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Case Presentation

Case Presentation. Bronchopneumonia PREPARED BY: SAUMYA BABY STAFF NURSE, PEDIA WARD. DEMOGRAPHIC DATA:. NAME: HALLA TARED MR NO: 181038 DIAGNOSIS: BRONCHOPNEUMONIA AGE: 2 YRS OLD GENDER: FEMALE DATE OF ADMISSION: 10/12/12 DATE OF DISCHARGE: 17/12/12. PHYSICAL ASSESSMENT:.

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Case Presentation

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  1. Case Presentation Bronchopneumonia PREPARED BY: SAUMYA BABY STAFF NURSE, PEDIA WARD

  2. DEMOGRAPHIC DATA: • NAME: HALLA TARED • MR NO: 181038 • DIAGNOSIS: BRONCHOPNEUMONIA • AGE: 2 YRS OLD • GENDER: FEMALE • DATE OF ADMISSION: 10/12/12 • DATE OF DISCHARGE: 17/12/12

  3. PHYSICAL ASSESSMENT: GENERAL ASSESSMENT: • Mild respiratory distress present • Looks lethargic • SKIN: • Dry and slightly pale • HEAD AND NECK: • No deformities found • THORAX: • Symmetrical in size • CARDIOVASCULAR: • Tachycardia and tachypnea present • GENITOURINARY: • Adequate urine output • GASTROINTESTINAL: • Abdomen is soft, not distended • MUSCULOSKELETAL: • No deformities noted. • No joint or muscle pain noted during examination • NEUROLOGY: • Growth and development is adequate as per Erikson Psychosocial Stage

  4. PATIENT HISTORY: PAST MEDICAL HISTORY: • NO family history of the bronchial asthma, bronchopneumonia, bronchiolitis. • DM • No allergic history • No previous breathlessness • History of gastroenteritis PRESENT MEDICAL HISTORY: • Shortness of breath and fever present since 1 day at the time of admission.

  5. TOPIC PRESENTATION: PNEUMONIA • DEFINITION: • Pneumonia is an inflammation of the lung parenchyma cause by various microorganisms including bacteria, mycobacterium, fungi and viruses.

  6. ANATOMY AND PHYSIOLOGY: LUNGS: • The lungs are paired elastic structures enclosed in the thoracic cage which is an air tight chamber with distensible walls • The lungs are enclosed in a serous membrane called pleura. The mediasternum is in the middle of the thorax between the pleural sacs that contains the two lungs and each lung is divided into lobes. There are several divisions of the brochi within each lobe of the lung. The subsegmentalbrochi then bracnhes into bronchioles which have no cartilage in their wall. The lung is made up about 300 million alveoli.

  7. PHYSIOLOGY: ALVEOLI – are tiny sacs in the lungs that perform gas exchange.that is the main process of respiration. BRONCHI – is basically an organ from the respiratory system. It acts as an caliber for the airway by conducting air into the lungs. BRONCHIOLES – are smaller airways that send the air on to the inside walls of the lungs.

  8. ETIOLOGY: • VIRAL ( cytomegalo virus is the most common) • BACTERIAL (streptococcal and staphylococcal pneumonia)

  9. PATHOPHYSIOLOGY ALVEOLAR INFLAMMATION AN EXUDATE INTERFERE WITH DIFFUSION OF O2 AND CO2 WBC, NEUTROPHIL MIGRATES TO ALVEOLI FILLED THE AIR SPACE NORMALLY PARTIAL OCCLUSION OF BRONCHI AND ALVEOLI ALVEOLAR OXYGEN TENSION DECREASED BROCHOSPASM HYPOVENTILATION HYPOXEMIA LOBAR PNEUMONIA BRONCHOPNEUMONIA

  10. SIGNS AND SYMPTOMS: BOOK BASE • Runny nose • Worsening cough • Fever • Increased Respiratory rate • Retraction • Wheezing • Cyanosis • Decreases breath sounds • Crackles • Chest pain • Abdominal pain • Vomiting PATIENT MANIFESTATIONS • Tachypnea • Poor feeding • Nasal flaring • Wheezing • Severe cough • Respiratory fatigue • SOB

  11. PRIORITIZATION OF NURSING PROBLEMS: • Ineffective breathing pattern. • Ineffective airway clearance due to secretion. • Altered nutritional pattern less than body requirement due to less food intake. • Hyperthermia related to infection. • Disturbed sleeping pattern due to cough and breathing difficulty.

  12. INTERVENTION: • Improving airway patency. • Promoting rest and conserving energy. • Promoting fluid intake and maintaining nutrition • Promoting family knowledge • Monitoring and preventing potential complications. • Promoting home and community based care.

  13. TREATMENT: BOOK BASE • Antibiotics • e.gCeftriaxone and other Cephalosporins. • Ampicillin • Supportive measures such IV fluids, antipyretic, humidified O2, hydration PATIENT TREATMENT • Treated with injection cefuroxime 500mg IV TID, neb Ventolin, pulmicort, atrovent and syrup adol.

  14. COMPLICATIONS: RESPIRATORY DISTRESS HYPOTENSION HEART FAILURE CARDIAC DYSRRYTHMIAS PERICARDITIS MYOCARDITIS PLEURAL EFFUSION

  15. NURSING CARE PLAN:

  16. NURSING HEALTH TEACHING: • Encourage mother to continue full course of antibiotics. • Advise to increase activities gradually after fever subsides. • Encourage follow up chest x-ray. • Increase steam inhalation. • Keep away from allergic substances. • Review principles of adequate nutrition and rest. • Recommended influenza vaccine (pneumovac) to all patients at risk. • Refer patient for home care to facilitate adherence to therapeutic regimen as indicated.

  17. CONCLUSION: Patient relieved from signs and symptoms. Discharged medications syrup Zinnat 125mg (6ml) BID. Neb ventolin 0.3ml + 2ml nss and neb pulmicort 0.5ml. Review after one week.

  18. BIBLIOGRAPHY • BRUNNER AND SUDDARTHS. TEXT BOOK FOR MEDDICAL – SURGICAL NURSING 12TH EDITION. • LIPPINCOTT MANUAL OF NURSING PRACTICE 9TH EDITION

  19. SHUKRAN for listening…

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