1. POLYTECHNIC COLLEGE OF DAVAO DEL SUR
MacArthur Highway, Digos City
A CASE STUDY OF
Empyema Thoracis, Left secondary to
BPN severe Community Acquired Pneumonia
s/p Chest Thoracostomy Tube
IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS IN
RLE/NCM 103
Presented to
Mr. Sajid S. Uy, RN
Presented by
Radee King R. Corpuz
May, 2009
1

2. INTRODUCTION
Pneumonia is an inflammation of the lungs caused by an infection. It is
also called Pneumonitis or Bronchopneumonia. Pneumonia can be a serious
threat to our health. Although pneumonia is a special concern for older adults
and those with chronic illnesses. It can also strike and young and healthy people
as well. It is a common illness that affects thousands of people each year in the
Philippines, thus, it remains an important cause of morbidity and mortality in the
country.
There are many kinds of pneumonia that range in seriousness from mild to
life-threatening. In infectious pneumonia, bacteria, viruses, fungi or other
organisms attack the lungs, leading to inflammation that makes it hard for an
individual to breathe. Pneumonia can affect one or both lungs. In young and
healthy individual, early treatment with antibiotics can cure bacterial pneumonia.
The drugs used to fight pneumonia are determined by the germ causing
pneumonia and the doctors findings.. It is best to do everything we can to prevent
pneumonia, but if one get sick, recognizing and treating the disease early offers
the best chance for a full recovery.
A case with a diagnosis of Pneumonia may catch one’s attention, though
the disease is just like an ordinary cough and fever, it can lead to death
especially when there is no immediate intervention done. Since the case is a
toddler, an appropriate care has to be done to promote faster recovery for the
patient. Treating patients with pneumonia is necessary to prevent its spread to
others and make them as another victim of this illness.
Bronchopneumonia is an illness of the lungs which is caused by different
organism like bacteria, viruses, and fungi and characterized by acute
inflammation of the walls of the bronchioles. It is also known as pneumonia. It is
common in women and causes 6% in mortality rate. Streptococcus pneumoniae
2

3. (pneumococcus) and Mycoplasma pneumoniae both are the common bacterium
which causes bronchopneumonia in the adults and children.
Acute inflammation of the walls of the smaller bronchial tubes, with
varying amounts of pulmonary consolidation due to spread of the inflammation
into peribronchiolar alveoli and the alveolar ducts; may become confluent or may
be hemorrhagic.
In United States, pneumonia is the most common cause of death from
infectious diseases. It accounts for almost 66,000 deaths per year and ranks as
the seventh leading cause of death in the United States (Brunner and Suddarth’s
Medical-Surgical Textbook, pp 628/pneumonia).
In Philippines, the case of pneumonia is one of leading cause of mortality
and morbidity among Filipinos, 75-85% of the population acquired the disease
and the one affected the disease are those who are in low income status and the
below poverty line individual. (www.DOH.org/pneumonia)
Our patient Baby C, was 1 year old, living at Gravahan, Matina Proper,
Davao City, was admitted at Davao Medical Center last March 28, 2009, at
6:37pm, with chief complain of difficulty of breathing.
According to her mother, she noticed that her baby is having substernal
retraction with rapid shallow breathing while asleep.
The family immediately took the baby to Davao Medical Center, and was
diagnosed with BPN severe, Community Acquired Pneumonia.
Weeks after, the doctors suggested for placement of chest thoracostomy
tube, due to the accumulation of pus in the pleural space.
3

4. IDENTIFICATION OF THE CASE
A. PERSONAL PROFILE
Name : Baby C
Address : Gravahan, Matina Proper, Davao City
Age : 1 year
Gender : Female
Civil status : Single
Occupation : none
Admitting Doctor : Dr. Veralou L. Sojor
Admitting Diagnosis : Empyema Thoracis, Left secondary to
BPN severe Community Acquired Pneumonia
s/p Chest Thoracostomy Tube
Religion : Roman Catholic
Nationality : Filipino
Educational Attainment: none
Spouse name : Mr. J
Occupation : Mini Store owner
Chief Complaint : Difficulty of breathing, Dyspnea
Date of admission : March 28, 2009; 6:37pm
B. Background/History
DM HPN CA ASTHMA
Maternal - - - -
Paternal - - - -
The parents of the client both manifest negative (-) history of the following
diseases: DM, Hypertension, Cancer, Asthma as interviewed.
4

