CHAPTER ONE

INTRODUCTION
Bronchopneumonia is one of the several different types of pneumonia; it
is an acute inflammation of the lungs and the walls of the bronchioles, usually
as a result of the spread of infection from the upper to the lower respiratory
tract. This form of pneumonia is also known as bronchial pneumonia or
bronchiogenic pneumonia. (Cortran, 2005)
Bronchopneumonia is the type of pneumonia which is characterised by
multiple foci of isolated acute consolidation, affecting one or more pulmonary
lobules. Bronchopneumonia is a radiological pattern associated with
suppurative peribronchiolar inflammation and subsequent patchy consolidation
of one or more secondary lobules of a lung in response to a bacterial
pneumonia.
The most common causative organisms is infection from viruses, bacteria
or fungi. They include staphylococcus aureus, klebsiella pneumonia,
haemophillus influenza, pseudomonas aeruginosa, Escherichia coli, and
anaerobes. It could also be either mild or severe (life threatening).
Nigeria has the highest pneumonia burden in Africa (second highest
worldwide). Children are the most vulnerable to bronchopneumonia.
Bronchopneumonia kills nearly 1.6 million children under 5years annually
worldwide. An estimated 98% of children who die of pneumonia live in
developing countries. According to 2008 estimates, about 177,000 children
under the age of 5 died of pneumonia in Nigeria. This means that within an
hour, 20 children across Nigeria will die from pneumonia.
Treating patients with bronchopneumonia is necessary to prevent its
spread and make them another victim of this illness because it can as well strike
1

young, healthy people as well. The disease might just be like an ordinary cough
and fever; it can lead to death especially when no intervention is done to make
the patient recover faster.
This is a care study of Master I.A, a 2year old boy who was admitted into
the childrens ward on the 9th of February 2015, with the history of cough of
2months duration, worse at night with excessive sweating, occasionally
producing thick whitish sputum.

OBJECTIVES OF THIS CARESTUDY:

To broaden my knowledge of the anatomy and physiology of the
affected organ (lungs).
To create good interpersonal relationship with my client and other
health workers.
To fulfil part of the requirement for the award of registered nurse
certificate by the nursing and midwifery council of Nigeria.

PATIENTS IDENTITY DATA

PATIENTS NAME:
AGE:
SEX:
ADDRESS:

Master I.A
2years
MALE
51, Oluwakemi Street, igbobi, Mowe.

MEDICAL DIAGNOSIS:
OCCUPATION:

Bronchopneumonia
Underage

DOCTOR-IN-CHARGE:

Professor Olanrewaju

DATE OF ADMISSION:

09/02/2015

DATE OF DISCHARGE:

23/02/2015

HOSPITAL NUMBER:

l 149147

WARD:

Childrens ward

NEXT OF KIN:

Mrs. M. I.

STATE OF ORIGIN:

Ogun State

CHAPTER TWO
LITERATURE REVIEW
DEFINITION:
Babara (2009) defines bronchopneumonia as a descending infection starting
around the bronchi and bronchioles.
She goes further to explain that in bronchopneumonia, infection spreads from
the bronchi to the terminal bronchioles. It occurs most commonly in infancy and
old age, and death is fairly common, especially when the condition complicates
debilitating diseases.

Saunders (2007) further explains that bronchopneumonia is an acute exudative

supporative inflammation of the lungs characterized by focci of consolidation
surrounded by normal parenchyma. Freeman (2006) states that
bronchopneumonia or bronchial pneumonia is an inflammation of the lungs
beginning in the terminal bronchioles. It consists of irregular areas of
consolidation due to spread of the inflammation into the peribronchiolar alveoli
and the alveoli ducts of the lungs.
Ayush (2008) says that bronchopneumonia is a radiological pattern associated
with suppurative peribronchiolar inflammation and subsequent patchy
consolidation of one or more secondary lobules of a lung in response to a
bacterial pneumonia.
Hayman (2011) explains that bronchopneumonia is one of the several different
types of pneumonia. It is an acute inflammation of the lungs and the
bronchioles, usually as a result of the spread of infection from the upper to the
lower respiratory tract.
CAUSES OF BRONCHOPNEUMONIA
Both forms of pneumonia are often caused by coming into contact with viruses
and bacteria in your day-to-day routine. Most cases of bacterial pneumonia are
caused by the bacterium streptococcus pneumonia; however, its not uncommon
for bronchopneumonia to be caused by more than one type of bacteria. Other
possible culprits include:
1.
2.
3.
4.

Staphylococcus aureus
Haemophillus influenza
Klebsiella pneumonia
Pseudomonas aeruginosa

Most causes of viral pneumonia are caused by the same viruses that cause cold
and flu.
5

According to the mayo clinic, very severe forms of bronchopneumonia are often
acquired in hospital settings. While they may be caused by some of the
aforementioned bacteria, this form of bronchopneumonia can be caused by a
host of antibiotic resistant germs within a healthcare setting. It develops due to
low body resistance and impaired defence function of the respiratory tract. It
can also be caused by aspiration of fluid or substance. (Anderson, 2011)
PREDISPOSING FACTORS OF BRONCHOPNEUMONIA
1. Conditions that produce mucous or bronchial obstruction and interfere
with normal lung drainage and cause damage to the epithelial lining of
the tract e.g. cigarette smoking, prolonged immobility etc.
2. Depressed cough reflex due to medications or weak respiratory muscles
or impaired coughing.
3. Aspiration of foreign objects to the lungs during a period of
unconsciousness.
4. General anaesthetic, sedative or opium preparations that promote
5.
6.
7.
8.
9.

