I.

Introduction

Pneumonia, an inflammation of the pulmonary parenchyma, is common in childhood, occurring more frequently in infancy and early childhood. Clinically, pneumonia may occur either as a primary disease or as a complication of another illness. A report published by UNICEF in cooperation with the World Health Organization, in 2006 has identified pneumonia as the forgotten killer of children. According to the report, pneumonia kills more children than any other illness more than AIDS, malaria and measles combined. Over 2 million children die from pneumonia each year, accounting for almost 1 in 5 underfive deaths worldwide. Yet, little attention is paid to this disease. Pneumonia can be classified according to morphology, etiologic agent, or clinical form. According to morphology, there are three types: Lobar pneumonia, Bronchopneumonia or Interstitial pneumonia. In this case, the study will be all about bronchopneumonia, where it begins in the terminal bronchioles which become clogged with mucopurulent exudate to form consolidated patches in nearby lobules. Another way to classify it is based on the etiologic agent. It may be caused by a virus, bacteria, mycoplasm or aspiration of foreign substances. The causative agent is usually introduced into the lungs through inhalation or from the bloodstream. In the whole case, it will deal about bacterial pneumonia, the causative agent of the bronchopneumonia of the patient. Bacterial pneumonia is often a serious infection. The pathogenetic mechanisms involved are often aspiration or hematogenous dissemination. The cause varies depending on the childs age, underlying illness, and degree of immunosuppression or immunocompetence. In the 3-month to 5-year age group, Streptococcus pneumoniae, Moraxella catarrhalis, and Group-A streptococci are common causes. Haemophilus influenzae

type b is causing fewer infections because of the Hib vaccine. Staphylococcus aureus pneumonia is also now rarely seen in infants and toddlers. Mycoplasma pneumoniae and S. pneumoniae are the dominant organisms in children over 5 years of age. The clinical manifestations of pneumonia vary depending on the etiologic agent, the childs age, the childs systemic reaction to the infection, the extent of the lesions, and the degree of bronchial and bronchiolar obstruction. For bacterial pneumonia, clinical manifestations are fever and toxic appearance. Infants and young children develop more severe symptoms than older children. Respiratory distress may or may not be present. In some cases, the only finding is an increased respiratory rate.

II. Nursing Process

A. ASSESSMENT

1. Personal History Mother Bear mentioned that she gave birth via normal spontaneous delivery without any complications at full term assisted by a midwife in the hospital. She was not picky on the foods she eats during her pregnancy, she will eat whatever food is available in their home and according to the mother, she usually have her prenatal check up at the barangay health center. Feeding Baby bear was breastfed right after he was born, until now. Immunization Status Baby bear had a complete immunization for his age. He had received 1 dose of BCG, 1 dose of DPT, 1 OPV, HepaB.

Growth and Development Erik Erikson (Theory of Trust and Mistrust) Infancy- 0-1 year old This is the period of The infant would be The infant failed to Currently, baby bear infancy through the able to gain a sense develop a sense of is within this Trust first one or two of trust her with his trust with his vs. Mistrust stage. of parents, This crying is after years of life. The parents, particularly parents, particularly As observed, he is mother the mother because capable basic with failure his Normal Response Untoward Response Clients response

child, well - handled, with

nurtured, and loved, because they are they are not able to developing his trust develops trust and able to meet their provide security and a basic responsibility optimism. handled, becomes and mistrustful. Badly provide he comfort, to support to especially with his mother. stops mother. evident when Baby being cuddled by his

warmth, meet infants needs. security,

insecure sensory stimulation, food to the infant.

Sigmund Freud (Psychosexual Theory-Oral Stage) Birth to 1 year old

Normal Response

Untoward Response

Clients Response

During this stage, the The baby exhibits The child's main focus is concern suckling Pleasure gratification and for the unable around the rooting and gratification self- oral stimuli

child to

is Baby bear is able elicit to demonstrate and from activities such as in swallowing. like

that gratification as passive by activities

reflex. can be felt from oral stimuli and is sucking are evidenced

acquired by the mouth. pleasure from is sucking, Because a sense of eating. The child swallowing satisfaction acquired is during

biting, and of

being also engages in manipulating this activities like various and of parts biting, the mouth.

stage, it also leads to a sucking, sense of trust for the swallowing infant.

manipulating various parts the mouth.

2. Family Health Illness History

3. History of Past and Present Illness Past Illness: This is babys first hospitalization diagnosed with bronchopneumonia. He never had any mild or severe past illness. He hasnt developed any signs and symptoms prior to asthma, although his family had a history of it. Present Illness: The patient is diagnosed with bronchopneumonia. He was admitted on November 10, 2009. The patient experienced fever and cough last November 6, 2009. However, mama thought that it is just a common colds and fever so she gave paracetamol (tempra) for medications. But then on November 10, 2009 the patient experienced difficulty of breathing and cyanosis. He was then rushed and admitted to Mabalacat District Hospital. Due to the observed signs and symptoms manifested by the patient, and after laboratory diagnosis was done, the doctor suspected that he has Bronchopneumonia. 4. Physical Examination (IPPA- Cephalocaudal approach) November 10, 2009 (Admission)

With complaint of difficulty of breathing (+) rales

Vital signs: T: 39.6 C P: 173 bpm R: 78 bpm

November 12, 2009 (First Nurse-Patient-Interaction 3-11 shift) The baby is wearing white layette and pajamas, does not wear socks, mittens or bonnet to protect him from cold. Vital Signs: T= 37.9 C P= 144bpm R= 78bpm I. Integument Skin: Has a fair complexion, the texture of skin is smooth; with normal skin turgor. Nails: With dirty long fingernails, convex curve in shape, with smooth texture. Performed blanch test, capillary refill return in usual color for a less than 2 seconds. II. Head: Hair: Evenly distributed, with thin straight hair, no presence of infestation, the color of the hair is black. Skull: Round, normocephalic and normal contour with frontal, parietal and occipital prominences, smooth skull contour, with no masses, depression, and nodules noted. Scalp: The color of his scalp is slightly brown, no presence of lesions III. Eyes: Eyebrow & Eyelashes Black in color, skin intact, evenly distributed and symmetrically aligned, the eyelashes are slightly curled outward, eyelids closes symmetrically, pinkish conjunctiva, pupils equally round and reactive to light accommodation that is when the penlight introduced the pupil constricted and vice versa, iris black in color

IV. Ears External: Symmetrically distributed, auricle aligned with outer canthus of the eye Internal: Absence of cerumen on both ears and no lesions noted. V. Mouth and Throat

No presence of sores noted No lesions and masses noted Lips - pinkish in color Gums and tongue - pinkish color

VI. Nose

Presence of clear nasal discharges and with no presence of nodules noted.

