BRONCHOPNEUMONIA PREPARED BY ,

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• BRONCHOPNEUMONIA PREPARED BY ,
• M. HASEENA
• ER DEPT.
• DR . AHMAD ABANAMY HOSPITAL

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NURSING CASE STUDY OF A PATIENT WITH
BRONCHOPNEUMONIA

• Demographic data
• NAME X
• AGE 9 YEARS
• SEX MALE
• NATIONALITY TURKISH
• DATE OF ADMISSION 12/01/13
• CHIEF COMPLAINTS fever,COUGH ,
• SOB.
• DIAGNOSIS BRONCHOPNEUMONIA

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PHYSICAL ASSESSMENT

• GENERAL APPEARANCE
• Child is looking dull respiratory distress
  present, wheezing present, skin is warm to touch
• Vital signs
• Temperature 38.8c
• Heart rate 115 /mnt,
• Respiration 54 b/ mnt nasal flaring present
• Blood pressure 100/ 80 mmHg
• Spo2 88 in room air
• GENERAL MEASUREMENT
• Head circumference 44cm
• Chest circumference 28cm
• Weight -33kg
• Length -110cm

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PHYSICAL ASSESSMENT

• SKIN
• Normal skin colour
• Hair soft and silky
• Warm to touch
• Nails to end of fingers and often extend
• NOSE
• Nostrills patent bilaterally
• Nasal flaring present
• Nasal discharges present

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PHYSICAL ASSESSMENT

• MOUTH AND THROAT
• Uvula midline
• Secretion present
• Tongue moves freely
• Gag reflex present
• Teeth is normal in colour
• Productive cough present
• NECK
• Short neck present
• Turns side to side easily
• No lymph node enlargement present

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PHYSICAL ASSESSMENT

• CHEST
• Bilateral chest movement present
• Nipple is symmetrical
• Retraction present
• Crackles present
• Decreased breath sound present
• Tachycardia present
• ABDOMEN
• Soft to palpate
• Umbilicus is normal
• Bowel sound is normal on auscultation
•  

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PHYSICAL ASSESSMENT

• GENITALIA
• Urinary meatus at tip of glans penis
• Palpable testes in scrotum and is normal in shape
• Adequate voiding and defecation present
• BACK
• Spine is intact
• No spinal deformity present
• EXTREMITIES
• Full range of motion present
• Ten fingers and ten toes present
• Nails are normal in shape and colour

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MILESTONES OF DEVELOPMENT
MILESTONES BOOK BASE PATIENT BASE
GROSS MOTOR Enjoying team games, eg foot ball, tennis, cricket Are able to swimm Showing increased body awareness and awareness of own physical skill MET
FINE MOTOR Can use adult type tools such as saws and hammers Handwriting become more legible Increase writing speed Writing can occur well without ruled lines MET
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MILESTONES OF DEVELOPMENT
TALKING AND UNDERSTANDING Use and understand very complex language PRESENT
SOCIAL Able to resolve problems like fight with friends and siblings Ability to understand others point of view   PRESENT
INTELLECTUAL Depends on the school curriculum
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IMMUNIZATION STATUS
VACCINE BIRTH 1MOS 2MOS 4MOS 6MOS 9MOS 12MOS 15MOS 18MOS 19-23MOS 2-3YRS 4-6YRS 7-10YRS
HEP B
RV
DPT
Hib
PCV
IPV
INFLUENZA
MMR
VARICELLA
HEP A
MCV 4
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ABBREVIATION OF VACCINES

• Hep B Hepatitis B
• RV Rotavirus
• DPT Diphtheria ,
  Pertuses, Tetanus
• HiB Haemophilus
  influenza type B
• PCV Pneumococcal
  vaccine
• IPV Inactivated
  poliovirus
• MMR Measeles, Mumps,
  Rubella
• Hep A Hepatitis A
• MCV 4 Meningococcal virus