5. C. Medical History
According to the medical history of the client, Baby C had no other
diagnosed illness except, bronchopneumonia, before the patient
experienced episodic fever and cough due to environmental factor. Baby
C. was hospitalized due to persistent cough with yellowish mucus
secretion. Baby C had completed the immunization process done in there
Barangay Health Center.
D. History of Present Illness
4 days prior to admission, Baby C experienced on and off high
fever, with substernal retraction, rapid and shallow breathing. With
yellowish mucus secretion present productively.
E. Socio-economic background
The family of baby C was very supportive, they have provided all
her medication. Specially her medicine and payments for other diagnostic
procedures to be done for her early and faster recovery
5

6. DEFINITION OF TERMS
Bradypnea – slower than normal rate (<10 breaths/minute), with normal dept
and regular rhythm (Brunner and Suddart’s Medical-Surgical Textbook, Chpt
21,pp 572)
Dyspnea – distressful sensation of uncomfortable breathing that may be caused
by certain heart conditions(Brunner and Suddart’s Medical-Surgical Textbook,
Chpt 23,pp 625)
Empyema – inflammatory fluid and debris in the pleural space. It results from an
untreated pleural-space infection that progresses from free-flowing pleural fluid to
a complex collection in the pleural space. (Brunner and Suddart’s Medical-
Surgical Textbook, Chpt 23,pp 625)
Hypoxemia – decrease in arterial oxygen tension in the blood (Brunner and
Suddart’s Medical-Surgical Textbook, Chpt 21,pp 625)
Mycoplasma pneumonia – another type of Community Acquired Pneumonia
(CAP), occurs most often in children and young adults and is spread by infected
respiratory droplets through person-to-person contact(Brunner and Suddart’s
Medical-Surgical Textbook, Chpt 23,pp 630)
Pleural effusion – abnormal accumulation of fluid in the pleural space(Brunner
and Suddart’s Medical-Surgical Textbook, Chpt 23,pp 625)
Pleural cavity – the area between the parietal and visceral pleurae a potential
space(Brunner and Suddart’s Medical-Surgical Textbook, Chpt 23,pp 625)
6

7. Substernal Retraction – indrawing beneath the breastbone, commonly
manifested to infant and neonate with respiratory distress(Fundamentals of
Nursing, Seventh Edition, Vital Signs unit VII, pp 507)
Thoracentesis – insertion of a needle into the space to remove fluid that has
accumulated and decrease pressure on the lung tissue; may also be used
diagnostically to identify potential causes of a pleural effusion(Brunner and
Suddart’s Medical-Surgical Textbook, Chpt 23,pp 625)
Thoracostomy - done to drain fluid, blood, or air from the space around the
lungs(Brunner and Suddart’s Medical-Surgical Textbook, Chpt 23,pp 625)
7

8. ANATOMY AND PHYSIOLOGY
A respiratory system functions to allow gas exchange. The gases that
are exchanged, 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.
8

9. The
respiratory system can be conveniently subdivided into an upper respiratory tract
(or conducting zone) and lower respiratory tract (respiratory zone), trachea and
lungs.
The conducting zone starts with the nares (nostrils) of the nose, which
open into the nasopharynx (nasal cavity). The primary functions of the nasal
passages are to: 1) filter, 2) warm, 3) moisten, and 4) provide resonance in
speech. The nasopharnyx opens into the oropharynx (behind the oral cavity).
9

