MDJ3272 Dg Noraini Binti Tajudin (26172) Shilla Binti Kilipus (25009) PAEDIATRIC NURSING

MDJ 3282 Paediatric Nursing Practicum Bronchopneumonia (Group C1)

Question 5: Child Abuse

Outline of Presentation

Definition Sign and symptoms Risk factor Summary of patients history Pathophysiology Investigation Complications Medical managements Nursing care plan Patients education during discharge Conclusion References
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Bronchopneumonia (Bronchial pneumonia )

Inflammation of

the lungs beginnings in the terminal bronchioles

Sign and symptoms

Cough Fever Chest

pain Rapid, shallow breathing SOB Headache Loss of appetite Fatigue(less active)
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Risk factors
Congenital or acquired immunodeficiency Prematurity Malnutrition and metabolic derangement

Intubation and tracheostomy

CNS depression ( inhibit cough and gag reflex)

Viral infection predispose bacterial infection

Sources of information : Pts mother, case notes Q,1 year 4 month (2nd child of two siblings),malay girl from Kota Samrahan, Kuching Comes to A&E Cuddled by his mother, weight: 6.29kg Mother: Housewife (20 y/old) Father: Fisherman (25y/old) 1st hospitalization( August 2011) Date of admission:7/12/12(2nd hospitalization) Past surgical history: none Allergies: no known allergies to medication, food

Reasons for hospitalization:

c/o:Fever 5/7, cough 5/7,less active ,rhinorrhea ,vomit x 1 after milk, tachypneic ,poor oral intake Past medical history: premature @24/52(admitted into NICU and was intubated),Failure to thrive, chronic lung disease, ROP(resolved by laser therapy), resolved bilateral IVH with hydrocephalus Birth history: SVD, premature baby(24th week),birth weight:695 gram Immunization history: up to date, given palvizumab(X 4) latest on 21/3/12 Developmental/growth pattern:weight:6.18 kg, able to sit alone, stand with support, able to call mama, has palmar grasp

Physical examination
General condition: less active, weak, irritable, difficult to approach Weight:6.18kg(on assessment) V/sign:temperature:36.5 Celsius(axila),HR:124/min,RR:44/ min,Spo2:97% Oxygen 0.5L/min Lung examination: Bilateral lung crepitation, rhonchi,subcostal and substernum recession. Chest examination: pectus carinatum(pigeon chest)

*Medical Diagnosis: Bronchopneumonia KIV D/C ON 22/12/2012

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Functional health pattern

Health Perception-Health Management Pattern Parents verbalized their worries regarding child condition This is second time admitted Admitted due to c/o:Fever 5/7, cough 5/7,less active ,rhinorrhea ,vomit x 1 after milk, tachypneic,poor oral intake Previously well and active playing at home Child was on MDI ventolin(prn) and beclomethasone (BD) using aerochamber (mother know how to use) Nutritional and Metabolic Pattern Dietary history's: B/F stopped at 3months of age, currently given bottle feeding 5-6oz ,4-6hly(lactogen),semisolid food(6-9 teaspoon),porridge Poor oral intake during sick, coughing during bottle feeding causing vomiting 9 Was supplied with folic acid and multivitamin

Elimination Pattern BO X 1-2/day with normal color and consistency of stool, PU (3-4 X diapers changed) with normal color urine Activity and exercise pattern Active playing toys at home, wathcing tv(cartoon) Bathing time: morning and evening Sleep-Rest Pattern No problem of insomnia,Usually sleep 8pm-6am,sleeping with parents Day sleeping(11am-2pm) initiates by bottle feeding Sleep position: knee-chest position(longer),supine(shortly) Cognitive-Perceptual Pattern Child alert, responsive,irritable Anxiety,fear to nurse
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Sensory-pattern Hearing ,vision normal, all other sensory intact(touch, taste, smell) Coping stress If child upset and tired/sleepy she will cry more Role Relationship Pattern 24 hour taken care by her mother childs play companion :cousins Support system: parents Stay with mother ,father ,grandfather and grand mother sexuality 2nd child of 2 siblings Sister 4 years old Value belief pattern muslim
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Pathophysiology
Microorganism enter alveolar Spaces by droplet inhalation(Etiologic Agent:bacteria,virus ,fungi)