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PATIENT HISTORY

• Past Medical History patient Xs is known case
  of bronchial asthma since
  childhood.
• And he
  is on medication (nebulization) , and no other
  treatment .
•  Present medical history patient xs is came
  to ER Dept due to the complaints of
• 
  high grade fever, severe cough, since 2
  days. Shortness of breath ,
  poor oral intake since one day. Seen and
  examined by our ER Paediatrition,
  nebulisation with ventolin, atrovent and
  pulmicort given. Inj . hydrocortisone 100mg
  IV given .But no improvement so the patient
  is admitted to ward for
  further conservative management
• Surgical history patient xs has no
  present and past surgical history
•  
•  

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TOPIC PRESENTATION

• Bronchopneumonia is a severe type of pneumonia
  that is characterized by multiple areas of acute
  and isolated consolidation that affect one or
  more pulmonary lobes. It is one of the most
  serious infection in childrens.The disease
  assumes alarming proportion if both the lungs are
  affected. Great care has to be taken if the
  patient suffers from bronchopneumonia. If it is
  left untreated, the outcome may be fatal.

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BRONCHOPNEUMONIA IMAGES
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BRONCHOPNEUMONIA IMAGES
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CROSS SECTION OF BRONCHOPNEUMONIA AFFECTED LUNGS
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ANATOMY AND PHYSIOLOGY OF RESPIRATORY SYSTEM

• The respiratory system is situated in the thorax,
  and is responsible for gaseous exchange between
  the circulatory system and the outside world.
•  

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RESPIRATORY SYSTEM
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RESPIRATORY SYSTEM
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ANATOMY AND PHYSIOLOGY

• The respiratory system is represented by the
  following structures
• THE NOSE
• It consist of the visible external nose and the
  internal nasal cavity. The nasal septum divide
  the nasal cavity into right and left sides. Air
  enters two opening , the external nares (nostrils
  and naris ) and pasess into the vestibule and
  through passages called meatuses. The bony wall
  of the meatus called concha , are formed by the
  facial bone ( the inferior nasal concha and the
  ethmoid bone ) . from the meatuses the air then
  funnels into left and right internal nares. Hair
  , mucus, blood capillaries and cilia that lines
  the nasal cavity filter, moisten ,warm and
  eliminate debris from the passing air .

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ANATOMY AND PHYSIOLOGY

• PHARYNX The pharynx ( throat ) consist of
  the following three region , listed in
  order through which incoming air passess
• NASOPHARYNX It receives the incoming air from
  the two internal nares , the two auditory tubes
  that equalize the air pressure in the middle ear
  also enter here . the pharyngeal tonsils (
  adenoid ) lies at the back of the nasopharynx.
•  
• OROPHARYNX It receives air from the
  nasopharynx and food from the oral cavity ,
  the palatine and lingual tonsils are located here
  .
•  
•  
• LARYNGOPHARYNX It passess food to the
  oesophagus and air to the larynx
•  
•  

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ANATOMY AND PHYSIOLOGY

• THE LARYNX
•   It receives air from the laryngopharynx .
  it consist of several piece of cartilage that are
  joined by membranes and ligaments .
•  EPIGLOTTIS
• It is the first piece of cartilage of the larynx
  , is a flexible flap that covers the glottis .
  the upper region of the larynx , during
  swallowing to prevent the entrance of the food .
•  
•   THYRIOD CARTILAGE
•  
•  It protect the front of the larynx , a forward
  projection of this cartilage appears as the ADAMS
  apple ( laryngeal prominence ) .
•  

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ANATOMY AND PHYSIOLOGY

•  
• The upper vestibular folds ( false vocal
  cords ) contain muscle fibres that brings the
  folds together and allow the breath to be held
  during periods of muscular pressure on the
  thoracic cavity ( eg straining while defecating
  , or lifting a heavy object )
•  
• The lower vocal folds ( true vocal cords )
  contain elastic ligament that vibrate when
  skeletal muscle move them into the path of out
  going air . various sound including speech are
  produced in this manner .
•  
•  
• CRICOID CARTILAGE
•  
• These are supporting the larynx

