Anemia secondary to Sepsis secondary to Bronchopneumonia

A Case Study

Presented to the Faculty of

The Ateneo de Davao University

College of Nursing

A Case Study on

Anemia 2o to Sepsis 2o

Bronchopneumonia

Submitted by:

Kristi Ann CabonitaMarie Allexis CampanerFrancis Thomie CaranayRico Janrev CastañedaRashed Eduard Ceniza

Joanna Paula Concepcion

Submitted to:

Loreen S. Marcelo, RN

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September 25, 2010

TABLE OF CONTENTS

i. Acknowledgement.……………………………………………………………………………. 2

I. Introduction……………………………………………………………………………………. 3

II. Objectives (General & Specific)………………………………………………………………. 5

III. Patient’s Data………………………………………………………………………………….. 8

IV. Genogram……………………………………………………………………………………… 13

V. Health History…………………………………………………………………………………. 14

VI. Developmental Data…………………………………………………………………………… 17

VII. Physical Assessment…………………………………………………………………………... 20

VIII. Complete Diagnosis…………………………………………………………………………… 27

IX. Anatomy and Physiology……………………………………………………………………… 30

X. Etiology……………………………………………………………………………………….. 39

XI. Symptomatology……………………………………………………………………………… 54

XII. Pathophysiology……………………………………………………………………………… 62

XIII. Doctor’s Order……………………………………………………………………………….. 66

XIV. Diagnostic Examination………………………………………………………………………. 93

XV. Drug Study……………………………………………………………………………………. 109

XVI. Nursing Theories……………………………………………………………………………… 184

XVII. Nursing Care Plans……………………………………………………………………………. 192

XVIII. Prognosis ……………………..………………………………………………………………. 217

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XIX. Discharge Planning ……………………..……………………………………………………. 222

XX. Recommendation …………………………………………………………………………….. 224

XXI. Bibliography …..……………………………………………………………………………… 225

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ACKNOWLEDGMENT

In accomplishing great things, we must not only think, but believe in the power of our

cognition; not only aim but make our visions tangible; and at the end of the day, not only smile

at the thought of accomplishment, but look back to where the strength to achieve such success

came from.

The proponents would like to extend their warmest gratitude to all the people who

helped make the success of this undertaking a reality.

First and foremost, to our parents, for giving us support and encouragement every day,

for making us feel loved and cared for.

To our Clinical Instructor, Mrs.Loreen Marcelo RN, for her invaluable time and effort

rendered to us; for her guidance all throughout the our ward exposure. For being a friend and

companion in the area.

And lastly, to the Almighty Father, for His unceasing love and blessings; for giving us

enough power and fortitude to face all the hardships in the making of this work. To Him be all

glory and praise!

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INTRODUCTION

Anemia is a common problem among acutely ill patients, especially those who develop

sepsis. There are many factors contributing to the development of anemia in these patients, in-

cluding blood sampling and other losses, decreased RBC synthesis and possibly increased RBC

destruction. Increased RBC uptake may be due to changes in RBC morphology during inflam-

matory processes. Anemia is common in sepsis in part because mediators of sepsis (TNF-α and

interleukin-1β) decrease the expression of the erythropoietin gene and protein. Although treat-

ment with recombinant human erythropoietin decreases transfusion requirements, its use in ran-

domized, controlled trials failed to increase survival. Erythropoietin takes days to weeks to in-

duce red-cell production and thus may not be effective. Sepsis is a severe illness caused by

overwhelming infection of the bloodstream by toxin-producing bacteria. Microorganisms invad-

ing the body cause infections. Sepsis is also called Systemic inflammatory response syndrome

(SIRS). Sepsis can also be triggered by events such as pneumonia,

With more than 750,000 new cases a year in the United States and a mortality rate of up to

50 percent, sepsis is a serious problem. The condition kills more than 1,400 Americans a day,

making it the leading cause of mortality in the ICU. There are approximately 1, 000,000 cases

of sepsis a year in the Asia,7 and the frequency is increasing, given an aging population with

increasing numbers of patients infected with treatment-resistant organisms, patients with

compromised immune systems, and patients who undergo prolonged, high-risk surgery

(University of British Columbia, Critical Care Medicine, St. Paul's Hospital, Vancouver, BC,

Canada.)

http://www.nejm.org/doi/full/10.1056/NEJMra043632#ref7

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The significance of studying this case is to enhance or broaden our knowledge as well as the

patient’s who are suffering this disease and also to those people who are in high risk of having

this disease for us to share our knowledge for the primary prevention and simple interventions

of the disease. Thus they are in a pursuit for knowledge to be able to impart it to others. It can

be alarming since many people are confused and unaware of the symptoms presented. With this

study, the student nurses hope to apply their learning in taking care not only of their patients but

also of themselves.

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OBJECTIVES

After 3 days of data gathering, research and analysis, the student nurse shall have

devised objectives that will guide them for the proper understanding and fair interpretation of

the case of their chosen patient.

GENERAL OBJECTIVES

Cognitive

The student nurse’s first main goal is to gain knowledge through the completion of the

case study and to impart this learning to the patient, and to those directly and indirectly involved

with the completion of this case.

Specific Objectives under Cognitive aspect

Within the 3 days span of duty, the student nurses will be able to:

- Gather significant data from the patient’s chart which includes the doctor’s order, labo-

ratory exams and etc. to have complete information about the patient’s current condition.

- Research on the anatomy and physiology of the client’s affected system.

- Research on the possible causes and also the symptoms the patient experienced that may

suggest the current condition of the patient.

- Research and understand the disease process of the patient’s illness.

- Determine and interpret the medical management employed including laboratory and di-

agnostic procedures.

- Identify and study the drugs prescribed to the patient which affects the patient’s current

situation.

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Psychomotor

- In this aspect, the student nurse’s goal is to apply all what they have learned during the

process of completing this case study to improve nursing care that will meet the patient’s

need for the improvement of her general welfare.

Specific Objectives under Psychomotor aspect


- Conduct a thorough physical assessment and to interpret the assessment in order to give

the care the patient need

- Formulate nursing care plans and apply them to satisfy the patient’s needs and give ap-

propriate nursing interventions.

- Make a discharge plan for the patient using M.E.T.H.O.D and validate the patient’s

prognosis according to categories.

Affective

- With the knowledge gained and through the application of this knowledge, another goal

is that the student nurses will be able to empathize with the current situation of the pa-

tient and to gain some values like the value of patience and calmness which is important

for a them to have in order to become better nurses in the future.

Specific Objectives under Affective aspect


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- Establish rapport and therapeutic communication in order to gain information about the

patient which includes the medical and family health history, expectations of her condi-

tion, gather significant data from the patient’s chart and to her family and etc.; and for

the betterment of nursing care.

- Assume the role of being the patient’s advocate.

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PATIENT’S DATA

Name: Trudis

Age: 4 months old

Address: Purok 2 Salvacion, Panabo City

Civil status: child

Nationality: Filipino

Religion: Roman Catholic

Birth Place: Panabo City

Birthdate: 5/15/10

Name of Father: Michael Visperas

Name of Mother: Shiela Mae

Admitting Diagnosis: Anemia secondary to sepsis secondary to pneumonia

Admitting physician: Dr. Evangeline Arnaiz

Date of Admission:

Hospital: Southern Philippines Medical Center

Informant: Mother

History record:

Immunization: I BCG, I DPT

(-) HPN (-) CA

(-) DM (-) Leukemia

(-) PTB

Chief Complaint: Fever

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History of Past illness:

Patient has no other past illness as verbalized by the mother. Trudis was born healthy

with a normal delivery. She has already been immunized with I BCG and I DPT.

History of present illness:

Six days prior to admission patient has intermittent high grade fever, (+) cough- non-

productive. She was first admitted at Carmen District hospital and at the same day she was

immediately referred to SPMC. The mother medicated ,the child with paracetamol and with a

herbal medicine called calabong. Three days PTA patient defecated soft stool for four times

approximately 2 tbsp per episode. Day of admission (+) for vomiting.

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FAMILY BACKGROUND AND HEALTH HISTORY

Family Background

The patient's parents; Shiela and Michael has been married for eight years. The couple

lives at Panabo city with their 4 children. Michael works as a truck driver for a businessman for

almost 5 years, where he earns 6,000 a month. On the other hand Shiela only stays at home to

take care of their children.Shiela's youger sister, also lives with them and helps them to look

after the children. The couple also owns a small sari-sari store at their house where they gain

2000-3000 a month. Tessa is the youngest among the four siblings. The oldest child in the

family is aged 8 years old, who studies at a public school near their place. The second child is

aged 5 years old who is still at playschool at a day care center. Their third child is aged 2 years

old who still doesn't go to school. The family belongs to the lower class. Shiela is a gravida 4

para 4. She stated that she has completed the prenatal check-ups needed with all the pregnancy

she had. She also claimed to be fully immunized with tetanus toxoid. Shiela gave birth to all her

children at the local government hospital in Carmen.

Lifestyle and Diet:

Shiela wakes up at around 5 a.m to prepare food for the children and her husband. Their

usual meals include fish, meat and vegetables. In the morning their eldest child is sent to school.

While Shiela stays at home and takes care of the other 3 children and at the same time watches

over their, with the help of her sister.

Effects/ Expectation of illness:

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Shiela verbalized that it was the first time that a child of hers was admitted to a hospital.

Because of this she stated to take better care of her children. She has learned to immediately

seek help to prevent further complications of her child's condition. She and her husband expects

their youngest child to recover after the treatment and management done to Trudis.

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GENOGRAM

Legend:

Male =

Female=

† = DeceasedЖ = Has Anemia 2o to Sepsis 2o

Bronchopneumonia = Hypertension∆ = Diabetic

GrandmamaGrandpapa†∆

Grandmommy∆

Grandaddy

FrancisMarie

CandiceMikko

Camille TudisЖ

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DEVELOPMENTAL DATA

Erikson's Stages of Psychosocial Development

Erikson's eight stages reflect both positive and negative aspects of the critical life periods.

Erikson envisions life as a sequence of levels of achievement. Each stage signals a task that must

be achieved. The resolution of the task can be complete, partial, or unsuccessful. Erikson

believes that the greater the task achievement, the healthier the personality of the person; failure

to achieve a task influences the person's ability to achieve the next task. These developmental

tasks can be viewed as a series of crises, and successful resolution of these crises is supportive to

the person's ego. Failure to resolve the crises is damaging to the ego.

Stage Description Result Justification

Infants

(0 to 18 months)

Trust vs.

Mistrust

The first stage of Erik Erikson's

theory centers around the infant's

basic needs being met by the par-

ents. The infant depends on the

parents, especially the mother, for

food, sustenance, and comfort. The

child's relative understanding of

world and society come from the

parents and their interaction with

ACHIEVED The parents of the baby always see to it

that the baby is comfortable. They

provide everything that the baby needs.

Trudis is breastfed on demand and

safety of the baby is the top priority of

the parents. The baby has everything

that she needs like blankets and

clothings which is provided by the

parents. The parents are warm towards

15

the child. If the parents expose the

child to warmth, regularity, and de-

pendable affection, the infant's

view of the world will be one of

trust. Should the parents fail to pro-

vide a secure environment and to

meet the child's basic need a sense

of mistrust will result. According

to Erik Erikson, the major develop-

mental task in infancy is to learn

whether or not other people, espe-

cially primary caregivers, regularly

satisfy basic needs. If caregivers

are consistent sources of food,

comfort, and affection, an infant

learns trust- that others are depend-

able and reliable. If they are ne-

glectful, or perhaps even abusive,

the infant instead learns mistrust-

that the world is in an undepend-

able, unpredictable, and possibly

their baby as shown by them carrying

the baby. They always think of the

needs of the baby especially if it comes

to health. They see to it that the baby

gets the proper health care needed.

16

dangerous place.

Piaget's Phases of Cognitive Development

Piaget concluded that there were four different stages in the cognitive development of

children. The first was the Sensory Motor Stage, which occurs in children from birth to

approximately two years. The Pre-operational Stage is next, and this occurs in children aged

around two to seven years old. Children aged around seven to eleven or twelve go through the

Concrete Operational stage, and adolescents go through the Formal Operations Stage, from the

age of around eleven to sixteen or more.


Sensory Motor

Stage (Birth -

2yrs)

Piaget's ideas surrounding the

Sensory Motor Stage are

centred on the basis of a

'schema'. Schemas are mental

representations or ideas about

what things are and how we

deal with them. Piaget deduced

that the first schemas of an

infant are to do with movement.

Piaget believed that much of a

ACHIEVED The client had achieved this

stage since the client, as what we

have observed is able to recognize

thing around her. The client was

also able to follow dangling toy,

which her parents have, from side to

side and tries to get them. She also

turns her head to the sound around

her especially to the voice of her

parents. Her motor development is

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baby's behaviour is triggered by

certain stimuli, in that they are

reflexive. A few weeks after

birth, the baby begins to

understand some of the

information it is receiving from

it's senses, and learns to use

some muscles and limbs for

movement. These

developments are known as

'action schemas'.

Babies are unable to consider

anyone else's needs, wants or

interests, and are therefore

considered to be 'ego centric'.

During the Sensory Motor

Stage, knowledge about objects

and the ways that they can be

manipulated is acquired.

Through the acquisition of

information about self and the

also good as she could held her head

up in a prone position for a long

time.

Trudis is positive for reflexes like

sucking, yawning and many more.

She begin to learn things as

evidenced by her laughing when

ever her mother or father makes

faces in front of her. She knows and

recognize her mother and father.

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world, and the people in it, the

baby begins to understand how

one thing can cause or affect

another, and begins to develop

simple ideas about time and

space.

Babies have the ability to build

up mental pictures of objects

around them, from the

knowledge that they have

developed on what can be done

with the object. Large amounts

of an infant's experience is

surrounding objects. What the

objects are is irrelevant, more

importance is placed on the

baby being able to explore the

object to see what can be done

with it. At around the age of

eight or nine months, infants

are more interested in an object

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for the object's own sake.

A discovery by Piaget

surrounding this stage of

development, was that when an

object is taken from their sight,

babies act as though the object

has ceased to exist. By around

eight to twelve months, infants

begin to look for objects

hidden, this is what is defined

as 'Object Permanence'. This

view has been challenged

however, by Tom Bower, who

showed that babies from one to

four months have an idea of

Object Permanence.