respiratory depressions that predisposes to pulling of bronchi secretions

Paralysis of airway
Upper respiratory tract infection
Exposure to cold and dampness
Intubation or mechanically assisted ventilation.
Impaired alveoli phagocytosis may be caused by alcohol, anoxia, and

oxygen toxicity.
10.Other factors like extremes of age, leukopenia, chronic diseases, and
hypothermia. (Allison Grant, 2010)
PROGNOSIS OF BRONCHOPNEUMONIA
Most people with bronchopneumonia improve after 3-5days of antibiotic
treatment, but a mild cough and fatigue can last longer, up to a month. Patients
who required treatment in a hospital may take longer to see improvement.
Bronchopneumonia can be fatal. The mortality (death) rate is up to 30% for
patients with severe bronchopneumonia who require treatment in an intensive6

care unit. Overall, around 5%-10% of patients who are treated in a hospital
setting die from the disease. Bronchopneumonia is more likely to be fatal in the
elderly or those with chronic medical conditions or a weakened immune system.
(Lewis, 2012)
WHO IS AT RISK?
Certain groups of people are more at risk of developing bronchopneumonia.
Risk factors include:
Being age 2 or younger
Being 65years or older
Having lung disease, such as cystic fibrosis, asthma or chronic
obstructive pulmonary disease (COPD)
Having HIV/AIDS
Having a chronic disease, such as heart disease or diabetes
Having a weakened immune system, which may be caused by
chemotherapy or use of immunossuppressive drugs
Being on a ventilator
(Oousterhout, 2007)
ANATOMY AND PHYSIOLOGY OF THE LUNGS
There are two lungs, one lying on each side of the midline of the thoracic cavity.
They are cone-shaped and have an apex, a base, a tip, coastal surface and
medial surface.
The apex: this is rounded and arises into the root of the neck, about 25mm
above the level of the midline third of the clavicle, it lies close to the first rib
and blood vessels and nerves in the root of the neck.
The base: this is concave and semilunar in shape, and lies on the upper
(thoracic) surface of the diagram.
The coastal surface: this surface convex and lies directly against the coastal
cartilages, the ribs and the intercoastal muscles.
7

The medial surface:this surface is concave and has a roughly triangular-shaped

area, called the hilum, at the level of the 5th, 6th and 7th thoracic vertebrae.
Structures forming the root of the lung enter and leave at the hilum. These
include the primary bronchus, the pulmonary artery supplying the lungs and the
two pulmonary veins draining it, the bronchial artery and veins, and the
lymphatic and nerve supply.
The area between the lungs is the mediastinum. It is occupied by the heart, great
vessels, trachea, right and left bronchi oesophagus, lymph nodes, lymph vessels
and nerves. The right lung is divided into 3 distinct lobes: superior, middle and
inferior. The left lung is smaller because the heart occupies space left of the
midline. It is divided into only 2 lobes: superior and inferior. The divisions
between the lobes are called fissures. (Waugh, 2010)
PLEURA AND PLEURA CAVITY: The pleura consists of a closed sac of
serous membrane (one for each lung) which contains a small amount of serous
fluid. The lung is invaginated (pushed into) into this sac so that it forms two
layers:one adheres to the lung (visceral pleura) and the other to the wall of the
thoracic cavity (parietal pleura). The pleura cavity is a potential space and
contains no air. In health, the two layers of pleura are separated by a thin film of
serous fluid (pleura fluid), which allows them to glide over each other,
preventing friction between the, during breathing. (Drayson , 2005)
INTERIOR OF THE LUNGS: Zijlstra, (2007) explained that the lungs are
composed of the bronchi and smaller air passages, alveoli, connective tissue,
blood vessels, lymph vessels and nerves, all embedded in an elastic connective
tissue matrix. Each lobe is made up of a large number of lobules.
BRONCHI AND BRONCHIOLES: the two primary bronchi are formed when
the trachea divides, at about the level of 5th thoracic vertebrae. The right
bronchus is wider, shorter and more vertical than the left bronchus and is
8

therefore more likely to become obstructed by an inhaled foreign body. It is

approximately 2.5cm long. After entering the lung at the hilum, it divides into
three branches, one to each lobe. Each branch then subdivides into numerous
smaller branches. The left bronchus is about 5cm long and is narrower than the
right. After entering the lung at the hilum, it divides into two branches, one to
each lobe. Each branch then subdivides into progressively smaller airways
within the lung substance.
STRUCTURE OF THE BRONCHI AND BRONCHIOLES
The bronchi walls are composed of the same tissues as the trachea, and air lined
with ciliated columnar epithelium. The bronchi progressively subdivide into
bronchioles, terminal bronchioles, respiratory bronchioles, alveolar ducts and
finally alveoli. The wider passages are called conducting airways because their
function is to bring air into the lungs, and their walls are too thick to permit
gaseous exchange. (Moleyneux , 2006)

