COLEGIO DE SAN JUAN DE LETRAN – CALAMBA

School of Nursing
Bo. Bucal, Calamba City

Case Study
On

Acute Bronchitis

Submitted by:
Alcantara, Aris N.
3BSN1/Group 1

Submitted to:
Ms. Marissa Nobleza RN MAN

August 24, 2009

 COLEGIO DE SAN JUAN DE LETRAN – CALAMBA
Nursing Department
Calamba City, Laguna

NAME OF STUDENT: Alcantara, Aris N.

AREA: St. John Hospital SHIFT: 6:00 AM – 2:00 PM DATE: August 17, 2009
CLINICAL INSTRUCTOR: MS. MARISSA NOBLEZA RN MAN

I. PATIENT’S PROFILE

Name: L.K.C.E
Age: 1 y.o
Sex: Male
Address: Barandal, Calamba City
Birthday: April 14, 2008
Birthplace: Calamba City
Civil Status: Child
Religion: Roman Catholic
Citizenship: Filipino
Occupation: None
Date of Admission: August 17, 2009
II. CHIEF COMPLAINT

2 days of fever with cough and cold, 37.6 °C

III. PRESENT HEALTH HISTORY

 3 days prior to admission the patient has fever with cough and cold.
 1 day prior to admission his parents brought him to his Pedia and Antibiotic (Cefalexin) was given to him. His Pedia
advised his parents to stay at the hospital for further treatment of the patient.

IV. PAST HEALTH HISTORY

 General Health – Weak looking child, restless and irritable.
 Childhood Illnesses – March 2009 the patient had amoebiasis.
 Accident and Injuries – None
 Hospitalization – March 2009 because of amoebaiasis
 Immunization – The patient is fully immunized.
 Allergies – None
 Surgeries – None
 Geographic Location – client’s residence is in a subdivision that is away from the highway and not an accident prone
area. There is a Health center near their house for accessibility for health facilities.
V. FAMILIAL HISTORY

M. L 65 y.o C. E 67 yo J.E 62 y.o

B.L 62 y.o
CVA A&W HPN
A&W

R.L 31 y.o C. E 30 y.o

K.E.L
A & W8 y.o K.E.L
HPN 1 y.o

A&W A&W

LEGEND:

Male Female Patient deceased A&W – Alive & Well

VI. REVIEW OF SYSTEMS/PHYSICAL EXAMINATION (August 12, 2009)

 REVIEW OF SYSTEM PHYSICAL EXAMINATION
A.General / Overall health status > received patient conscious, awake and coherent lying on bed
> with IVF of D5LR 500ml @ 30gtts/min infusing well
> RR = 34 cpm
> PR = 138 bpm
> Temp = 37.6°C
> (+) weakness
> (+) productive cough

B. Integument Skin

> Inspection
- brown skin color
- good skin turgor
- (-) scaling
- (-) cyanosis
- (-) edema
- (-) dryness
> Palpation
- (+) smooth and flabby skin
- (-) edema

Hair
> Inspection
- black hair evenly distributed
- wavy hair
- (-) dandruff

Nails
> Inspection
- clean, well trimmed nails
 - pink nail beds
- (-) clubbing of fingers
> Palpation
- poor capillary refill (>3 seconds)
- smooth on surfaces
- skin warm to touch
C. Head > Inspection
- normocephalic
- bilaterally symmetric
- (-) lesions
>Palpation
- (+) smooth surface

D. Eyes > Inspection

- bilaterally symmetrical
- iris round, dark brown in color
- eyeballs moist and glossy
- (+) PERRLA
- (+) pinkish upper and lower conjunctiva

E. Ears > Inspection

- bilaterally symmetrical
- (-)swelling
- (-) lesions
- (-) discharges
- (-) impaired hearing
> Palpation
- pinna recoils after it is folded

F. Nose and Sinuses > Inspection

- bilaterally symmetrical
 - nasal septum at midline
- no deformities
- (+) colds
- (-) swelling
- (-) lesions
- (-) epistaxis
- (-) nasal flaring

G. Mouth and Throat Lips

> Inspection
- symmetrical lips
- red lip color
- (-) dry lips

Mouth
> Inspection
- pinkish gum color
- tongue in the midline

H. Neck > Inspection

- (+) bounding carotid artery
- (-) lesions
- (-) inflammation
> Palpation
- trachea at midline
- (-) swollen lymph nodes