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Freud's Model of psychosexual development

According to Freud’s theory of psychosexual development, the personality develops in

five overlapping stages from birth to adulthood. The libido changes its location of emphasis

within the body from one stage to another. Therefore, a particular area has special significance to

a client at a particular stage. If the individual does not achieve a satisfactory progression at each

stage, the personality becomes fixated at that stage.


Oral (Birth to 1

½ year)

The oral stage begins at

birth, when the oral

cavity is the primary

focus of libidal energy.

The child, of course,

preoccupies himself

with nursing, with the

pleasure of sucking and

ACHIEVEDTrudis is a 4 months old baby

who shows pleasure in sucking

and putting things into her mouth.

She is breastfed on demand by

her mother. Her mother said that

if Trudis cries, she either checks

the diaper or breastfed the baby.

The mother has no problems in

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accepting things into the

mouth. The oral

character who is

frustrated at this stage,

whose mother refused to

nurse him on demand or

who truncated nursing

sessions early, is

characterized by

pessimism, envy,

suspicion and sarcasm.

The overindulged oral

character, whose nursing

urges were always and

often excessively

satisfied, is optimistic,

gullible, and is full of

admiration for others

around him. The stage

culminates in the

primary conflict of

weaning, which both

breastfeeding the baby and she is

equipped with adequate

knowledge on the proper

breastfeeding technique. She is

very attached to her baby and

cares for her a lot. But, she just

not let the baby put anything on

her mouth. She doesn’t disregard

the child’s safety which is far

more important.

22

deprives the child of the

sensory pleasures of

nursing and of the

psychological pleasure

of being cared for,

mothered, and held. The

stage lasts

approximately one and

one-half years.

23

Physical Assessment

General Survey

Physical assessment was taken on September 12, 2010 at 11:45am, approximately 120

hours after time of admission. Received lying on bed in supine position, awake, conscious

though visibly tired.

Upon entering the room of a four month old female who lying next to parents with a

height of 61 centimeters and a weight of 6.2 kilograms, head circumference of 39 centimeters,

chest circumference of 41 centimeters and abdominal circumference of 44 centimeters and is

wearing a white colored tank top and a diaper underneath one layer of blue colored underwear.

Appears clean. No noted foul body odor. Appeared relaxed though tired. With occasional

smiling. No noted crying throughout assessment. Noted lesion on right posterior area of the

wrist. Skin on noted parted is significantly darker than that of the rest of the body. Initial vital

signs during time of assessment are:

Cardiac Rate: 139

Temperature: 37.5

Respiratory Rate: 39

Neurologic Status

Is able to smile though with no noted crying throughout the duration of the assessment.

Able to suck and swallow especially evident during breastfeeding. Eye movement in unison.

Blinks when eyes are exposed to light. Turns head when sound is generated. Sucking reflex is

present; Palmar reflex is present; Planter reflex is present.

No noted signs of neurologic disabilities.

24

Skin

Skin is generally light brown in color and uniform throughout most of the body; areas of

lighter pigmentation include the palms, lips and nail beds. Noted bruising, dark in color, on right

posterior wrist approximately 3 by 4 centimeters in size. Noted redness on left gluteus maximus.

No noted foul body odor. Upon palpation, noted skin is dry. Skin felt generally warm on areas

under the cover of clothing but cooler on the arms and extremities. No noted significant

birthmarks, bleeding or lesions aside from the aforementioned. With a Temperature of 36.0°C.

Skin has fair skin turgor.

Head

Inspection, the skull is normocephalic and symmetric has smooth skull contour. With a

head circumference of 39 centimeters. Hair is black in color, unevenly distributed, soft and thin.

Has dry hair. No noted change in pigmentation. No noted bruises, lesions, nodules or swelling.

Posterior fontanelle is hard indicating it has closed. Anterior fontanelle is soft and flat. No noted

bulging or depression. Facial movements are symmetrical and is particularly evident when

showing emotions such as smiling.. No presence of infection or infestation was noted.

Eyes

During inspection, eyebrows are evenly distributed, have thin hair that are black in color.

Eyebrows were symmetrically aligned with equal movement. The skin of the eyelids were intact,

no discharges and no discoloration. Lids close symmetrically however with noted infrequent

blinking with a rate of 4 blinks per minute; bilateral blinking. Upon inspection, sclera is

generally white. No noted visible sclera above cornea. When lids are closed, sclera is not visible.

No noted tearing from lacrimal duct and lacrimal sac. No noted discharge. Has brown colored

25

iris; pupils are black in color, equal in size of about 2mm. Both pupils constrict when illuminated

and are briskly reactive to light. Both eyes coordinated and move in unison. No noted strabismus,

bleeding or purulent discharge.

Ear

Auricles are aligned with the outer canthus of the eye. Upon palpation, found to be firm and not

tender; no noted pain. No noted tenderness upon palpation of the mastoid process. Pinnea recoils

after it is folded. Upon inspection with a penlight, no noted excessive discharge of cerumen or

blood. Blinking reflex noted when producing loud noise. No noted difficulty in hearing.

Nose

Upon inspection, nose is wide, symmetric straight and uniform in color. Upon palpation,

no noted tenderness or lesions. With noted minimal amount of mucous discharge from the nose.

Upon inspection with a penlight, mucosa is pink; no noted swelling, redness, growth or lesions.

Nasal septum is intact and in the midline between the nasal chambers. No noted nasal flaring.

Mouth

Upon inspection outer lips are dark pink in color; appeared soft, moist and smooth; with

symmetrical contour. No noted dryness and roughness. Inner, lips are pinkish red and uniform in

color; is moist, soft and smooth. Has no teeth. Gums are pink, moist and appear firm. No noted

swelling on gums. Tongue is in central position of the mouth, light pink in color; moist; slightly

rough with noted thin whitish coating in some areas. Able to move side to side. Smooth tongue

base with prominent veins. No noted lesions or dryness. Palate is intact. Soft palate is pink and

smooth. Hard palate is light pink and irregular in texture. Uvula is positioned in midline of

palate.

26

Neck

Neck is generally uniform in color. Neck is short with not noted head lag when turning

head. Lymph nodes are not swollen and tender. Thyroid gland is not visible. Trachea is in the

center of the neck.

Chest and Lungs

Has symmetrical anterior chest expansion with a respiratory rate of 39 breaths per

minute. Spine is vertically aligned. Noted productive coughing with green colored sputum. Upon

auscultation, faint crackles can be heared. Noted occasional irregular breathing pattern. Right

and left shoulders are of the same height. Anterior chest wall is intact, no noted tenderness or

masses. Posterior chest has full and symmetric respiratory excursion. Upon percussion of the

posterior chest, sounds resonate; no noted dullness or flatness over lung tissue. Upon

auscultation of the upper chest using a stethoscope, noted faint wheezing. No noted chest

indrawing.

Back and Extremities

Upon inspection upper extremities are grossly proportional to body shape for age, equal

in size on both sides of the body. Noted bruise on right posterior wrist. No noted deformities or

edema on upper extremities. No noted tremors or palpable nodules. Clavicles are intact, no

lumps noted; No noted variation in size of hands; Has five phalanges on each hand; No noted

deformities or unusual length of fingers; Two prominent palmar creases are visible and do not

completely transverse the palm; No noted single transverse or Simian crease. Nails of upper

extremities are trimmed and cleaned. Noted capillary refill of approximately 3 seconds. Lower

extremities are grossly proportional to body shape for age, equal in size and length on both sides

27

of the body. Toenails are trimmed and cleaned. No noted deformities or edema. Unable to

ambulate. Manipulation of the ankles reveals full flexibility in the form of plantar flexion of the

foot. Foot returns to neutral position after manipulation. Joints in upper and lower extremities

have good range of motion; No noted signs of hip dislocation; No noted signs of abnormal

curvature of the spine; No protrusions or deformities noted. Joints move smoothly with no noted

deformities, swelling, pain, tenderness. Spinal column vertically aligned. Spinal column is

straight with no noted protrusions or deformities.

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COMPLETE DIAGNOSIS

Anemia secondary to Sepsis Secondary to Bronchopneumonia

ANEMIA

Anemia is a condition that occurs when the number of red blood cells (RBCs) and/or the amount

of hemoglobin found in the red blood cells drops below normal. Red blood cells and the

hemoglobin contained within them are necessary for the transport and delivery of oxygen from

the lungs to the rest of the body. Without a sufficient supply of oxygen, many tissues and organs

throughout the body can be adversely affected. Anemia can be mild, moderate or severe

depending on the extent to which the RBC count and/or hemoglobin levels are decreased. It is a

fairly common condition, affecting both men and women of all ages, races, and ethnic groups.

P. 769 Brunner & Sudddarths Textbook of Medical Surgical Nursing 7th edition J.B Lippincott

Company

Anemia is a medical condition in which the red blood cell count or hemoglobin is less than

normal. The normal level of hemoglobin is generally different in males and females. For men,

anemia is typically defined as hemoglobin level of less than 13.5 gram/100ml and in women as

hemoglobin of less than 12.0 gram/100ml. These definitions may vary slightly depending on the

source and the laboratory reference used.

P. 336 Rick Randle Contemporary Medical Surgical Nursing 2007

29

Anemia is a condition in which your blood has a lower than normal number of red blood cells.

Anemia also can occur if your red blood cells don't contain enough hemoglobin Hemoglobin is

an iron-rich protein that gives blood its red color. This protein helps red blood cells carry oxygen

from the lungs to the rest of the body.

Hopper P.D., Williams, L.S. ; Understanding Medical Surgical Nursing 3rd edition

SEPSIS

Sepsis is any adverse medical conditions due to the presence of any microorgansim in the blood.

Usually, the layperson using the term blood poisoning is referring to the medical condition that

arise when bacteria or their products reach the blood.

Mosby’s Pocket Dictionary of Medicine, Nursing & Health Professions 5th edition

Sepsis is a serious infection usually caused by bacteria which can originate in many body parts,

such as the lungs, intestines, urinary tract, or skin that make toxins that cause the immune

system to attack the body's own organs and tissues

Infection that progress to the blood stream causing systemic infection is called sepsis. It results

from the presence of microorganism in the blood stream.

30

P,1482 Brunner & Sudddarths Textbook of Medical Surgical Nursing 7 th edition J.B Lippincott

Company

Bronchopneumonia

Bronchopneumonia occurs as a diffuse pattern of infection in both lungs more often in the lower

lobes. One or Several species if microorganisms cause the infection beginning in the bronchial

mucosa and spreading into the local alveoli the inflammatory exudates form in the alveoli

interfering with oxygen diffusion. Onset tends to insidious with mild fever, cough and rales.

Congestion causes productive cough and purulent sputum.

P.382 Gould B, Patho physiology for Health Professions 3rd edition, Saunders

Bronchopneumonia or bronchial pneumonia or "Bronchogenic pneumonia is the acute inflam-

mation of the walls of the bronchrioles. It is a type of pneumonia characterised by multiple foci

of isolated, acute consolidation, affecting one or more pulmonary lobes.

Smeltzer, Suzzane C. and Brenda G. Bare. Medical Surgical Nursing. Volme 2. 10 th

Edition. Lippincott Williams & Wilkins: Philadelphia. Copyright © 2004.

31

Bronchopneumonia is a type of pneumonia that is characterized by an inflammation of the lung

generally associated with, and following a bout with bronchitis. This is really a specific type of

pneumonia that is localized in the bronchioles and surrounding alveoli.

P. 464 Brunner & Sudddarths Textbook of Medical Surgical Nursing 7 th

edition J.B Lippincott Company

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ANATOMY AND PHYSIOLOGY

Respiratory System

The respiratory system consists of all the organs involved in breathing. These include the

nose, pharynx, larynx, trachea, bronchi and lungs. The respiratory system does two very impor-

tant things: it brings oxygen into our bodies, which we need for our cells to live and function

properly; and it helps us get rid of carbon dioxide, which is a waste product of cellular function.

The nose, pharynx, larynx, trachea and bronchi all work like a system of pipes through which the

air is funneled down into our lungs. There, in very small air sacs called alveoli, oxygen is

brought into the bloodstream and carbon dioxide is pushed from the blood out into the air. When

something goes wrong with part of the respiratory system, such as an infection like pneumonia,

chronic obstructive pulmonary diseases, it makes it harder for us to get the oxygen we need and

to get rid of the waste product carbon dioxide.

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The Upper Airway and Trachea

When you breathe in, air enters your body through your nose or mouth. From there, it

travels down your throat through the larynx (or voicebox) and into the trachea (or windpipe) be-

fore entering your lungs. All these structures act to funnel fresh air down from the outside world

into your body. The upper airway is important because it must always stay open for you to be

able to breathe. It also helps to moisten and warm the air before it reaches your lungs.

The Lungs

Structure

Air travels to the lungs through a series of air tubes and passages. It enters the body

through the nostrils or the mouth, passing down the throat to the larynx, or voice box, and then to

http://nursingcrib.com/wp-content/uploads/respiratorysystem3D.jpg

34

the trachea, or windpipe. In the chest cavity the trachea divides into two branches, called the

right and left bronchi or bronchial tubes, that enter the lungs.

In the adult human, each lung is 25 to 30 cm (10 to 12 in) long and roughly conical. The

left lung is divided into two sections, or lobes: the superior and the inferior. The right lung is

somewhat larger than the left lung and is divided into three lobes: the superior, middle, and infe-

rior. The two lungs are separated by a structure called the mediastinum, which contains the heart,

trachea, esophagus, and blood vessels. Both right and left lungs are covered by an external mem-

brane called the pleura. The outer layer of the pleura forms the lining of the chest cavity.

The branches of the bronchi eventually narrow down to tubes of less than 1.02 mm (less

than 0.04 in) in diameter. These tubes, called bronchioles, divide into even narrower tubes, called

alveolar ducts. Each alveolar duct ends in a grapelike cluster of thin-walled sacs, called alveoli (a

single sac is called an alveolus). From 300 million to 400 million alveoli are contained in each

lung. The air sacs of both lungs have a total surface area of about 93 sq m (about 1000 sq ft),

nearly 50 times the total surface area of the skin.

In addition to the network of air tubes, the lungs also contain a vast network of blood ves-

sels. Each alveolus is surrounded by many tiny capillaries, which receive blood from arteries and

empty into veins. The arteries join to form the pulmonary arteries, and the veins join to form the

pulmonary veins. These large blood vessels connect the lungs with the heart.

