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