Bronchopneumonia

Inflammation occurs

Ventilation decreases as secretion thicken

Alveolar fluid increase

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Investigation

Chest X-ray : Right perihilar haziness -connection between the mediastinum and the pleural cavities meet

Hematology report (abnormal) a) Full blood count - Hb low(IDA) b) Differential count -Monocytes high ,neutrophils low 12 lead ECG Normal reading (To look out for spreading of disease to heart)

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Complications
*Empyema or lung abscesses - cavity containing pus *Septic shock. Blood fills the veins and leaks through the walls of the capillaries, causing uncontrolled tissue swelling and possibly organ failure, which can lead to death

*Pleuritis. Inflammation of the pleura

*Bronchiectasis -airways that are inflamed and collapsible *Reactive airways disease - persistent asthma

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Medical management
A) Syrup Erythromycin Ethylsuccinate 140mg BD Actions: Treat upper and lower respiratory tract infections Indication: Bronchopneumonia Cautions: Impaired hepatic function, renal impairment Side effects: Nausea, upper stomach pain, loss of appetite Drug interactions: Verapamil , digoxin, oral anticoagulant B) Syrup folic acid 1mg OD Actions: To treat vitamin deficiencies Indication: As a supplement where a poor dietary intake Cautions: Take with or without food , allergies to contents Side effects: Diarrhea, nausea, itchiness, dizziness, allergic reaction Drug interactions: 15

C) Syrup multivitamin 2.5ml OD Actions: To treat vitamin deficiencies Indication: As a supplement where a poor dietary intake Cautions: Allergic to the contents Side effects: Diarrhea, nausea, dizziness Drug interactions: D) Syrup Prednisolone 6mg OD Actions: To treat asthma Indication: Child have asthma Cautions: Take with food, allergic to the contents, eye disease, heart problems, kidney disease Side effects: Nausea, headache, dizziness, increased sweating Drug interactions: Aspirin, nonsteroidal anti-inflammatory drugs
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E) IV Augmentin 140mg BD Actions: To treat bacterial infections Indication: Broncopneumonia Cautions: Blood disorders, kidney problems, liver disease Side effects: Diarrhea, nausea, itching, dizziness Drug interactions: Probenecid F) Metered dose inhaler (MDI) Salbutamol 100 mcg 8 hourly Actions: To relieve and prevent bronchospasm Indication: Bronchopneumonia Cautions: Allergy to contents, cardiac arrhythmia ,cardiovascular disorders Side effects: Headache, nausea, dizziness Drug interactions: Do not used with some beta-blockers (e.g. propranolol) , other bronchodilators (e.g. terbutaline) and digoxin
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G) Metered dose inhaler (MDI) Beclomethasone 100 mcg BD Actions: To treats inflammation Indication: Bronchopneumonia Cautions: Allergic to the contents, heart problems, stomach problems Side effects: Headache, nausea, dizziness, upset stomach Drug interactions: Diltiazem, aspirin

H)Close monitoring of oxygen saturation Keeps SPO2 > 95 % to prevents hpoxia ( NPO2 0.5 L/min)