The lungs are paired, cone-shaped organs which take up most of the space in our chests,

along with the heart. Their role is to take oxygen into the body, which we need for our cells to

live and function properly, and to help us get rid of carbon dioxide, which is a waste product. We

each have two lungs, a left lung and a right lung. These are divided up into ‘lobes’, or big sec-

35

tions of tissue separated by ‘fissures’ or dividers. The right lung has three lobes but the left lung

has only two, because the heart takes up some of the space in the left side of our chest. The lungs

can also be divided up into even smaller portions, called ‘bronchopulmonary segments’.

These are pyramidal-shaped areas which are also separated from each other by mem-

branes. There are about 10 of them in each lung. Each segment receives its own blood supply

and air supply.

Blood Supply

The lungs are very vascular organs, meaning they receive a very large blood supply. This

is because the pulmonary arteries, which supply the lungs, come directly from the right side of

your heart. They carry blood which is low in oxygen and high in carbon dioxide into your lungs

so that the carbon dioxide can be blown off, and more oxygen can be absorbed into the blood-

stream. The newly oxygen-rich blood then travels back through the paired pulmonary veins into

the left side of your heart. From there, it is pumped all around your body to supply oxygen to

cells and organs.

The Pleurae

The lungs are covered by smooth membranes that we call pleurae. The pleurae have two

layers, a ‘visceral’ layer which sticks closely to the outside surface of your lungs, and a ‘parietal’

layer which lines the inside of your chest wall (ribcage). The pleurae are important because they

help you breathe in and out smoothly, without any friction. They also make sure that when your

ribcage expands on breathing in, your lungs expand as well to fill the extra space.

36

The Diaphragm and Intercostal Muscles

When you breathe in (inspiration), your muscles need to work to fill your lungs with air.

The diaphragm, a large, sheet-like muscle which stretches across your chest under the ribcage,

does much of this work. At rest, it is shaped like a dome curving up into your chest. When you

breathe in, the diaphragm contracts and flattens out, expanding the space in your chest and draw-

ing air into your lungs. Other muscles, including the muscles between your ribs (the intercostal

muscles) also help by moving your ribcage in and out. Breathing out (expiration) does not nor-

mally require your muscles to work. This is because your lungs are very elastic, and when your

muscles relax at the end of inspiration your lungs simply recoil back into their resting position,

pushing the air out as they go.

The Cardiovascular System

The Blood

37

Blood is denser and more viscous than water, which is part of the reason it flows more

slowly than water. The temperature of blood is about 38°C, which is slightly higher than normal

body temperature, and it has a slightly alkaline pH ranging from 7.35 – 7.45. Blood constitutes

about 8% of the total body weight. The blood volume is 5 - 6 liters in an average-sized adult

male and 4 – 5 liters in an average-sized adult female. Several hormonal negative feedback

systems ensure that blood volume and osmotic pressure remain relatively constant. Especially

important systems are those involving aldosterone, antidiuretic hormone, and atrial natriuretic

peptide, which regulate how much water is excreted in the urine.

Components of Blood

Whole blood is composed of two components: blood plasma, a watery liquid that

contains dissolved substances, and formed elements, which are cells and cell fragment.

Blood Plasma

38

When formed elements are removed from blood, a straw-colored liquid called

blood plasma is left. Plasma is about 91.5% water and 8.5% solutes, most of which are proteins.

Some of the proteins in plasma are also found elsewhere in the body, but those confined to blood

are called plasma proteins. Among other functions, these proteins play a role in maintaining

proper blood osmotic pressure, which is an important factor in the exchange of fluids across

capillary walls.

Plasma proteins:

- Albumins (54% of plasma proteins)

- Globulins (38%)

- Fibrinogen (7%)

Formed Elements:

RBC or Red Blood Cell

Red blood cells or erythrocytes contain the oxygen-carrying protein hemoglobin, which is

a pigment that gives whole blood its red color. A healthy adult male has about 5.4 million red

blood cells per microliter of blood, and a healthy adult female has about 4.8 million. To maintain

39

normal quantities of RBCs, new mature cells must enter the circulation at the astonishing rate of

at least 2 million per second, a pace that balances the equally high rate of RBC destruction.

Red blood cells are biconcave discs with a diameter of 7-8 micrometers and are highly

specialized for their oxygen transport function. Each one contains about 280 millions

hemoglobin molecules. A hemoglobin molecule consists of a protein called globin.

Red blood cells live only about 120 days because of the wear and tear their plasma

membranes undergo as they squeeze through blood capillaries.

WBC or White Blood Cell

Unlike red blood cells, white blood cells or leukocytes have a nucleus and do not contain

hemoglobin. WBCs are classified as either granular or agranular, depending on whether they

contain conspicuous chemical-filled cytoplasmic vescicles that are made visible by staining.

40

Granular leukocytes include neutrophils, eosinophils, and basophils; agranular leukocytes

include lymphocytes and monocytes.

In a healthy body, some WBCs, especially lymphocytes, can live for several months or

years, but most live only a few days. During a period of infection, phagocytic WBCs may live

only a few hours. WBCs are far less numerous than red blood cells, about 5,000-10,000 cells per

microliter of blood. RBCs therefore outnumber white blood cells by about 700:1. Leukocytosis,

an increase in the number of WBCs, is a normal, protective response to stresses and surgery.

Platelet

Besides the immature cell types that

develop into erythrocytes and leukocytes,

hemopoietic stem cells also differentiate

into cells that produce platelets. Under the

influence of the hormone thrombopoietin,

myeloid stem cells develop into

megakaryocyte-colony-forming cells that,

in turn, develop into precursor cells called

megakaryoblasts. Megakaryoblasts transform into megakaryocytes, huge cells that splinter into

2000-3000 fragments. Each fragment, enclosed by a piece of the cell membrane, is a platelet or

thrombocyte. Platelets break off from the megakaryocytes in red bone marrow and then enter the

blood circulation. Between 150,000 – 400,000 platelets are present in each microliter of blood.

They are disc-shaped, 2-4 micrometers in diameter, and exhibit many granules but no nucleus.

41

Platelets help stop blood loss from damaged blood vessels by forming a platelet plug. Their

granules also contain chemicals that, once released, promote blood clotting. Platelets have a short

life span, normally just 5 – 9 days.

The Blood Vessels

There are 3 types of

blood vessels: the arteries, the

veins and the capillaries. An

artery is a vessel that carries

blood away from the heart. It

carries oxygenated blood.

Small arteries are called

arterioles. Veins, on the other

hand are vessels that carries

blood toward the heart. It

contains the deoxygenated blood. Small veins are called venules. Often, very large venous spaces

are called sinuses. Lastly, capillaries are microscopic vessels that carry blood from small arteries

to small veins (arterioles to venules) and back to the heart.

42

The walls of the blood vessels, the arteries and veins have three main layers: tunica

adventitia, tunica media and tunica intima. Tunica adventitia which is a fibrous type of vessel is a

connective tissue that helps hold vessels open and prevents tearing of the vessel wall during body

movement. Tunica media is a smooth muscle, sandwiched together with a layer of elastic

connective tissue. It permits changes of the blood vessel diameter. It allows the constriction and

dilation of the vessels. Last but not the least is the tunica intima. Tunica intima, which in Latin

means inner coat, is made up of endothelium that is continuous with the endothelium that lines

the heart. In arteries, it provides a smooth lining. However in veins it maintains the one-way flow

of the blood. The endothelium, which makes up the thin coat of the capillary, is important

because the thinness of the capillary wall

allows the exchange of materials between

the blood plasma and the interstitial fluid of

the surrounding tissues.

Circulation of the blood in blood vessels

There are two circulatory routes

of blood as it flows through the blood

vessels: the systemic and the

pulmonary circulation. In systemic

circulation, blood flows from the left

ventricle of the heart through blood vessels

to all parts of the body (except gas

exchange tissues of lungs) and back to the

43

atrium. In pulmonary circulation on the other hand, venous blood moves from the right atrium to

right ventricle to pulmonary artery to lung arterioles and capillaries where gases exchanged;

oxygenated blood returns to the left atrium via pulmonary veins; from left atrium, blood enters

the left ventricle.

Inflammation

Cells damaged by microbes, physical agents, or chemical agents initiate a defensive

response called inflammation. The four characteristic signs and symptoms of inflammation are

redness, pain, heat, and swelling. Inflammation can also cause the loss of function in the injured

area, depending on the site and extent of injury. Inflammation traps microbes, toxins, and foreign

material at the site of injury and prepares the site for tissue repair. Thus, it helps restore tissue

homeostasis.

Because inflammation is one of the body’s nonspecific defenses, the response of a tissue

to, say, a cut is similar to the response to damage caused by burns, radiation, or bacterial or viral

44

invasion. In each case, inflammation has three basic stages: vasodilation and increased

permeability of blood vessels, phagocyte emigration, and ultimately, tissue repair.

Among the substances that contribute to vasodilation, increased permeability, and other

aspects of the inflammatory response are the following:

Histamine. In response to injury, mast cells in connective tissue and basophils and

platelets in blood release histamine. Neutrophils and macrophages attracted to the site of

injury also stimulate the release of histamine, which causes vasodilation and increased

permeability of blood vessels.

Kinins. These polypeptides, formed in blood from inactive precursors called kininogens,

induce vasodilation and increased permeability and serve as chemotactic agents for

phagocytes.

Prostaglandins. These lipids are released by damaged cells and intensify the effects of

histamine and kinins. It may also stimulate the emigration of phagocytes through capil-

lary walls.

45

ETIOLOGY AND SYMPTOMATOLOGY

A. ETIOLOGY

Predisposing

Factors

Present/

AbsentRationale Justification

Age Present Extremes of age predisposes an individual to pneumonia.

Those who are aged 65 and above and those who are very

young are more susceptible to acquiring pneumonia due

to weakened immune system and under developed

immune system respectively.

http://emedicine.medscape.com

The patient is aged 4

months, by this age, the

immune system is not

yet well developed as

compared to adults and

older children, thus

predisposing the child

to pneumonia.

Congenital

Anomalies

Absent Congenital Anomalies such as hereditary dyskinesis of

the cilia and squamous metaplasia hinder the body’s

ability to eliminate invading pathogens, thus predisposing

one to acquiring infections in the respiratory tract.

Congenital Abnormalities of the Lung by Karan Madan.

http://www.indiachest.org

There are no diagnostic

findings that would

indicate any congenital

abnormalities in the

child that would

predispose her to the

condition.

Precipitating Present/ Rationale Justification

46

Factors Absent

Immobility Absent Prolonged immobility causes limited expansion of the

lungs immobility changes the distribution of ventilation

and blood flow through the lungs and patients are unable

to take a deep breath, also, respiratory muscle weakness

occurs due to limited physical activity and metabolic

changes. It results in an increase in the work of breathing

which causes a decrease in the ability of the patient to

cough. With decreased lung expansion and weakened

respiratory muscles, secretions stagnate and pool which

increases the risk for hypostatic pneumonia.

http://www.healthcentral.com/encyclopedia/408/205.html

The patient did not

have immobility.

Whooping cough,

measles, or

bronchitis,

Absent Weakening of the body's defenses occurs in many

illnesses, particularly in the very young and very old. It is

for this reason that bronchopneumonia is a frequent

complication of childhood diseases such as measles and

whooping cough. In adults it is often a complication of

influenza, and it is likely to attack old people who are

confined to bed with any illness or injury which prevents

them from moving about properly. Bronchopneumonia

may follow an attack of bronchitis at any age.

http://www.rnceus.com/

The patient did not

have any history of

such diseases.

47

Immunesuppression Absent The cause of bronchopneumonia is seldom the virulent

microbe Streptococcus pneumoniae, but usually one or

other of several different microbes which are commonly

found in the respiratory passages of healthy people.

Under normal circumstances these microbes are held in

check by the body's natural defenses – the immune

system – but when these defenses are weakened the

microbes multiply rapidly and may then cause disease.

The patient is not

immnunocompromised.

Alcoholism Absent Alcohol abuse is associated with an increased incidence

and severity of pneumonia. In both the general

population and individuals consuming excess alcohol,

Streptococcus pneumoniae is the most frequent lung

infection pathogen. Alcohol intoxication impairs the

pneumococcal-induced increase in granulocyte

recruitment into the alveolar space, decreased bacterial

clearance from the lung, and increased mortality.

Acute Alcohol Intoxication Impairs the Hematopoietic

Precursor Cell Response to Pneumococcal Pneumonia.

The patient did not

have any intake of

alcohol; nor did the

mother in the course of

pregnancy.

48

Raasch CE, Zhang P, Siggins RW 2nd, Lamotte LR,

Nelson S, Bagby GJ.

http://www.ncbi.nlm.nih.gov/pubmed/20659065

Malnutrition Absent Malnutrition is a condition caused by a deficiency or ex-

cess of one or more essential nutrients in the diet. Malnu-

trition is characterized by a wide array of health prob-

lems, including extreme weight loss, stunted growth,

weakened resistance to infection, and impairment of in-

tellect. Severe cases of malnutrition can lead to death.

Microsoft ® Encarta ® 2009. © 1993-2008 Microsoft

Corporation. All rights reserved.

The patient is well

nourished.

Smoking Absent Smoking depresses the activity of scavenger cells and

affects the respiratory tract’s ciliary cleansing

mechanism, which keeps breathing passages free of

inhaled irritants, bacteria, and other foreign matter. When

smoking damages this cleansing mechanism, airflow is

This was not present in

the patient.

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Bagby%20GJ%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Nelson%20S%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Lamotte%20LR%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Siggins%20RW%202nd%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Zhang%20P%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Raasch%20CE%22%5BAuthor%5D

49

obstructed and air becomes trapped behind the

obstruction. The alveoli greatly distend, diminished lung

capacity. Smoking also irritates the goblet cells and

mucus glands, causing an increased accumulation of

mucus, which in turn produces more irritation, infection,

and damage to the lung. In addition, carbon monoxide (a

by product of smoking) combines with hemoglobin to

form carboxyhemoglobin. Hemoglobin that is bound by

carboxyhemoglobin cannot carry oxygen efficiently.

Microsoft ® Encarta ® 2009. © 1993-2008 Microsoft

Corporation. All rights reserved.

Environment Absent Environmental conditions such as those with high

incidences of inhalational exposure to noxious substances

contribute much in the formation of pneumonia.

Inhalation of certain chemicals or smoke may cause

pulmonary inflammation.

http://www.healthcentral.com

The patient lives in

Exposure to

Microorganisms

Entry of microorganisms causative of the pneumonia

cause infection. Streptococcus pneumonia,

Staphylococcus pneumonia and Haemophilus influenza

50

are among the most common causes of pneumonia.