I.Neurologic > Inspection

- Loc: Conscious and Coherent

J.Lymphatic >Palpation
- No palpable lymph nodes
K. Breast and axillae > Inspection
- bilaterally symmetrical
- color the same as skin tone of extremities
- dark pigmented, not inverted, bilaterally symmetrical
nipples
- (-) lesions

L. Respiratory > Inspection

- use of accessory muscles in breathing
- (-) noisy breathing
- (+) shallow respirations
- RR = 34 cpm
- (+) cough
- (+) productive cough
> Palpation
- bilateral chest expansion
> Auscultation
- (+) crackles

M. Cardiovascular > Inspection

- (-) cyanosis
- (-) edema
- (-) varicose veins on the legs
> Palpation
- PR = 138 bpm
- with poor capillary refill mora than 3 seconds
- (-) edema
> Auscultation
- (-) irregular heart rhythm

N. Gastrointestinal > Inspection

 - umbilicus in midline
- skin color even with chest color
- (+) yellowish to light brownish stool
- (-) nausea and vomiting
>Percussion
- Hyper Resonant
> Auscultation
- normoactive bowel sounds
>Palpation
- No tenderness

O. Urinary > Inspection

- urine color is yellow
- no fruity smelling odor

P. Genitalia >Inspection
- (-) lesions
- (-) swelling

Q. Musculoskeletal > Inspection

- (+) weakness
- (+) limitation of motion
- (-) deformities

R. Endocrine > Inspection

- no visible enlargement of the thyroid gland
VII. LIFESTYLE PRACTICES
 Activity of daily living
o 6:00 am – the patient wakes up and take a bath
o 7:00 am – the patient drinks milk as his breakfast
o 7:30 am – takes a sleep
o 9:30 am – watches t.v or play his toys
o 11:30 am – the patient drinks milk as hid lunch
o 12:00 nn – watches t.v and play his toys
o 2:30 pm – takes a sleep
o 3:30 pm – watches t.v and play his toys
o 6:00 pm – drinks his milks as his dinner
o 8:00 pm – the client time for sleeping
*the client takes a bath 3-4 times a day, and drinks his milk 8-10 times day in no particular time
  Client’s Preferred Lifestyle

The client usually spend his day by playing his toys, watching cartoons in the television, sleeping 3-4 times a day and drinking his
milk 8-10 time a day.

 Home and Neighbor Environment

Their home is just enough for their family when it comes to size. The location is suitable for accessibility of health facilities,
educational establishment and for buying their everyday needs. A quiet neighborhood. Far from pollutions of the urban areas.

VIII. HEALTH PROMOTION AND MAINTENANCE ACTIVITY

 Personal Habit
o Use of Tobacco - client doesn’t use tobacco
o Alcohol - client doesn’t drink alcohol
o Prohibited Drugs - client doesn’t use prohibited drugs
o OTC and Prescribed medicine - client drinks his vitamins
o Hygiene - client takes a bath 3-4 times/day
o Elimination Pattern - client has a regular urination and defecation
 Sleep and Wake Pattern

Client usually wakes up at 6:00 in the morning. His mother makes sure that he will take a sleep once in the morning, once in
the afternoon and once at night.

 Exercise and Activity

 Most of the time he plays with his toy; this serve as his only form of exercise. Aside of playing with his toys he also watches a
lot of cartoons at the television. These are his usual activities.

 Recreation
He usually plays a lot and watches television. Sometimes his parents bring them to malls whenever they are free of having a
leisure time.

 Nutrition

The client still don’t eat solid food, instead he drinks milk 8 – 10 bottles per day. He also takes his Vitamins that is prescribed
by his pedia regularly.

 Stress and Coping Pattern

According to his mother, when the client is mad he usually cries a lot and throw all of his toys everywhere. In order to stop
his crying they give him his milk.

 Socio-Economic status
o Educational Background – Client is not yet schooling.
o Financial Status – His parents provide him financial support. They earn P40, 000 – P50, 000/month.
 Occupational Health Pattern
o Nature of work – The client is still a child.
IX. ROLE AND RELATIONSHIP PATTERN
 a. Self-Concept
 Self expectation

Her mother expects him to grow up a very humble and respectful child.

 Perceived strength and weaknesses

According to his mother, he is good in dancing.

b. Spiritual and Religious Influences

Their family regularly attends the mass every Sunday. They pray for good health. His parents teaches him about God and
about Catholic religion.