VII. Neck

No enlargement of lymph nodes Has coordinated movement.

VIII. Chest & Lungs:

Skin in chest is free of lesions; rales heard on both lung fields upon

auscultation. IX. Heart

Normal cardiac rate.

X. Abdomen

Skin integrity with uniform color, with no presence of masses, without

abdominal distention XI. Extremities

Hair is evenly distributed on both upper and lower extremities; the legs are

proportion to the body, and with no presence of masses.

November 13, 2009 (Second Nurse-Patient-Interaction 3-11 shift) The baby was wearing white layette and pajamas. He was not wearing socks, mittens or bonnet to protect him from cold. Vital Signs: T= 36.8 C P= 140 bpm R= 78 bpm I. Integumentary Skin: Has a fair complexion, the texture of skin is smooth, with normal skin turgor. Nails: With clean fingernails, convex curve in shape, with smooth texture. Performed blanch test, capillary refill return in usual color for less than 2 seconds. II. Head: Hair: Evenly distributed, with thin straight hair, the color of the hair is black. Skull: Round, normocephalic and normal contour with frontal, parietal and occipital prominences, smooth skull contour, with no masses, depression, and nodules noted. Scalp: The color of his scalp is slightly brown, no presence of lesions, with no dandruff noted. III. Eyes: Eyebrow & Eyelashes Black in color, skin intact, evenly distributed and symmetrically aligned, the eyelashes are slightly curl, eyelids closes symmetrically, pinkish conjunctiva, pupils equally round and reactive to light accommodation that is when the penlight introduced the pupil constricted and vice versa, iris black in color

IV. Ears External: Symmetrically distributed, auricle aligned with outer canthus of the eye Internal: Absence of cerumen on both ears and no lesions noted. V. Mouth and Throat

No presence of sores noted No lesions and masses noted Lips - pinkish in color Gums and tongue - pinkish color

VI. Nose

Presence of clear nasal discharges and with no presence of nodules noted.

VII. Neck

No enlargement of lymph nodes Has coordinated movement.

VIII. Chest & Lungs:

Skin in chest is free of lesions; rales heard on both lung field upon auscultation.

IX. Heart

Normal cardiac rate.

X. Abdomen

Skin integrity is uniform color, with no presence of masses, without abdominal

distention. XI. Extremities Hair is evenly distributed on both upper and lower extremities; the legs are proportion to the body, and with no presence of masses.

5. Diagnostic/Laboratory Procedures

Diagnostic/ Laboratory Procedures COMPLETE BLOOD COUNT

Date Ordered Date Results DO: 09

Indication/Purposes

Results

Normal Values

Analysis Interpretation

&

11-10- CBC is frequently ordered for Hgb= 95 g/L patients basic screening and diagnostic test that provides information about hematological

Hgb= 170 g/L

140- The result show that the patients hemoglobin is below the normal range. The MO reached the tree tracheobronchial

DR: 11-10-09

system. It is needed in routine physical diagnosis. examination and in It helps in the

and then to the lungs causing an irritation to the airway and thus excessive production mucus are

management of disease that originated in other body system. Generally numbers platelets, includes or absolute of and leukocytes, percentages

erythrocytes,

secreted by the goblet cell causing the mucus production accumulate in to the

hemoglobin,

hematocrit in the blood sample.

lungs thus oxygen and Abnormalities in Hgb indicate defects in the red blood cell homeostasis. This procedure is used to assess or determine Severity of anemia to the or carbon leading Hgb RBCs decrease in to that dioxide decrease lead the to circulating blood exchange are reduced,

polycythemia& to measures

monitor oxygen

response to therapy as well as carrying capacity of the blood.

which are responsible in carrying oxygen and carbon dioxide from the lungs. This is caused

Nursing Responsibilities: Prior During After

Check the doctors order. Determine the prescribed test and other restrictions prior to the test.

Explain to the patient what test should be done. Prepare all the equipments to be used. Tell the patient when to insert the needle for her to be

Apply direct pressure to the venipuncture site until bleeding stops.

Send the blood sample to the laboratory immediately. Proper documentation. Instruct patient that if hematoma results or develops at the venipuncture site, apply warm compress.

Get the laboratory requisition slip. Explain to the patient what the procedure to be done is. Inform the patient that this requires a blood sample. Inform the patient how the procedure is performed, the equipment to be used.

prepared. Encourage the patient to remain calm during the test. Assist the patient if necessary. Ensure a sterile blood sample from the patient

No food or fluid restriction is required prior to the exam. Take note of the medications

the client is taking, as this may affect results. the outcome of the

Diagnostic/Laboratory Date Ordered Procedures Date Results

Indication/Purpose s

Results

Normal Values

Analysis Interpretation

&

To

identify

the

abnormalities of the lungs and structure Chest X-Ray DO:10- 11- 09 on the thorax. And also to identify the size of the heart and DR: abnormalities in the ribs and diaphragm.

Prior

During

After

 Check the doctors order.