51

B. SYMPTOMATOLOGY

Symptoms Present/Absent Rationale Justification

Fever Present Is a frequent medical

symptom that

describes an increase

in internal body

temperature to levels

that are above

normal. It is

stimulated by

cytokines (IL-1 &

IL-6). These

cytokines send

signals in the

hypothalamus that

serves as our

thermoregulatory

center, thus

prostaglandin is

released. Once

prostaglandin is

Vital Signs upon admission

reveal a temperature of 38.6.

http://en.wikipedia.org/wiki/Body_temperature

http://en.wikipedia.org/wiki/Body_temperature

http://en.wikipedia.org/wiki/Symptom

http://en.wikipedia.org/wiki/Medicine

52

released, it causes an

increase in the set

point. In response to

this, the

hypothalamus

neurally initiates

shivering and

vasoconstriction that

increases the core

body temperature to

the new set point,

and fever is

established.

Pain in the chest

over the affected

lung

Absent Difficulty of

breathing may lead

to chest pain due to a

deprivation of

oxygen circulating in

the lungs and heart.

Chemical mediators

like bradykinin and

prostaglandin also

This is not manifested by the

patient.

53

play a role in the

pain felt.

Dyspnea Present The alveoli are the

main site for oxygen

and carbon dioxide

exchange in the

lungs. Once the

exudates are poured

into the alveoli, it

impairs the oxygen-

carbon dioxide

exchange because

the space intended

for air is already

filled with fluid

causing dyspnea or

difficulty in

breathing.

There are occasions within the

shift that that the patient’s

respiratory rate rises above

the normal range with

apparent labored breathing,

indicating dyspnea.

Productive cough Present It is a sudden audible

expulsion of air from

the lungs with

The patient had productive

cough.

54

sputum. It is an

essential protective

response that serves

to clear the lungs,

bronchi, and trachea

or irritants and

secretions or to

prevent aspiration of

foreign material into

the lungs.

Alterations in

body temperature

Present Hyperthermia or

hypothermia are

characteristic signs

of sepsis, occurring

due to

The patient was febril upon

admission.

Decreased red

blood cells

Present A decrease in the

number of red blood

cells is called ane-

mia. Anemia is a

common problem in

acutely ill patients,

especially in those

Laboratory results show a

decrease in RBCs, and a

blood transfusion was

ordered.

55

who develop sepsis.

There are many fac-

tors contributing to

the development

of anemia in these

patients, including

blood sampling and

other

losses, decreased red

blood cell (RBC)

synthesis, and possi-

bly increased

destruction. In-

creased RBC uptake

may be due to

changes in RBC

morphology

and the RBC

membrane during

inflammatory

processes.

Anemia in sepsis:

56

the importance of

red blood cell

membrane changes

Micheal Piagnerelli,,

MD, Et al.

Tachycardia Absent Tachycardia is

characterized by

rapid beating of the

heart. Heart rate

considered as

tachycardia is above

120 in newborns,

above 180bpm in 6

month old infants,

more than 160bpm

in 1 year old clients

and above 130 in

two-year olds.

RN Notes. 2nd

Edition, by Ehren

Myers, RN.

This was not manifested by

the patient.

57

Since there is an

impaired exchange

of gases in the lungs,

and oxygen transport

to tissues is

inefficient, the heart

compensates by

pumping fast.

Crackles Present Crackles (or rales)

are caused by fluid

in the small airways

or atelectasis.

Crackles are referred

to as discontinuous

sounds; they are

intermittent,

nonmusical and

brief. Crackles may

be heard on

inspiration or

expiration. The

Upon auscultation, crackles

were heard on both lung

fields.

58

popping sounds

produced are created

when air is forced

through respiratory

passages that are

narrowed by fluid,

mucus, or pus.

Crackles are often

associated with

inflammation or

infection of the small

bronchi, bronchioles,

and alveoli. Crackles

that don't clear after

a cough may indicate

pulmonary edema or

fluid in the alveoli.

This is common in

pneumonia.

Tachypnea Present Also known as fast

breathing. For

There are occasions within the

shift that that the patient’s

59

pediatric clients,

breathing is

considered fast when

it reaches the rate of

above 30cpm in ages

1 to 4 years, above

35cpm in those aged

6-11 months and

above 60cpm in

newborns to

5months.

RN Notes. 2nd

Edition, by Ehren

Myers, RN.

. A decrease in

oxygen would cause

the body to

compensate to

increase the oxygen

supply in the body.

This results to the

increase in the

respiratory rate rises above

the normal range with

apparent labored breathing.

60

respiratory rate.

WBC changes Present White blood cells are

responsible for the

defense system in

the body. White

blood cells fight

infections and

protect our body

from foreign

particles, which

includes harmful

germs and

bacteria.Thus,

elevated WBC

counts indicate

infection.

Laboratory results show

elevated levels of white blood

cells.

Decreased blood

pressure

Absent Due to the cascade

of interactions

between WBCs and

microorganisms that

invades the body,


patient.

61

components of blood

WBC also increase

in number. One

component of WBC,

neutrophils, release

nitric oxide in the

process, a potent

vasodilator. Thus

causing a decrease in

blood pressure.

Easy Fatigability Absent A decrease in

circulating red blood

cells impairs the

transport of oxygen

in the different areas

in the body.

Decreased oxygen

delivery to the

musculoskeletal

tissues cause easy

fatiguability.


patient.

Respiratory Absent Respiratory acidosis No ABG results would

62

Acidosis is acidosis

(abnormally

increased acidity of

the blood) due to

decreased ventilation

of the pulmonary

alveoli, leading to

elevated arterial

carbon dioxide

concentration. In

cases of pneumonia,

respiratory acidosis

occur as a result of

the impaired gas

exchange in the

lungs.

indicate respiratory acidosis.

Pallor Present Pallor is due to a

reduced amount of

oxyhemoglobin in

skin or mucous

membrane, a pale

color which is

The baby was reported to be

pale.

63

caused by anemia. It

is more evident on

the face and palms.

64

Pathophysiology(Community Acquired Pneumonia)

Precipitating Factors:

Predisposing Factors:Age

Causative agent gains access to the reparatory

tract

Through aspiration or inhalation

Penetrates the LRT

Irritation of the site occurs

Alveolar macrophages (primary defense) in the site fights off the

microorganisms

Bacteria adheres to the alveolar

macrophages

Phagocytosis (cell eating mechanism) occurs

Engulfed microorganisms will be removed

65

Weakened immune system due to predisposing factors

Microorganism become virulent and is

present in large number

Overwhelms the alveolar macrophages

Activation of the inflammatory response

Release of multiple inflammatory mediators

Bradykinin Histamine Prostaglandin

Increase capillary permeability

Causes vasodilation

Cause pain Cause pain and fever

Extravasation of fluid into tissues and cavity

Plasma enters into the inflammatory site

(bronchioles and alveoli)

66

Terminal bronchioles are filled with debris

and exudates

Cytokines send signal in the

hypothalamus

Prostaglandin is released

Increase set point in the

hypothalamus

Hypothalamus neurally initiates

shivering and vasoconstriction

Increase in the core body

temeprature

Exudates in the alveoli

cause irritation

Body attempts to expel out

foreign substances

and fluid out of the lungs

Stimulation of the cough

reflex

Increase mucus production by goblet cells

Exudates in the alveoli

Impairs oxygen-carbon dioxide

exchange in the alveoli

Body compensates

dyspnea

Increase in respiratory rate

tachypnea

Productive coughChills and fevers

67

Continuous inflammation of the alveoli and bronchioles

occur

Bacterial dissemination

Conditions exacerbate and bacterial spread

becomes systemic

Sepsis

Exudation of fluids into the cavity

Fluids accumulate and consolidate

Fluids consume a lot of space in the lungs

Decreased lung expansion

Dyspnea

68

Continuous inflammation of the alveoli and bronchioles

occur

Bacterial dissemination

Conditions exacerbate and bacterial spread

becomes systemic

Sepsis

Exudation of fluids into the cavity

Fluids accumulate and consolidate

Fluids consume a lot of space in the lungs

Decreased lung expansion

Dyspnea

14

Outer membrane component of microorganisms trigger the release of

chemical mediators

Cytokines, tumor-necrosis factor, platelet-activating factors, interleukin, prostaglandins and leukotrines are released

Increased RBC destruction

Mediators damage endothelial liningProduction of adhesion

molecules and neutrophils

Neutrophilic endothelial reaction leads to further endothelial injury

Neutrophil components release nitric oxide

Septic shock

anemia

Decrease in the oxygen carrying capacity of the blood

Tissue hypoxia

musculoskeletal skin CNS Circulatory

Easy fatigability, weakness

pallorConfusion, dizziness High pulse rate,

increased

15

If treated:AntibioticsIron SupplementsDietary Modifications

Good Prognosis

If not treated: ComplicationsHeart ProblemsNerve DamageImpaired Mental Function

Bad Prognosis

DOCTOR’S ORDER

DATE ORDER RATIONALE REMARKS

09/07/10 Admitting orders

Please admit to IMCU

under Pedia 3 service

level 3

For close monitoring of the patient

and proper management of his

condition

Admitted

BF with SAP Mothers are encouraged to give their

newborns breastmilk because of the

benefits of Breastfeeding such as

nutritional, immunological,

emotional and psychological. A

strict aspiration precaution if ordered

when patient is at risk for aspiration,

because of this, feeding would be

strictly watched.

Mother

informed

Start venoclysis with D5

0.3 NaCl 500 cc @ 25

cc/hr

Intravenous lines provide easy

access for drug administration

intravenously (IVTT). Intravenous

solutions containing dextrose and

sodium chloride are indicated for

parenteral replenishment of fluid,

Started

minimal carbohydrate calories, and

sodium chloride as required by the

clinical condition of the patient.

Labs:

WT = 6.2

kL

CBC with PC CBC with PC determines the

quantity of each quantity of blood

cell in a given specimen of blood,

often including the amount of

hemoglobin, hematocrit, and the

proportion of various white blood

cells. This is done to know any

condition of the client that may

affect his medical management.

Done

BT Blood typing is a method to tell what

specific type of blood you have.

What type you have depends on

whether or not there are certain

proteins, called antigens, on your red

blood cells.

Done

Urinalysis Urinalysis is performed to screen for

urinary tract disorders, kidney

disorders, urinary neoplasm and

Done

other medical conditions that

produce changes in the urine. This

test also is used to monitor the

effects of treatment of known renal

or urinary condition. This test is also

used to monitor the effects of certain

procedures done to patient and to

check if genito-urinary is in normal

state or not.

Chest X-ray – APL A chest radiograph, commonly

called a chest x-ray (CXR), is

a projection radiograph of

the chest used to diagnose conditions

affecting the chest, its contents, and

nearby structures. Chest radiographs

are among the most common films

taken, being diagnostic of many

conditions. By convention on the PA

View, the x-rays enter the patient

posteriorly and exit anteriorly (with

the patient’s chest on the film

cassette), therefore minimizing the

Not done

cardiac magnification. On the lateral

view, the patients left side is against

the film, therefore the right side

would be magnified.

Blood GS/CS A blood culture is done when a

person has symptoms of a blood

infection. Blood is drawn from the

person one or more times and is

tested in a laboratory to find and

identify any microorganism present

and growing in the blood. If a

microorganism is found, more

testing is done to determine the

antibiotics that will be effective in

treating the infection.

Not done

PBS Examination of the peripheral blood

smear should be considered, along

with review of the results of

peripheral blood counts and red

blood cell indices, an essential

component of the initial evaluation

of all patients with hematologic

Not done

disorders. The examination of blood

films stained with Wright's stain

frequently provides important clues

in the diagnosis of anemias and

various disorders of leukocytes and

platelets.

Coomb’s test – direct

and indirectCoomb’s test (antiglobulin test or

AGT) refers to two clinical blood

tests used in immunohematology and

immunology. The Coombs' test

looks for antibodies that may bind to

your red blood cells and cause pre-

mature red blood cell destruction

(hemolysis). The two Coomb’s tests

are the direct Coomb’s test (also

known as direct antiglobulin test or

DAT), and the indirect Coomb’s test

(also known as indirect antiglobulin

test or IAT). The indirect Coomb’s

test looks for unbound circulating

antibodies against a series of stan-

Done

dardized red blood cells.

Serum Na, K This is done to measure the

concentration of electrolytes which

are needed for both the diagnosis

and management of renal, endocrine,

acid-base, water balance, and many

other conditions. Their importance

lies in part with the serious

consequences that follow from the

relatively small changes that diseases

or abnormal conditions may cause.

This is done for diagnosing dietary

deficiencies, excess loss of nutrients

due to urination, vomiting, and

diarrhea, or abnormal shifts in the

location of an electrolyte within the

body.

Done

Meds:

Ampicillin 30 mg

IVTT q6 hours

Ampicillin is a beta-lactam antibiotic

that has been used extensively to

treat bacterial infections.

Given

Gentamycin 30 mg Gentamicin is an aminoglycoside Given

IVTT OD antibiotic, used to treat many types

of bacterial infections, particularly

those caused by Gram-negative

bacteria. Gentamycin is given

together with ampicillin bcause one

of the concern of giving antibacterial

is the number of bacteria that

become resistant to the drug

necessitating combination therapy or

use of other antibiotics.

TSB for fever Tepid sponge bath would help lower

the temperature of the body thus

providing comfort to the body

relieves it from distress

Done

I&O q shift and record Intake and output helps gauge fluid

balance in the body of the patient.

This would also check if patient’s

elimination pattern is normal or

impaired.

Done

VS q4 hours and record Vital signs are important for baseline

assessment and to monitor patients

condition which evaluates the whole

Taken and

recorded

treatment course, especially the

medications he received that could

be a contributing factor in the

variation results of the vital signs.

Inform Dr. Sojor/

Quinones/ Pedrero

regarding admission

This may create a collaborative

treatment among the client and the

health care providers; thus it also

makes a good coordination on the

treatment of the client.

Done

O2 inhalation via face

mask in cone @ 6 LPM

as needed for DOB

This is to relieve hypoxia, headache,

nausea, as well as to restore the

ability of the cells of the body to

carry on normal metabolic function.

Given

Refer accordingly This may create a collaborative





Referred

Paracetamol 100 mg

IVTT, 0.6 mL q 4 hours

for T>38oC

Paracetamol is used for fever

reduction.

Noted

09/08/10 Dx:

S/F PBS please give

referral form

Examination of the peripheral blood












platelets.