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ANATOMY AND PHYSIOLOGY

• TRACHEA
•  
• The trachea ( wind pipe )is a flexible tube
  about 10-12 cm long and 2.5 cm in diameter
•  
• The mucosa is the inner layer of the trachea
  contain mucus producing goblet cells and pseudo
  stratisfied ciliated epithelium . the movement of
  the cilia sweeps debris away from the lungs
  towards the pharynx .
•  
• The submucosa is a layer of areolar connective
  tissue that surround the mucosa .
•  
• The adventitia is the outermost layer of the
  trachea . it consist of areolar connective tissue
  .
• LUNGS
• The lungs are a pair of cone shaped bodies that
  occupy the thorax , the mediastenum , the cavity
  containing the heart , separate the two lungs .
  left and right divided by the fissure into two
  and three lobes . each lobe is further divide d
  into lobules with terminal bronchioles . blood
  vessels , lymphatic vessels and nerves penetrate
  each lobe .

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ANATOMY AND PHYSIOLOGY

• The lungs are the sites for gaseous exchange, and
  are situated within the thoracic cavity. They
  occupy 5 of the body volume in mammals when
  relaxed., and their elastic nature allow them to
  expand and contract with the process of
  inspiration and expiration.
•  
• Pleura is a double layered membarane consisting
  of an inner pulmonary ( visceral ) pleura which
  surround each lung . the narrow space between the
  two membarane is the pleural cavity is filled
  with pleural fluid , a lubricant secreted by the
  pleura .
• Each lung has the following superficial features
• The apex and the base identify the top and bottom
  of the lung
• The costal surface of each lung borders the ribs
• On the medial ( mediastenal surface ) where each
  lung faces the other lung , the bronchi , blood
  vessels, and lymphatic vessels enter the lungs
  at the hilus .
•  

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ANATOMY AND PHYSIOLOGY

• The primary bronchi are two tubes that branch
  from the trachea to the left and right lungs
  .
• 
  Inside the lungs , each primary bronchus divides
  repeatedly into branches of secondary
  ( lobar ) bronchi , tertiary ( segmental
  ) bronchi , and numerous bronchioles , including
  terminal bronchioles and respiratory bronchioles
  . the wall of the primary bronchi is constructed
  like the trachea , but as the branches of the
  tree get smaller . the cartilaginous rings and
  the mucosa are replaced by smooth muscle .
•  
• ALVEOLAR DUCTS
• These are the final branches of the bronchial
  tree . each alveolar ducts has enlarged bubble
  like swelling along its length . each bubble is
  called alveolus . some adjacent alveoli are
  connected by alveolar pores .
•  
• The respiratory membrane consist of the alveolar
  and capillary walls . gas exchange occurs across
  these membarane .
•  
•  

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ANATOMY AND PHYSIOLOGY

• The characteristics are
•  
• TYPE 1 CELLS are thin , squamous epithelial
  cells that constitute the alveolar wall . oxygen
  diffusion occurs across these cells .
•  
•  
• TYPE 2 CELLS These are cuboidal epithelial
  cells that are interspersed among type 1 cells .
  it will secrete pulmonary surfactant that reduce
  the surface tension of the moisture that cover
  the alveolar walls . a reduction in surface
  tension permit oxygen to diffuse more easly into
  moisture . a lower surface tension also
  prevent the moisture on opposite wall of an
  alveolus , alveolar duct from cohering and
  causing the airway to collapse .
•  
• ALVEOLAR MACROPHAGE
• Alveolar macrophage cells ( dust cells ) wanders
  among the other cells of the alveolar wall ,
  removing debris and micro organisam . a dense
  network of capillaries surround each alveolus .
  the capillary wall consist of endothelial cell
  surrounded by a thin basement membarane . the
  basement membarane of the alveolus and the
  capillary are often so close that they fuse .
•  

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MECHANISM OF BREATHING 

• Breathing occurs when the contraction or
  relaxation of muscle around the lungs changes the
  total volume of air within the air passages , (
  bronchi , bronchioles ) inside the lungs . when
  the volume of the lungs changes , the pressure of
  the air in the lungs also changes . if the
  pressure is greater in the lungs than out side
  the lungs , the air rushes out . if the opposite
  occurs , the air rushes in .
• INSPIRATION PHASE
• Inspiration occurs when the inspiratory muscle
  that is the diaphragm and the external
  intercostals muscle contract , the contraction
  of the diaphragm causes an increase in the size
  of the thoracic cavity , while contraction of the
  external inter costal muscle elevate the ribs and
  sternum . thus both muscle causes the lungs to
  expand , increasing the volume of their internal
  air passages . in response the air pressure
  inside the lungs decreases below that of air
  outside the body . because gases moves from
  region of high pressure to low pressure , air
  rush into the lungs .

