General Objectives:

After an hour of case presentation, the student

nurse will be able to present the summary of the
different aspect of the client’s case in order to
promote further consciousness and awareness of
the condition for the promotion of health and
prevention of further complications as equally
significant to the client’s wellness.
Specific Objectives:

After an hour of case presentation, the students

will be able to:

 accomplish assessment to gather pertinent data

about the client as deemed relevant to the case
 name the major health problem of the client
 defined the technical terms found in the course of
study to facilitate better understanding
 present the anatomy and physiology
 discuss the pathophysiology of the client’s
disease condition
 present laboratory studies conducted therein
 present other ideal laboratory studies and their
implication to support the diagnosis of the
disease
 determine the appropriate nursing diagnosis for
the client’s case
 create a plan of care appropriate for the
client’s condition
 commit to effectively execute or
implement nursing care plan for the client,
including all nursing interventions suited
 evaluate the efficiency of the nursing
care provided according to the nursing
care plan
 Pneumonia is an inflammation of the
lungs caused by an infection. It is also
called Pneumonitis or Bronchopneumonia.
Pneumonia can be a serious threat to our
health. Although pneumonia is a special
concern for the older adults and those with
chronic illnesses.
It can also strike young and healthy
people as well. It is a common illness
that affects thousands of people each
year in the Philippines, thus, it remains
an important cause of morbidity and
mortality in the country. There are
many kinds of pneumonia that range in
seriousness from mild to life-
threatening.
In infectious pneumonia, bacteria,
viruses, fungi or other organisms attack
the lungs, leading to inflammation that
makes it hard for an individual to
breathe. Pneumonia can affect one or
both lungs. In young and healthy
individual, early treatment with
antibiotics can cure bacterial pneumonia.
The drugs used to fight pneumonia are
determined by the germ causing
pneumonia and the doctors findings. It
is best to do everything we can to
prevent pneumonia, but if one get
sick, recognizing and treating the
disease early offers the best chance for
a full recovery.
A case with a diagnosis of Pneumonia
may catch one’s attention, though the
disease is just like an ordinary cough and
fever, it can lead to death especially
when there is no immediate intervention
done. Since the case is an infant, an
appropriate care has to be done to
promote faster recovery for the patient.
Treating patients with pneumonia is
necessary to prevent its spread to others
and make them as another victim of this
illness. Bronchopneumonia is an illness
of the lungs which is caused by different
organism like bacteria, viruses, and fungi
and characterized by acute inflammation
of the walls of the bronchioles.
It is also known as pneumonia.
Streptococcus pneumoniae (pneumococcus)
and Mycoplasma pneumoniae both are the
common bacterium which causes
bronchopneumonia in the adults and
children. Acute inflammation of the walls of
the smaller bronchial tubes, with varying
amounts of pulmonary consolidation due to
spread of the inflammation into
peribronchiolar alveoli and the alveolar
ducts; may become confluent or may be
hemorrhagic.
In Philippines, the case of pneumonia
is one of leading cause of mortality and
morbidity among Filipinos, 75-85% of
the population acquired the disease and
the one affected the disease are those
who are in low income status and the
below poverty line individual. (
www.DOH.org/pneumonia)
 DEFINITION OF TERMS

 Bradypnea - slower than normal rate (<10 breaths/minute),

with normal dept and regular rhythm

 Dyspnea – distressful sensation of uncomfortable breathing

that may be caused by certain heart conditions

 Empyema – inflammatory fluid and debris in the pleural

space. It results from an untreated pleural-space infection that
progress from free-flowing pleural fluid to a complex collection
in the pleural space.

