosinophil 4 Basophil 0 Platelet count 200,000/cu mm Normal Clinical Values Significance F: 1.86- Obstructive 2.48 Pulmonary dse, mmol/L Failure of oxygenation F: 0.37- dehydrated 0.47 F: 4.2- Pulmonary disease 5.4 5.0-10.0 Overwhelming viral infection 55-75 Viral infection 20-40% 2-10 1-8 0-1 Remarks -increased-increased-increased-decreased-decreased- normal range-normal range-normal range-normal range-normal range-

Laboratory Chemistry
Test Na+ K+ Ca+ Serum Mg+ Result 144.00 H 5.9 2.50 H 1.42 Normal Values 135-145mmol/L 3.5-5mmol/L 2.15-2.55 mmol/L 0.62-0.95mmol/L Clinical significance Tissue breakdown Excess ingestion of Mg+-containing antacids -increasedRemarks -normal range-increased-normal range-

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Laboratory ABG
Test pH pCO2 HCO3 O2 Sat Cf CO2 PO2 Result 7.42 41.6 27.6 98.2% 28.6 74.0 Normal Values 7.35-7.45 35-45 22.0-27.0 80-100% 23.0-30.0 Chronic 80-100 obstructive lung disease -decreasedDepressed respiration Clinical significance Remarks -normal range-normal range-increased-normal range-normal range-

MEDICAL MANAGEMENT

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Ideal Management Antibiotics are prescribed based in Gram stain results and antibiotic guidelines (resistance patterns, risk factors, etiology must be considered). Combination therapy may also be used. Supportive treatment includes hydration, antipyretics, antihistamines, or nasal decongestants. Bed rest is recommended until infection shows signs of clearing Oxygen therapy is given for hypoxemia Respiratory support includes endotracheal intubation, high inspiratory oxygen concentrations, and mechanical ventilation Treatment of atelectasis, pleural effusion, shock, respiratory failure, or superinfection is instituted, if needed For groups at high risk for community-acquired pneumonia, pneumococcal vaccination is advised Increased fluid intake to thin viscous and tenacious secretions

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NURSING ASSESSMENT
Physical Assessment

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Neurological The patient had a GCS score of 11, she can able to express self through crying and understand given by her mother, patient is able to interact person-to-person. Eye/Vision Our patient, have pale conjunctiva due to high grade fever and generalized weakness upon admission Ears/Hearing Our patient doesnt have hearing problem, no discharges, symmetrical, no swelling and tenderness. Can respond normal voice tone Nose Our patient doesnt have nasal problem, no discharges, no swelling and tenderness noted upon inspection and, uniform in color. Mouth/Tongue/Teeth/ Speech The patients had a crack and pallor lips, reddened gums, with distant teeth. And the patient had a slurred speech. Tongue is slightly pale. Throat/Neck Neck is symmetrical with head, can turned head from right to left gradually, but with resistance, no palpable lymph nodes

Respiratory System

29

Patient use accessory muscle in order to breathe normally, presence of wheezes and rales is heard upon auscultation and in normal hearing, with respiratory rate of 48cpm Circulatory/Cardiovascular Patient has an O2 Sat of 98%, heart rate of 90bpm, and and blood pressure reading of 80/50, pulse rate was 130bpm with skipping beats. No edema, swelling, good capillary refill less than 3secs. Gastrointestinal Flat abdominal contour, audible bowel sound, no tenderness or distention. Thorax had dullness of sound due to decrease confluent and pleural effusion Genitourinary Patient had excessive urination, with minimum of 800cc per diaper Muscoloskeletal The patient had normal upper and lower extremeties, symmetrical and no tenderness, Integumentary The patienst skin was warm to touch,with temperature of 38C , febrile,with good skin turgor

NURSING MANAGEMENT

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NURSING ASSESSMENT AND DIAGNOSIS Assess for fever, chills night sweats, pleuritic-type pain, fatigue, tachypnea, use of accessory muscle, bradycardia or relative bradycardia, coughing, and purulent sputum, and auscultate breath sounds for consolidation Note changes in temperature, pulse; amount, odor, and color of secretions; and breath sounds Frequency and severity of cough Degree of tachypnea or shortness of breath Changes in chest x-ray findings Assess the characteristic of drained pus from the lungs of the patient. Assess for complication, including continuing or recurring fever, failure to resolve, atelectasis, pleural effusion, cardiac complication, and superinfection Encourage bronchial hygiene, such as increased fluid intake and directed coughing to remove secretions. Put patient into moderate high back rest for lung expansion and clearing, and to cough effectively and prevent retention of mucopurulent sputum,

NURSING THEORIES
Florence Nightingale

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Her Notes on Nursing emphasized that a clean environment, warmth, ventilation, sunlight, and a quiet environment lead to good health. Reaction: a non-stimulating environment is essential especially for our patient, in a way that it promotes faster recovery on our patient through minimizing external and stressful stimuli such as limiting visitors during resting periods that may worsen the situation of our client. Virginia Henderson Virginia Henderson defined nursing as "assisting individuals to gain independence in relation to the performance of activities contributing to health or its recovery"

Hildegard Peplau Hildegard Peplau used the term, psychodynamic nursing, to describe the dynamic relationship between a nurse and a patient. She identified nursing roles of the nurse and in our case this three roles fitted us for our client: Counseling Role - working with the patient on current problems Teaching Role - offering information and helping the patient learn Reaction: As a nursing student, we had many roles to perform to our patient. One of these roles is being a councilor. As a councilor, it is our duty to lessen if not alleviate the clients problem.