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MECHANISM OF BREATHING

• EXPIRATION PHASE
• It occurs when the diaphragm and external
  intercostals muscle relax . in response , the
  elastic fibres in lung tissue cause the lung to
  recoil to their original volume . the pressure of
  the air inside the lungs then increases above the
  air pressure out the body and air rushes out .

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ETIOLOGY

• Bronchopneumonia is caused by viruses, bacteria
  , fungi protozoa and myco plasma
• Bacteria
• Streptococcus
• Staphylococcus
• Hemophilus influenza
• Klebsella
• Virus
• legionella pneumonia
• Fungi
• candida albicans
•  
• Other predisposing factors include
• common in hospitalized patients
• its occur as a complication of some other
  diseases , eg in children diphtheria, measles,
  and whooping cough
• In adults- influenza, typhoid and paratyphoid
  fever
• its caused by organism aspirated from mouth

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SIGNS SYMPTOMS
BOOK BASE PATIENT MANIFESTATION
HIGH GRADE FEVER FEVER 38.8 C
COUGH W/ MUCUS PRESENT
CHEST PAIN MILD CHEST PAIN PRESENT
FATIGUE PRESENT
IRRITABILITY NOT PRESENT
DECREASED APETITE PRESENT
DECREASED BREATH SOUND PRESENT
HEADACHE ABSENT
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SIGNS AND SYMPTOMS

• High grade fever
• Any body temperature that goes above 37 c is
  considered as fever . in bronchopneumoniamfever
  may be he symptoms for having the disease,
  especially if it is accompanied by other symptoms
  such as cold , cough and difficulty of breathing
• Frequent and excessive coughing accompanied by
  mucus
• Cough is a natural reaction of the body to the
  presence of certain elements that may irritate
  the throat. However if coughing may become
  pesistant and accompanied by mucus , then its a
  sign of something more serious than normal
  coughing. A person with bronchopneumonia
  experience frequent and excessive coughing
  sometime accompanied by mucus.
• Chest pain
• The persons experience difficulty of breathing
  and also sensation of not getting enough air , as
  a result the person gasping for air frequently
• Fatigue
• Irritability
• Decreased apetite
• Decreased breath sound on auscultation
• Headache

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PATHOPHYSIOLOGY

• When bacteria infect the pulmonary lobes, the
  lungs produce mucus that fills the alveolar sacs.
  this will cause a condition known as
  consolidation, which occurs when the lungs fill
  with mucus, lead to reduce in air space. This
  reduction in air space makes breathing difficulty
  causing shortness of breath and labored or
  shallow breathing

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PATHOPHYSIOLOGY

• VIRUS ENTER THE RESPIRATORY
  TRACT
• INFLAMMATION
• ACCUMULATION OF
  BRONCHIAL SECRETION
• ALVEOLI
  COLLAPSE
• NARROWING OF AIRWAYS
• SOB DOB
  
• BRONCHOPNEUMONIA

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INTERVENTIONS

• Perform comprehensive assessment
• Auscultate breath sound , noting areas of
  decreased or absent ventilation
• remove secretions by encouraging coughing
• Regulate fluid intake to optimize fluid balance
  and liquefy secretions
• Administer oxygen if hypoxemic
• Administer medication as prescribed
•  

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DIAGNOSIS

• Auscultation of breathing pattern
• Chest xray
• CBC, Sputum culture , c- reactive protein
•  

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INVESTIGATIONS
TEST PATIENT VALUE NORMAL VALUE
C- REACTIVE PROTEIN POSITIVE NEGATIVE
WBC 15.62uL 4.23-9.07uL
SODIUM 135mmol/L 135-150mmol/L
POTASSIUM 3.6mmol/L 3.5-5.0 mmol/L
CHLORIDE 103mmol/L 98-11mmol/L
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TREATMENT