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Lists of Nursing Care Plan

1) Ineffective airway clearance related accumulation of secretion(narrow airway) and inflammation of airway secondary to bronchopneumonia evidenced by tacypnea,RR:44,bilateral rhonci, generalized lung crepitation, substernal and subcostal recession 2) Imbalanced nutrition less than body requirement related to poor oral intake, loss appetite, and coughing evidenced by weight loss (from 6.29kg -6.18 kg),less active and weak 3) Parental anxiety related to lack of knowledge about the disease , prognosis , and treatment evidence by facial expression and verbalization of worries by parents 4) Risk for nosocomial infection related to hospitalization
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Nsg diagnosis : Ineffective airway clearance related to accumulation of secretion (narrow airway) and inflammation of airway secondary to bronchopneumonia as evidenced by tachypnea, RR:44, bilateral rhonci, generalized lung crepitation, substernal and subcostal recession Goal: Patient will not having respiratory distress as evidence by RR within normal range(24-40),minimal rhonci ,less substernal , subcostal recession ,coughing and spo2 >95% within 4 days (17/12/12 @ 11 am) Intervention: 1) Assess the RR ,pattern, depth of respiration to identify any sign of respiratory distress 2) Position the child in a propped up position to enhance lung expansion for effective breathing 3) Administer oxygen 0.5 L/min via nasal prong to prevent respiratory distress and to ensure patient receive adequate oxygenation (prevent hypoxia) 20

4)

5)

6)
7) 8)

Administer MDI Salbutamol 100mcg (2puffs,8hly) as a bronchodilator to prevent respiratory muscle spasm and Beclomethasone 100mcg (2puffs,BD) , Syrup Prednisolone 6mg OD to reduce the inflammation on respiratory tract Watch out and explain to the parents about side effect of salbutamol and Beclomethasone (eg: tachycardia, headache,N/V, tremors, nasal dryness/irritation) so parents will understand more and can report as soon if this side effect need an urgent intervention from nurses/doctor Do suction via nasal when necessary to help remove the secretion out Encourage caregiver to give more fluid to the child to help moisten the secretion Monitor RR, SPO2 readings, breathing pattern, presence of recession during breathing after each therapeutic intervention to evaluate the effectiveness of the intervention

Evaluation: Patient not having respiratory distress as evidence by comfortable, active with RR :38,less coughing ,less rhonchi and less crepitations on lungs, spo>97% under N/P 0,5L/Min (21/12/12@11 am)
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Nsg diagnosis: Imbalanced nutrition less than body requirement related to poor oral intake, loss appetite, and coughing as evidenced by weight loss (from 6.29kg -6.18 kg), less active and weak Goal: Patient will have balance nutrition as evidence by good tolerance to oral intake, active and regain appetite within 2 days ( 17/12/ 12 @ 11am) Intervention: 1) Assess the progressive of nutritional imbalance by monitoring the daily weight to initiate a proper management 2) Assess the child preferred food so caregiver can prepare food that based on her choice and she will more tolerate to such kind of food 3) Teach caregiver to give small frequent meals to child ,so that she will more tolerate and enhance absorption of the nutrient effectively

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4)

Teach caregiver to give food when child are relax, not crying ,after enough rest and dont force child to eat if she refuse to ensure cooperation from the child to eat Provide a pleasant environment during her mealtime (eg: music, conversation, be on her side ) and provide support to enhance her mood to eat Administer Syrup multivitamin 2.5ml OD, Syrup folic acid 1mg OD as a dietary supplement for the child that she need for her growth and development.

5)

6)

Evaluation: Patient able to maintain balance nutrition as evidence by no loss of weight ,good tolerance to oral intake, appear energetic, active (willing to play),and regain an appetite to eat (19/12/12 @ 11 am)
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Nsg diagnosis: Parental anxiety related to lack of knowledge about the disease , prognosis , and treatment as evidence by facial expression and verbalization of worries by parents Goal: Parents will feel less anxiety during hospitalization as evidence by verbalized, understand about the disease , prognosis , and treatment and cheerful facial expression within 2 days (17/12/12 11am ) Intervention: 1) Assess the S/S of having anxiety (eg:anger, denial ,refuse to answer question ) 2) Assess their level of anxiety and identify the other potential cause that make them anxious to carry out appropriate intervention(eg: financial problem) 3) Assess their level of understanding regarding disease condition, treatment ,prognosis to make sure information to be delivered to them are according to their needs
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4)