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HEALTH TEACHINGS PRIMARY 37

1. 2.

Instruct the SO to have patient an oxygen therapy for continuous normal breathing, and or breathing exercise Instruct the SO to kept the patient away in open place such as in road where their store located and dusty place, to prevent inhalation of airborne microorganisms Instruct the SO to maintain the patient proper diet that she can tolerate, such as fruits, to help promote wellness. Advice the SO to monitor patients fluid intake or adequate hydration, to help her body re-hydrate to prevent fluid imbalance. Instruct SO to assist patient in performinf self-hygience activities she cannot tolerate, to help her maintain her activities of daily living. Encourage SO to perform self care activities within her level of own ability Assist patient to perform as much as possible and then to call for assistance. Collaborate with patient for progressive activity before and after schedule activity. SECONDARY 1. Administer medications regularly as ordered by the physician 2. Advice SO to the patient to have proper nutrition to enhance immune system TERTIARY 1. Instruct SO to comply patients medication regimen 2. Discuss the importance of having a regular check-up with his physician, with the mother or with the parents.

3. 4. 5. 6. 7.

DISCHARGE PLAN When the doctor noted that the patient is for discharge it is very important to continue the medication depending on the duration the doctor ordered for the total recovery of the patient. Patient with Bronchopneumonia severe Community

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Acquired Pneumonia needs to have deep breathing exercise for lung expansion and clearing for progressive normal breathing pattern and have adequate rest periods. It is also important to maintain proper hygiene to prevent further infection. The client must relax in order to recover her 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. 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. Regular consultation to the physician can be factor for recovery to assess and monitor her condition

M- advice SO not to skip patients medication that the doctor ordered

E- instruct SO, keep away the patient in smoky area or dusty environment T- oxygen therapy, for maintenance H- separate utensils for the patient and other personal things that will be use for the whole family O- provide SO information about how to control or prevent the spread of the disease, present on your patient D- encourage patient to eat nutritious food such as vegetable and fruits especially those that contains vitamin C S- provide emotional support and provide care for the mother

PROGNOSIS Good Poor Justification

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Duration of Illness Onset of Illness Compliance to Medication Family Support Environment

Age

Precipitating Factors

Duration of illness is good since the condition occur and she was given ample treatment. At the onset of illness, the patient experienced poor respiration (DOB) Patient can afford to sustain the needed laboratory exams and the feasibility of having the condition The family members supported the patient both financially and emotionally. The hospital setting is not well ventilated and may promote for further infection of the patients current situation. Patient is 1 year old therefore she has a good chance of recovering for her immune system is still generating in the process of development. The patient manifested all the factors that may lead to Bronchopneumonia sev, CAP which urged the family and the health provider to set-up the proper action

Percentage Good: 4/7x100=42.85/43% Poor: 3/7x100= 57.14/57% Overall Prognosis The prognosis is good, because the duration of illness, compliance of medication, family support and age are the contributing factors that result to have a good prognosis

EVALUATION

40

Through our hardship in preparing for this research, as we try to interact and communicate to our patient and her family in a good manner for us to gather the specific and accurate data that we needed that could help us in studying the disease which could lead us into successful research. The patients condition is in recovery period as she had already undergone medication therapy for her present condition, which thereby prevented occurrence of complications. They are financially capable in sustaining such respiratory condition and the medications after. Her mother is the one taking good care of her in throughout her hospitalization, giving emotional and moral support.

IMPLICATION

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Nursing Practice this can be used as a guide for practice by other nurses. They may get many relevant ideas in giving proper care and interventions to patients with related illness or those who have the same illness (BPN severe with Community Acquired Pneumonia)

Nursing Education this study may serve as a helpful learning tool for student nurses. They may utilize this complied study as their reference for research; this will also give them good examples on nursing managements, and nursing diagnoses, which will be a very useful guide when they will be making their own Nursing Care Plans.

Nursing Research - students may use this compilation as their guide for research. This will hand them good views and factual ideas which will be very essential for their added learning on knowledge for BPN severe with Community Acquired Pneumonia

REFERENCES

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Medical-Surgical, Brunner and Suddart 11th Ed, Respiratory function and Gas Exchange/pneumonia, pp 628-631

Medical-Surgical, Brunner and Suddart 11th Ed, Diagnostic Test and Results, pp 2148-2152

Handbook for Medical-Surgical Nursing, 11th Ed, Management for Respiratory function,pneumonia, pp665-668

www.americanthoracicsociety.com/ thoracostomy http://www.springerpub.com/prod.aspx?prod_id=72628 wikipedia.org/wiki/Pneumonia wikipedia.org/wiki/Pleural cavity www.medicinenet.com/Bronchopneumonia/article.htm www.who.int/topics/bronchopneumonia www.DOH.org/bronchopneumonia_prevalence www.vetmed.wsu.edu/ClientEd/diabetes

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