 Hypoxemia – decrease in arterial oxygen tension in the

blood
 Mycoplasma pneumonia – another type of
Community Acquired Pneumonia (CAP),
occurs most often in children and young adults
and is spread by infected respiratory droplets
through person-to-person contact

 Pleural effusion – abnormal accumulation of

fluid in the pleural space

 Pleural cavity – the area between the

parietal and visceral pleurae a potential space
 Substernal Retraction – indrawing beneath the
breastbone, commonly manifested to infant and
neonate with respiratory distress

 Thoracentesis – insertion of a needle into the

space to remove fluid that has accumulated and
decrease pressure on the lung tissue; may also be
used diagnostically to identify potential causes of a
pleural effusion

 Thoracostomy - done to drain fluid, blood, or air

from the space around the lungs
Name: Baby Boy
BASELINE DATA

Address: P-5 Aguada Ozamiz City, Misamis Occidental

Age: 4 months old

Birth date: April 9, 2009

Birthplace: Aguada, Ozamiz City

Gender: Male

Religion: Roman Catholic

Nationality: Filipino
Father’s name : Felly Baguio Rone

Mother’s name: Neiva Dumanjug Dayondon

Date of Admission: September 6, 2009

Time of Admission: 6:25 AM

Chief Complaint : on and off cough associated

with fever
Admitting Diagnosis: Bronchopneumonia

Admitting Physician: Dr. Alimyon Montolo, MD

 BACKGROUND HISTORY

DM HPN CANCER ASTHMA

Maternal - - - -
Paternal - - - -

 The parents of the client both manifest (-)

history of the following diseases: DM,
Hypertension, Cancer, Asthma as interviewed.
 HISTORY OF
PRESENT ILLNESS

1 month prior to admission, Baby

boy experienced on and off cough and
associated with fever, with intercostal
retraction, rapid and shallow
breathing.
 SOCIO-ECONOMIC
BACKGROUND

The family of baby boy was very

supportive; they have provided all his
medication. Especially his medicine and
payments for other diagnostic procedures
to be done for his early and faster recovery.
GENERAL APPERANCE
• A 4-month old baby boy
• Weigh 6.8 kilograms
• Short brown hair
• Cyanosis noted upon coughing
• Rapid shallow breathing noted
• Expressed his self through crying
• Skin is warm to touch
• Irritability noted due to his condition
VITAL SIGNS

September 8, 2009

4 pm 8 pm
HR: 156 bpm HR: 160 bpm
RR: 60 cpm RR: 64 cpm
TEMP: 38.3 °C TEMP: 37.8 °C
September 9, 2009

4 PM 8 PM
• HR: 150 bpm HR: 162 bpm
• PR: 63 cpm PR: 54 cp
• TEMP: 38 °C TEMP: 37.3 °C
• September 10, 2009

4 pm 8 pm
HR: 149 bpm HR: 149 bpm
RR: 38 cpm RR: 40 cpm
TEMP: 37.5 °C TEMP: 37.4 °C
• September 11, 2009

4 pm
HR: 140 bpm
RR: 33 cpm
TEMP: 36.9 °C
 PHYSICAL ASSESSMENT
Neurological
The patient can able to expressed his self
through crying.

Eye/Vision
Our patient, have pale conjunctiva due
to fever. Eyelashes present curving outward. No
lesions noted on the eyelid. Pupil equal, round,
reactive to light and accommodation.
Ears/Hearing
Our patient doesn’t have hearing
problem, no discharges, symmetrical, no
swelling and tenderness. Can respond
normal voice tone. Intact with no lesions.

Nose
Our patient doesn’t have nasal
problem, any discharges, any swelling and
tenderness noted upon inspection and
uniform in color.
Mouth/Tongue/Teeth/ Speech
The patient had a pallor lips, reddened
gums, without teeth. Thin whitish coating
noted in the tongue, it moves freely without
lesions.

Throat/Neck
Neck is symmetrical with head, can
turned head from right to left gradually, but
with resistance, no palpable lymph nodes.
Respiratory System
Patient use accessory muscle in order to
breathe normally, presence of wheezing sound is
heard upon auscultation and in normal hearing,
with respiratory rate of 60-42 cpm., and
nebulization was given.
Circulatory/Cardiovascular
Patient has a heart rate of 156-140
beats per minute. No edema and swelling noted.
Good capillary refill less than 2sec.

