Bronchopneumonia (A Case Analysis)

Ms. Kelly Deinla Clinical Instructor

Rose Abigail Atienza BSN 321

I.Introduction Growth and Development of a Toddler At this age you can expect him to put on clothing, brush his teeth with help, stack 4-6 blocks, combine words, know over 50 words, use pronouns (I, me, you, mine), follow two step commands, know his body parts, walk up steps, kick a ball, jump up, throw a ball overhead, and his speech should be half understandable. Over the next year his speech will become more understandable, and he will be able to name pictures and colors. He may begin to play with other children, but it will be 'parallel play.' Children at this age are very self-centered and may play alongside each other, but it will be some time before they actually start playing together. Your child will probably not want to share his things and he may be very possessive. It is important to closely supervise children that are playing together at this age and reassure them that the other child will not keep his toys. Keep a few of his favorite items separate and not available for sharing so that he feels he has some control over things. This is also a time that your child will begin to explore and try and figure out how things work and will enjoy playtime. It is important to give lots of praise and many opportunities for exploration. Most toddlers take at least one naps (length of naps are usually very variable between different children, but naps are usually 1-1 1/2 hours long) during the day at this age and are able to sleep all night (for 11-12 hours). If not, check to make sure that your toddler has a good bedtime routine and has developed the proper sleep associations. Once your child is able to climb out of his crib (and you have already lowered the mattress and removed the bumper pads), it is time to move him into a toddler bed. If your child is three feet tall, you may want to move him to a toddler bed even if he isn't climbing out of his crib yet. The usual age for moving out of a crib is about eighteen months to two years.

II.Definition of the Disease Bronchopneumonia or bronchial pneumonia (also known as lobular pneumonia is a type of pneumonia characterized by multiple foci of isolated, acute consolidation, affecting one or more pulmonary lobes. It is one of two types of bacterial pneumonia as classified by gross anatomic distribution of consolidation (solidification), the other being lobar pneumonia Bronchopneumonia is less likely than lobar pneumonia to be associated with Streptococcus.[3] The bronchopneumonia pattern has been associated with hospitalacquired pneumonia, and with specific organisms such as Staphylococcus aureus, Klebsiella, E. coli, and Pseudomonas.[4] In bacterial pneumonia, invasion of the lung parenchyma by bacteria produces an inflammatory immune response. This response leads to a filling of the alveolar sacs with exudate. The loss of air space and its replacement with fluid is called consolidation. In bronchopneumonia, or lobular pneumonia, there are multiple foci of isolated, acute consolidation, affecting one or more pulmonary lobes. It should be noted that although these two patterns of pneumonia, lobar and lobular, are the classic anatomic categories of bacterial pneumonia, in clinical practice the types are difficult to apply, as the patterns usually overlap. Bronchopneumonia (lobular) often leads to lobar pneumonia as the infection progresses. The same organism may cause one type of pneumonia in one patient, and another in a different patient. From the clinical standpoint, far more important than distinguishing the anatomical subtype of pneumonia, is identifying its causative agent and accurately assessing the extent of the disease

III. Pathophysiology

Predisposing factorsAge (very young)Gender Exposure (living)

Pecipitating factorsDaily ActivitiesEnvironment Diet

Pathological Entry (inhalation)of organism: Bacteria or Viruses

Occurrence of localized inflammation

Mucus production

Manifested by wheezing

Diminished surfactant productionFormation of Hyaline membrane

Bacteria invades alveolar cellin the lungs

Bronchopneumonia

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

IV 1.Personal Data a. Name of the patient: X b. Address: 19A Bayanan, Bacoor, Cavite c. History of present illness: 5 days PTA (+) cough, (+) fever, no retraction d. Past Medical History: no history of asthma or any diseases just common colds. e. Lifestyle: patient stated he loves playing with his sisters , usually sleeps once a day especially at noon. The baby is formula fed since his parents are working. f. Social Data: f.1: Family relationships and friends: the patient is the youngest in their family. f.2: Educational History: N/A f.4: Economic status: patients parents are both working. 2. Review of system 2.1 Physical Examination a. General Survey: conscious and coherent b.Mental Status: conscious and coherent c. Cephalocaudal: 1. Head: a. Skull: symmetrical in curvature b. Scalp: (-)lice and dandruff no tenderness c. Hair: color black, fine texture d. Face: symmetrical, no lesions e. Eyebrows: evenly placed and in line with one another. f. Eyelashes: evenly distributed, turned outward. g. Eyelids: symmetrical, (-)tenderness, (-) ptosis h. Sclera: white and clear i. Pupils: symmetrical and dilates equally j. Cornea: looks smooth, clear and transparent k. Iris: symmetrical, color black 2. Nose: at the midline, symmetrical 3. Mouth: a. Lips: color pink, symmetrical, smooth and moist b. Gums: whitish, smooth, no swelling c. Teeth: free from dental caries (-) halitosis d. Tongue: pink, slightly rough on top, moist. e. Cheek: pinkish, smooth and moist f. Tonsils: (-) enlarge tonsils 4. Ears: symmetrical 5. Neck: symmetrical, proportional to the size of the body.

