Nursing Case Study

Topics: Pneumonia, Respiratory system, Complete blood count Pages: 13 (3349 words) Published: October 31, 2012
Introduction of case study
My case study done at ward 3(female ward), Hospital T and the title is bronchopneumonia, I choose this title because that is often occur at the ward. Patient L is a 14 years old Chinese girls and she came to hospital complaint of cough with greenish sputum as long as 2 weeks, she had fever at home and complaint of chest pain. She came from A&E admitted at ward 3 at 30/4/2012 (Monday), 3.35pm accompanied with PPK. She admitted at the ward 3 as long as 5 days and she discharge at 4/5/2012 (Friday), 10.20am. Patient L was diagnosed as bronchopneumonia. Bronchopneumonia also known as bronchial pneumonia and catarrhal pneumonia and it is an acute inflammation of the lungs and bronchioles. It is characterized by chills, fever, high pulse and respiratory rates, bronchial breathing, cough with purulent bloody sputum, severe chest pain, and abdominal distension. This disease always occur at immunocompromised host like child and elderly. The disease is usually a result of the spread of infection from the upper to the lower respiratory tract and it’s pattern has been associated with hospital-acquired pneumonia, and with specific organisms such as Staphylococcus aureus, Klebsiella, E. coli, and Pseudomonas.

Ways can get pneumonia include:
* Bacteria and viruses living in nose, sinuses, or mouth may spread to lungs. * May breathe some of these germs(bacteria, viruses, fungi) directly into lungs. * Breathe in (inhale) food, liquids, vomit, or fluids from the mouth into lungs (aspiration pneumonia)

Background of patient
Name: Miss L
Gender: Female
Age: 14 years old
Date of birth: 16/2/1998
Status: Single
Race: Chinese
Religion: Buddha
Allergic: NIL
Admitted date/time: 30/4/2012(Monday)/3.35pm
MRN: 12345
Ward/bed no.: 3/18
Diagnosis: Bronchopneumonia
Further history: NIL
Admission condition: complaint cough as long as 2 weeks, fever, chest pain and cough out greenish color of sputum.Bp 114/73 , PR 110, SpO2 98% and T 37 ℃.

Anatomy of bronchopneumonia

Pathophysiology of bronchopneumonia
Bronchopneumonia started from accumulation of mucus and edema of bronchioles. After that, the bronchiolar become obstructed and the alveoli wall become thicker. The alveoli will filled with inflammatory exudates and it will impaired the normal exchanges of gases in the lung. That will caused the diminished ventilation of the alveoli. Hypoxemia and carbon dioxide retention will formed and it will interfere normal metabolic process and normal function of chief organs.

Risk factors
* Cerebral palsy
* Chronic lung disease (COPD, bronchiectasis, cystic fibrosis) * Cigarette smoking
* Difficulty swallowing (due to stroke, dementia, Parkinson's disease, or other neurological conditions) * Immune system problem (immunocompromised host)
* Impaired consciousness (loss of brain function due to dementia, stroke, or other neurologic conditions) * Living in a nursing facility(health care worker)
* Other serious illnesses, such as heart disease, liver cirrhosis, or diabetes mellitus * Recent surgery or trauma
* Recent cold, laryngitis, or flu.

Clinical manifestation
* Cough (may cough up greenish or yellow mucus, or even bloody mucus) * Fever (may be mild or high)
* Shaking chills
* Shortness of breath (may only occur when you climb stairs) * Confusion, especially in older people
* Excess sweating and clammy skin
* Headache
* Loss of appetite, low energy, and fatigue
* Sharp or stabbing chest pain that gets worse when you breathe deeply or cough

* Signs (Working hard to breathe, or breathing fast).
* Listening abnormal breathing sounds through stethoscope or via percussion. * Perform chest x-ray.
* Arterial blood gases (to see if enough oxygen is getting into blood from the lungs) * Complete Blood Count (CBC) (to check white blood cell count) * CT scan of the chest
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