10. The oropharynx leads to the laryngopharynx, and empties into the larynx
(voicebox), which contains the vocal cords, passing through the glottis,
connecting to the trachea (wind pipe).
The trachea leads down to the thoracic cavity (chest) where it divides into
the right and left quot;main stemquot; bronchi. The subdivision of the bronchus are:
primary, secondary, and tertiary divisions (first, second and third levels). In all,
they divide 16 more times into even smaller bronchioles.
The bronchioles lead to the respiratory zone of the lungs which consists of
respiratory bronchioles, alveolar ducts and the alveoli, the multi-lobulated sacs in
which most of the gas exchange occurs.Ventilation of the lungs is carried out by
the muscles of respiration.
Ventilation occurs under the control of the autonomic nervous system from
the part of the brain stem, the medulla oblongata and the pons. This area of the
brain forms the respiration regulatory center, a series of interconnected neurons
within the lower and middle brain stem which coordinate respiratory movements.
The sections are the pneumotaxic center, the apneustic center, and the
dorsal and ventral respiratory groups. This section is especially sensitive during
infancy, and the neurons can be destroyed if the infant is dropped or shaken
violently. The result can be death due to quot;shaken baby syndrome.”
Inhalation is initiated by the diaphragm and supported by the external
intercostal muscles. Normal resting respirations are 10 to 18 breaths per minute.
Its time period is 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. These consist of sternocleidomastoid,
platysma, and the strap muscles of the neck.
Inhalation is driven primarily by the diaphragm. When the diaphragm
contracts, the ribcage expands and the contents of the abdomen are moved
downward. This results in a larger thoracic volume, which in turn causes a
decrease in intrathoracic pressure. As the pressure in the chest falls, air moves
into the conducting zone. Here, the air is filtered, warmed, and humidified as it
flows to the lungs.
10

11. During forced inhalation, as when taking a deep breath, the external
intercostal muscles and accessory muscles further expand the thoracic cavity.
Exhalation is generally a passive process, however active or forced exhalation is
achieved by the abdominal and the internal intercostal muscles.
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.
During forced exhalation, as when blowing out a candle, expiratory
muscles including the abdominal muscles and internal intercostal muscles,
generate abdominal and thoracic pressure, which forces air out of the lungs.
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.
Virtually all the body's blood travels through the lungs every minute. The
lungs add and remove many chemical messengers from the blood as it flows
through pulmonary capillary bed . The fine capillaries also trap blood clots that
have formed in systemic veins.
The major function of the respiratory system is gas exchange. 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
11

12. could occur: 1) respiratory acidosis, a life threatening condition, and 2)
respiratory alkalosis.
Upon inhalation, gas exchange occurs at the alveoli, the tiny sacs which
are the basic functional component of the lungs. The alveolar walls are extremely
thin (approx. 0.2 micrometres), and are permeable to gases. The alveoli are lined
with pulmonary capillaries, the walls of which are also thin enough to permit gas
exchange. All gases diffuse from the alveolar air to the blood in the pulmonary
capillaries, as carbon dioxide diffuses in the opposite direction, from capillary
blood to alveolar air. At this point, the pulmonary blood is oxygen-rich, and the
lungs are holding carbon dioxide. Exhalation follows, thereby ridding the body of
the carbon dioxide and completing the cycle of respiration.
In an average resting adult, the lungs take up about 250ml of oxygen
every minute while excreting about 200ml of carbon dioxide. During an average
breath, an adult will exchange from 500 ml to 700 ml of air. This average breath
capacity is called tidal volume.
The respiratory system lies dormant in the human fetus during pregnancy.
At birth, the respiratory system is drained of fluid and cleaned to assure proper
functioning of the system. If an infant is born before forty weeks gestational age,
the newborn may experience respiratory failure due to the under-developed
lungs.
This is due to the incomplete development of the alveoli type II cells in the
lungs. The infant lungs do not function due to the collapse of the alveoli caused
by surface tension of water remaining in the lungs. Surfactant is lacking from the
lungs, leading to the condition. This condition may be avoided if the mother is
given a series of steroid shots in the final week prior to delivery. The steriods
accelerate the development of the type II cells.
12