Identify the client. Explain to the SO that this

> If the patient is intubated, check that no tubes have been dislodged during positioning. > To avoid exposure to radiation, leave the room or the immediate area while the films are being taken. If you must stay in the area, wear a leadlined apronI

Inform the SO for possible x-ray follow-up. Document informations. necessary

test assesses respiratory status. Tell the SO that no fasting is required. Inform the SO that the test takes 5 to 10 minutes. Describe the test to the SO including who will perform it and when will it take place. Assist client and SO in going to the x-ray room.

6. Anatomy and Physiology

Primary function is to obtain oxygen for use by body's cells & eliminate

carbon dioxide that cells produce. Includes respiratory airways leading into (& out of) lungs plus the lungs

themselves

The respiratory system is divided into Upper Respiratory System and Lower Respiratory System and consists of the airways, the two lungs which have further divisions, and the respiratory muscles. Within the alveoli, molecules of oxygen and carbon dioxide are passively exchanged, through diffusion, between the gaseous environment and the blood. Thus, the respiratory system facilitates oxygenation of the blood with a concomitant removal of carbon dioxide and other gaseous metabolic

wastes from the circulation. Respiratory System also helps in maintaining the acid-base balance of the body through the excretion of carbon dioxide from the blood. The lungs are the major part of the Respiratory System and are considered to be the largest organ and resemble large pink sponges because of their appearance. The left lung is slightly smaller in size compare with the right lung because it shares space with the heart and so as to accommodate the two. The two lungs are divided into lobes; two in the left lung and three in the right. The pleura, which is a slippery membrane covers and lines the inside of the chest wall. This helps the lungs move and glide smoothly during each breath cycle.

Lower Respiratory System

Larynx The larynx or voice box is a short passageway connecting laryngopharynx with the trachea. It is situated at the midline of the neck anterior to the fourth through sixth

cervical vertebrae. Its wall consists of nine pieces of cartilage. Three occur singly (thyroid cartilage, epiglottis, and cricoid cartilage), and three occur in pairs (arytenoid, cuneiform, and corniculate cartilages). The lining of the larynx has cilia and goblet cells. The mucus produced by the said structure helps trap dust not expelled in the upper passages. The cilia in the upper respiratory tract move mucus and trapped particles down toward the pharynx, the cilia in the lower respiratory tract move them up toward the pharynx. Trachea The trachea or windpipe is a tubular passageway for air that is about 5 inches long and 1 inch in diameter. It is located anterior to the esophagus and extends from the larynx towards the superior border of the fifth thoracic vertebra, thereon it divides into right and left primary bronchi. The epithelium on the lining of the trachea provides the same protection as the membrane lining the nasal cavity and larynx against foreign material such as dust. There are 16-20 incomplete, horizontal rings of hyaline cartilage resembling the letter C and is stacked one on top of the other. The open part of each cartilage ring faces the esophagus. The cartilage rings provide a semi-rigid support so that the tracheal wall does not collapse inward and obstruct the air passageway and during inhalation and expiration as well.

Bronchi After the trachea, it divides into a right primary bronchus, which goes into the right lung, and a left primary bronchus, which goes into the left lung. The right primary bronchus is more vertical, shorter, and wider than the left. The bifurcation or the point of intersection where the trachea divides into right and left primary bronchi is called the carina. Like the trachea, the primary bronchi contain incomplete rings of cartilage, and the carina is formed by an inferior projection of the last tracheal cartilage. The mucous membrane of the carina is one of the most sensitive areas for triggering a cough reflex. Going deeper into the lungs, the main or primary bronchi divide to form the secondary (lobar) bronchi, one for each lobe of the lung (three on the right and two on the left). The secondary bronchi continue to branch, forming still smaller bronchi, called tertiary (segmental) bronchi, that divide into bronchioles, which branch into even smaller terminal bronchioles. This branching from the trachea going down resembles an inverted tree and is commonly referred to as the bronchial tree. Some of the bronchioles are no larger than 0.5 mm (0.02 inches) in diameter. The bronchioles divide many more times in the lungs into an upside-down tree-like structure with progressively smaller branches.

Alveoli Tiny air sacs called alveoli are at the end of every bronchioles. The alveoli comprise most of the lung tissue, with about 150 million alveoli per lung, and resemble bunches of grapes. The alveoli send oxygen to the circulatory system while removing carbon dioxide. Alveoli have thin elastic walls, thus allowing air to flow into them when they expand; they collapse when the air is exhaled. Alveoli are arranged in clusters, and a dense network of capillaries surrounds each cluster. The walls of the capillaries are very thin; thus the air in the wall of the alveoli is very near to the blood in the capillaries (only about 0.1 to 0.2 microns). Carbon dioxide is one of the waste products that are excreted into the outside environment from the cells. The oxygen diffuses from the alveoli to the capillaries since the concentration of oxygen is much higher in the alveoli than in the capillaries. From the capillaries, the oxygen flows into larger vessels and is then carried to the heart where it is pumped to the rest of the body. The forces of exhalation cause the carbon dioxide to go back up through the respiratory passages and out of the body. Numerous macrophages are interspersed among the alveoli. Macrophages are large white blood cells that remove foreign substances from the alveoli that have not been previously filtered out. The presence of the macrophages ensures that the alveoli are protected from infection; they are the last line of defense of the respiratory system.

7. The Patient and His Illness

Definition of the disease Pneumonia is an illness of the lungs and respiratory system in which the alveoli (microscopic air-filled sacs of the lung responsible for absorbing oxygen from the atmosphere) become inflamed and flooded with fluid. Pneumonia can result from a variety of causes, including infection with bacteria, viruses, fungi, or parasites, and chemical or physical injury to the lungs.