STRUCTURAL CHANGES IN THE BRONCHIAL PASSAGES

10

According to Aaron, (2008), the following are the structural changes that take
place in the bronchi and the bronchioles:
As the bronchi divides and become progressively smaller, their structure
changes to match their function.
Cartilage: since rigid cartilage would interfere with expansion of the lung
tissue and exchange of gases, its present for support in the larger airways only.
The bronchi contain cartilage rings like the trachea, but as the airways divide,
these rings become much smaller plates, and at the bronchiolar level there is no
cartilage present in the airway walls at all.
Smooth muscle: as the cartilage disappears from airway walls. It is replaced b y
smooth muscle. This allows the diameter of the airways to be increased or
decreased through the action of the autonomic nervous system, regulating
airflow within each lung.
Epithelial lining: the ciliated epithelium s gradually replaced with non-ciliated
epithelium, and goblet cells disappear.
FUNTIONS OF THE BRONCHI AND BRONCHIOLES
CONTROL OF AIR ENTRY: the diameter of the respiratory passages is altered
by the contraction or relaxation of the smooth muscles in their walls, thus
regulating the speed and volume of airflow into and within the lungs. These
changes are controlled by the autonomic nerve supply: parasympathetic
stimulation causes constriction and sympathetic stimulation causes dilation. The
following functions continue as in the upper airways:
1.
2.
3.
4.

Warming and humidifying

Support and patency
Removal of particulate matter
Cough reflex (Vandemheen, 2008)

11

STRUCTURE OF THE RESPIRATORY BRONCHI AND BRONCHIOLES

Within each lobe, the lung tissue is further divided by fine sheets of connective
tissue into lobules. Each lobule is supplied with air by a terminal bronchiole,
which further subdivides into respiratory bronchioles, alveolar ducts and large
numbers of alveoli (air sacs). There are about 150million alveoli in the adult
lung. It is in these structures that the process of gas exchange occurs. As airways
progressively divide and become smaller and smaller, the walls gradually
become thinner until muscle and connective tissue disappear, leaving a single
layer of simple squamous epithelial cells in the alveolar ducts and alveoli. These
distal respiratory passages are supported by a loose network of elastic
connective tissue in which macrophages, fibroblasts, nerve and blood and
lymph vessels are embedded. The alveoli are surrounded by a dense network of
capillaries. Exchange of gases in the lungs (external respiration) takes place
across a membrane made up of the alveoli wall and the capillary wall fused
together firmly. This is called the respiratory membrane.
On microscopic examination, the extensive air spaces are clearly seen and
healthy lung tissue has a honey comb appearance.
Lying between the squamous cells are septal cells that secret surfactants, a
phosphor lipid fluid which prevents the alveoli from drying out. In addition, the
surfactants reduce surface tension and prevent alveolar walls collapsing during
expiration. Secretion of surfactants into the distal air passages and alveoli begin
about the 35th week of foetal life. Its presence in new born babies facilitates the
expansion of the lungs and establishment of respiration. It may not be present in
sufficient amounts in the immature lungs of premature babies, causing serious
breathing problems. (Naftel, 2010)
PULMONARY BLOOD SUPPLY

12

The pulmonary trunk divides into the right and left pulmonary arteries, which
transports deoxygenated blood to each lung. Within the lungs, each pulmonary
artery divides into many branches, which eventually end in a dense capillary
network around the walls of the alveoli. The walls of the alveoli and the
capillaries each consists of only one layer of flattened epithelial cells. The
exchange of gases between the air in the alveoli and blood in the capillaries take
place across these very two fine membranes (together called the respiratory
membrane). The pulmonary capillaries join up, forming two pulmonary veins in
each lung. They leave the lung at the hilum and carry oxygenated blood to the
left atrium of the heart. The innumerable blood capillaries and blood vessels in
the lungs are supported by connective tissue. (Lewis, 2009)
BLOOD AND NERVE SUPPLY, LYMPH DRAINAGE
The arterial supply to the walls of the bronchi and smaller air passages through
the branches of the right and left bronchial arteries and the venous return is
mainly through the bronchial veins. On the right side they empty into the
azygous vein and on the left into the superior intercoastal vein.
The vagus (parasympathetic) stimulates contraction of the smooth muscle in the
bronchial tree, causing broncho constriction and sympathetic stimulation causes
bronchodilation. (Rodger, 2011)
Lymph is drained from the walls of the air passages in a network of lymph
vessels. It passes around lymph nodes situated around the trachea and the
bronchial tree, then into the thoracic duct on the left side and the right lymphatic
duct on the other side. (Belargo,2013)

PATHOPHYSIOLOGY OF BRONCHOPNEUMONIA

13

Upper airway characteristics normally prevent potentially infectious particles

from reaching the normally sterile lower respiratory tract. Thus, patient with
bronchopneumonia often have acute or chronic underlying disease that impairs
the host defences. Bronchopneumonia arises from the normally present flora in
a patient whose resistance has been altered or it may result from aspiration of
flora present in the oropharynx. It may also result from blood-borne organisms
that enter the pulmonary circulation and are trapped in the pulmonary capillary
beds becoming a potential source for bronchopneumonia, which affects both
ventilation and perfusion. The inflammation of the lungs causes exudation of
fluid which fills the alveolar sac and interferes with diffusion of oxygen and
carbon dioxide. Serous exudates are a product of increased permeability of the
dilated capillaries which releases fibrinogen, plasma protein and erythrocytes.
The fluid is an excellent culture medium and as organisms grow in the fluidfilled alveoli sacs, the body responds as it does to all infections by increasing
blood supply to the area (hyperaemia). Bronchopneumonia spreads as the fluid
filled alveoli sac spills some fluid into the adjoining sac. (Kevin, 2012)
Consolidation occurs as the alveoli are filled with thick exudates leading to
impaired gas exchange in the affected area of the lung, resulting into dyspnoea.
Fever can result into insensible fluid loss, stabbing chest pain occurs as the
pleura becomes infected and rubbing together of inflamed tissue over each other
during inspiration phase of respiration. Cough results due to the initiation of
mucus membrane with accumulated secretion. Cough initially may be dry and
non-productive but later there is secretion which may also become
mucocululent. (Manic, 2014)
CLINICAL MANIFESTATIONS OF BRONCHOPNEUMONIA
Burtis, (2014), listed the following as the most common signs and symptoms of
bronchopneumonia:
14