13. A transverse section of the thorax, showing the contents of the middle and the posterior
mediastinum. The pleural and pericardial cavities are exaggerated since normally there is no
space between parietal and visceral pleura and between pericardium and heart
In human anatomy, the pleural cavity is the body cavity that surrounds
the lungs. The lungs are surrounded by the pleura, a serous membrane which
13

14. folds back upon itself to form a two-layered, membrane structure. The thin space
between the two pleural layers is known as the pleural space; it normally
contains a small amount of pleural fluid. The outer pleura (parietal pleura) is
attached to the chest wall.
The inner pleura (visceral pleura) covers the lungs and adjoining
structures, i.e. blood vessels, bronchi and nerves.
The parietal pleura is highly sensitive to pain; the visceral pleura is not, due to its
lack of sensory innervation.
The pleural cavity, with its associated pleurae, aids optimal functioning of
the lungs during respiration. The pleurae are coated with lubricating pleural fluid
which allows the pleurae to slide effortlessly against each other during
ventilation. Surface tension of the pleural fluid also leads to close apposition of
the lung surfaces with the chest wall. This physical relationship allows for optimal
inflation of the alveoli during respiration. Movements of the chest wall, particularly
during heavy breathing, are coupled to movements of the lungs since the closely
opposed chest wall transmits pressures to the visceral pleural surface and,
hence, to the lung itself.
ETIOLOGY AND SYMPTOMATOLOGY
14

15. Etiology
Ideal Actual Justification
Predisposing Factor
Specifically 6 months and above
children has low immune system, that can’t
resist any bacterial infection, such as
Age (+) airborne transmission.
Our patient is, 1 year old baby girl and
she acquires the said disease in their
community
The family of the pt owned a little “sari-sari”
store, which is the source of the family’s
Exposure
(+) income and which is situated near the road,
(living)
as interviewed the client was often baby
sited at their store
Precipitating Factors
Daily activities of an individual can be a
Daily causal factor of the disease. Playing is the
Activities (+) common activity at a very young age (1y/o).
This individual is not conscious of the
environment.
The patient common food intake are
Diet rice, hotdogs, eggs, chocolates, candies,
(+) sometimes fruits ( banana ), combination of
breast and formula milk.
Such as exposure to certain viruses
and foods early in life, may trigger the
autoimmune response.
Mycoplasma Our patient is living in a poor
pneumonae and environment, because they’ve live in a dusty
(+)
environmental place where near the highway, where many
factors vehicle passed by. Vehicular smoke and
dust particles can be the carrier of the
bacteria, viruses.
Symptomatology
15

16. Ideal Actual Justification
The bronchioles contain
submuscosal gland, which
Cough with greenish produce mucus that covers
or yellow mucus the inside lining of the
(-)
airways. Infected
bronchioles produce
greenish or yellow mucus
secretions.
On and Off high fever,
Fever cause by infection in the
body, invaded by specific
(+)
viruses or bacteria, our
body produces body
defenses in order to fight.
Caused by infection in the
Chest pain (-)
lining of the airway
Presence of foreign
pathogens, and fluid
accumulation in the airway
Bradypnea (+)
lining may cause slow
breathing pattern, depth
and rhythm
Accumulation on the lining
of airway, presence of
Shortness of breath (+) mucus secretion and
pathogenic bacteria invades
in the body
Due to compensatory
mechanism such as low
Loss of appetite immune response, any
(+) infection due to a disease
will result to the loss of
(poor feeding)
appetite
COMPLICATION
16