5) 6) 7)

Provide and give information about their child condition, treatment and prognosis using simple language(avoid medical jargon) to promote understanding Collaborate and allow parents to participate in decision making and procedure so they feel less anxious and more cooperative Discuss the choices of treatment with parents ,so they wont feel hopeless that will worsen their anxiety Encourage parents to ask question and reply them with a calm and unhurried manner so they wont feel helpless

Evaluation: Parents have more understanding about their child's condition ,prognosis and treatment as evidenced by ability to explain when been asked to explain by nurses, appear less anxious and having cheerful facial expression (19/12/12 @ 11 am )

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Patients education during discharge

-Teach

mother and family importance of hand washing before touch the child -Counsel parents regarding the need to prevent exposure to tobacco smoke, allergens -Educate parents about signs & symptoms of increasing respiratory distress (seek medical attention immediately) -Drink plenty of fluids to prevent dehydrated and help loosen mucus in their lungs. -Take all prescribed medications. -Keep all of child follow-up appointments to monitor condition of lungs -Stay rested and sleep well. Proper rest and enough sleep can help keeps immune system strong -Eat a healthy diet. Include plenty of fat-free dairy products,protiens, fruits, vegetables and whole grains. -Teach mother about the medication (name, how to used, side effect, cautions) to prevent from wrong medication given
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Conclusion

Overall pts general conditions was improved

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References
Aschenbrenner, D. S., & Venable, S. (2009). Drug Therapy in Nursing. Retrieved December 17, 2012, from http://books.google.com.my/books?id=5zd_W_PUwvYC&pg=PA929&dq=medication+ used+to+treat+Bronchopneumonia++in+children&hl=en&sa=X&ei=LYXUUKqCCYGS rgfa3YGQCQ&redir_esc=y#v=onepage&q=medication%20used%20to%20treat%20Bro nchopneumonia%20%20in%20children&f=false Datta, BN. (2004). Textbook of Pathology . Retrieved December 17, 2012, from http://books.google.com.my/books?id=3eycgFfYpBAC&pg=PT246&dq=Bronchopneum onia&hl=en&sa=X&ei=83_UUPP2DITMrQeu7YDoCw&redir_esc=y Dorlands Pocket 28th ed Medical Dictionary.(2011).Phildelphia:Elsevier

Health care medical soweto trust.(2005) . Primary clinical care manual. Retrieved December 17, 2012, from http://books.google.com.my/books?id=zrGHXbW07vQC&printsec=frontcover#v=onepa ge&q&f=false
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Lange, S. , & Walsh, G. (2002). Radiology of Chest Diseases. Retrieved December 17, 2012, from http://books.google.com.my/books?id=3E_byg7VxrsC&pg=PA65&dq =Bronchopneumonia&hl=en&sa=X&ei=83_UUPP2DITMrQeu7YDo Cw&redir_esc=y#v=onepage&q=Bronchopneumonia&f=false
Moeckel, E., & Mitha, N. (2008). Textbook of pediatric osteopathy. Retrieved December 17, 2012, from http://books.google.com.my/books?id=Y9Dpcqr7PZMC&pg=PA302& dq=Bronchopneumonia+treatment+in+children&hl=en&sa=X&ei=po HUUNiNLMLirAe_tIDYAg&sqi=2&redir_esc=y#v=onepage&q=Bro nchopneumonia%20treatment%20in%20children&f=false Tessa, M., Ohansson, W.E., & Hodge, J. (2006) . Pneumonia: The Forgotten Killer of Children. Retrieved December 17, 2012, from http://books.google.com.my/books?id=F_vhfZ8EFAoC&pg=PA9&dq= medication+used+to+treat+Bronchopneumonia++in+children&hl=en& sa=X&ei=LYXUUKqCCYGSrgfa3YGQCQ&redir_esc=y#v=onepage &q=medication%20used%20to%20treat%20Bronchopneumonia%20% 20in%20children&f=false
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Thank You..
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