1. Dyspnea
2. Cough
3. Chestpain
4. Fever
5. Chills
6. Anorexia
7. Production of rusty-coloured sputum
8. Sweating
9. Tachycardia
Diagnosis of bronchopneumonia
Behera (2010) explains that bronchopneumonia is usually diagnosed
using a combination of physical signs and chest x-ray:
Laboratory tests done on the mucus or phlegm that you cough up from your
lungs which includes
1. Sputum examination is used to detect bacteria or fungi that infect the
lungs or breathing passage. Sampling may be performed by sputum being
expectorated (coughing), induced (spraying of saline of the lungs) or via
an endotracheal tube with a protected specimen brush in an intensive care
setting
2. Blood tests- its a laboratory analysis performed on a blood sample that is
usually extracted from a vein in the arm using a needle. A tight band
(tourniquet) is usually put around the upper arm/ this squeezes the arm,
temporarily slowing down the flow of blood out of the arm and causing
the vein to swell with blood. The area needs to be cleaned with antiseptic
wipe. A needle attached to a syringe is pushed into the vein to draw out a
sample of blood, the needle is then removed and pressure is applied to the
tiny break in skin for a few minutes using a cotton wool pad to stop the
bleeding. A plaster may then be put on the small wound to prevent
infection and keep it clean. It can be used to detect organ function and as
well confirm the presence of bacterial or viral infection
3. Chest x-ray is a projection radiograph of the chest used to diagnose
conditions affecting the chest, its contents and nearby structures. It

15

employs ionizing radiation in form of x-rays to generate images of the

chest
4. Physical examination
Physical examination may sometimes reveal low blood pressure, high heart
rate or low oxygen saturation. The respiratory rate may be faster than normal
and this may occur a day or two before other signs. Crackles may be heard
over the affected area during inspirations, vocal resonance distinguishes
pneumonia from pleural effusion. However, the underlying cause can be
difficult to confirm, as there is no definitive test able to distinguish between
bacterial and non-bacterial origin. The World Health Organisation has
defined pneumonia in children as clinically based on either a cough or
difficulty breathing and a rapid respiratory rate, chest in drawing or
decreased level of consciousness. A rapid respiratory rate is defined as
greater than 60 breaths per minute in children under 2months old to 1year
old, or greater than 40 breaths per minute in children 1-5years old. In
children, increased respiratory rate and lower chest in drawing are more
sensitive than hearing chest crackles with a stethoscope.
MEDICAL MANAGEMENT OF BRONCHOPNEUMONIA
According to Maclennan (2007), the following could be done to manage
bronchopneumonia.
May be given erythromycin 4 x 500 mg daily or tetracycline 3-4mg a
day, these drugs ease and speed healing, especially in severe cases.
Antibiotics: intravenous antibiotics are the first line of approach,
usually levaquin
if organism is unclear, if patient does not need to be hospitalized, oral
antibiotics are satisfactory.
White (2007) encouraged symptomatic treatment such as:
1.Breaks, generally the patient does not need to be treated, get enough rest at
home.
2.Symptomatic of a cough
3.A productive cough should not suppress with antitusive (cough suppressants).
16

4.If there is airway obstruction and mucus and there is a febrile, give
bronchodilator.
5.Oxygen administration generally is not required except for severe cases. The
best antibiotic is an antibiotic corresponding to the causes that have a narrow
spectrum
NURSING MANAGEMENT OF BRONCHOPNEUMONIA
According to Frank (2007), nurses are involved in all aspects of the processes
of care of patients with bronchopneumonia, from the initial diagnosis to the
treatment and follow up care. Nursing responsibility includes health educating
the patient on the need to increase the daily fluid intake and to quit smoking.
Other nursing management include:
1. Admit patient in a well ventilated environment.
2. Patient should be placed in a fowler or upright position to promote adequate
lung expansion and facilitate easy breathing.
3. Vital signs should be checked which include temperature, pulse, respiration
and blood pressure.
4. General observation should also be carried out.
5. Monitor patients response to treatment and detect complication on time.
6. Rest enhances mobilisation of the bodys defence thereby ensuring quick
recovery.
7. Give food in little or small quantity, as patient can tolerate.
8. Administration of oxygen when necessary
9. Fluid therapy to replace insensible fluid loss, this could either be by oral
intake or intravenous intake based on patients condition.
10.Patients education on proper disposal of sputum.
COMPLICATIONS OF BRONCHOPNEUMONIA
According to Denny (2007), complication of bronchopneumonia includes;
1.
2.
3.
4.
5.
6.

pulmonary fibrosis
bronchiectasis
lung abscess
emphysema
bacteraemia with abscess in other organs
necrotizing pneumonia
17

7. lung infarction
8. cavitation
9. broncho pleural fistula
10.pneumothorax
11.ARDS (acute respiratory distress syndrome)
12.Lung fibrosis
13.Pleural adhesions
14.Atelectasis
15.Systemic infection
16.Endocarditis
17.Meningitis.
PREVENTION OF BRONCHOPNEUMONIA
Ashwoodh(2012) suggested the following methods for prevention of
bronchopneumonia and they include:

Vaccination
environmental measures
Smoking cessation
Reducing indoor air pollution such as that from cooking indoors with

wood or dung.
Hand hygiene
Coughing into ones sleeves or handkerchief may also be effective
preventative measures.
Wearing surgical mask by the sick may also prevent illness.
Appropriately treating underlying illness (such as HIV/AIDS, diabetes
mellitus and malnutrition) can decrease the risk of pneumonia.
In children less than 6months of age, exclusive breastfeeding reduces
both the risk and severity of the disease.
In the frail elderly, good oral health care may lower the risk of
aspiration pneumonia

18

CHAPTER THREE
GENERAL DESCRIPTION OF PATIENT ON ADMISSION.
Master I.A, a dark complexion boy, weighs 10kg, was brought into the ward
via the children emergency department on a wheel chair by the nurse, in
company of the patients mother at about 2:15pm on the 9th of February, 2015.
On admission, patient was looking weak, lean and febrile, with cough and
dyspnoea.
Patients mother complained of cough of 2 months duration, worse at night
with excessive sweating, occasionally producing thick whitish sputum.
PATIENT UNDERSTANDING OF ILLNESS
Master I. A only understands that he is in pains and he expresses it by crying,
but his mother is fully aware of her sons illness.
ATTENDANCE AT OUT PATIENT DEPARTMENT
Master I. As mother explained that they do not visit the hospitals outpatient
department, because they usually visit a private hospital.
ASSESSMENMT OF PATIENT
PAST MEDICAL HISTORY
Master I.A doesnt have any past medical illness, no allergies, neither is there
any history of asthma.
PRESENT MEDICAL HISTORY
On admission, patient presented with cough of 2 months duration, worse at
night with excessive sweating, occasionally producing thick whitish sputum.
Patient was taken to a private hospital where he was given antimalaria and
antibiotics, making the fever to subside but cough is still persistent and weight
loss also evident.
Nutritional metabolic pattern
19

Master I. A. Normally awakes up in the morning (7AM) to take tea and bread
and is usually forced to take food in the afternoon but takes a lot of snacks. He
likes to eat golden morn at night. He drinks an adequate amount of water a day
(200mls) and urinates more than 6 times a day. He weighed 15kg as at 1year 6
months but he is now 10kg at 2years of age. He lost his appetite as a result of
his illness but now prefers to eat bananas.
ELIMINATION PATTERN
Master I. A normally requests for a potty to defecate by telling his mother to
bring him Poe and usually defecates at least once in a day but during
hospitalization, he defecates once in 2 days
Master I. A normally urinates more than 6 times a day and still maintains the
same rate on hospitalization. He adheres strictly to his medication time
ACTIVITY OR EXCERCISE
Master I.A plays a lot and loves to run around but due to his present condition,
he prefers to be carried about by his mother since he is too weak to play. He
feels fatigue after performing little exercise like sitting on the bed and also
experiences insomnia.
SLEEP OR REST PATTERN
Master I.A normally sleeps by 8:30pm and wakes up around 7:30am but he is
no longer usually able to sleep at night as a result of his night cough and
excessive sweating, he sleeps for 4-5hours during the day
COGNITIVE-PERCEPTION PATTERN
Master I.A has a good vision; he is willing to learn new things he loves to take
good food or sweet drinks. He can call names like mummy, daddy, poe,
wee-wee amongst others. He can perceive odours, he can make his decisions
by rejecting certain foods and choosing the kind of foods he wants. He
remembers peoples faces.
SELF PERCEPTION-SELF CONCEPT PATTERN.
Master I.A has high self esteem which is seen in the way he chooses to talk to
people,
ROLE-RELATIONSHIP PATTERN
Master I.A has close friends which include his parents, and his elder sisters as
well as cousins and playmates.
20

COPING-STRESS TOLERANCE PATTERN.

Master I. A is able to manage the stress he has been going through one of
which is the stress of being carried around for various tests most of which are
painful, and the excessive night cough.
VALUE-BELIEF PATTERN
Master I.A is a Muslim by religion and he believes in Allah by calling his
name whenever he feels pain.
PHYSICAL EXAMINATION AND SYSTEMIC REVIEW
1. Physical examination:
Generally, patient was looking weak, lean and febrile, with cough and dyspnoea.
Head: On examination, patients hair was neatly cut down, with well moistened
scalp, neither scar nor injury observed on the scalp. Hair appears healthy.
Face: on examination, no sign of pallor, no jaundice, neither was there any scar
or abnormal discharge from the eyes.
Nose and lips: on examination of the nose, the nose was found to be congested
with thick, white mucus and there was nasal discharge. The lips were dry.
Neck: on inspection, no enlarged lymph nodes.
Upper and lower limbs: on examination, patients limbs are of equal sizes but
nil pedal oedema on both upper and lower limbs.
2. CARDIOVASCULAR SYSTEM
On examination, no palpitation, but difficulty in breathing was noticed.
3. RESPIRATORY SYSTEM
Chest x-ray review consolidation of the lungs and respiratory rate was
56cycle per minute. Dyspnoea was observed.
4. GENITO-URINARY SYSTEM: there was no urinary disorder, neither any
abnormal discharge.
5. GASTROINTESTINAL TRACT: on inspection of the abdomen, the
abdominal cavity appears round and smooth; no scar was seen on the
abdomen. Abdomen moves with respiration. On palpitation, no visible mass
noted nor abdominal distension was detected on auscultation, bowel sound
indicated normal intestinal functioning.