17. Empyema
is inflammatory fluid and debris in the pleural space. It results from an
untreated pleural-space infection that progress from free-flowing pleural fluid to a
complex collection in the pleural space.
Empyema most commonly occurs in the setting of bacterial pneumonia.
About 20-60% of all cases of pneumonia are associated with parapneumonic
effusion. With appropriate antibiotic therapy, parapneumonic effusions most often
resolve without complications, and they are of little clinical significance. The
resulting infection and inflammatory response can proceed until adhesive bands
form. The infected fluid becomes loculated pus in the pleural space.
Pleurisy
is an inflammation of both layers of the pleurae (parietal and visceral).
Pleurisy may develop in conjunction with pneumonia or an upper respiratory tract
infection, TB, or collagen disease: after trauma to the chest, pulmonary infarction,
or PE; in patients with primary or metastatic cancer; and after thoracostomy. The
parietal pleura has nerve endings; the visceral pleura does not. When the
inflamed pleural membranes rub together during respiration.
Lung abscess
is an acute or chronic infection of the lung, marked by a localized
collection of pus, inflammation, and destruction of tissue. Lung abscess is the
end result of a number of different disease processes ranging from fungal and
bacterial infections to cancer.
Pericarditis
17

18. Refers to an inflammation of the pericardium, the membranous sac
enveloping the heart. It may be a primary illness or it may develop during various
medical and surgical disorders. One of the cause of pericardits, is disorders of
adjacent structures: myocardial infarction, dissecting aneurysm, pleural and
pulomonary disease (pneumonia)
PATHOPHYSIOLOGY
18

19. Predisposing factors Precipitating factors
Age (very young) Daily Activities
Gender Environment
Exposure (living) Diet
Pathological Entry (inhalation)
of organism: Bacteria or Viruses
Occurrence of localized inflammation
Mucus production Manifested by wheezing
Bacteria invades alveolar cell
Diminished surfactant in the lungs
production
Formation of
Hyaline membrane
Bronchopneumonia Sign and Symptoms
Fever
Cough
Pulmonary Edema Chest pain
Airway
Obstruction Rapid, shallow breathing
Shortness of breath
Headache
Loss of appetite
Fatigue
Chest Thoracostomy
Tube
If disorderDaily Activities If disorder is Treated,
Environment Normal breathing pattern
Diet Normal respiratory rate and
urs: Breath sounds
Empyema
Lung Abscess
Pleurisy
Pericarditis
19

20. Etiologic agents gain entry into the respiratory tract through either
inhalation or aspiration of secretions. The pathogen creates a localized
inflammatory reaction on the airway mucosa that results in swelling and
increased mucus production. Significant inflammation and obstruction may result
in wheezing.
As entering the pathogen in the body compensatory mechanism: body line
of defense such as cilia, whipping motion that propels mucus and foreign
substances away from the lungs toward the lungs, for expectoration. As more
pathological microorganism into the respiratory tract, cilia may injure in some
way, the escalator or the whipping mechanism may have less effective.
The bacteria or viruses as progressively entering into the lungs, it may
reach to alveolar cell, type II cells lose their structural integrity and surfactant
production is diminished, a hyaline membrane forms, and pulmonary edema
develops.
Accumulation of mononuclear cells in the submucosa and perivascular
space, resulting in partial obstruction of the airway. They clinically manifest as
wheezing and crackles.
Hematogenous spread of bacteria from an extra-pulmonary infection site
—bacteria from another infected site can be carried in the blood to the lungs
Resulting from these infections causes the lungs to become stiff and less
distensible, thereby decreasing tidal volume. The patient must increase his
respiratory rate to maintain adequate ventialtion
MEDICAL MANAGEMENT
Under Dr. Veralou L. Sojor, M.D
20

21. 03/28/09
 Admit patient at IMCU transferred to SVIX under blue level II
o v/s q 4hr, BF with SAP
o CBC, Pt. U/A
o CXR
 IVF D5IMB at 20cc/hr
 Meds:
o Chloramphenicol at IVTT q8hr
o Paracetamol, PRN
o Salbutamol Nebuli
03/29/09
 Ff up CBC
 Ff U/A
 Ff up CXR
03/30/09
 For ABG, CBC, PC and U/A
 Continue IVF at same rate
 Continue Meds
o Start chloramphenicol
o Cefuraxime 335mg IVTT q8hrs
o Amikaxin 75mg IVTT, OD
o Decrease Salbutamol Neb, q4
03/31/09
 Still for Na+, K+, Ca+, Mg+
 Still for LP
 Review CXR-APL
 Continue IVF at same rate as ordered