Pneumonia is an acute infection of one or both lungs that can be caused by a bacterium, usually Streptococcus or by a virus, fungus, or other organism. The causal organisms reach the lungs through the respiratory passages. Usually an upper respiratory infection precedes the disease. The lungs' air sacs fill with pus, mucus, and other liquid and can not function properly. Oxygen cannot reach the blood. If there is not enough oxygen in the blood, body cells cannot work right and might die. Alcoholism, extreme youth or age, debility, immunosuppressive disorders and therapy, and compromised consciousness are predisposing factors. When one or more entire lobes of the lung are involved, the infection is considered a lobar pneumonia. When the disease is confined to the air spaces adjacent to the bronchial area, it is considered a bronchial pneumonia.

Predisposing/Precipitating Factors Non-modifiable Factors:

Age- At extremes of ages, different body systems and processes are either

immature or degenerating. For infants, their body defenses and immunologic responses are just starting to develop. susceptibility to different pathologic conditions. Such condition increases their

 Lack of normal anatomical structure- There are certain inherited defects of

cilia which result in less effective protection. Cigarette smoke, inhaled directly by a smoker or second-hand by an innocent bystander, interferes significantly with ciliarys function, as well as inhibiting macrophage function.

Modifiable Factors:

Chronic conditions- Predispose a person to infection with pneumonia. These include asthma, cystic fibrosis, diabetes, sickle cell anemia, lymphoma, leukemia, emphysema and neuromuscular diseases; interfere with the seal of the epiglottis. This increases the risk of aspiration into the lungs of those stomach contents with their resident bacteria. Environment- The mode of transmission of pneumonia is through airborne or person contact because of the droplets that can be inhaled from an infected person. Health Status/ Bodys resistance- Health Status clearly points out on how an individual will fight or favor a pathologic condition. Certainly, poor or unstable health status will hasten the occurrence of any type of disease since poor health suggests poor resistance and defense against disease. Parasitic infection- It also includes some previously rare parasitic, such as worms which would be able to cause illness in an individual possessing a normal immune system. Viruses - It interfere with ciliarys function, allowing other microorganism invaders (such as bacteria) access to the lower respiratory tract. In recent years virus has resulted in a huge increase in the incidence of pneumonia. It may cause by certain viruses and associated with symptoms of fever, cough, and shortness of breath. Smoke - Millions of microscopic hairs (cilia) cover the surface of the cells lining

the bronchial tubes. The hairs beat in a wave-like fashion to clear airways of normal secretions, but irritants such as tobacco smoke paralyze the cilia, causing secretions to accumulate. If these secretions contain bacteria, they can develop into pneumonia.

Alcohol - interferes with normal gag reflex as well as with the action of the

white blood cells that fight infection.

Are exposed to certain chemicals or pollutants. The risk of developing some

types of pneumonia may be increased if an individual works in agriculture, construction or around certain industrial chemicals or even with animals. Exposure to air pollution or toxic fumes can also contribute to lung inflammation, which makes it harder for the lungs to clear themselves.

Contact to a Person with Pneumonia Pneumonia is a communicable

disease, thus having a close contact with person or an article, which is contaminated, can contribute to having Pneumonia.

General signs of pneumonia:

Fever (usually quite high) Cough: unproductive to productive with whitish sputum Tachypnea Breath sounds: rhonchi or fine crackles Dullness with percussion Chest pain Retractions Nasal flaring Pallor to cyanosis (depends on severity) Diffuse or patchy infiltration with peribronchial distribution on CXR Irritable, restless or lethargic

Anorexia, vomiting, diarrhea, abdominal pain

Initially, the cough is usually hacking and nonproductive, and breath sounds are diminished or heard as scattered crackles. When consolidation is present, breath sounds may be tubular in quality with no adventitious noises. As the infection resolves, coarse crackles and wheezing are heard, and the cough becomes productive with purulent sputum. Lack of specific signs indicating infection makes diagnosis in infancy particularly difficult. An early sign of infection is often irritability or lethargy and poor feeding. Abrupt fever may be accompanied by seizures. Respiratory distress is evident with air hunger, tachypnea and circumoral cyanosis. Because pneumonia in newborns carries a high morbidity and mortality, bacterial infection should be suspected in all neonates with respiratory symptoms. Staphylococcal pneumonia is rare but particularly progressive and must be treated aggressively. The onset is rapid, with rapid deterioration. Conjunctivitis and furuncles are signs of a probable staphylococcal infection.

Synthesis of the Disease (Book-based)

Invasion of microorganism which lodges in the upper respiratory tract Reaches the lower respiratory tract causing damage to the lung tissues

Stimulates inflammatory response Release of chemical mediators (cytokine, bradykinin, histamine) Attraction of neutrophils and accumulation of fibrinous exudates & bacteria Increase in WBC

Lung parenchyma & alveoli consolidation

Cytokine

Bradykinin

Histamine

Stimulation of hypothalamus Increase body temperature

Stimulates goblet cells Increase in mucosal secretions Accumulation of secretions (+) rales (+) cough

Causes narrowing of the airways Air passes through narrowed lumen Decrease blood oxygenation and ineffective tissue perfusion DOB & Dyspnea

Hyperthermia

Synthesis of the disease (client-centered)

Invasion of microorganism which lodges in the upper respiratory tract Reaches the lower respiratory tract causing damage to the lung tissues

Non-modifiable factors: Age Modifiable factors: Bodys resistance, contact to a person with pneumonia, environment, health status

Stimulates inflammatory response Release of chemical mediators (cytokine, bradykinin, histamine) Attraction of neutrophils and accumulation of fibrinous exudates & bacteria Lung parenchyma & alveoli consolidation

Cytokine

Bradykinin

Histamine

Stimulation of hypothalamus Increase body temperature

Stimulates goblet cells Increase in mucosal secretions Accumulation of secretions (+) rales (+) cough

Causes narrowing of the airways Air passes through narrowed lumen Decrease blood oxygenation and ineffective tissue perfusion DOB & Dyspnea

Hyperthermia

(Decreased Hct and Hgb)