21

22

3 Chest x-ray
infiltrates in
both lower
lungs.
Cardiac size
is normal.

Genotype

HIV

Malaria

8 Sputum m/c/s pneumonia

screening
6

parasite
5

Klebsiella

Ac

Negative

++

0.519

Patchy
increased
opacity in
both
lungs.There
is confluent
reticular haze

64mm/hr

WBC- Hct-31.7%
WBC-6.020.8x109/l
17.5x109/l

2 Erythrocyte westergreen
0-10mm/hr

Full blood
count

Creatinine= Urea=10-40 138

(e/u/cr) 4 Electrolyte,
0.5-1.5
urea
and
creatinine

sedimentatio

Normal

Norma

Normal

TIONSS/N INVESTIGAOBTAINED
NORMAL WITH
RESULT INFERENCE

L ABORATORY INVESTIGATIONS WITH RESULTS

SUBSEQUENT DAILY REVIEW

Admission day: 09/02/2015
Patient came into the ward around 3:30pm accompanied by his mother and a
nurse from the children emergency ward.
OBSERVATION
On admission, he was conscious but looks weak, febrile and had dyspnoea. He
looked undernourished and weighed 10kg. Patient was made comfortable in bed
in fowlers position with the head of the bed raised to allow easy expansion of
the lungs.
On inspection of the chest, there were no signs of dyspnoea. Respiration rate was
56cycle per minute.
On examination of the abdomen, it appears normal and o distension was noted.
The genitourinary system appears normal with no discharge.
Vital signs on admission were: T 390c P 158b/m R 70c/m Wt 10kg
INTAKE AND OUTPUT
Intake: type of fluid, dextrose saline 500mls
Water
100mls
Output:
urine
500mls
PSYCHOLOGICAL CARE: good interpersonal relationship was established
between the nurse and the patient, relative inclusive. The relative was allowed to
ventilate her mind, fear and ask questions. This paved the way for adequate
health education on the disease, treatment and possible outcome. This makes the
relative have more knowledge about the disease condition. Patient was provided
with toys in the ward which serves as diversion therapy.
PHYSICAL CARE: patient was made comfortable on bed and the head of the
bed was raised to assist patient in breathing well. Patient was duly cared for and
assisted with activities of daily living.
DIET: patient was fed with little food and plenty of water.
MEDICAL CARE: On admission, Master I.A was seen by the doctor who
prescribed drugs and drugs were procured. Same was administered immediately.
The drugs prescribed include:
Syrup erythromycin 250mg 6hrly
Syrup cefuroxime 250mg two times daily x 1/52
Intravenous gentamicin 25mg 12hrly
Intravenous lasix
10mg
Intravenous hydrocortisone 26mg 6hrly
23

Intravenous 10% dextrose saline 20mls stat

Other treatment plans include:
Laboratory tests: full blood count, E/U/CR, malaria parasite, sputum m/c/s,
sputum AFB x 3
Chest x-ray
DRUGS
Patients due drugs were served and his relative was counselled on how his drug
will be administered so as to be able to cooperate with the nurses.
In the meantime, blood sample was collected by the doctor and was sent to the
lab for investigation. Patient had chest x-ray done.
Patients fever was reduced and he was able to tolerate mashed banana and was
made comfortable and left calm on bed. All other nursing care was rendered.
10/02/15 2nd day of hospitalization
Master I.A was febrile and crying, he was then taken to have a shower and his
temperature subsided from 380c to 37.60c. The following additional drugs were
prescribed by the doctor,
Parentheral antibiotics and furosemide.
Steam inhalation 6hrly
The malaria parasite result was reviewed in which the result is mp++ and tablet
coartem 1bd x 3/7 was prescribed and to continue other management.
11-16/02/2015 3rd day of hospitalization
His mother complained that the cough had not subsided hence I raised the bed
rails for easy expansion of his lungs and I opened for adequate ventilation. The
following was subsequently ordered by the doctor.
- Discontinue IV fluid
- Continue antibiotics and antimalaria
- Normal feeding as tolerated
12/02/2015 4th day of hospitalization
Master I.A was getting better but still not looking cheerful. I helped to adjust his bed
to make him comfortable, i equally ensured his oral drugs were taken.
13/02/2015 5th day of hospitalization

24

Master I.A looked a lot much better with vital signs of temperature: 36.8oc, pulse:
102beats per minute and respiratory rate of 26counts per minute. Master I.As mother
was psychologically reassured.
14/02/2015 6th day of hospitalization
Master I.A spent most of the day sleeping and only woke up when he felt hungry and
when his oral drugs were due. His diaper was changed when wet to ensure
comfortability.
15/02/2015 7th day of hospitalization
Master I.A was taken round the ward and outside the ward to feel his external
surroundings and as well aid in his quick recovery. He felt a lot relaxed after this.
Oral drugs and intravenous fluid were duly served.
16/08/2015 8th day of hospitalization
Master I.A was fed with little food and lots of fluid for hydration. His vital signs were
checked and it read, temperature: 37.5oc, pulse: 95bheats per minute and respiration:
28counts per minute.
17/02/2015 9th day of hospitalization
Master I.A felt a lot better and was playing with his toys on his bed. I helped to
straighten the bed linen and adjust the bed to the level he was comfortable with.
18/02/2015 10th day of hospitalization
Master I.A was met playing with his mother. Nil fresh complaints lodged. Due drugs
were administered.
19/02/2015 11th day of hospitalization
Master I.A was sleeping for the most part of the day hence drugs duly administered at
the right time.
25

20/02/15 12th day of hospitalization

Master I.A was stable ad very cheerful
21/02/15 13th day of hospitalization
Master I.A was fine with vital signs of temperature: 36.50c, pulse: 100beats per
minute and respiration: 30counts per minute.