X. LABORATORY FINDINGS
a. Urinalysis

Actual Findings Actual Findings

Color Yellow Red Blood Cells 0-2 HPF
Transparency Clear Bacteria Negative
Specific Gravity 1.010 Epithelial Cells Rare
Ph 8.0 Mucus Threads Negative
Albumin Negative Amorphous Urates Moderate
Sugar Negative Calcium Oxalates Negative
White Blood Cells 1.3 HPF

b. Hematology
 Actual Findings Normal Range Interpretation
Hemoglobin 12.8 Female: 12-16 Decrease in hemoglobin is a
Male: 13-18 sign anemia, or excessive fluid
Child: 14-26 intake
Hematocrit 38 Female: 36 - 57 Decreased hematocrit is a sign
Male: 40 – 54 of anemia.
White Blood Cells 4.0 x 10^9/L 5-10 x 10^9/L Decreases no. of WBC is a sign
of infection
Red Blood Cells 4.7 x 10^12/L 4 – 6.0 x 10^12/L Client’s finding is within
normal range.
Platelet Count 201 x 100^g/L 150 – 400 x 100^g/L Client’s finding is within
normal range
Monocytes - 0.02 – 0.04 Decreased no. may be a sign
of infection
Eosinophils - 0.02 - 0.05 Decreases no. may be a sign of
infection
Lymphocytes 0.41 0.25 – 0.35 Increased no. is a sign of
infection.

XI. DISEASE OVERVIEW

Acute bronchitis is an inflammation of the large bronchi (medium-sized airways) in the lungs that is usually caused by viruses or
bacteria and may last several days or weeks. Characteristic symptoms include cough, sputum (phlegm) production, and shortness of
breath and wheezing related to the obstruction of the inflamed airways. Diagnosis is by clinical examination and sometimes
microbiological examination of the phlegm. Treatment for acute bronchitis is typically symptomatic. As viruses cause most cases of
acute bronchitis, antibiotics should not be used unless microscopic examination of Gram stained sputum reveals large numbers of
bacteria.

In bronchitis, areas of the bronchial wall become inflamed and swollen, and
mucus increases. As a result, the air passageway is narrowed.

 Causes

Acute bronchitis can be caused by contagious pathogens. In about half of instances of acute bronchitis a bacterial or viral
pathogen is identified. Typical viruses include respiratory syncytial virus, rhinovirus, influenza, and others.
 Damage caused by irritation of the airways leads to inflammation and leads to neutrophils infiltrating the lung tissue.
 Mucosal hypersecretion is promoted by a substance released by neutrophils.
 Further obstruction to the airways is caused by more goblet cells in the small airways. This is typical of chronic bronchitis.
 Although infection is not the reason or cause of chronic bronchitis it is seen to aid in sustaining the bronchitis.
  Symptoms
o Sore throat
o Fever
o A cough that may bring up yellow or green mucus
o Chest congestion
o Shortness of breath
o Wheezing
o Chills
o Body aches
 Diagnostic Examination

A physical examination will often reveal decreased intensity of breath sounds, wheezing, rhonchi and prolonged expiration. Most
doctors rely on the presence of a persistent dry or wet cough as evidence of bronchitis.
A variety of tests may be performed in patients presenting with cough and shortness of breath:

 A chest X-ray that reveals hyperinflation; collapse and consolidation of lung areas would support a diagnosis of pneumonia.
Some conditions that predispose to bronchitis may be indicated by chest radiography.
 A sputum sample showing neutrophil granulocytes (inflammatory white blood cells) and culture showing that has pathogenic
microorganisms such as Streptococcus spp.
 A blood test would indicate inflammation (as indicated by a raised white blood cell count and elevated C-reactive protein).
 XII. ANATOMY
o Respiratory System

A respiratory system's function is to allow gas exchange. The space between the
alveoli and the capillaries, 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.

Breathing is an active process - requiring the contraction of skeletal muscles. The

primary muscles of respiration include the external intercostal muscles (located
between the ribs) and the diaphragm (a sheet of muscle located between the thoracic &
abdominal cavities).

FUNCTION OF RESPIRATORY SYSTEM

 Ventilation

Ventilation of the lungs is carried out by the muscles of respiration.