 Continue Meds:
o Cefutaxime
o Amikacin
o Paracetamol
04/01/09
 V/S q4 with O2 Sat
 Still for NPO
 LP done, place pt on bed flat x4hrs
04/02/09
 Rpt CXR-APL today
21

22.  Ff up CSF analysis, GS/CS
 Ff up sugar and protein
 Continue Meds:
o Cefutaxime
o Amikacin
o Paracetamol
o Cloxacilline
04/17-24/09
 D5IMB at 45cc/hr
 Meds:
o Cloxacilline (D12)
o Pencillin Mg (D9)
o V/S q4hr
04/18/09
 Cloxalline (D12-13)
 Pencillin Mg (D10)

04/19/09 04/25/09
 Cloxalline (D13-14)  Cloxalline (D14)
 Pencillin Mg (D10)  Pencillin Mg (D12)
04/20/09  Rpt CXR –APL
 Cloxalline (D14)  Insert CTT
 Pencillin Mg (D11)
04/22/09 04/26/09
 Cloxalline (D15)  Retained CTT
 Pencillin Mg (D12)  Drained every shift
04/23-24/09 04/27/09
 Cloxalline (D13)  D5IMB at 45cc/hr
 Pencillin Mg (D11)  Meds:
o Pencillin Mg
(D13)
o Cloxacilline
(D15)
Laboratory
22

23. Hematology
Normal Clinical
Test Result Remarks
Values Significance
CBC+Plt Hemoglobin – F: Obstructive
H 3.5 1.86-2.4 Pulmonary dse,
-increased-
8 Failure of
mmol/L oxygenation
Hematocrit – .50 F: dehydrated
0.37-0.4 -increased-
7
RBC – H 6.59 F: Pulmonary disease
-increased-
4.2-5.4
WBC – H 4.52 5.0-10.0 Overwhelming viral -decreased-
infection
Neutrophil – L 48 55-75 Viral infection -decreased-
Lymphocytes –26 20-40% - normal range-
Monocytes – 4 2-10 -normal range-
Eosinophil – 4 1-8 -normal range-
Basophil – 0 0-1 -normal range-
Platelet count –
-normal range-
200,000/cu mm
Laboratory
Chemistry
Test Result Normal Values Clinical significance Remarks
Na+ 144.00 135-145mmol/L -normal range-
K+ H 5.9 3.5-5mmol/L Tissue breakdown -increased-
Ca+ 2.50 2.15-2.55 mmol/L -normal range-
Excess ingestion of
Serum Mg+ H 1.42 0.62-0.95mmol/L Mg+-containing -increased-
antacids
Laboratory
23

24. ABG
Clinical
Test Result Normal Values Remarks
significance
pH 7.42 7.35-7.45 -normal range-
pCO2 41.6 35-45 -normal range-
Depressed
HCO3 27.6 22.0-27.0 -increased-
respiration
O2 Sat 98.2% 80-100% -normal range-
Cf CO2 28.6 23.0-30.0 -normal range-
Chronic
PO2 74.0 80-100 obstructive -decreased-
lung disease
MEDICAL MANAGEMENT
Ideal Management
24

25. • 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
25

26. 26

27. 27

28. NURSING ASSESSMENT
Physical Assessment
28

29. Neurological
The patient had a GCS score of 11, she can able to express self through crying
and understand given by her mother, patient is able to interact person-to-person.
Eye/Vision
Our patient, have pale conjunctiva due to high grade fever and generalized
weakness upon admission
Ears/Hearing
Our patient doesn’t have hearing problem, no discharges, symmetrical, no
swelling and tenderness. Can respond normal voice tone
Nose
Our patient doesn’t have nasal problem, no discharges, no swelling and
tenderness noted upon inspection and, uniform in color.
Mouth/Tongue/Teeth/ Speech
The patient’s had a crack and pallor lips, reddened gums, with distant teeth. And
the patient had a slurred speech. Tongue is slightly pale.
Throat/Neck
Neck is symmetrical with head, can turned head from right to left gradually, but
with resistance, no palpable lymph nodes
Respiratory System
29