22/02/2015 14th day of hospitalization

Master I.A was fine. He smiled when I called his name to denote that he is feeling
better. He was assessed to be satisfactory and doctor ordered the following:
- Discontinue hydrocortisone injection after the next dose.
- Continue antibiotics i.e. cefuroxime and gentamicin inj.
- Discontinue the antimalaria drug.
Discharge day 23/02/2015. 15th day of hospitalization.
Master I.A was looking cheerful and stable.nil fresh complaint from mother.
Temperature was 370c, and he had 23 doses of intravenous cefuroxime throughout his
hospital stay. The present management was continued, he tolerated food well. The
following was prescribed by the doctor.
- Discontinue intravenous cefuroxime injection and commence syrup
cefuroxime 250mg
- Discontinue i/v gentamycin 25mg 12hrly
- Continue oral feeding.
Master I.A was given two weeks appointment for medical check up.
NURSING MANAGEMENT

26

OBJECTIVES OF MANAGEMENT
1.

To promote adequate lung expansion and facilitate easy breathing

To promote fluid intake
To promote the nutritional status
To prevent complication
TO PROMOTE ADEQUATE LUNG EXPANSION AND FACILITATE EASY
BREATHING.
Master I.A was admitted into the paediatric ward, Olabisi Onabanjo University
Teaching Hospital, sagamu. He was accompanied by his mother, she
complained that her child had been coughing for two months, worse at night
with excessive sweating, occasionally producing thick, whitish sputum. She
also complained of fever, weight loss and dyspnoea.
Position/admission

He was nursed in fowlers position with the head of the bed raised so that it supports
the entire back as this promotes adequate lung expansion and facilitates easy
breathing and relaxes smooth muscle of the bronchial airways thereby facilitates easy
breathing.
2. TO PROMOTE FLUID INTAKE
Master I.As respiratory rate was increased because of the increased workload
imposed by laboured breathing and fever. An increased respiratory rate leads to
an increase in insensible fluid loss during exhalation and can lead to
dehydration. Therefore his mother was encouraged to increase his fluid intake
in other to prevent fluid volume deficit. Also, prescribed intravenous fluid was
administered to promote the fluid intake.
3. TO PROMOTE NUTRITIONAL STATUS (DIET)
Due to difficulty in breathing and weakness encountered by Master I.A, he was
unable to tolerate food as usual. His mother was encouraged to give tea frequently of
any other food of his choice to replace lost electrolytes
4. TO PREVENT COMPLICATIONS
Physical care
27

Master I.A was assisted in oral toileting, daily bathing and cutting of the nails.
These made him feel much more comfortable and prevent further progress of
the disease which may cause complications.
HEALTH EDUCATION
His mother was educated on how to avoid exposing her child to cold, also she was
educated on the symptoms and signs of the disease and to bring him down to the
hospital in case she observes any sign and symptom to prevent complications.
She was also advised to continue administering the prescribed drugs and to bring her
child on the appointed date for checkup. She was equally advised and health educated
bon how to prevent the child from aspiration of fluid.
NURSING DIAGNOSIS
Below is a list of 4 nursing diagnosis for master I.A, a nursing care plan is prepared
for three of the nursing diagnosis.
1. Ineffective airway clearance related to accumulated mucus in the airway
evidenced by dyspnoea.
2. Ineffective breathing pattern related to disease condition evidenced by
respiration of 56cycle per minute.
3. Hyperthermia related to infection evidenced by temperature of 390c.
4. Imbalanced nutrition less than body requirement related to fatigue evidenced

28

Master I.As

Master I.A
breathes with
ease between
30-35 cycles
per minute
within 48 hours
of admission.

Master I.A has

clear breath
sounds with
effective cough
and
expectoration
of sputum
within 30
minutes of
nursing
intervention.

EVALUATION

by weight loss.

29

PHARMACOLOGY OF SPECIFIC DRUGS USED BY

will weighi
Master
I.As
as for
Gentamisi
antibioIneffective
Bacter
cholecyst
It Master
acts on I.A
Pneumon
uscula
Intramtrimes
60- This
Firstserves
Watch
tics
n breathing
ic idal the
is, breathe
bacteriaat the
r,ia ng breathing
ter
80mg,
of baseline data.
side
pattern related
rate
of
30-35
pattern
was
ribosomes
more
8hourly
effects,
to the disease binding
cycles per
assessed.
than
for 7serve the
condition itself
minute
within
with
50kg
10 days
correct
evidenced by the48hours
of
30
or
dose to the
respiration ofsubunits
admission.
280mg
right
56 cycles per and
in
patient
minute. inhibiting
single
protein
dose to
synthesis
patients
within the
Hyperthermia bacteria
Master I.As
1.assess the 1.this serves as