B. PLANNING (NCP) PROBLEM #1 Ineffective Airway Clearance r/t presence of productive cough 2 to Bronchopneumonia ASSESSMENT S= O = Patient manifested: -Appears weak & restless -Appears tachypneic -With changes in rate, rhythm and depth of breathing -With DOB and (+) wheezes on the right lung -Appears cyanotic -With (+) nonNURSING DIAGNOSIS Ineffective Airway Clearance r/t presence of productive cough 2 to Bronchopneumonia SCIENTIFIC OBJECTIVES EXPLANATION The inflammation and increased secretions make it difficult to maintain a patent airway, which is cause by decrease ability to expel the excessive mucus produced that will lead to extensive obstruction of the airway. SHORTTERM: After 4 hours of NI, the SO will demonstrate behaviors to improve airway patency. NURSING INTERVENTION INDEPENDENT NURSING FUNCTION: -Establish rapport. - To gain patients trust. RATIONALE EXPECTED OUTCOMES SHORTTERM: After 4 hours of NI, the SO shall have demonstrated behaviors to improve airway patency.

-To evaluate -Monitor V/S especially degree of respiratory rate compromise -To ascertain status and note progress or complications

-Auscultate breath sounds, note areas of decreased/adventitious breath sounds as well LONG-TERM: as fremitus After 4 days of NI, the patient will be able to maintain airway patency.

LONGTERM: After 4 days of NI, patient shall have been able to maintain airway

-Elevate HOB or change position every 2 hours as necessary

-To enhance ventilation to various lung segments

productive cough Patient may manifest: -Appears tachycardiac -Wide-eyed -Keep environment allergen-free -Encourage client to increase OFI to at least 2000 ml/day within level of cardiac tolerance. -Encourage adequate rest and limit activities to within client tolerance. DEPENDENT NURSING FUNCTION: -Administer medications such as bronchodilators/ expectorants as indicated. -To treat underlying conditions and mobilize secretions -For adequate patent airway -To help liquefy secretions

patency.

-To promote wellness

PROBLEM # 2 Hyperthermia ASSESSMENT NURSING DIAGNOSIS S= O = Patient SCIENTIFIC EXPLANATION OBJECTIVES NURSING INTERVENTION INDEPENDENT NURSING FUNCTION: RATIONALE EXPECTED OUTCOMES SHORTTERM: After 4 hours - To gain patients trust. of have in -Monitor VS data. -To prevent further respiratory complication. -Encourage SO to dress -To LONG-TERM: pt in comfortable and loss. loose clothing. After 3 days promote heat LONGTERM: body temperature from 37.9 to 37.2 C. NI, the shall gained patient

Hyperthermia Because of the SHORTinflammatory response, there will be release of chemical a will the mediators. Cytokine, chemical mediator act on After 4 hours of have decrease body temperature NI, patient TERM:

manifested: -Appears weak and restless -Diaphoretic -warm skin

the -Establish rapport. will

-To obtain baseline a decrease in

when touched -increased body temperature (T= 37.9C) -convulsions

hypothalamus which will result in increase in epinephrine and norepinephrine, vasoconstrictio

from 37.9 to -Kept dry back 37.2 C.

n of cutaneous vessels. heat will produced peripheral vasodilation results in skin flushing touch. and skin is warm to The be as of NI, the will -To VS -Perform TSB -For mobilization of secretions -Encourage increase OFI -To energy -Encourage adequate rest and limit activities to within client tolerance DEPENDENT NURSING FUNCTION: -Administer anti-pyretic medication - To decrease the elevated body temp. regain lost client to promote evaporation of heat. After 3 days of have manifested normal specifically temperature. VS NI, the will patient patient manifest normal specifically temperature.

PROBLEM # 3 Ineffective Breathing Pattern r/t dyspnea 2 Bronchopneumonia ASSESSMENT NURSING DIAGNOSIS S= O = Patient Ineffective Breathing r/t manifested: -Appears weak & restless dyspnea SCIENTIFIC EXPLANATION In 2 Pattern presence spasm effective SHORTTERM: occurs of and OBJECTIVES NURSING INTERVENTION INDEPENDENT NURSING FUNCTION: To gain patients trust. RATIONALE EXPECTED OUTCOMES SHORTTERM: After 4 hours of NI, the been to patient shall of able improve

Pattern Breathing

Bronchopneumonia when there is

After 4 hours -Establish rapport. of able improve breathing pattern AEB NI, the patient will be

inflammation of the lung tissue and parenchyma,

to -Monitor V/S especially -To evaluate have respiratory rate degree compromise

breathing -To ascertain pattern AEB absence or -Auscultate breath these results in status and absence or decrease sounds, note areas of inability of the note cough and decrease decreased/adventitious pt to move air in progress or cough and dyspnea. breath sounds as well as and out of the complications dyspnea fremitus lungs as needed maintain adequate tissue oxygenation to -Elevate HOB or change position every 2 hours as LONG-TERM: necessary -To enhance ventilation to various lung segments

and perfusion. Appears tachypneic -With changes in rate, rhythm and depth of breathing -With DOB and (+) wheezes on the right lung -Appears cyanotic -With (+) nonproductive cough Patient manifest: -irritability may After 4 days -Keep of NI, the allergen-free will and -Encourage client to -To increase OFI to at least liquefy 2000 ml/day within level secretions of cardiac tolerance. -Encourage patient improve maintain effective breathing pattern environment -For adequate patent airway After 4 days help of NI, the been to patient shall have able LONGTERM:

improve and adequate -To promote maintain rest and limit activities to wellness effective within client tolerance. DEPENDENT NURSING FUNCTION: -Administer expectorants indicated. medications as To treat breathing pattern