30. Patient use accessory muscle in order to breathe normally, presence of wheezes
and rales is heard upon auscultation and in normal hearing, with respiratory rate of
48cpm
Circulatory/Cardiovascular
Patient has an O2 Sat of 98%, heart rate of 90bpm, and and blood pressure
reading of 80/50, pulse rate was 130bpm with skipping beats. No edema, swelling, good
capillary refill less than 3secs.
Gastrointestinal
Flat abdominal contour, audible bowel sound, no tenderness or distention.
Thorax had dullness of sound due to decrease confluent and pleural effusion
Genitourinary
Patient had excessive urination, with minimum of 800cc per diaper
Muscoloskeletal
The patient had normal upper and lower extremeties, symmetrical and no
tenderness,
Integumentary
The patien’st skin was warm to touch,with temperature of 38°C , febrile,with
good skin turgor
NURSING MANAGEMENT
30

31. NURSING ASSESSMENT AND DIAGNOSIS
• 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,
NURSING THEORIES
Florence Nightingale
31

32. Her Notes on Nursing emphasized that a clean environment, warmth,
ventilation, sunlight, and a quiet environment lead to good health.
Reaction: a non-stimulating environment is essential especially for our patient, in
a way that it promotes faster recovery on our patient through minimizing external
and stressful stimuli such as limiting visitors during resting periods that may
worsen the situation of our client.
Virginia Henderson
Virginia Henderson defined nursing as quot;assisting individuals to gain
independence in relation to the performance of activities contributing to health or
its recoveryquot;
Hildegard Peplau
Hildegard Peplau used the term, psychodynamic nursing, to describe the
dynamic relationship between a nurse and a patient. She identified nursing roles
of the nurse and in our case this three roles fitted us for our client:
• Counseling Role - working with the patient on current problems
• Teaching Role - offering information and helping the patient learn
Reaction: As a nursing student, we had many roles to perform to our patient.
One of these roles is being a councilor. As a councilor, it is our duty to lessen if
not alleviate the client’s problem.
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33. 33

