Post on 09-Apr-2015
COLEGIO DE SAN JUAN DE LETRAN – CALAMBASchool 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
C. E 67 yo
A & W
J.E 62 y.o
HPN
R.L 31 y.o
A & W
C. E 30 y.o
HPN
K.E.L 8 y.o
A & W
K.E.L 1 y.o
A & W
M. L 65 y.o
CVA
B.L 62 y.o
A & W
LEGEND:
Male Female Patient deceased A&W – Alive & Well
VI. REVIEW OF SYSTEMS/PHYSICAL EXAMINATION (August 12, 2009)
REVIEW OF SYSTEM PHYSICAL EXAMINATIONA.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
Male: 13-18
Child: 14-26
Decrease in hemoglobin is a
sign anemia, or excessive fluid
intake
Hematocrit 38 Female: 36 - 57
Male: 40 – 54
Decreased hematocrit is a sign
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
Predisposing factors
When inhaled, viruses and noxious gases enters the respiratory tract
Initial respiratory response of the body
Because of increased mucous production airway is narrowed
Bronchial walls is thickened
Noxious Gases Viruses
Inhalation
Increased mucous production
Narrowing of airway
Flow of air is altered because of blockage of increase mucous
Contributing factor that thickens blood vessels in the lungs
Macrophages destroys foreign particles including bacteria and viruses
Because of the absence of macrophages infectious microorganisms is free
to enter the body
When infection reach the bronchial walls
Prolonged infection of the respiratory system may lead to pneumonia
XIV. MEDICAL MANAGEMENT
MEDICAL MANAGEMENT RATIONALE
MEDICATION
Hemostan
Tobramycin
Salbutamol
Antihemorrhage and homeostasis for clinical cases
Anti-infective for lower respiratory infections
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
Airflow obstruction
Increased no. of goblet cells
Cigarette smoking
Altered function of alveolar macrophages
Increased susceptibility of respiratory infection
BRONCHITIS
Pneumonia
Generic Name: Tranexamic acidBrand 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
CONTRAINDICATION- Severe renal sufficiency. Patients with hematuria.
SIDE EFFECTSGI disturbances, giddiness, menstrual cramps, hypotension
ADVERSE REACTION-nausea, vomiting, anorexia, headache and hypotension
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: TobramycinBrand Name: Artobin
Aminoglycosides
Anti-infective for lower respiratory infections
Steroid responsive inflammatory ocular conditions where corticosteroids is indicated
CONTRAINDICATION- Hypersensitivity, Epithelial herpes simplex keratitis, varicella
SIDE EFFECTSLocalized ocular toxicity and hypersensitivity including itching and swelling
ADVERSE REACTION-Neurotoxicity, ototoxicity, GI effects, fever, blood coagulation abnormalities
Generic Name: SalbutamolBrand Name: Ventolin
Bronchodilator
Treatment and prevention of bronchial asthma and bronchitis.
Emphysema with associated reversible airway obstruction.
CONTRAINDICATIONThreatened abortion during 1st or 2nd trimesters of pregnancy
SIDE EFFECTSSlight tachycardia, tenseness, headache
ADVERSE REACTION-Fine tremor of skeletal muscle, feelings of tension, peripheral vasodilation, headache
I: Positioned head midline with flexionR: To maintain open airway
I: Elevated head of the bed at 45°R: To decrease pressure in the diaphragm
I: Changed position every 2 hoursR: To enhance drainage of lung segments
XVII. CONCEPT MAPPING
Receives the nursing Outcome Diagnosis
Nursing Interventions
Ineffective airway clearance related to excessive, thickened mucus secretions
After the nursing interventions the patient demonstrated improvement of clear airway.
A patient experiencing acute bronchitis
S: “Nahihirapan siyang huminga, tapos my plema din yung pag-ubo niya” – as verbalized by the mother of the patientO:> LOC: Conscious and Coherent >Use of accessory muscle in breathing >Crackles during auscultation >Productive cough > RR: 34cpm
Planning
Receives the nursing Outcome Diagnosis
Nursing Interventions
I: Administered salbutamol
R: To promote air passage to the lungs
After the nursing intervention the patient will demonstrate behavior to improve clear airway
Hyperthermia related to deficient fluid as evidenced by elevated body temperature
After the nursing interventions the patient’s temperature lowered down from 37.6°C to 37.4°C
A patient experiencing acute bronchitis with fever for 2 days
S: “Dalawang araw na siyang nilalagnat” – as verbalized by the mother of the patientO:> LOC: Conscious and Coherent > Skin warm to touch > Weakness > Temp: 37.6°C > RR: 34cpm > PR: 138 bpm
I: Provided Tepid sponge bath
R: To promote heat loss
I: Provided cool environment
R: To promote heat loss
Planning
Receives the nursing Outcome Diagnosis Nursing Interventions
Activity Intolerance related to impaired respiratory function.
After the nursing interventions goal partially met ,increased activity in bed of the patient
A patient experiencing acute bronchitis
S: “Dati ang likot-likot niyan ngayon di na masyado” – as verbalized by the mother of the patientO:> LOC: Conscious and Coherent > Weakness > (-) Independent function > PR: 138 bpm
I: Provided positive environment
R: To conserve energy
I: Adjusted activities
R: To prevent over exertion
After the nursing intervention the patient’s temperature will lower down from 37.6°C to normal range
I: Maintained bedrest
R: To reduce metabolic demands
I: Administered Paracetamol
R: To lower down temperature
I: Monitored vital signs
R: To promote timely interventions as needed
Planning
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.
After the nursing intervention the patient can demonstrate increase in activity tolerance
I: Promoted rest
R: To reduce fatigue
I: Increased activity level gradually
R:To conserve energy
I: Put side rails up
R: To promote security in moving
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