such as bronchodilators/

underlying conditions and mobilize secretions

-nasal flaring

PROBLEM # 4 Risk for Deficient Fluid Volume r/t fever and diaphoresis 2 Bronchopneumonia ASSESSMENT NURSING DIAGNOSIS O> Patient Risk for Deficient Fluid fever -Delayed capillary refill -Appears tachycardiac -Dry mucous diaphoresis Volume SCIENTIFIC EXPLANATION Fluid volume SHORTmay TERM: After 4 hours of NI, the SO - Establish rapport. will demonstrate behaviors monitor prevent deficit. to OBJECTIVES NURSING INTERVENTION INDEPENDENT NURSING FUNCTION: - To gain pts After 4 hours trust & of NI, the SO cooperation. shall have to demonstrated behaviors RATIONALE EXPECTED OUTCOMES SHORTTERM:

may manifest:

r/t deficit

and result from loss 2 of bodily fluids, and more when occurs rapidly

Bronchopneumonia volume

fluid inside the lung drains due to fever as and a diaphoresis tat -Dry skin serves membranes

and - Monitor and record - To obtain monitor and fluid V/S. prevent fluid baseline data. deficit. -To note - Assess patients condition. patients

compensatory -Poor turgor -Sunken anterior fontanelle skin mechanism the Daiphoretic of LONG-TERM: -Note for signs of and body.

progress.

LONG-To further complications. After 4 days of have maintained adequate fluid volume. NI, the shall patient prevent TERM:

episodes After 4 days dehydration experienced by of NI, patient bleeding. the patient may will be able to lead decrease body not or to maintain fluid adequate fluid -Monitor intake volume in the volume. output balance. of the -Weigh client patient if it is prevented given

and

-To status.

monitor

hydration

& -To determine compare with recent occurrence of weight history. -Keep clients fluids deficit

management.

within -To maximize reach and intake of fluids

encourage

frequent and prevent intake as needed. dehydration. -Encourage increase -To intake of food rich in replace

iron.

nutrients loss

DEPENDENT NURSING FUNCTION: -Administer ordered. -Administer medications as indicated and -To fluid deficit. -To comply on therapeutic regimen. replace loss or

regulate IVF strictly as

Problem #5 risk for Aspiration r/t impaired swallowing ASSESSMENT NURSING DIAGNOSIS O> may the patient Risk manifest Aspiration impaired swallowing >Depressed cough SCIENTIFIC EXPLANATION for Owing epiglottis to Short term: and After 4 hours of NI, SO will identify causative/ risk factors. OBJECTIVES NURSING INTERVENTION -Assess respiratory secretions strength of cough reflex. and gag/ amount -To RATIONALE EXPECTED OUTCOMES asses Short term: After 4 hours of NI, the SO shall identified causative/ risk factors. Long term: -Suction as needed -To with secretions clear Long term: After 3 days of NI, the pt shall have have

r/t inability of the true vocal cords to move close off trachea and with presence secretions the of the is at

and consistency of contributing factors.

the following:

>Impaired swallowing

patients risk aspiration

for After 3 days of due NI, the pt will -Assist

to the inability experience no postural drainage >Difficulty of of the epiglottis aspirations

Breathing >Secretions the nasal cavity in

and secretions AEB noiseless that will block respiration, the airway. patients clear sounds odorless secretions breath clear, -Determined the

-To thickened

mobilized experienced no aspirations AEB noiseless respiration, clear breath upper sounds clear, by secretions

secretions that may interfere swallowing. -Because facilitated with

best position, head of bed elevated to 30 side degrees on and right propped

airway patency is odorless upright position and turning to right side decreases likelihood drainage trachea of into

C. IMPLEMENTATION 1. MEDICAL MANAGEMENT 1.a. Intravenous fluids: MEDICAL TREATMENT DATE ORDERED, DATE GENERAL DESCRIPTION DISCONTINUED INDICATIONS PURPOSES OR CLIENTS RESPONSE TREATMENT Hypertonic solution that It draws water out in No Sugar. draws This water to solution bloodstream, so that from the kidneys will the eliminate excess fluid, since the pt. has fluidThese is also used for route given of medication. untoward TO

MANAGEMENT & GIVEN/PERFORMED,

D5 0.3 NaCl 500cc DO: 11-10-09 x 40 ugtts/min DP: 11-10-09 DC: 11-11-09

provides Na, Cl, and tissue space into the reaction noted.

intracellular extracellular D5 0.3 NaCl 500cc DO: 11-10-09 x 40 ugtts/min DP: 11-11-09 DC: 11-11-09 cell to

compartment and cause filled alveolar sacs. It shrink. are solutions

cautiously and usually when serum osmolality has decreased to dangerous low levels.

NURSING RESPONSIBILITIES:

Before Check for the doctors order. When inserting an IV line to a patient, always prepare all the materials needed. Wash hands thoroughly before performing the procedure. Identify the correct patient by checking the name on the chart or by asking the patient. Explain the procedure to the SO.

During: Maintain the use of aseptic technique. Hook the IVF bottle properly.

After Regulate and monitor infusion rate. Monitor patients response to the fluid and monitor the vital signs. Check the IV insertion site for signs of infiltration: bulging, pain, and redness. Document the essential information.

1.b. Nebulization

MEDICAL TREATMENT

DATE

ORDERED,

DATE GENERAL DESCRIPTION

INDICATIONS OR CLIENTS PURPOSES RESPONSE THE TREATMENT TO

MANAGEMENT & GIVEN/PERFORMED, DISCONTINUED

Salbutamol-neb ml q 12

1 DO: 11-10-09 DP: 11-10-09 DC: 11-11-09

Nebulization fine particles

is Prevention of bronchospasms to

and The pt loosened of his secretions and the PR and RR in normal (11/11/09loosen are relieve range

used to dispense treatment medication into the used the respiratory tract

deeper passages of secretions; Salbutamol-neb ml q 4 1 DO: 11-11-09 DP: 11-11-09 (continuous)

pt. from dyspnea.

discharge)

NURSING RESPONSIBILITIES:

Before Check for the doctors order. Prepare all the materials and equipments needed. Add the prescribed amount of medication. Wash hands thoroughly before performing the procedure. Identify the correct patient by checking the name on the chart or by asking the patient. Explain the procedure to the SO. Show the nebulizer equipment to the SO and teach them on how to use it correctly.