34. 34

35. 35

36. 36

37. HEALTH TEACHINGS
PRIMARY
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38. 1. Instruct the SO to have patient an oxygen therapy for continuous
normal breathing, and or breathing exercise
2. Instruct the SO to kept the patient away in open place such as in road
where their store located and dusty place, to prevent inhalation of
airborne microorganisms
3. Instruct the SO to maintain the patient proper diet that she can tolerate,
such as fruits, to help promote wellness.
4. Advice the SO to monitor patient’s fluid intake or adequate hydration,
to help her body re-hydrate to prevent fluid imbalance.
5. Instruct SO to assist patient in performinf self-hygience activities she
cannot tolerate, to help her maintain her activities of daily living.
6. Encourage SO to perform self care activities within her level of own
ability
7. Assist patient to perform as much as possible and then to call for
assistance. Collaborate with patient for progressive activity before and
after schedule activity.
SECONDARY
1. Administer medications regularly as ordered by the physician
2. Advice SO to the patient to have proper nutrition to enhance immune
system
TERTIARY
1. Instruct SO to comply patient’s medication regimen
2. Discuss the importance of having a regular check-up with his
physician, with the mother or with the parents.
DISCHARGE PLAN
When the doctor noted that the patient is for discharge it is very important
to continue the medication depending on the duration the doctor ordered for the
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39. total recovery of the patient. Patient with Bronchopneumonia severe Community
Acquired Pneumonia needs to have deep breathing exercise for lung expansion
and clearing for progressive normal breathing pattern and have adequate rest
periods. It is also important to maintain proper hygiene to prevent further
infection.
The client must relax in order to recover her present condition and
instructed significant others for minimal exposure, to an open environment such
as dusty and smoky area, which airborne microorganisms are present that can
be a high risk factor that may cause severity of her condition. The diet of the
patient is also a factor for fast recovery. Encouraged to eat nutritious foods
intended for respiratory problem patient, the family of the patient plays a big role
for the fast recovery.
Regular consultation to the physician can be factor for recovery to assess
and monitor her condition
M- advice SO not to skip patient’s medication that the doctor ordered
E- instruct SO, keep away the patient in smoky area or dusty environment
T- oxygen therapy, for maintenance
H- separate utensils for the patient and other personal things that will be use for
the whole family
O- provide SO information about how to control or prevent the spread of the
disease, present on your patient
D- encourage patient to eat nutritious food such as vegetable and fruits
especially those that contains vitamin C
S- provide emotional support and provide care for the mother
PROGNOSIS
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40. Good Poor Justification
Duration of Duration of illness is good since the
Illness - condition occur and she was given
ample treatment.
Onset of At the onset of illness, the patient
Illness - experienced poor respiration (DOB)
Compliance Patient can afford to sustain the
to - needed laboratory exams and the
Medication feasibility of having the condition
Family The family members supported the
Support - patient both financially and
emotionally.
Environment The hospital setting is not well
ventilated and may promote for
- further infection of the patient’s
current situation.
Age Patient is 1 year old therefore she
has a good chance of recovering for
- her immune system is still
generating in the process of
development.
Precipitating The patient manifested all the
Factors factors that may lead to
- Bronchopneumonia sev, CAP which
urged the family and the health
provider to set-up the proper action
Percentage
Good: 4/7x100=42.85/43%
Poor: 3/7x100= 57.14/57%
Overall Prognosis
The prognosis is good, because the duration of illness, compliance of
medication, family support and age are the contributing factors that result to have
a good prognosis
EVALUATION
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41. Through our hardship in preparing for this research, as we try to
interact and communicate to our patient and her family in a good manner for
us to gather the specific and accurate data that we needed that could help us
in studying the disease which could lead us into successful research.
The patient’s condition is in recovery period as she had already
undergone medication therapy for her present condition, which thereby
prevented occurrence of complications. They are financially capable in
sustaining such respiratory condition and the medications after. Her mother is
the one taking good care of her in throughout her hospitalization, giving
emotional and moral support.
IMPLICATION
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42. Nursing Practice
- this can be used as a guide for practice by other nurses. They
may get many relevant ideas in giving proper care and
interventions to patients with related illness or those who have
the same illness (BPN severe with Community Acquired
Pneumonia)
Nursing Education
- this study may serve as a helpful learning tool for student
nurses. They may utilize this complied study as their reference
for research; this will also give them good examples on nursing
managements, and nursing diagnoses, which will be a very
useful guide when they will be making their own Nursing Care
Plans.
Nursing Research
- students may use this compilation as their guide for research. This
will hand them good views and factual ideas which will be very
essential for their added learning on knowledge for BPN severe
with Community Acquired Pneumonia
REFERENCES
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43. • Medical-Surgical, Brunner and Suddart 11th Ed, Respiratory function and
Gas Exchange/pneumonia, pp 628-631
• Medical-Surgical, Brunner and Suddart 11th Ed, Diagnostic Test and
Results, pp 2148-2152
• Handbook for Medical-Surgical Nursing, 11th Ed, Management for
Respiratory function,pneumonia, pp665-668
• www.americanthoracicsociety.com/ thoracostomy
• http://www.springerpub.com/prod.aspx?prod_id=72628
• wikipedia.org/wiki/Pneumonia
• wikipedia.org/wiki/Pleural cavity
• www.medicinenet.com/Bronchopneumonia/article.htm
• www.who.int/topics/bronchopneumonia
• www.DOH.org/bronchopneumonia_prevalence
• www.vetmed.wsu.edu/ClientEd/diabetes
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