2. INTRODUCTION: STATISTICS
WORLDWIDE
*WHO: “150 million cases of pneumonia occur annually
among children younger than 5 years old.”
PHILIPPINES
*DOH: “829 cases of pneumonia per 100,000 occur
annually among children younger than 5 years old.”
3. PERSONAL DATA:
NAME: Baby RN
ADDRESS: Crame, San Juan
AGE: 1 year/ 9 mos.
GENDER: Male
DATE OF ADMISSION: Nov. 17, 2011 (12:45pm) Thursday
CHIEF COMPLAINT: dry cough, colds, fever
DIAGNOSIS: BPN. Mod. Distress w/ down syndrome
4. HEALTH HISTORY
PAST HEALTH HISTORY:
Baby RN has Down syndrome before he is diagnosed to have
bronchopneumonia.
PRESENT HEALTH HISTORY:
3 days PTA: dry cough, colds, fever, irritability
FAMILY HEALTH HISTORY:
The parents of the patient have no family illness and anomalies (as
interviewed)
COURSE IN THE WARD:
MGH (no IV, no medication, no oxygen support)
5.
6. Day1 Day2
Nutrition:
-breastfeed Good at sucking (lactating Good at sucking (lactating
mother) mother)
-lunch Good at sucking (lactating Good at sucking (lactating
mother) mother)
-dinner Good at sucking (lactating Good at sucking (lactating
mother) mother)
Sleep pattern:
-hrs. of sleep 9 to 10 hrs. 9 to 10 hrs.
Elimination:
-urine 1 1
-stool 1 2
8. ASSESSSING THE SKULL AND FACE
(inspection method)
ASSESSMENT FINDINGS
Size, shape and symmetry Rounded and symmetrical
Nodules and masses No nodules and masses
Facial features Symmetrical features
Facial grimace Slightly irritated and shows discomfort
9. ASSESSING THORAX (inspection
method)
ASSESSMENT FINDINGS
Shape and symmetry Chest symmetrical
Spinal alignment (posterior) No deformities
Breathing pattern (anterior) Rhythmic, fast (tachypnea-31bpm)
10. ASSESSING PERIPHERAL VASCULAR
SYSTEM (upon touching the patient
while taking vital signs)
ASSESSMENT FINDINGS
Peripheral pulses Symmetric pulse volumes
Peripheral perfusions Skin: not cold or warm, moisture
Capillary refill test Immediate return of color, no cyanosis
11. NEUROLOGIC ASSESMENT:
LEVELS OF CONCIOUSNESS
NURSING CARE DONE LOC
VS checking (8:00 am and Alert, oriented, awake
12:00 NN)
Morning care (8:30 am) Alert, oriented, awake
15. INTRODUCTION OF THE DISEASE:
Bronchopneumonia:
- type of pneumonia that is characterized by an
inflammation of the lung due to infection
- localized in the bronchioles (first airway
branches) and surrounding alveoli (tiny air
sacs act as the primary gas exchange units of
the lung)
17. PATHOPHYSIOLOGY:
• aspirstion of Streptococcus
pneumoniae
• adherence to alveolar walls
• inflammatory response
• damage to lung parenchyma
(bronchioles,alveoli)
18. PREDISPOSING AND PRECIPITATING
FACTORS:
*PREDISPOSING FACTORS:
-Malnutrition
-Place of residence
*PRECIPITATING FACTORS:
-Heredity
19. COMPLICATIONS:
1.)Empyema: is a collection of pus within
a naturally existing anatomical
cavity, such as the lung pleura.
2.)Pleurisy: is an inflammation of the
pleura, the lining of the pleural cavity
surrounding the lungs.
3.)Lung Abscess: necrosis of the
pulmonary tissue and formation of
cavities
4.)Pericarditis: is an inflammation of the
pericardium (the fibrous sac
surrounding the heart).
22. NCP: BRONCHOPNEUMONIA
ASSESSME NURSING RATIONALE PLANNING INTERVENT RATIONALE EVALUATIO
NT DIAGNOSIS ION N
*SUBJECTI *ineffectiv “nurse After 30 *increase *to Within 30
VE CUES: e breathing pocket mins. to fluid strengthen mins. To
pattern r/t guide” 1hr. of intake: immune 1hr. of
“Inuubo at BPN as nursing system rendering
sinisipon” manifested (12th interven- -water nursing
as by dry edition) tion: therapy interventio
verbalized cough and -citrus n:
by the colds By: -normal:VS fruits
patients Doonges * to Goal met!
mother. and -decrease: facilitate
Murmur irritability *complete comfort *vital signs:
*irritability rest and and NORMAL
-relieved: sleep decrease
Dry cough irritability
*OBJECTIV and colds *pan scale
E CUES: of 2-10
23. NCP: DOWN SYNDROME
ASSESSME NURSING RATIONAL PLANNING INTERVEN RATIONAL EVALUATIO
NT DIAGNOSIS E TION E N
*SUBJECTI *alteration “fundamen After 30 *play with *establishi Within 30
VE CUES: s on the tal of mins. of the patient ng rapport mins. Of
mood of nursing” nursing and let him and rendering
“special the patient interven- feel that he therapeuti nursing
child ang r/t down KOZIER& tion: can trust c interventio
anak ko at syndrome ERBS you and relationshi n:
napansin as you p will
ko ito mula manifested 8th edition, *decrease understand decrease Goal met!
nung mag by vol.1 d: him and the
iisang taon Irritability, irritability, his patients
na siya” Discomfort discomfort, situation feeling of *patients
As Stress, anxiety Irritability, irritability,
verbalized Anxiety and stress Discomfort discomfort,
by the of the Stress, anxiety
patients patient Anxiety and stress
mother is relieved
*OBJECTIV
25. GENERIC NAME CLASSIFICATION CONTRA- SIDE EFFECTS
BRAND NAME INDICATIONS
cefurox ANTI INFECTIVES hypersensitivity Skin rash, urticuria,
Cefuroxime fever, GI disturbance,
Axetil nausea and vomitting
INDICATIONS NURSING RESPONSIBILITY
Treatment against: if given to pregnant and
lactating women:
-H.influenzae
-S.aureus *may cause bleeding
-S.pneumoniae
-Klebsiella spp.
26. DISCHARGE PLANNING:
M-medications
*Dependent intervention: physicians order
E-exercise and environment
*Exercise: N/A
*Environment: keep the patient away from smoky and duty area
T-treatment
*Dependent intervention: physicians order
*Home-based care: cleaning the surroundings
H-health teachings
*Explain the common causes of the disease and how it is acquired and how to avoid it.
O-out patient
*MGH
*consult a doctor again if there are complications and problems encountered
D-diet
*Nutritious foods: vegetables, fruits, vitamin c supplement
S-spiritual
*Emotional support for the family of the patient
27. REFERENCES:
1. Seeley’s Principle of Anatomy and Physiology
2. The Filipino Doctor’s Drug Guide 10th edition (2011)
3. Nanda 2009
4. www.wikipedia.com
5. www.allnurses.com