During Monitor for chest expansion.

After Monitor the heart rate after the treatment for patients using bronchodilator drugs (Bronchodilator may cause tachycardia, palpitations, dizziness, nausea or nervousness). Record medication used and description of secretion (If there are presence of secretions). Disassemble and clean nebulizer after each use. Each patient should have their own breathing circuit (Nebulizer, tubing, and mouthpiece). Through proper cleaning, sterilization, and storage of equipment, organisms can prevent form entering the lungs. Document all necessary information.

1.c. Drugs

NURSING RESPONSIBILITIES:

Before

Name Drugs; Generic

of Date Date

Ordered, Route Administration Dosage Frequency

of Mechanism Action &

of Indication or Purpose

Clients Response to the Meds w/ Actual S/E

& Performed/Give n, Discontinued

Brand Name

Generic Name: Cefuroxime

DO: 11-10-09

100 mg IV q 6

Mechanism Action

of Treatment of No respiratory tract infections. reactions declines other infection noted.

allergic noted. and signs no of were

DP: 11-10-09

Bind to bacterial cell membrane causing cell death.

The clients fever

Classificatio n: Anti-infective

Check for the doctors order. Prepare all the materials and equipments needed. Prepare the exact amount of medication. Wash hands thoroughly before performing the procedure. Identify the correct patient by checking the name on the chart or by asking the patient. Explain the procedure to the SO, the purpose and the action of the drug.

 Obtain a history to determine previous use of and reactions to penicillin or cephalosporin.

During Clean the IV insertion site for medications with a cotton ball with alcohol. Gradually inject the drug into the port.

After Observe patient for signs of anaphylaxis (rashes, pruritus, wheezing) discontinue medication and notify physician or other HCP immediately if the symptoms occur and advise SO to also notify any HCP if signs of anaphylaxis occur. Assess patient for renal or liver dysfunction and adjust dose accordingly. Monitor for dose related adverse CNS effect and nephrotoxicity. Document all necessary information.

Name Drugs; Generic

of Date Date

Ordered, Route Administration Dosage Frequency

of Mechanism Action &

of Indication or Purpose

Clients Response to the Meds w/ Actual S/E

& Performed/Give n, Discontinued

Brand Name

Generic Name: Ambroxol

DO: 11-10-09

5 ml PO q 4

Splits links in the Treatment of No mucoproteins contained respiratory in disorders with viscid or the excessive of the mucus. reactions

adverse noted.

The client loosened his secretions.

DP: 11-10-09

respiratory mucus associated secretions, decreasing viscosity mucus.

Classificatio n: Mucolytic

NURSING RESPONSIBILITIES:

Before Check for the doctors order. Prepare all the materials and equipments needed. Wash hands thoroughly before performing the procedure. Prepare the exact amount of medication. Identify the correct patient by checking the name on the chart or by asking the patient.

 Explain the procedure to the SO. Explain to the SO the proper administration of the drug

During Allow the SO to administer the medication and assist him/her.

After Advise the SO to report signs of allergy. Assess patient for renal and hepatic dysfunction and adjust dose accordingly. Instruct SO not to exceed recommended dosage and frequency. Document all necessary information.

Name Drugs; Generic

of Date Date

Ordered, Route n Dosage Frequency

of Mechanism Action

of Indication or Purpose

Clients Response to the Meds w/ Actual S/E

Administratio

& Performed/Give n, Discontinued

Brand Name

&

Generic Name: Paracetamol

DO: 11-10-09

5 ml PO q 4

Mechanism Action

of To fever

reduce The in temperature or lowered

clients after

DP: 11-10-09

Decreases fever by acting directly on the hypothalamic heatregulating center to cause vasodilation and sweating, which helps dissipate heat.

bacterial viral infections.

administration and there are no side effects or adverse reactions noted.

Classificatio n: Anti-pyretic

NURSING RESPONSIBILITIES:

Before Check for the doctors order. Prepare all the materials and equipments needed. Prepare the exact amount of medication.

 Check the latest temperature of the patient. Identify the correct patient by checking the name on the chart or by asking the patient. Explain the procedure to the SO. Explain the right administration of the drug to the SO.

During Allow the SO to administer the medication and assist him/her.

After Report paleness, weakness and heart beat skips; s/sx of hemolytic anemia. Report for any symptoms of abdominal pain, yellow discoloration of skin and eyes, dark urine, itching or clay-colored stools because it may indicate liver toxicity. S/sx of acute toxicity that requires immediate reporting includes nausea and vomiting or abdominal pain. Advise SO to notify HCP when the signs mentioned above occur. Instruct SO to notify if fever do not improve within 3 days. Instruct SO not to exceed recommended dosage and frequency. Document all necessary information.

Name Drugs; Generic

of Date Date

Ordered, Route Administration Dosage Frequency

of Mechanism Action &

of Indication or Purpose

Clients Response to the Meds w/ Actual S/E

& Performed/Give n, Discontinued

Brand Name

Generic Name: Hydrocortison e

DO: 11-11-09

70 mg IV now Produces 8

intense Suppression of inflammation

The client did not develop any adverse reactions.

then 35 mg IV q metabolic effects. DP: 11-11-09

Classificatio n: Antiasthmatic s

NURSING RESPONSIBILITIES:

Before Check for the doctors order. Prepare all the materials and equipments needed. Prepare the exact amount of medication.

 Wash hands thoroughly before performing the procedure. Identify the correct patient by checking the name on the chart or by asking the patient. Explain the procedure to the SO, the purpose and the action of the drug. Assess patient for signs of adrenal insufficiency (hypotension, weight loss, weakness, nausea, vomiting, anorexia, lethargy, confusion, restlessness).