Ineffective Master I.A will

1.Nurse in
1.Nursing
airway
breathe with
fowlers
patient in
Cefuroxim
ospori clearance
Cephal
membran
It inhibits
Respirato
intram
Intrav
sensiti
alcohol
750- Hyper
Instruct
ease at the
rate
position
fowlers
ne related to e,of
the30-35 cycle
ry tract enous
containing
vity
1.5g,
to 6-positionpatient
helps to
synthesis
of infection, and
8
take full
accumulated
per minute
For easy
hourly expansion
course
mucus in thebacteria
within 15-30
of of
the drug to
airway cell wall,
minutes of
lungs.
mitosisnursing
and
maintain
evidenced by
of
therapeutic
dyspnoea growth
intervention
bacteria
blood
levels.
Instruct
patient not
to drink

P/CLA
DRUG GROU MODE OF
ADMI
INDICA
OMME
ROUT
RESPONS
TRAI
RECCFOR
CON
NURSING
I.A
NURSING
CARE
PLAN
MASTER
SS
ACTION TION
NDED
E OFIBILITIES
FORDOSE
DIAGNOSIS
NURSINGINTERVENTI
OBJECTIVE
RATIONALE
NURSING SCIENTIFIC
USE

MASTER I.A.

plasmodiuncompliIt
Treatmen Orally Initially
feedin
headache
4 Breast Abdomin
Give
um
cated
destroys
t of
tablets
g, ,
al pain,
normsal
malariathe
followed
dizziness,
anorexia, dose at the
caused by
by
sleep
diarrhea, right time
5further
disorders,
nausea and to the
doses
fatigue
of 4
and
right patient,
tablets
vomiting, advise client
each at 8,
to take the
24, 36, 48
tablet with
and 60
food.
hours

convolut pregnanc
It acts on Toxaemia
intram 80mgdail
Orally, failur20hypocalcemi
Renal
Monitor the
hypoglyc
Deafness,
ed tubule y, prethe loop
of
y, initially e, a, weigh the
intake and
emia,
of henle
40mg burns, patient daily
output chart
and even
twice
or restrict
for the
the distal
daily
salt intake in
patient. Give
orally
the diet to
the
then
enable the
prescribed
increasing
drug to be
potassium
dosage
effective
supplement
based on
to prevent
patients
response

30

31

Lasix

loop
potent
diuretic

combinat
Coarte Anti
tion m amalria
therapy
artemisin
(ACT)
baesd

CHAPTER FOUR
This care study on Master I.A, a 2year old baby with diagnosis of
bronchopneumonia, he was admitted on the 9th of February, 2015 with the history of
cough of 2months duration, worse at night with excessive sweating, occasionally
producing thick whitish sputum and history of weight loss.
According to Babara (2009), bronchopneumonia is a descending infection, starting
around the bronchi and the bronchioles.
The affected person develops the following signs and symptoms: dyspnoea, cough,
chest pain, anorexia, and fever, production of rusty coloured sputum, weak thread
pulse and sweating. (Famakinwa, 2011)
Early treatment of bronchopneumonia is very vital to avoid complications like pleura
effusion, emphysema, lung abscess, septicaemia, shock and respiratory failure,
pleurisy, pericarditis and peritonitis (francis, 2012)
Master I.A was properly nursed throughout hospitalization. Care rendered includes:
physical care, health education, vital signs, monitoring intake and output.
Hence Master I.A was discharged with advice on how to prevent bronchopneumonia
like avoiding smoking, either active or passive, deep breathing exercises to clear
secretions and vaccines that offer partial protection against pneumococcal pneumonia
caused by bacterium streptococci pneumonia and haemophilic influenza.
CONCLUSION
This study revealed some of the predisposing factors to bronchopneumonia and they
include conditions that produce mucus, depressed cough reflex, aspiration of foreign
objects into the lung during period of unconsciousness, exposure to cold and
intubations as well as people of extreme ages. (Waugh 2006)

32

Assessment and diagnostic findings include history taking, physical examination of

the chest, blood culture, chest x-ray which may reveal consolidation. (Chris 2010)

RECOMMENDATION
Based on the knowledge acquired and derived during the course of this study, the
following recommendations are made:
Nurses should health educate the public at every opportunity especially at the
outpatient department on bronchopneumonia, its causes, signs and symptoms,
treatment and prompt report at the hospital before complication sets in.
Government along with the health care system should carry out public enlightenment
on the preventive measures of bronchopneumonia though journals, radio newspaper
and television. Campaign against self medication should be done.
Patient should be advised on observing good environmental hygiene; copious fluid
intake, balanced diet and adequate rest

33

REFERENCES
Anne Waugh and Allison Grant (2011): Ross and Wilson, anatomy and
physiology in health and illness, 12th edition, Philadelphia hancourt publishing
company.
Barbara F. W. (2009): ballieres nurses dictionary for nurses and health care
workers, 25th edition, Elsevier limited.
Chris c. (2011): Emdex, the complete drug formulatory for Nigerias health
professionals, Canada; Linoz booksltd, intl.

http://www.medicimmune.com/pdf/investors/analysis_day_12606.pdf.

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

Famakinwa T.T. (2011) a synopsis of medical surgical nursing, Agbor, Delta State,
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Kenneth S. S. (2012) anatomy and physiology; intake of raw materials and

elimination of waste, churchillstone, New York.
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34

Mustapha R O (2011): the easier approach to pharmacology for all health

professionals, 1st edition, Ilorin printers, Nigeria limited.
Suzanne C. Brenda, Janice L, Kerry H (2011); Brunners and Suddharts textbook
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35