Gastrointestinal
Flat abdominal contour, no tenderness or
distention. Thorax had dullness of sound due to
decrease confluent and pleural effusion.
Genitourinary
Patient had excessive urination, with
minimum of 800cc per diaper

Musculoskeletal
The patient had normal upper and lower
extremities, symmetrical and no tenderness

Integumentary
The patient's skin was warm to touch, he
experience on and off fever, with good skin turgor.
Negative of rashes, sores, and lesions.
A respiratory system functions to
allow gas exchange. The gases that
are exchanged, the anatomy or
structure of the exchange system
and the precise physiological uses
of the exchanged gases vary
depending on the organism.
In humans and other mammals, for
example, the anatomical features of the
respiratory system include airways, lungs,
and the respiratory muscles. Molecules
of oxygen and carbon dioxide are
passively exchanged, by diffusion,
between the gaseous external
environment and the blood. This
exchange process occurs in the alveolar
region of the lungs.
The respiratory system can be
conveniently subdivided into an
upper respiratory tract (or conducting
zone) and lower respiratory tract
(respiratory zone), trachea and lungs.
The conducting zone starts with the
nares (nostrils) of the nose, which
open into the nasopharynx (nasal
cavity).
The primary functions of the
nasal passages are to: 1) filter, 2)
warm, 3) moisten, and 4) provide
resonance in speech. The
nasopharnyx opens into the
oropharynx (behind the oral cavity).
PATHOPHYSIOLO
GY
Predisposing Precipitating factors
factors Age (very Daily Activities
young) Environment
Exposure (living) Diet

Pathological Entry (inhalation) of

organism: Bacteria or Viruses

Occurrence of localized inflammation

Mucus production Manifested

by wheezing
 Diminished
Signs And
surfactant Bacteria invades
Symptoms
production alveolar cell in
Fever,
Formation of the lungs
cough, chest
Hyaline
pain, Rapid,
membrane
swallow
breathing
Airway
Bronchopneumonia
Obstruction
 LABORATORY REPORTS
Urinalysis

Color: pale yellow • Pus cells 0-1/hpf

Transparency: clear
• Epithelial cells: rare
Sp. Gravity: 1.010
• Crystals: Amorphous
pH: 6.0 Urates (PD 4) –
rare/hpf
Microscopic findings

RBC: 0-1/hpf • Bacteria: rare

 HEMATOLOGY
TEST NORMAL RESULT
VALUES
Hematocrit 35.0-50.0% 33.0

Hemoglobin 12.0-16.5 g/dl 11.0

White cell count 5,000-10,000mm³ 3,600

Platelet count 150,000- 275,000

400,000/mm³
Segmenters 55-65% 42

Lymphocytes 25-35% 58

Blood Type “B” RH type(+)

 BLOOD CHEMISTRY

TEST NORMAL RESULT

VALUES

Sodium 136-145 mEq/L 132.7 mEq/L

Potassium 3.5-5 mEq/L 3.23 mEq/L

 Ra dio gra phic Repo rt
Chest X-ray: AP/Lateral view

– There are inhomogeneous parasites

in both lower lung fields.

– The cilia and pulmonary vascular

markings are within normal limits.

– The trachea is midline

 The heart is not enlarged.

The hemi diaphragms and costophrenic

angles are intact.

The rest of the osseous and soft tissue

structures are unremarkable.

Impression:
Pneumonia, bilateral follow
up chest x-ray is suggested.
DISCHARGE TEACHING PLAN
 The medication of the patient is very
important to continue depending on the
duration that the doctor ordered for the total
recovery of the patient.

 Patient with Bronchopneumonia needs to

have deep breathing exercise for lung
expansion and clearing for progressive
normal breathing pattern and have adequate
rest periods.
 The client must relax in order to
recover his present condition and instructed
significant others for minimal exposure to an
open environment such as dusty and smoky
area, which airborne microorganisms are
present that can be a high risk factor that may
cause severity of her condition.
 It is also important to maintain proper
hygiene to prevent further infection.
Significant others of the patient instructed
that the baby should be bathe everyday.
 Regular consultation to the physician
can be factor for recovery to assess and
monitor his condition
 The diet of the patient is also a
factor for fast recovery. Encouraged
to eat nutritious foods intended for
respiratory problem patient, the family of
the patient plays a big role for the fast
recovery