6. Thorax: a. Respiratory system: chest is symmetrical, (+) crackles, Abnormal depth in breathing b. Heart: normal heart rate c. Abdomen: flat, soft. d. Upper extremities: no tenderness, (-) mass, (-) lesion, smooth and temperature is uniform. e. Upper extremities: symmetrical, (-)lesions,. V. Anatomy and Physiology In humans, the trachea divides into the two main bronchi that enter the roots of the lungs. The bronchi continue to divide within the lung, and after multiple divisions, give rise to bronchioles. The bronchial tree continues branching until it reaches the level of terminal bronchioles, which lead to alveolar sacs. Alveolar sacs are made up of clusters of alveoli, like individual grapes within a bunch. The individual alveoli are tightly wrapped in blood vessels and it is here that gas exchange actually occurs. Deoxygenated blood from the heart is pumped through the pulmonary artery to the lungs, where oxygen diffuses into blood and is exchanged for carbon dioxide in the hemoglobin of the erythrocytes. The oxygen-rich blood returns to the heart via the pulmonary veins to be pumped back into systemic circulation. Human lungs are located in two cavities on either side of the heart. Though similar in appearance, the two are not identical. Both are separated into lobes by fissures, with three lobes on the right and two on the left. The lobes are further divided into segments and then into lobules, hexagonal divisions of the lungs that are the smallest subdivision visible to the naked eye. The connective tissue that divides lobules is often blackened in smokers. The medial border of the right lung is nearly vertical, while the left lung contains a cardiac notch. The cardiac notch is a concave impression molded to accommodate the shape of the heart. Lungs are to a certain extent 'overbuilt' and have a tremendous reserve volume as compared to the oxygen exchange requirements when at rest. Such excess capacity is one of the reasons that individuals can smoke for years without having a noticeable decrease in lung function while still or moving slowly; in situations like these only a small portion of the lungs are actually perfused with blood for gas exchange. As oxygen requirements increase due to exercise, a greater volume of the lungs is perfused, allowing the body to match its CO2/O2 exchange requirements. Additionally, due to the excess capacity, it is possible for humans to live with only one lung, with the other compensating for its loss. The environment of the lung is very moist, which makes it hospitable for bacteria. Many respiratory illnesses are the result of bacterial or viral infection of the lungs. Inflammation of the lungs is known as pneumonia; inflammation of the pleura surrounding the lungs is known as pleurisy.

Vital capacity is the maximum volume of air that a person can exhale after maximum inhalation; it can be measured with a spirometer. In combination with other physiological measurements, the vital capacity can help make a diagnosis of underlying lung disease.

VI. Laboratory Results Examination References Hemoglobin M 140180g/L F 120150g/L M 0.40-0.54 F 0.37-0.47 M 4.5-5.5 x 10**/L F 4.0-5.5 x 10**/L 5.0 100 x 106/L 142-424 Results 112 Differential count Neutrophil References Results 0.51-0.37 0.35

Hematocrit RBC count

0.33 3.53

Lymphocyte 0.25-0.33 Monocyte 0.02-0.06

0.60 0.03

WBC count Platelet count Peticulocyte count Nucleated RBC Toxic granulation Erythrocyte Rate Bleeding time Clotting time

7.0 272

Eosinophils Basophils Stabs Blood typing Rh typing

0.01-0.04 0-0.01 0.02-0.05

0.02

O positive

M 010mm/hr F 0.20mm/hr 2-4 min 2-5min

Malarial Smear Peripheral smear

Hemoglobin: if the hemoglobin is decrease in may indicate anemia, recent hemorrhage and fluid retention Hematocrit: if hematocrit is decrease it may indicate anemia or hemodilution. RBC; if RBC is decrease it may indicate anemia, fluid overload of >24 hrs.

Lymphocyte: if lymphocyte is increase t may indicate TB, hepatitis, infectious mononucleosis, mumps, rubella and lymphocytic leukemia.