During Clean the IV insertion site for medications with a cotton ball with alcohol. Gradually inject the drug into the port. Assess patient for signs of adrenal insufficiency (hypotension, weight loss, weakness, nausea, vomiting, anorexia, lethargy, confusion, restlessness).

After Report worsening of condition or lack of improvement may need dosage adjustment. Report any fever, sore throat or muscle aches, sudden weight gain or swelling of extremities. Use appropriate prescribed form only as directed; call with questions or problems. Assess patient for renal or liver dysfunction and adjust dose accordingly. Document all necessary information.

1.d. Diet

DATE TYPE OF DIET ORDERED; DATE PERFORMED; DATE CHANGED GENERAL DESCRIPTION INDICATIONS AND PURPOSES SPECIFIC FOODS TAKEN CLIENTS RESPONSE DIETS TO

Milk Feeding with DO: 11-10-09 Strict Aspiration Precaution (SAP)

The pt. can drink To give the client Breast milk milk formula but adequate nutrition with Aspiration Precaution (SAP) which will prevent for further complications such as aspiration pneumonia. Strict

The client remains good in terms of nutritional and prevented aspiration. status was from

NURSING RESPONSIBILITIES:

Before Verify doctors order. Check the patients identity. Instruct SO to feed with strict aspiration precaution.

During Assist clients SO in feeding. Stress to the SO the importance in complying with the diet.

After Assess the health status of the patient. Compare previous health status from the present. Document all necessary information.

2. NURSING MANAGEMENT Keep a record of the vital signs and monitor Perform regular assessment of patients general condition Encourage bed rest Keep the back dry Maintain high-calorie, high protein diet, adequate vitamin intake (especially Vit. C) and increase fluid intake Turn patient frequently Raise the head of the bed Perform TSB for fever Monitor ABG Administer bronchodilators Perform chest physiotherapy Provide a calm, quiet environment for the patient
Teach the SO to avoid activities of the client that increases oxygen demand Teach SO and encourage proper secretions disposal. Tell the SO to sneeze and

cough into a disposable tissue and wrap it in a plastic bag

Teach SO and encourage to do proper handwashing, especially after handling

secretions, going to the bathroom and before and after eating

Teach SO to avoid patients exposure to irritants

 Administer medications as prescribed

D. EVALUATION 1. Clients Daily Progress

Days

November 10, 2009 (Admission)

November 11, 2009

November 12, 2009

November 13, 2009

November 14, 2009

November 15, 2009

November 16, 2009

Nursing Problems 1. Ineffective Airway Clearance

2. Hyperthermia 3. Ineffective Breathing Pattern 4. Risk for Deficient Fluid

Volume

5. Risk for Aspiration Vital Signs T CR RR 39.6C 173 bpm 78 cpm 37.4C 136 bpm 56 cpm

37.9C 144 bpm 78 cpm

36.8C 140 bpm 78 cpm 36.8C 37C 37.2C 110 bpm 44 cpm

Diagnostic/Lab Procedures 1. CBC

2. Chest X-Ray

Medical Management

1. D5 0.3 NaCl

Drugs

1. Salbutamol neb

2. Cefuroxime

3. Ambroxol 4. Paracetamol

5. Hydrocortisone

Diet

Milk Feedings with Strict Aspiration Precaution

2. Discharge Planning Baby Bear was discharged last November 16, 2009. Unfortunately, the student nurses did not see him and was not able to handle the patient upon his discharge.

M: >Cefalozine drops 1 ml BID x I week >Salbutamol (Efamed) syrup 2.5 ml TID >Prednisone 1.75 ml BID after feeding x 3 days E: >instruct mother to provide adequate rest periods >instruct SO to allow tolerable play activities T: > H: >encourage adequate rest periods >encourage mother to provide comport and safety measures >encourage SO to keep pts back dry >instruct SO to keep allergen-free environment O: >instruct mother to return after a few days for follow-up check-up to the hospital D: >encourage SO to increase fluid intake of the baby >instruct the mother to feed the infant as long as he wants

III. CONCLUSION, SOCIOGRAM, BIBLIOGRAPHY

Conclusion: There are different types of pneumonia and it depends on how you classify it. Through this case study, the group was able to learn and understand the disease bronchopneumonia; therefore it gave knowledge in proper management, prevention and treatment of the said disease. As a student nurse, it is very important to know many things including the disease condition. This is a disease that when given prompt treatment and proper attention could give a good prognosis. But when neglected, it could lead you to a more severe condition just like other diseases. Nowadays, it is not a difficult condition to cure since we have so many available ways and medications to manage such disease. However, there are also an increasing number of factors that predispose everyone in acquiring the different types of Pneumonia depending on what causes it but there are ways to prevent from having them especially through good hygiene practices, having a clean and safe environment and practicing healthy lifestyle.

Sociogram:

DAY 1: November 12, 2009

Symbols and their Interpretation:

- Nursing student

- Nursing Interventions

- Health Assessment

- Interaction

- Baby Bear

DAY 2: November 13, 2009

Symbols and their Interpretation:

- Nursing student

- Nursing Interventions

- Health Assessment

- Interaction

- Baby Bear

References:

A. Books: Black, Joyce, and Hawks, Jane Hokanson: Medical-Surgical Nursing, ed 7. Elsevior Inc., 2004. Hockenberry, M.J. and Wilson, D. (2007). Wongs Nursing Care of Infants and Children, 8th ed. Mosby: Philippines. Deglin, H.D. and Vallerand, A.H. (2007). Daviss Drug Guide for Nurses, 10 th ed. F.A. Davis Company: Philadelphia, Pennsylvania. Karch, A.M. (2010). Nursing Drug Guide. Lippincott Williams and Wilkins: Philadelphia, Pennsylvania.

B. Internet: http://en.wikipedia.org/wiki/Pneumonia http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=35692 http://health.yahoo.com/infectiousdisease-overview/pneumonia-topicoverview/healthwise--hw63870.html http://www.acponline.org/ear/vas2001/pneumonia.html