• Advise to drink plenty of fluid
• Enough rest
• Elevate the head of the bed to minimize
  respiratory effort
• Administer oxygen, if needed
• Use antibiotics as prescribe
• Antipyretics as ordered

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COMPLICATIONS

• Pleural damage leads to pleural effusion, pleural
  empyema
• Cardiovascular disease
• Respiratory deficiency
• Acute renal insufficiency in dehydration
• Septic distribution of the pneumonia agents
  through the blood with the development of otitis,
  meningitis, brain abscess, endo carditis
•  

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PRIORITIZATION OF NURSING PROBLEMS

• Ineffective airway clearance related to
  accumulation of trachea bronchial secretion
• Hyperthermia related to the inflammatory process
• Impaired gas exchange related to inflammation of
  airways and accumulation of sputum
• Acute pain related to ineffective comfort
  measures and inflammation
•  

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NURSING HEALTH TEACHING

• Follow up the regimen as per order
• Frequent hand washing with soap and water or use
  hand sanitizer
• Advise to have healthy diet and adequate
  rest,that will keep the immune system strong
•   Advice to cover the mouth while coughing
• Follow up to the hospital after finishing the
  antibiotic course

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NURSING CARE PLAN FOR BRONCHOPNEUMONIA
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subject Difficulty in breathing Objective Restlessness with naslal flaring, warm flushed skin , Ineffective airway clearance related to accumulation of tracheobronchial secretion After 3- 4 hrs, patient able to improve airway clearance, reduction of congestion with breath sound clear - Record vital signs -Assessment of breathing pattern -Advise to drink plenty fluids -Elevate head of bed -Do suctioning if necessary -To obtain baseline data -To know the patient general condition -To clear secretion -To promote maximxl inspiration -To clear airway After 3-4 hrs patient shall have demonstrated improved airway clearance, reduction of congestion
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ASSESSMENT NUSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective Sleeping disturbance Objective Child is restless, nasal flaring noted Disturbed sleeping pattern related to difficulty of breathing After 3-4 hrs of nursing intervention he will be able to verbalise understanding of sleep disturbance -Monitor vitals -Encourage to increase intake of warm milk for the child - Provide a quiet environment -Instruct to elevate head of the bed -Oxygen administration (if necessary) -To have a comparable base line data -To promote comfort and relaxation -To promote comfort for the child -To maximize lung expansion of the child and decrease difficulty of breathing -To improve the o2 saturation The child shall have verbalized understanding of sleep disturbance
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ASSESSMENT NUSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective Difficulty of breathing, Objective Presence of Circum oral cyanosis Spo2 88 in room air Impaired gas exchange related to inflammation of airways After 4-6 hrs of nursing intervention, patient will be able to demonstrate improvement in gas exchange -Monitor and record vital signs -Observe color of skin,mucous membrane and nails beds -Promote adequate rest -Keep environment allergen freE -Suction secretion Prn -Administer oxygen as ordered -To obtain base line data -Cyanosis may represent vasoconstrictionor the body response to fever, chills -Rest will prevent fatigue and decrease oxygen demand -To reduce irritant effects on airway -To clear airways -To increase oxygen saturation Patient shall demonstrate improvement in gas exchange
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ASSESSMENT NUSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective Increased body temperature _at_38.8c Objective skin is warm to touch Vital signs Temp 38.8c PR 115/mt RR 54 b/ mt Spo2 88 in room air Hyperthermia related to the inflammatory process After 3 hrs of nursing intervention patient temperature will decrease to normal limit -Assess patient condition and monitor vitals -perform tepid sponge bath -Instruct to increase fluid intake -Maintain patent airways and provide blanket -Provide antipyretics as ordered -To know base line data -To promote heat loss by evaporation and conduction -To support circulatory volume and perfusion -To promote patient safety and reduce chills -To reduce fever After 3-4 hrs of nursing intervention patient temperature shall have decreased to normal limits
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