  Inhalation

Inhalation is initiated by the diaphragm and supported by the external

intercostal muscles. Normal resting respirations are 10 to 18 breaths per minute,
with a time period of 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.

 Exhalation

Exhalation is generally a passive process; however, active or forced

exhalation is achieved by the abdominal and the internal intercostal muscles.
During this process air is forced or exhaled out.

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.

 Circulation

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.

 Gas Exchange

The major function of the respiratory system is gas exchange between the external environment and an organism's circulatory
system. In humans and mammals, this exchange facilitates oxygenation of the blood with a concomitant removal of carbon dioxide
and other gaseous metabolic wastes from the circulation. 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 could occur: 1) respiratory acidosis, a life
threatening condition, and 2) respiratory alkalosis.

Disease and the respiratory system

Disorders of the respiratory system can be classified into four general areas:

 Obstructive conditions (e.g., emphysema, bronchitis, asthma attack)

 Restrictive conditions (e.g., fibrosis, sarcoidosis, alveolar damage, pleural effusion)
 Vascular diseases (e.g., pulmonary edema, pulmonary embolism, pulmonary hypertension)
 Infectious, environmental and other "diseases" (e.g., pneumonia, tuberculosis, asbestosis, particulate pollutants): Coughing is
of major importance, as it is the body's main method to remove dust, mucus, saliva, and other debris from the lungs. Inability
to cough can lead to infection. Deep breathing exercises may help keep finer structures of the lungs clear from particulate
matter, etc.
 XIII. PATHOPHYSIOLOGY

Noxious Gases Viruses

Predisposing factors

Inhalation When inhaled, viruses and noxious gases enters the respiratory tract

Increased mucous production Initial respiratory response of the body

Because of increased mucous production airway is narrowed

Narrowing of airway

Bronchial walls is thickened

Increased no. of goblet cells

Flow of air is altered because of blockage of increase mucous

Airflow obstruction

Contributing factor that thickens blood vessels in the lungs

Cigarette smoking

Macrophages destroys foreign particles including bacteria and viruses

Altered function of alveolar
macrophages Because of the absence of macrophages infectious microorganisms is free

Increased susceptibility of
to enter the body
respiratory infection
When infection reach the bronchial walls
BRONCHITIS
Prolonged infection of the respiratory system may lead to pneumonia

Pneumonia
XIV. MEDICAL MANAGEMENT
 MEDICAL MANAGEMENT RATIONALE
MEDICATION
 Hemostan  Antihemorrhage and homeostasis for clinical cases
 Tobramycin  Anti-infective for lower respiratory infections
 Salbutamol  Bronchodilator and anti-asthmatic
IV THERAPY
 D5LR  Replacement therapy for extracellular fluid deficit
accompanied by acidosis
INTAKE AND OUTPUT MONITORING  To promote expectoration of secretions
VITAL SIGNS MONITORING  To assess changes and prevent further complications

XV. NURSING MANAGEMENT

 Encourage bronchial hygiene, such as increase fluid intake and directed coughing to remove secretions.
 Assist the patient to sit up frequently to cough effectively and to prevent retention of mucopurulent sputum.
 Emphasize the need of to complete the full course of antibiotics prescribed.
 Caution the patient against overexertion, which can induce a relapse or exacerbation of the infection.
 Advise the patient to rest.

XVI. DRUG STUDY Generic Name: Tranexamic acid

Brand Name: Hemostan

Anti-Hemorrhagic

Anti-fibrinolytic for effective hemostasis in various surgical and clinical cases.

 It is widely used in traumatic injuries and dental extractions

ADVERSE REACTION CONTRAINDICATION SIDE EFFECTS

-nausea, vomiting, anorexia, headache and hypotension - Severe renal sufficiency. GI disturbances, giddiness, menstrual cramps, hypotension
Patients with hematuria.

NURSING RESPONSIBILITIES
Arrange to taper dosage gradually after long-term therapy.
Provide patient with written information regarding recovery and follow-up care.

Generic Name: Tobramycin

Brand Name: Artobin

Aminoglycosides

Anti-infective for lower respiratory infections

 Steroid responsive inflammatory ocular conditions where corticosteroids is indicated

ADVERSE REACTION CONTRAINDICATION SIDE EFFECTS

- Hypersensitivity,
eurotoxicity, ototoxicity, GI effects, fever, blood coagulation abnormalities Epithelial herpes simplexLocalized
keratitis, ocular
varicella
toxicity and hypersensitivity including itching and swelling

NURSING RESPONSIBILITIES
instruct the patient on proper use of OTC preparation as indicated
Remind patient to take once daily prescription drug at bedtime for best results.