Referral

form

Follow up all labs re-

sult now

This is done since the laboratory

results are needed in the medical

management of the patient’s

condition.

Followed up

Rx:

IVF @ same rate This may continuously administer




Hooked


Meds: Day 1 please give Rx

Ampicillin Ampicillin is a beta-lactam antibiotic


treat bacterial infections. Strict

compliance for treatment regimen is

very important for proper treatment

and prevent the growth of drug-

resistant bacteria

Given

Still w/ Gentamycin Gentamicin is an aminoglycoside

antibiotic, used to treat many types










Given

febrile

episodes

VS q 4 hours Vital signs are important for baseline


Taken and

recorded

(+) LBM











referred

Follow up BT result This is done since the laboratory

result is needed in the medical


condition which is blood transfusion.

Followed up

To secure PRBC 100cc

aliqout and transfuse 70

cc to run un 4 hours after

proper cross matching

Packed red blood cells (PRBCs),

also called "packed cells," are a

preparation of red blood cells that

are transfused to correct low blood

levels in anemic patients. This

increases the amount of hemoglobin

in the blood that can carry oxygen

perfused from alveoli of the lungs to

Not done

tissues.

For PBS prior to Blood

transfusion

This is done to have a baseline data

to determine whether the medical

management given was right.

Not done

09/09/10

8:20 am

Dx: S/F PBS give

request

Examination of the peripheral blood












platelets.

DONE

Continue IVF with D5

0.3 NaCl 500 cc @ 25

cc/hr





sodium chloride are continuously

Continued

given for parenteral replenishment of

fluid, minimal carbohydrate calories,

and sodium chloride as required by

the clinical condition of the patient.

Continue medications: Day 2

(-) fever

(+) pale

looking

(+) cough

(+) rash

Ampicillin

Gentamycin







resistant bacteria

Given

Gentamicin is an aminoglycoside










Given


Continue VS monitoring

q4 hours

Vital signs are important for baseline







Taken and

recorded

Continue I&O

monitoring q4 hours

Intake and output helps gauge fluid




impaired.

Monitored

Refer accordingly if with

unusualities

This may create a collaborative





Referred

Still securing PRBC for

BT





Secured





tissues.

09/10/10

7:20 am

Dx: PBS result after 10

working days

This is done to allow enough time

for further testing in case of

inclusive or doubtful results

Continue IVF with D5

0.3 NaCl 500 cc @ 25

cc/hr










Continued

(-) fever

comfortable

Asleep

(+) rash

Continue medications: Day 3

Ampicillin Ampicillin is a beta-lactam antibiotic




Given



resistant bacteria

Gentamycin Gentamicin is an aminoglycoside











Continue VS monitoring

q4 hours

Vital signs are important for baseline







Taken and

recorded

Continue I&O

monitoring q shift, then

record

Intake and output helps gauge fluid




impaired.

Monitored

and recorded






Referred

9 am Still for PRBC

transfusion









tissues.

Noted

Please extract blood for

cross matching without

fail – c/o clerk on duty

Blood Cross Matching refers to the

complex testing that is performed

prior to a blood transfusion, to

Done

determine if the donor's blood is

compatible with the blood of an

intended recipient, or to identify

matches for organ transplants.

09 /11/10

7 am

Dx: F/U PBS result after

10 working days

This is done to allow enough time

for further testing in case of

inclusive or doubtful results

Noted

Rx:

awake

comfortable

afebrile

IVF @ SR This may continuously administer





Done

Ampicillin day

Gentamycin 4



treat bacterial infections. Gentamicin

is an aminoglycoside antibiotic, used

to treat many types of bacterial

infections, particularly those caused

by Gram-negative bacteria.

Gentamycin is given together with

ampicillin bcause one of the concern

of giving antibacterial is the number

of bacteria that become resistant to

the drug necessitating combination

therapy or use of other antibiotics.

Given

VS q4 hours and record Vital signs are important for baseline







Taken and

recorded

I&O q shift and record Intake and output helps gauge fluid


Monitored

and recorded



impaired.






Referred

09/12/10 F/U with

Rx: IVF @ SR

This may continuously administer





Followed up

awake

comfortable

(-) fever

Continue meds: day 5

Ampicillin

Gentamycin



treat bacterial infections. Gentamicin

is an aminoglycoside antibiotic, used

to treat many types of bacterial

infections, particularly those caused

by Gram-negative bacteria.

Gentamycin is given together with

ampicillin bcause one of the concern

Given

of giving antibacterial is the number

of bacteria that become resistant to

the drug necessitating combination

therapy or use of other antibiotics.

Please monitor:

VS q4 hours Vital signs are important for baseline







Taken and

recorded

I&O q shift Intake and output helps gauge fluid




impaired.

Monitored

and recorded






referred

09/13/10 Follow up CBC, platelet This is done since the laboratory



condition.

Not done

comfortable IVF @ same rate This may continuously administer





Done

(-) fever Continue

NRD Ampicillin – D6 Ampicillin is a beta-lactam antibiotic



Given

Gentamycin – D6 Gentamicin is an aminoglycoside









Given










Taken and

recorded





impaired.

Monitored

and recorded






Referred

09/14/10 Dx: ff. up CBC, platelet

count

This is done since the laboratory



Followed up

condition.

(-) fever

comfortable

Continue IVF @ SR Intravenous lines provide easy









Continued

Meds:

Ampicillin – D7 Ampicillin is a beta-lactam antibiotic



Given

Gentamycin – D7 Gentamicin is an aminoglycoside








Given











Taken and

monitored





impaired.

Monitored

and recorded






Referred

42

DIAGOSTIC EXAMS

A. Actual Laboratory Tests and Diagnostic Examinations

Urinalysis

Urinalysis is performed to screen for urinary tract disorders, kidney disorders, urinary neoplasm and other medical conditions that

produce changes in the urine. This test also is used to monitor the effects of treatment of known renal or urinary condition.

Date Laboratory

Test

Normal Value /

Results

Result Clinical

Significance

Nursing Interventions

S

E

P

T

E

M

B

Color Straw yellow to

amber

Light

yellow

NORMAL Pretest:

Inform patient that he should avoid intense athletic

training or heavy physical work before the test, as these

activities may cause small amounts of blood to appear

in the urine.

Provide patient with urine container with lid.

Instruct the patient to collect a sample of urine,

Appearance Clear to faintly

hazy

Clear NORMAL

Reaction 4.0-8.0 7.0 NORMAL

43

E

R

8,

2

0

1

0

preferably on arising in the morning; must not be

contaminated by toilet paper, toilet water, feces or

secretions.

Tell females patients that they should use a clean

cotton ball moistened with lukewarm water (or antisep-

tic wipes provided with collection kits) to cleanse the

external genital area before collecting a urine sample.

To prevent contamination with menstrual blood, vagi-

nal discharge, or germs from the external genitalia, they

should release some urine before beginning to collect

the sample.

To minimize sample contamination, women who

require a urinalysis during menstruation should insert a

fresh tampon before providing a urine sample.

Inform males patients that they should use a piece

of clean cotton moistened with lukewarm water or anti-

septic wipes to cleanse the head of the penis and the

Specific

gravity

1.003- 1.030 1.005 NORMAL

Albumin Negative Negative NORMAL

Sugar Negative ++++ Glycosuria (glucose

in the urine) may be

the first indicator

that diabetes or

another

hyperglycemic

condition is present.

The glucose test

may be used to

screen newborns

for galactosuria and

other disorders of

44

carbohydrate

metabolism that

cause urinary

excretion of a sugar

other than glucose.

urethral meatus (opening). Inform uncircumcised males

that they should draw back the foreskin. After the area

has been thoroughly cleansed, they should use the mid-

stream void method to collect the sample.

If urine for culture is to be collected from an in-

dwelling catheter, it should be aspirated (removed by

suction) from the line using a syringe and not removed

from the bag in order to avoid contamination.

Posttest:

The lid must be sealed completely and the container must

be labeled properly.

Specimen must be delivered to the laboratory.

Pus cells ≤ 4 cells/hpf 1.2 NORMAL

Red Blood

Cells

≤ 2 rbc hpf 0.5 NORMAL

COMPLETE BLOOD COUNT AND PLATELET COUNT

45

The complete blood count (CBC) is a screening test, used to diagnose and manage numerous diseases. It can reflect problems with

fluid volume (such as dehydration) or loss of blood. It can show abnormalities in the production, life span, and destruction of blood

cells. It can reflect acute or chronic infection, allergies, and problems with clotting.

Date Exam Normal

Value

Rationale Result Remarks Clinical Significance Nursing Responsibilities

S

E

P

T

E

M

B

E

R

8,

Hemoglobin 115 – 155

g/dL

Measures the

amount of

oxygen-carrying

protein in the

blood.

78 Low Low hemoglobin may suggest

anemia, which can have many

causes. Possible causes of high

red blood cell count or

hemoglobin (erythrocytosis) may

include bone marrow disease or

low blood oxygen levels

(hypoxia).

1. Discuss and explain the

procedure and purpose of

the test.

2. Inform the patient that

no fasting is needed.

3. Inform the patient that a

needle and a syringe is used

to get a sample blood for the

test.

4. Assess the patient for

any factor that will probably

Hematocrit 0.36 – 0.46 Measures the

percentage of red

blood cells in a

0.25 Low Decreased hematocrit indicates

anemia, such as that caused by

iron deficiency or other

46

2

0

1

0

given volume of

whole blood.

deficiencies. Other conditions

that can result in a low

hematocrit include vitamin or

mineral deficiencies, recent

bleeding, cirrhosis of the liver,

and malignancies.

affect the results of the test.

5. Make sure patient is

well hydrated. Dehydration

elevates the test results.

6. If patient is connected

to IVF, make sure that the

blood is not taken from the

arm connected to the IVF.

Hemodilution causes false

decrease of the test results.

7. After the puncture,

assess the site for bleeding

or bruising.

8. If patient is under

treatment from an infection,

inform the patient that the

RBC count 4.20 – 6.10 Count of the

actual number of

red blood cells

per volume of

blood.

3.11 Low Low RBC count may indicate

iron deficiency anemia, Vitamin

B6, B12, and/or Folic Acid

deficiency, hereditary anemia,

and chronic diseases.

WBC count 5.0 – 10.0 Count of the

actual number of

white blood cells

per volume of

blood. Both

increases and

32.40 High A high WBC count

(leukocytosis) may signify an

infection somewhere in the body

or, less commonly, it may signify

an underlying malignancy.

47

decreases can be

significant.

test will be repeated to

monitor progress.

9. Any unnusualities noted

will be reported to the

physician.

Neutrophil 55 – 75 Count of the

actual number of

neutrophil per

volume of blood.

56 Normal NORMAL

Lymphocyte 20 – 35 Count of the

actual number of

lymphocyte per

volume of blood.

31 Normal NORMAL

Monocyte 2 – 10 Count of the

actual number of

monocyte per

volume of blood.

13 High Levels of monocytes can increase

in response to infection of all

kinds as well as to inflammatory

disorders. Monocyte counts are

also increased in certain

malignant disorders, including

48

leukemia.

Eosinophils 1 – 6 Count of the

actual number of

eosinophils per

volume of blood.

0 Low Decreased levels of eosinophils

can occur as a result of infection.

Thrombocyte 150 – 400 Number of

platelets in a

given volume of

blood. Both

increases and

decreases can

point to abnormal

conditions of

excess bleeding

or clotting.

527 High High blood platelet count is due

to high production of

thrombocytes in the bone

marrow. The other cause is that

the spleen removes less number

of thrombocytes from the body.

In majority of the cases, high

platelet count is caused, due to

increase in thrombocytes

production in the body.

MCH 25.60 –

32.20 pg

(mean

corpuscular

25.1 Low MCHC is decreased

("hypochromic") in microcytic

49

hemoglobin) the

average amount

of hemoglobin

per red blood cell,

in picograms.

anemias.

MCHC 32.20 –

35.50 g/dL

(mean

corpuscular

hemoglobin

concentration) the

average

concentration of

hemoglobin in the

RBC.

31.7 Low Decreased values point to

hypochromasia, decreased

oxygen- carrying capacity

because of decreased hemoglobin

inside the cell. Hypochromasia is

seen in iron deficiency anemia

and in thalassemia.

MCV 79.40 –

94.80 fl

(mean

corpuscular

volume) the

average volume

79.1 Low A low MCV, indicates your

RBCs are smaller than normal

(microcytic), such as is seen in

50

of the red cells,

measured in

femtolitres.

iron deficiency anemia.

Chemistry

Sodium 136 – 155

mmol/L

The test measures

the sodium levels

in the blood.

134.50 Low A low level of blood sodium

means you have hyponatremia,

which is usually due to too much

sodium loss, too much water

intake or retention, or to fluid

accumulation in the body

(edema). Hyponatremia is rarely

due to decreased sodium intake

(deficient dietary intake or

deficient sodium in IV fluids).

Most commonly, it is due to

sodium loss (Addison's disease,

diarrhea, excessive sweating,

51

diuretic administration, or kidney

disease).

Potassium 3.5 – 5.6

mmol/L

The test measures

potassium levels

of the blood.

4.95 Normal NORMAL

Blood typing

Blood type - Blood typing is a

method to tell

what specific

type of blood you

have. What type

you have depends

on whether or not

there are certain

proteins, called

antigens, on your

A - People with blood type A contains

the A antigen and contains B

antibodies.

52

red blood cells.

Bood type

Rh

- This is also an

antigen on the red

blood cell’s

surface and those

who have it are

called Rh+. Those

who haven't are

called Rh-.

Positive - Rh factor strictly refers only to

the most immunogenic D antigen

of the Rh blood group system.

Rh negative blood does not have

the D antigen. Immunization

against Rh can generally only

occur through blood transfusion

or placental exposure during

pregnancy.

Date Exam Normal

Value

Rationale Result Remarks Clinical Significance Nursing Responsibilities

S

E

P

Hemoglobin 115 – 155

g/dL

Measures the

amount of

oxygen-carrying

121.0 Low Low hemoglobin may suggest

anemia, which can have many

causes. Possible causes of high

10. Discuss and explain the

procedure and purpose of

the test.

53

T

E

M

B

E

R

14,

2

0

1

0

protein in the

blood.

red blood cell count or

hemoglobin (erythrocytosis) may

include bone marrow disease or

low blood oxygen levels

(hypoxia).

11. Inform the patient that

no fasting is needed.

12. Inform the patient that a

needle and a syringe is used

to get a sample blood for the

test.