VII. Drug Study Paracetamol Other name; Acetaminophen Action: Decreases fever by inhibiting the effects of pyrogens on the hypothalamic heat regulating centers and by a hypothalamic action leading to sweating and vasodilatation. Relieves pain by inhibiting prostaglandin synthesis at the CNS but does not have anti-inflammatory action because of its minimal effect on peripheral prostaglandin synthesis. Indication: Relief of mild to moderate pain; treatment of fever. Contraindication: Hypersensitivity; intolerance to tartrazine(yellow dye #5), alcohol, table sugar, saccharin Adverse reaction: Stimulation, drowsiness, nausea, vomiting, abdominal pain, hepatotoxicity, hepatic seizure (overdose), renal failure (high, prolonged doses), leucopenia, neutropenia, hemolytic anemia ( long term use). Nursing Consideration: -Assess patients fever or pain, type of pain, location, intensity, duration, temperature, diaphoresis. -Assess allergic reactions; rash, urticaria, if these occur drug must have to be discontinued. -Assess hepatotoxicity; dark urine, clay-colored stools, yellowing of skin and sclera, itching, abdominal pain, fever. -Monitor liver and renal functions -Check input and output ration, decreasing output may indicate renal failure. -Assess for chronic poisoning: rapid, weak pulse, dyspnea, cold, clammy extremities.

Salbutamol Other name: Albuterol Action: Stimulates beta 2 receptor of bronchioles by increasing levels of cAMP which relaxes smooth muscles to produce bronchodilation. Also cause CNS stimulation, cardiac stimulation, increase diuresis, skeletal muscle tremors and increase gastric acid irritation.

Indication: Relief of bronchospasm in bronchial asthma, chronic bronchitis, emphysema, chronic obstructive pulmonary disease. Also useful in treating bronchospasm in patients with coexisting heart disease of hypertension. Contraindication: Hypersensitivity to salbutamol, also to atropine and its derivatives. Threatened abortion during the 1st or 2nd trimester. Cardiac arrhythmia associated with tachycardia cause by digitalis intoxication. Hypertrophic obstructive cardiomayopathy or tachyarrryhtmia. Adverse Reaction: Fine skeletal muscle tremor, leg cramps, palpitations, tachycardia, HPN, headache, nausea, vomiting, dizziness, hyperactivity, insomia, hypotesion peripheral vasodilatation, flushing, feeling of nervousness and other emotional upsets. Nursing Responsibility: -Asssess cardio-respiratory function: BP, heart rate and rhythm and breath sounds. Determine history of precious medications and ability to self medicate to prevent additive. <Monitor for evidence of allergic reactions and paradoxical bronchospasms. Cefuroxime Other name: Zinacef Action: Second generation cephalosporin that inhibits cell wall synthesis promoting osmotic instability, usually bactericidal. Indication: Pharyngitis, tonsillitis, infection of the urinary or lower respiratory tracts, and akin or akin structure infection caused by S. pneumoniae, Uncomplicated UTI, Otitis media, Perioperative prevention, uncomplicated gonorrhea Contraindication:-Contraindicated in pt hypersensitivity to drug and ither cephalosporins. -Use cautiously in pt hypersensitive to penicillin because of possibility of cross-sensitivity with other beta lactam antibiotics. -use cautiously in breast feeding women and in pt with history of colitis or renal insufficiency. Adverse reaction: Thrombophlebitis, nausea, anorexia, vomiting, diarrhea, urticaria, pain induration, aterile abscesses, temperature elevation and tissue sloughing.

Nursing Responsibility: -Ask pt if he is allergic to penicillin or other cephalosporins -Obtain specimen for culture and sensitivity test before giving first dose.\ -For IM use, inject deep into a large muscle -Absorption of oral drug is enhance by food. -Tablets may be crushed, if absolutely necessary for patients who cant swallow tablets. VIII.Medical Management Antibiotics are prescribed based in Gram stain results and antibiotic guidelines (resistance patterns, risk factors, etiology must be considered). Combination therapy may also be used. Supportive treatment includes hydration, antipyretics, antihistamines, or nasal decongestants. Bed rest is recommended until infection shows signs of clearing Oxygen therapy is given for hypoxemia Respiratory support includes endotracheal intubation, high inspiratory oxygen concentrations, and mechanical ventilation Treatment of atelectasis, pleural effusion, shock, respiratory failure, or superinfection is instituted, if needed For groups at high risk for community-acquired pneumonia, pneumococcal vaccination is advised Increased fluid intake to thin viscous and tenacious secretions IX. Nursing Intervention Assess for fever, chills night sweats, pleuritic-type pain, fatigue, tachypnea, use of accessory muscle, bradycardia or relative bradycardia, coughing, and purulent sputum, and auscultate breath sounds for consolidation Note changes in temperature, pulse; amount, odor, and color of secretions; and breath sounds Frequency and severity of cough Degree of tachypnea or shortness of breath Changes in chest x-ray findings Assess the characteristic of drained pus from the lungs of the patient. Assess for complication, including continuing or recurring fever, failure to resolve, atelectasis, pleural effusion, cardiac complication, and superinfection Encourage bronchial hygiene, such as increased fluid intake and directed coughing to remove secretions. Put patient into moderate high back rest for lung expansion and clearing, and to cough effectively and prevent retention of mucopurulent sputum.