Generic Name: Salbutamol

Brand Name: Ventolin

Bronchodilator

Treatment and prevention of bronchial asthma and bronchitis.

 Emphysema with associated reversible airway obstruction.

ADVERSE REACTION CONTRAINDICATION SIDE EFFECTS

e tremor of skeletal muscle, feelings of tension, peripheral Threatened
vasodilation,abortion
headacheduring 1st or 2nd trimesters of pregnancy
Slight tachycardia, tenseness, headache

NURSING RESPONSIBILITIES
Monitor v/s
Improve patient’s compliance by giving drug

XVII. CONCEPT MAPPING A patient experiencing acute bronchitis

S: “Nahihirapan siyang huminga, tapos my plema din

yung pag-ubo niya” – as verbalized by the mother of
the patient
O:> LOC: Conscious and Coherent
>Use of accessory muscle in breathing
>Crackles during auscultation
>Productive cough
> RR: 34cpm
 Receives the nursing Outcome

Diagnosis

Nursing Interventions After the nursing

Ineffective I: Positioned head midline with flexion interventions the
R: To maintain open airway patient
airway clearance
related to demonstrated
excessive, improvement of
I: Elevated head of the bed at 45°
thickened mucus clear airway.
R: To decrease pressure in the diaphragm
secretions

I: Changed position every 2 hours

R: To enhance drainage of lung segments
Planning
After the nursing I: Instructed deep breathing and coughing exercise
intervention the R: To promote expectoration of secretions
patient will
demonstrate
behavior to I: Monitored vital signs
R: To promote timely interventions as needed
improve clear
airway
I: Administered
A patient experiencing salbutamol
acute bronchitis with fever for
2 days
R: To promote air passage to the lungs
S: “Dalawang araw na siyang nilalagnat” – as
verbalized by the mother of the patient
O:> LOC: Conscious and Coherent
> Skin warm to touch
> Weakness
> Temp: 37.6°C
> RR: 34cpm
> PR: 138 bpm
 Receives the nursing Outcome

Diagnosis

Nursing Interventions After the nursing

Hyperthermia interventions the
related to I: Provided Tepid sponge bath patient’s
deficient fluid as temperature
R: To promote heat loss
evidenced by lowered down
elevated body from 37.6°C to
I: Provided cool environment
temperature 37.4°C
R: To promote heat loss

I: Maintained bedrest
Planning
After the nursing R: To reduce metabolic demands
intervention the
patient’s I: Administered Paracetamol
temperature will
R: To lower down temperature
lower down from
37.6°C to normal I: Monitored vital signs
range
R: To promote timely interventions as needed
 A patient experiencing acute bronchitis

S: “Dati ang likot-likot niyan ngayon di na masyado” –

as verbalized by the mother of the patient
O:> LOC: Conscious and Coherent
> Weakness
> (-) Independent function
> PR: 138 bpm
Receives the nursing Outcome

Diagnosis Nursing Interventions

I: Provided positive environment
After the nursing
Activity R: To conserve energy interventions
Intolerance goal partially met
related to I: Adjusted activities ,increased
impaired activity in bed of
R: To prevent over exertion the patient
respiratory
function.
I: Promoted rest

R: To reduce fatigue

Planning I: Increased activity level gradually

After the nursing R:To conserve energy
intervention the
patient can I: Put side rails up
demonstrate
increase in R: To promote security in moving
activity tolerance
XVIII. DISCHARGE PLANNING

HEALTH PROMOTION STRATEGY

 MEDICATION  Write the exact time and instruction when to take the
medication and how to take the medication.
 Emphasize to the significant others the importance of taking
medications as prescribed.
 ENVIRONMENT  Advise significant others for having a frequent hand washing
to prevent transmission of bacteria to the susceptible
patient.
 TREATMENT  Advise significant others to follow the drug regimen of
the patient
 HEALTH TEACHING  Encourage client to practice general hygiene to prevent
infection
 FOLLOW-UP CARE  Remind when will they come back and provide a copy
of schedule of the doctor, room and how they visit for
follow-up check up
 DIET  Lecture patient and care giver regarding the diet