13. Assess the patient for

any factor that will probably

affect the results of the test.

14. Make sure patient is

well hydrated. Dehydration

elevates the test results.

15. If patient is connected

to IVF, make sure that the

blood is not taken from the

arm connected to the IVF.

Hematocrit 0.36 – 0.46 Measures the

percentage of red

blood cells in a

given volume of

whole blood.

0.35 Low Decreased hematocrit indicates

anemia, such as that caused by

iron deficiency or other

deficiencies. Other conditions

that can result in a low

hematocrit include vitamin or

mineral deficiencies, recent

bleeding, cirrhosis of the liver,

and malignancies.

RBC count 4.20 – 6.10 Count of the

actual number of

red blood cells

4.54 Normal NORMAL

54

per volume of

blood.

Hemodilution causes false

decrease of the test results.

16. After the puncture,

assess the site for bleeding

or bruising.

17. If patient is under

treatment from an infection,

inform the patient that the

test will be repeated to

monitor progress.

18. Any unnusualities noted

will be reported to the

physician.

WBC count 5.0 – 10.0 Count of the

actual number of

white blood cells

per volume of

blood. Both

increases and

decreases can be

significant.

10.67 High A high WBC count

(leukocytosis) may signify an

infection somewhere in the body

or, less commonly, it may signify

an underlying malignancy.

Neutrophil 55 – 75 Count of the

actual number of

neutrophil per

volume of blood.

27 Low The low neutrophil count causes

are commonly related to the

function of the bone marrow,

which can be hampered due to

congenital disorders, cancer and

viral infections. In some cases, a

person may be affected by such

55

an infection which is too

overwhelming to be handled by

the white blood cells. As a result,

neutrophils are utilized at a rater

faster than they are produced.

Lymphocyte 20 – 35 Count of the

actual number of

lymphocyte per

volume of blood.

55 High Lymphocytes help provide a specific

response to attack the invading

organisms. Increase in levels would

indicate foreign invasion of bacteria

Monocyte 2 – 10 Count of the

actual number of

monocyte per

volume of blood.

11 High Levels of monocytes can increase

in response to infection of all

kinds as well as to inflammatory

disorders. Monocyte counts are

also increased in certain

malignant disorders, including

leukemia.

Eosinophils 1 – 6 Count of the 6 Normal NORMAL

56

actual number of

eosinophils per

volume of blood.

Thrombocyte 150 – 400 Number of

platelets in a

given volume of

blood. Both

increases and

decreases can

point to abnormal

conditions of

excess bleeding

or clotting.

624 High High blood platelet count is due

to high production of

thrombocytes in the bone

marrow. The other cause is that

the spleen removes less number

of thrombocytes from the body.

In majority of the cases, high

platelet count is caused, due to

increase in thrombocytes

production in the body.

MCH 25.60 –

32.20 pg

(mean

corpuscular

hemoglobin) the

average amount

26.7 Normal NORMAL

57

of hemoglobin

per red blood cell,

in picograms.

MCHC 32.20 –

35.50 g/dL

(mean

corpuscular

hemoglobin

concentration) the

average

concentration of

hemoglobin in the

RBC.

34.8 Normal NORMAL

MCV 79.40 –

94.80 fl

(mean

corpuscular

volume) the

average volume

of the red cells,

measured in

76.7 Low A low MCV, indicates your

RBCs are smaller than normal

(microcytic), such as is seen in

iron deficiency anemia.

58

femtolitres.

Coomb’s Test

Coomb’s test (antiglobulin test or AGT) refers to two clinical blood tests used in immunohematology and immunology. The

Coombs' test looks for antibodies that may bind to your red blood cells and cause premature red blood cell destruction (hemolysis).

The two Coomb’s tests are the direct Coomb’s test (also known as direct antiglobulin test or DAT), and the indirect Coomb’s test (also

known as indirect antiglobulin test or IAT). The indirect Coomb’s test looks for unbound circulating antibodies against a series of

standardized red blood cells.

Date Laboratory Test Normal

values

Rationale Result Clinical

significanc

e

Nursing Interventions

09/09/1

0

Direct Coomb’s

Test

Negative The direct Coomb’s test

is used to detect

antibodies that are

already bound to the

Negative NORMAL 1. Prior to performing the venipunc-

ture, the nurse should document any

medications the patient is currently

taking, since many medications have

59

surface of red blood

cells. These antibodies

sometimes destroy red

blood cells and cause

anemia. This test is

sometimes performed to

diagnose the cause of

anemia or jaundice.

been implicated in autoimmune

hemolytic anemia.

2. A blood sample collected by

venipuncture is used for antiglobulin

tests. The nurse collecting the speci-

men should observe universal pre-

cautions for the prevention of trans-

mission of bloodborne pathogens.

3. Do not refrigerate since refrigeration

of blood specimens that have cold

agglutinins may cause a false posi-

tive test.

4. Store the blood at room temperature

until separation of red cells and

serum or plasma.

5. Inform the patient that he/she may

feel discomfort when blood is drawn

Indirect Coomb’s

Test

Negative The indirect Coombs'

test is only rarely used

to diagnose a medical

condition. More often, it

is used to determine

whether a person might

have a reaction to a

blood transfusion.

Negative NORMAL

60

from a vein.

6. Inform also that bruising may occur

at the puncture site or the person

may feel dizzy or faint.

7. Apply pressure to the puncture site

until the bleeding stops to reduce

bruising.

8. Warm packs can also be placed over

the puncture site to relieve discom-

fort.

Blood Cross Matching

Blood Cross Matching refers to the complex testing that is performed prior to a blood transfusion, to determine if the donor's

blood is compatible with the blood of an intended recipient, or to identify matches for organ transplants. Cross-matching is usually

61

performed only after other, less complex tests have not excluded compatibility. Blood compatibility has many aspects, and is

determined not only by the blood types (O, A, B, AB), but also by blood factors.

Serial no. NVBSP 201000 54765

Date Cell

typing

Serum typing Rh

typing

Result of

compatibility

Nursing interventions

A cell B cell

09/10/10 Patient A NEG + + Three phases

Compatible

1. Adhere strictly to the policies regarding

typing cross-matching, and administering

the blood.

2. Make sure that the recipient’s blood sample

is correctly labelled when it is sent to the

laboratory.

3. Check each unit before administration to

make sure that it is not outdated, that the

unit has been designated for the correct re-

cipient, that the patient’s medical records’

donor A NEG + +

62

number matches the number on the blood

component, and that the blood type is ap-

propriate for the patient.

4. Maintain universal precautions when han-

dling all blood products to protect yourself.

5. Dispose used containers appropriately in

the hazardous waste disposal.

63

DRUG STUDY

Generic Name

Paracetamol

Brand Name Biogesic , Tempra

Classification Non-narcotic analgesic, Antipyretic

Ordered Dose Paracetamol 100 mg IVTT, 0.6 mL q 4 hours for T>38oC

Mode of ActionProduces analgesia by unknown mechanism, but it is cen-

trally acting in the CNS by increasing the pain threshold by

inhibiting cyclooxygenase. Reduces fever by direct action

on hypothalamus heat-regulating center with consequent

peripheral vasodilation, sweating, and dissipation of heat.

Unlike aspirin, has little effect on platelet aggregation, does

not affect bleeding time, and produces no gastric bleeding.

IndicationsFever reduction. Temporary relief of mild to moderate

pain. Generally as substitute for aspirin when the latter is

not tolerated or is contraindicated

Contraindications Hypersensitivity to acetaminophen or phenacetin;

64

use with alcohol. Renal insufficiency

Anemia

Clients with cardiac or pulmonary disease are more

susceptible to toxicity.

Hypersensitivity to paracetamol

severe liver diseases

Drug Interactions

Cholestyramine may decrease acetaminophen absorption.

With chronic coadministration, barbiturates,

carbamazepine, phenytoin, and rifampin may increase

potential for chronic hepatotoxicity. Chronic, excessive

ingestion of alcohol will increase risk of hepatotoxicity

Side Effects and Adverse

Reactions

In rare cases hypersensitivity reactions, predominantly skin

allergy (itching and rash), may appear. Long-term

treatment with high doses may cause a toxic hepatitis with

following initial symptoms: nausea, vomiting, sweating,

and discomfort. Occasionally a gastrointestinal discomfort

may be seen. Body as a Whole: Negligible with

recommended dosage; rash. Acute poisoning: Anorexia,

nausea, vomiting, dizziness, lethargy, diaphoresis, chills,

epigastric or abdominal pain, diarrhea; onset of

65

hepatotoxicity—elevation of serum transaminases (ALT,

AST) and bilirubin; hypoglycemia, hepatic coma, acute

renal failure (rare). Chronic ingestion: Neutropenia,

pancytopenia, leukopenia, thrombocytopenic purpura,

hepatotoxicity in alcoholics, renal damage.

Nursing Responsibilities 1. Monitor for S&S of: hepatotoxicity, even with

moderate acetaminophen doses, especially in indi-

viduals with poor nutrition or who have

2. ingested alcohol over prolonged periods; poisoning,

usually from accidental ingestion or suicide at-

tempts; potential abuse from psychological depen-

dence (withdrawal has been associated with restless

and excited responses).

3. Administer tablets or caplets whole or crushed and

give with fluid of patient's choice.

4. Chewable tablets should be thoroughly chewed and

wetted before they are swallowed.

5. Do not coadminister with a high carbohydrate meal;

absorption rate may be significantly retarded.

6. Store in light-resistant containers at room tempera-

66

ture, preferably between 15°–30° C (59°–86° F).

7. Do not take other medications (e.g., cold prepara-

tions) containing acetaminophen without medical

advice; overdosing and chronic use can cause liver

damage and other toxic effects.

8. Do not self-medicate adults for pain more than 10 d

(5 d in children) without consulting a physician.

9. Do not use this medication without medical direc-

tion for: fever persisting longer than 3 d, fever over

39.5° C (103° F), or recurrent fever.

10. Do not give children more than 5 doses in 24 h un-

less prescribed by physician.

67

Generic Name

Ampicillin

Brand Name Ampicillin, Principen

Classification Antibiotic,penicillin

Ordered Dose Ampicillin 30 mg IVTT q6 hours

Mode of Action Ampicillin exerts bactericidal action on both gram-positive

and gram-negative organisms. Its spectrum includes gram-

positive organisms e.g. S pneumoniae and other

Streptococci, L monocytogenes and gram-negative bacteria

e.g. M catarrhalis, N gonorrhoea, N meningitidis, E coli, P

mirabilis, Salmonella, Shigella, and H influenzae.

Ampicillin exerts its action by inhibiting the synthesis of

bacterial cell wall.

Indications Mild to moderate infections (i.e.; skin, intra-abdominal and

gynecological infections)

Prevention of Bacterial endocarditis

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68

Respiratory and soft tissue infection

GI and GU infections

Gonococcal infections

Bacterial meningitis

Septicemia

Contraindications Allergy to penicillins, infectious mononucleosis

Use cautiously with reanal disorders

Indications Increased ampicillin effect with Probenecid

Increased rsik of rash with allupurinol

Increased bleeding effect with heparin and anticoagulatnts

Decreased effectiveness of tetracycline, chloramphenicol

DRUG –food

Oral ampicillin amy be less effective with food take on

with empty stomach


Reactions

Side Effects: Mild diarrhea; pain, swelling, or redness at

69

injection site.

Adverse Effects:

CNS: Lethargy , Hallucinations, seizures

CV : heart failure

GI: stomatitis,gastritis, sore mouth, abdominal pain ,

bloody diarrhea

GU: Nephritis

Hematologic: Anemia , thrombocytpopenia, leucopenia,

prolonged bleeding time

Local: phlebitis,

Other: superinfections

Nursing Responsibilities Nursing Responsibilities:

1. Culture infected area before treatment

2. Give drug after negative Skin Test

3. Check IV site carefully for signs of thrombosis or

drug interaction

4. Take this drug around the clock

5. Take the full course of Therapy, do not stop taking

drug if feeling better

6. This antibiotic is specific to your problem and

should not be used to treat other infections

7. Instruct patient to report pain and discomfort on IV

70

Sites

71

Generic Name

Gentamicin Sulfate

Brand Name Pediatric Gentamicin Sulfate

Classification aminoglycosides

Ordered Dose Gentamycin 30 mg IVTT OD

Mode of ActionBactericidal: inhibits protein synthesis in susceptible

strains of gram negative bacteria; appears to disrupt func-

tional integrity of bacteria cell membrane , causing cell

death.

Indications Serious infections caused by strains of pseudomonas aerug-

inosa, proleus species, Escherichia coli, Klebsiella Enter-

obacter Serratia Species, citrobacter , Staphylococcus

species

Serious infection when causative organisms are not known

(often in conjuction with a penicillin)

ContraindicationsContraindicated to patients with allergy to any aminoglyco-

sides

Drug Interactions Drug-Drug: Increased ototoxic, nephrotoxic, neurotoxic

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72

effects with other aminoglycosides, potent Diuretics ,

cephalosporins, ,vancomycin

Increased neuromuscular blockade and muscular paralysis

with aneasthetic,

Increased bactericidal effect with penicillins and

cephalosporins to treat gram negative organisms


Reactions CNS: ototoxicity- tinnitus,dizziness, vertigo ,deafness

Vestibular paralysis,disorientation, depression, lethargy ,

visual disturbances , numbness, tremors

Muscle twitching, seizures, muscular weakness,

neuromuscular blockade

CV: palpitations, Hypotension , Hypertension

GI : hepatotoxicity, nausea, vomiting, anorexia , weight

loss, stomatitis , increased salivation,

GU: Nephrotoxicity

Hematologic: Thrombocytopenia, eosinophelia, anemia,

hemolytic anemia, luekopenia

Hypersensitivity : Purpura , Rash , urticaria, exfoliative

dermatitis, itching

73

LOCAL: Pain , irritation , arachnoiditis at IM injections

Sites

Other: Fever ,apnea,joint Pain and superinfections.

Nursing Responsibilities 1. Culture infected area before theraphy

2. Give drug after negative Skin Test

3. Avoid long term therapies because of in-

creased toxicities. Reduction in dose may

be clinically indicated

4. Monitor hearing with long term therapy

Ototoxicity may occur.

5. Ensure adequate hydration of patient before

and during the therapy

6. Monitor renal function test , CBC , Serum

drug levels during long term therapy

7. Report pain at injection stie,severe

headache.difficuly in hearing difficulty

breathing and rash.

74

NURSING THEORIES

Florence Nightingale’s Environmental Theory

Often referred to as the first nursing theorist, Florence Nightingale defined nursing as

“the act of utilizing the environment of the patient to assist him in his recovery”. This is because

during her time in hospitals during the 1800’s she discovered that the sanitary condition had a

direct effect on the health of the patients within the facilities. Poor sanitation in the hospital

often lead to sickness, infection or even death to the patients. Florence Nightingale theorized that

the environment in which the patient is in has a profound effect on the maintenance and

restoration of health of the said patient. She proceeded to like health with six environmental

factors

These include:

1. Pure/Fresh Air

2. Pure Water

3. Sufficient Food Supply

4. Efficient Drainage

5. Cleanliness

6. Light

These factors must be maintained in order to optimize the maintenance in health and/or facilitate

the recovery of the patients.

75

Nightingales Theory is a timeless and very important guide to all health professionals and

is also very important to our case. Our client is only four months of age and already has several

illnesses afflicting her. Due to these illnesses her body is a delicate state and may be even more

susceptible to environmental influences, most notably further infection. In order to prevent infec-

tion, the sanitary condition must be kept good. Also, her body must have the necessary nutrients

in order to recover meaning nutrition must be kept at optimal level. Pure air and water are para-

mount to the recovery of the patient to provide nourishment and proper ventilation. Efficient

drainage is necessary to prevent infection from waste products. Light is also important to provide

warmth and an ambience conducive to health. The environment must never be neglected since

good sanitary condition is key to a good, quick recovery. We have utilized this theory by at-

tempting to provide all of the necessary elements nightingale has specified for our patient during

the course of our clinical exposure.

Faye Glenn Abdellah’s 21 Nursing Problems

Faye Glenn Abdellah emphasized that nursing should always be patient-focused. What

she meant by patient-focused is that nurses should be able to identify the detectable conditions

ailing the patient and provide a nursing intervention in order to better the condition of the patient.

She professed that a nurse must first identify a problem of the patient and through the use of

critical thinking, subsequently solve the problem.

Abdellah’s Metaparadigm

76

Although she did not clearly provide a definition for each major concept, abdellah did

refer to individuals and/or families as “recipients of care.” Her description of health is the “total

health needs” of a person and “a healthy state of mind and body.” She includes society in the

planning for optimum health on local, state and international levels but emphasizes that nursing

service is primarily for the individual. Nursing for Abdellah is a comprehenseive service that is

based on an art and science and aims to help people, sick or well, cope with their health needs.

In order to aid nurses in identification and solving, Abdellah formulated a typology called

the 21 nursing problems. These problems were based on the physical, social and emotional needs

of the patient, the types of interpersonal relationships between the nurse and the patient and the

common elements of patient care.

Abdellah’s Typology of the 21 Nursing Problems are as follows:

1.To promote good hygiene and physical comfort

2. To promote optimal activity, exercise, rest, and sleep

3. To promote safety through prevention of accidents, injury, or other trauma and through the

prevention of the spread of infection

4. To maintain good body mechanics and prevent and correct deformities

5. To facilitate the maintenance of a supply of oxygen to all body cells

6. To facilitate the maintenance of nutrition of all body cells

7. To facilitate the maintenance of elimination

8. To facilitate the maintenance of fluid and electrolyte balance

77

9. To recognize the physiologic responses of the body to disease conditions

10. To facilitate the maintenance of regulatory mechanisms and functions

11. To facilitate the maintenance of sensory function

12. To identify and accept positive and negative expressions, feelings, and reactions

13. To identify and accept the interrelatedness of emotions and organic illness

14. To facilitate the maintenance of effective verbal and nonverbal communication

15. To promote the development of productive interpersonal relationships

16. To facilitate progress toward achievement of personal spiritual goals

17. To create and maintain a therapeutic environment

18. To facilitate awareness of self as an individual with varying physical, emotional, and

developmental needs

19. To accept the optimum possible goals in light of physical and emotional limitations

20. To use community resources as an aid in resolving problems arising from illness

21. To understand the role of social problems as influencing factors in the cause of illness

Abdellah and her colleagues also found use of the typology as a means to evaluate

student nurses and the competency of nurses.

The 21 nursing problems are important in our case because our client has several of these

nursing problems. Through the 21 nursing problems we are able to identify the problem and

perform necessary interventions. This systematic approach enables more specific approaches to

the patient’s needs, especially one that is still recovering her illnesses. There are several of

problems that are present in our patient. Since our patient is still an infant, she cannot care for

78

herself in terms of maintenance of hygiene. We therefore identified it as our duty as student

nurses to provide good hygiene by means of performing diaper changes and perineal care for her.

Tepid sponge bathing was also performed not only for temperature control but also for hygienic

purposes. The bed of the patient did not feature bed rails, and since the patient is an infant she

maybe prone to accidents. We intervened with this problem by placing pillows near the edge of

the bed, removing any possible sharp and small objects from the perimeter of her rest area and

positioned her in the center of the bed. There were also problems that we tended to and

performed interventions such as the maintenance of good oxygen and nutrition supply, as well as

maintaining a therapeutic environment. Abdellah’s theory is an indispensable part of the nursing

practice since it provides a road map as to how we can provide precise, patient focused care.

Lydia Eloise Hall’s Care, Core, Cure Model

Lydia E. Hall formulated the Care, Core, Cure theory in the late 1960’s. The theorized

that care should only be provided by health professionals and that the patient or individual is

separated into three domains namely the care, cure and the core. These three represent the body,

the illness and the person respectively. The theory likens these to three independent but

interconnecting circles. The core is the person or patient to whom is in need nursing care is given

that service. The care circle represents the nurses whose focus is nurturing the patient and

maintenance of health through intervention and teaching to help the patient meet their needs. The

cure circle represents the role of the physicians, who are to intervene with the objective of

returning the patient to optimal health and alleviate him/her from their illness.

79

Lydia Hall’s theory is particularly applicable to the case of our patient because the theory

provides a clear outline to the roles of each of the health professionals and the patient when

dealing with health care. Our is a four month old infant and represents the core. Although the

patient is unable to set goals for herself due to her age, it is the will of the parents and the

obligation of the health professionals to return her to optimal health as evidenced by her

admission to the hospital. We as student nurses represent the care circle. As student nurses we

accomplished this goal by tending to her identified needs such as nutrition, hygiene and

performed close monitoring for any alterations in her condition. Comparatively speaking the

nurses also spend the most time with the patient more than any other health professional and

hence the circle for care is significantly larger than that of the other circles. Through the

systematic use of this theory we were able to assist in returning the patient to optimal health.

80

NURSING CARE PLAN

Name: Trudis Medical Diagnosis: Anemia 2o to Sepsis 2o to Bronchopneumonia

Age: 4 months old Sex: Female

DATE CUES NEED NSG

DIAGNOSIS

OBJ. OF CARE INTERVENTION EVALUATION

S

E

P

T

E

M

B

Subjective:

“Dili makahinga

ug tarong akong

anak paspas,

unya naa pud

siyay sipon.

A

I

R

W

A

Y

Ineffective

airway clearance

related to

presence

ofbronchial

secretions

secondary to

Within our eight

hours span of

care our patient

will be able to

maintain

patent airway as

1.) Assess respiratory

function, and respiratory

rate

e.g.,

breath

sounds

R:Provides a basis for

GOAL PARTIALLY MET

September 14,2010

@

7AM

After our eight hours span

of care our patient was

81

E

R

13,

2

0

1

0

11PM

Objective:

(+) Tachypnea

RR: 65 cpm

(+)clear Nasal

Secretions

Dyspnea

C

L

E

A

R

A

N

C

E

pneumonia

R: Maintaining a

patent airway is

vital to life.

Coughing is the

main mechanism

for clearing the

airway. However,

the cough may be

ineffective in

both normal and

disease states

secondary to

factors such as

pain from

surgical

evidenced by:

a.)

Independence

from oxygen

b.) Normal

respiration as

evidenced by

absence of

dyspnea and

crackles.

c.)Normal RR of

60 cpm

evaluating

adequacy of ventilation

2.) Auscultate breath

sounds.

R: Crackles indicate

presence of secretions

and inability to clear

airway.

3.) Checked for

obstruction

R; to maintain adequate

airway patency

4.) Document amount

and characteristic of

respiratory secretion

able to maintain

patent airway as evidenced

by:

a.) Independence from

oxygen

b.) Normal respiration as

evidenced by absence of

dyspnea.

c.)Normal RR of 60 cpm

*crackles still present

82

incisions/ trauma,

respiratory

muscle fatigue, or

neuromuscular

weakness,

neonates are also

at high risk.

Other

mechanisms that

exist in the lower

bronchioles and

alveoli to

maintain the

airway include

the mucociliary

system,

macrophages,

R: serves as baseline data

5.) Encouraged active

participation of mother in

care and treatment

decisions.

R: Maintains

independence and control

of decisions.

6.) Maintained a relaxed,

calm and quiet

environment.

R:To assist client to gain

optimal rest and sleep.

7.) Performed back

tapping.

83

and the

lymphatics.

Factors such as

anesthesia and

dehydration can

affect function of

the mucociliary

system. Likewise,

conditions that

cause increased

production of

secretions (e.g.,

pneumonia,

bronchitis, and

chemical

irritants) can

overtax these

R: To loosen secretions.

8.) Encouraged

breastfeeding of mother

per child's demand.

R: To provide optimum

nutrition and prevent

child from crying.

84

mechanisms.

Ineffective

airway clearance

can be an acute

(e.g.,

postoperative

recovery) or

chronic (e.g.,

from

cerebrovascular

accident [CVA]

or spinal cord

injury) problem.

Date Cues Needs Nursing Diagnosis Plan of Care Nursing Interventions Evaluation

85

September

14, 2010

@

2:00 AM

11-7

OBJECTIVE:

Temperature

of 38°C.

Pulse rate of

135bpm.

Flushed skin

noted.

Patient’s

skin is warm

to touch.

Diaphoresis

noted.

Restlessness

noted

N

U

T

R

I

T

I

O

N

A

L

&

M

E

T

Hyperthermia related to

increased metabolic

rate

® A state in which an

individual’s

temperature is elevated

above normal level.

Most incidents of

hyperthermia are due to

activity and salt and

water deprivation in a

hot environment.

Gulanick, et. al.

Nursing Care Plans.

At the end of

1 hour of nursing

care, the patient

will:

have a tem-

perature at

normal range,

be able to rest

1. Monitor body temper-

ature every 30 minutes

or more often if indi-

cated.

® Evaluates the ef-

fectiveness of inter-

ventions.

2. Employ measures to

reduce excessive

fever, such as remov-

ing blankets, applying

ice bags to axilla and

groins.

® Promotes patient’s

comfort and lowers

GOAL MET

September

15,2010

@

3:00 AM

Tempera-

ture

rechecked:

37.4°C.

Pulse rate:

130 bpm

Patient was

able to rest

86

A

B

O

L

I

C

P

A

T

T

E

R

N

body temperature.

3. Perform tepid sponge

bath.

® Provide patient

with comfort and

lowers body tempera-

ture.

4. Monitor and record vi-

tal signs.

®Increased heart rate,

cool skin and de-

creased blood pres-

sure may indicate hy-

povolemia, which

leads to decrease tis-

sue perfusion. In-

crease respiratory rate

87

compensates for tis-

sue hypoxia.

5. Remind the watcher of

the client on the im-

portance of having ad-

equate rest periods.

® Adequate rest peri-

ods promote client

comfort and avoid

exertional activities

that might worsen

fever.

6. Provide patient with

proper ventilation.

® Proper ventilation

would provide com-

fort to the patient thus

88

patient could be able

to rest

7. Encourage the watcher

to increase oral fluid

intake in feeding the

baby.

®Encouraging patient

may promote ade-

quate hydration.

8. Discuss precipitating

factors with the parent,

if known.

® Develops recom-

mendation for keep-

ing cool and avoiding

heat-related illnesses.

9. Encourage the watcher

89

about the adherence to

other aspects of health

care management, in-

cluding dietary habits.

® Encouraging ad-

herence to proper

care management

would help in provid-

ing wellness to the

patient.

10. Administer antipyretic

medication as ordered

and record effective-

ness.

® Antipyretic medi-

cations aids in the re-

90

duction of fever.

91


September

12, 2010

@

12:00 AM

11-7

OBJECTIVE:

Weak periph-

eral pulse

Capillary re-

fill time = 3

seconds

Pallor noted

Weakness

noted

Irritable

Awakening

earlier than

desired

A

C

T

I

V

I

T

Y

-

E

X

E

R

C

Disturbed Sleep

Pattern related to

discomfort due to the

coughing secondary to

bronchopneumonia

® Sleep is required to

provide energy for

physical and mental

activities. Disruption in

the individual’s usual

diurnal pattern of sleep

and wakefulness may

be temporary or

At the end of 7

hours of nursing

care, the patient

will be able to

have an adequate

amount of sleep

as evidenced by

the patient able to

have undisturbed

and enough time

to sleep.

1. Check patient’s

vital signs and monitor.

® Close monitoring

would help in knowing

any changes in the

patient’s body.

2. Document nursing

or caregiver observations

of sleeping and wakeful be-

haviors. Record number of

sleep hours. Note physical

(e.g., noise, pain or discom-

fort, urinary frequency)

and/or psychological (e.g.,

fear, anxiety) circum-

GOAL UNMET

September 13,

2010

@

7:00 AM

11-7

At the end of 7

hours of nursing

care the patient

was able to

sleep without

92

I

S

E

P

A

T

T

E

R

N

chronic. Such

disruptions may result

in both subjective

distress and apparent

impairment in

functional abilities.

Sleep patterns can be

affected by

environment, especially

in hospital critical care

units.

NANDA 11th edition

(Doenges)

stances that interrupt sleep..

® Often, the patient’s

perception of the

problem may differ from

objective evaluation.

3. Provide a quiet

and restful atmosphere.

® This would help

patient rest and prevent

fatigue.

4. Position patient

properly.

® This promotes optimal

lung ventilation and

perfusion and will

provide comfort to the

any disturbance.

93

patient.

5. Evaluate timing or

effects of medications that

can disrupt sleep.

® In both the hospital

and home care settings,

parents may be following

medication schedules

that require awakening of

the baby in the early

morning hours.

6. Limit the stimuli

around the area.

® This reduces stress felt

by the baby and

promotes sleep.

7. Instruct watcher

94

to promote position

changes for patient and

discourage staying at the

same position for a long

period of time.

® This would help in

reducing discomfort felt

by the baby.

8. Remind watcher

to provide patient with

proper hygiene for the

baby.

® Proper hygiene would

provide comfort which

may help the patient

sleep.

9. If patient is

95

asleep avoid doing any

interventions

® This would help the pa-

tient have a continuous

sleep

10. Record , evaluate

and refer the result of the

interventions done

® This would help in

providing the patient

with quality health care.

96


September

12, 2010

@

12:00 AM

11-7

OBJECTIVE:

Productive

cough with

yellowish

secretions

Respiratory

rate of 39

cpm

Diaphoretic

Faint wheez-

ing can be

heared.

A

C

T

I

V

I

T

Y

-

E

X

E

R

C

I

Risk for impaired gas

exchange related to

alveolar-capillary

membrane changes

® Pneumonia is

characterized by the

consolidation of the

alveoli causing

impairement of the gas

exchange and the

organisms causes

inflammation which

stimulates

tracheobronchial

At the end of 7

hours of nursing

care, the patient

will be able to

prevent the

impairment of gas

exchange as

evidenced by:

Maintain res-

piration at

normal rate

within normal

range

1. Check the client’s

vital signs.

® This would help

check for any abnor-

malities of the body.

2. Monitor patient for

signs of cyanosis

® Close monitoring

would prevent hy-

poxia.

3. Maintain oxygen ad-

ministration device

as ordered, attempt-

ing to maintain oxy-

GOAL MET

September

13,2010

@

7:00am

11-7

At the end of 7

hours of nursing

care, the

impairment of

gas exchange

97

S

E

P

A

T

T

E

R

N

secretions causing

decreased in airway

patency.

NANDA 11th edition

(Doenges)

gen saturation at

90% or greater.

®This would ensure

that the patient

would be provided

with adequate oxy-

genation.

4. Position client in a

moderate high back

rest

® This promotes op-

timal lung ventila-

tion and perfusion.

The patient will ex-

perience optimal

lung expansion in

was prevented

as evidenced by

the baby

maintaining the

respiratory rate

at 35cpm which

is at normal

range.

98

upright position.

5. Monitor the effects

of position changes.

® Putting the most

congested lung areas

in the dependent po-

sition (where perfu-

sion is greatest) po-

tentiates ventilation

and perfusion imbal-

ances.

6. Provide proper ven-

tilation.

® Adequate ventila-

tion would help the

patient to be com-

fortable and be able

99

to rest.

7. Use pulse oximetry

to monitor for oxy-

genation and pulse

rate.

®Pulse oxymetry is

a useful device in

monitoring for the

patient’s oxygena-

tion.

8. Anticipate need for

intubation and me-

chanical ventilation

if patient is unable to

maintain adequate

gas exchange.

®Early intubation

100

and mechanical ven-

tilation are recom-

mended to prevent

full decompensation

of the patient.

9. Administer oxygen

as ordered by the

physician

®This would aid in

the gas exchange.

10. Refer physician for

any problems

®Proper referral

helps in giving

proper management

for the problem of

101

the patient.

102


September

12, 2010

@

12:00 AM

11-7

OBJECTIVE:

Noted bruis-

ing, dark in

color, on

right poste-

rior wrist

approxi-

mately 3 by

4 centime-

ters in size

Noted red-

ness on left

gluteus

maximus

N

U

T

R

I

T

I

O

N

A

L

-

M

Risk for impaired skin

integrity related to

mechanical factors

such as pressures and

friction.

® Skin is the primary

defense of the body; it

protects the body

against infections

and diseases brought

about by the invasion

of microbes in the

At the end of the

8 hours shift the

client will

maintain tissue

integrity as

evidenced by:

a. absence of

redness and

irritation

b. no skin break-

down.

1. Assess general

condition of skin

® Assessment

would help check

for any abnormal-

ities of the body

2. Assess for environ-

mental moisture.

® Moisture may

contribute to skin

maceration.

3. Encourage the

watcher for the im-

plementation and

GOAL UNMET

September

13,2010

@

7:00am

11-7

At the end of the

8 hours shift the

client was not

able maintain

tissue integrity

103

Diaphoretic

Dry skin

noted

Fair skin

turgor

E

T

A

B

O

L

I

C

P

A

T

T

E

R

N

body. A normal skin is

moist and intact;

dryness of the skin is

more prone to friction

that may result to

impairment of the skin

integrity as compared

with a moist skin.

NANDA 11th edition

(Doenges)

posting of a turning

schedule, restricting

time in one position

to 2 hours or less

and customizing the

schedule to patient’s

routine and care-

giver’s needs

®Building up of

pressures on the

body could be pre-

vented through turn-

ing.

4. Encourage caregiver

to maintain func-

tional body align-

as evidenced by:

a. presence of

redness

and irrita-

tion but

there was

no skin

breakdown

noted.

104

ment.

®This would main-

tain the alignment of

the body.

5. Increase tissue per-

fusion by massaging

around affected area.

®Massaging red-

dened area may

damage skin further.

6. Clean, dry, and

moisturize skin, es-

pecially over bony

prominences, twice

daily or as indicated

by incontinence or

105

sweating.

® This would thus

help in preventing

the impairment of

the skin

7. Encourage the par-

ent to provide ade-

quate nutrition and

hydration

® Hydrated skin is

less prone to break-

down.

8. Remind watcher to

change the clothing

and diapers if

soaked

®This would help

106

prevent the irritation

of the skin.

9. Instruct the watcher

to maintain the hy-

giene of the patient.

®Hygiene is impor-

tant for the body to

prevent any impair-

ment of the skin.

10. Refer physician for

any problems

®Proper referral

would give the pa-

tient proper manage-

ment for the prob-

lem.

107

PROGNOSIS

GOOD FAIR POOR JUSTIFICATION

Onset of the

illness

√ The onset of anemia that results from sepsis 2o to

bronhochopneumonia, unlike diseases that has

sudden onset like heart attack, is not sudden

therefore it can still be treated while it is still at

early stage.

Duration of illness √ Anemia 2o to sepsis 2o to bronchopneumonia is a

disease that needs immediate intervention. The

duration of this disease depends upon the

intervention given. If these problems are not

treated, it may be fatal to the patient.

Precipitating

factors

√ The precipitating factor present in the patient is

exposure to microorganisms. Exposure to

microorganisms easily modified by cleaning the

cause of the exposure thus decreasing exposure to

microorganisms.

Willingness to

take medications

and treatment

√ The patient complies with the medications strictly.

Moreover, the mother is very willing to let her

child take the medications prescribed to her by the

doctor. The patient was also brought to the

108

hospital be her mother for treatment.

Age √ The age of the patient is 4 months. She is still an

infant therefore she is susceptible to disease. The

immune systems of infants are not yet properly

developed.

Environmental

factors

√ The client’s home as reported is conducive for rest

and sleep. The patient lives in a therapeutic

environment. There are smaller chances of

pollution and noise. It can be said that the

environment as well was generally peaceful and

calm is very favorable for rest and promotes better

health.

Family Support √ The family has been very supportive throughout.

Her mother was supportive. Her father may not be

with her in the hospital but he is working so hard

to gain money for her hospitalization.

Total 3 3 1 Computation:

Poor: (2*1)/7 = 2/7

Fair: (0*2)/7 = 0/7

Good: (5*3)/7 = 15/7

Total: 2.43

General Prognosis:

109

1-1.6 = POOR

1.7-2.3 = FAIR

2.4-3.0 = GOOD

Rationale for a Good Prognosis

As shown by the calculated prognosis in relation to the different factors involved,

the patient has a good chance of survival. The factors presented in relation to prognosis shows

that patient can cope up after being discharged. Anemia 2o to sepsis 2o to bronchopneumonia is a

disease that needs immediate intervention. The duration of this disease depends upon the

intervention given. If these problems are not treated, it may be fatal to the patient. The age of the

patient is 4 months. She is still an infant therefore she is susceptible to disease. The immune

system of infants are not yet properly developed. Therefore in this area, she has poor chance of

survival.

However, the onset of anemia that results from sepsis 2o to bronhochopneumonia, unlike

diseases that has sudden onset like heart attack, is not sudden therefore it can still be treated

while it is still at early stage. The precipitating factor present in the patient is exposure to

microorganisms. Exposure to microorganisms easily modified by cleaning the cause of the

exposure thus decreasing exposure to microorganisms. The patient complies with the

medications strictly. Moreover, the mother is very willing to let her child take the medications

prescribed to her by the doctor. The patient was also brought to the hospital be her mother for

treatment. The client’s home as reported is conducive for rest and sleep. The patient lives in a

110

therapeutic environment. There are smaller chances of pollution and noise. It can be said that the

environment as well was generally peaceful and calm is very favorable for rest and promotes

better health. The family has been very supportive throughout. Her mother was supportive. Her

father may not be with her in the hospital but he is working so hard to gain money for her

hospitalization. Because of these justifications, she has good chance of survival.

111

Discharge Plan

Medication:

Instruct the mother to strictly comply with all of the doctor’s orders

Instruct to take the entire course of any prescribed medications. Otherwise

the disease may recur. Relapses can be far more serious than the first

strike.

Encourage the watcher to take the exact dosage of medication.

Inform the watcher and significant others about the possible adverse ef -

fects of the drugs,

Provide information about the effects of skipping medication,

Promote proper storage of the medication to avoid losing its potency,

Instruct to check date of expiry before taking the medication,

Immediately notify health care provider if adverse reactions occur while

taking the medicine,

Exercise:

Encourage the patient to have adequate sleep.

Bed rest should be encouraged.

Encourage alternating activity with rest.

Treatment:

Inform watcher and significant others about the effects of the treatment.

112

Clarify some misconceptions about the treatment and its purposes

Inform watcher and significant others about the compliance of medication

and other treatment recommended outside the hospital

Encourage significant others to provide care and support to enhance pa -

tient’s recovery

Health teachings:

Instruct watcher to bathe the child regularly.

Encourage the mother to wash the hands of her baby properly, before and

after meals. The hands come in daily contact with microorganisms that can

cause diseases. Washing of hands thoroughly and often can help reduce

the risk.

Explain the risk of spreading the disease. Protect others from the infec -

tion.

Instruct significant others to avoid exposing the patient to an environment

with too much pollution. Such as, aerosols used in the bathroom or even

colognes and perfumes that can irritate the patient.

.

Outpatient order:

Instruct significant others and watcher to come back to the OPD for the

scheduled check-up.

Inform the significant others to report any abnormalities and unusualities

manifested by the patient.

113

Instruct watcher and significant others not to take medicines without the

doctor’s advice.

Diet:

Advise planning the diet of the watcher as prescribed by the physician

Encourage mother to breast the baby on demand

Advise increasing fluid intake.

114

RECOMMENDATION

Ther case study about Anemia secondary to Sepsis secondary to Bronchopneumonia had

given the group more information that could help us in the future during the course of our

nursing practice. It is necessary to promote and maintain optimum health of the patient necessary

for one’s wellness; in line with ther the group would like to recommend the following:

To the Parents:

Since this is a pediatric patient with several disorders and is unable to care for herself yet,

we advise that the parents should be more cautious and aware of her condition that may worsen,

reoccur or give rise to further complications. We recommend that the parent’s should follow the

discharge plan given to them for the care of the patient diligently, to follow her recommended

medication regimen religiously and comply with the diet and lifestyle modification given in

order to maintain and/or improve her health condition. Upon the occurrence of any unusualities,

they must immediately be take the initiative to seek medical attention and not allow a time gap

between the onset of symptoms and the beginning of treatment to take place.

The family plays an important role during the recovery of the patient. Our patient’s

present condition and ailments are something that should not be taken lightly for it brings stress

to the family not only on a physical level but also in the psychological, emotional and financial

aspect. Therefore, the family should always show their support and concern for the patient all

throughout her recovery. The family should also work hand in hand with the patient, carefully

giving just the right amount of care to facilitate return of normal daily functions without

115

overreliance. Other accountabilities of the family are to monitor continuously assisting the

patient in taking medications, check-ups, and providing appropriate food and rest. Also, they

should understand and learn more about her conditions and ailments for the purpose of avoiding

complications. Lastly, the family should also be an example to the patient by doing the right

exercises and taking the proper diet.

To the Student Nurses

Student nurses handle the lives of the patient while the patient is in their care. Therefore,

the student nurses should be very strict and careful in carrying out the different nursing

interventions that were formulated specifically for that patient. One should have a continuous

dedication and conscience to provide proper and essential needs to patients they cared for. The

totality of all skills and knowledge taught to the student nurse should be reflected on their actions

and effectiveness in caring for others.

To the Clinical Instructors

The clinical instructors should continue to provide not just knowledge but wisdom to

their students and bear in mind that students are, compared to the CI’s, new to the world of

nursing. Thus the clinical instructors must have patience and be able to guide their pupils through

demonstration of their admirable qualities and positive reinforcement rather the more detrimental

method of harsh verbal criticism. The clinical instructors should also remember to teach skills

that are essential to a nurse and do so with same clarity and consistency as they so ask from their

students.

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To the Hospital

To the all the medical professionals in South Philippines Medical Center Pediatrics Ward,

we recommend that they continue their work and maintain and/or improve their quality of care.

May they keep in the life and quality of life of all those under their care lies in their hands.

To the College of Nursing

We recommend that the College of Nursing continue in its endeavor to train competent

student nurses and to assign us to areas that is most suited to our capabilities. We trust that

College of Nursing will assign us to areas of gradually increasing difficulty according to what

they see fit. We further advise that the we student nurses be assigned to areas more relevant to

the present concepts being discussed in our lecture classes as well to prove a more thorough and

enlightening related learning experience.

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REFERENCES

Kozier and Erb’s Fundmentals of Nursing 8th Edition

Nursing Pocket Guide to Diagnoses, Prioritized Interventions and Rationale

Doenges et. al.

Textbook of Medical Surgical Nursing 11th Edition

Lippincot and Willers

David Mullins (2007) 501 Human Diseases

Thomsom Asian Edition (p.306), Singapore

Delamar Learning

Robert Berkow, MD (1997).The Merck Manual of Medical Information

Home Edition (p. 1284). New Jersey; Merck and Co. Inc.

WEBSITES

http://emedicine.medscape.com/

http://www.medterms.com/script/main/art.asp?articlekey=9809

http://www.medcompare.com/jump/650/Anemia.html

http://emedicine.medscape.com/article/1222849-overview

Anemia secondary to Sepsis secondary to Bronchopneumonia

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