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CONTENT
NO CONTENT P5AGES

1. APPRECIATION 1-2

2. LEARNING OBJECTIVES 3-4

3. INTRODUCTION 5-6

4. PATIENT PERSONAL DATA 7-9

5. PHYSICAL ASSESSMENT 10-14

6. ASSESSMENT 15-17

7. ADMISSION/ORIENTATION 18-21

8. ANATOMY AND PHYSIOLOGY 22-26

9. DEFINITION 27-30

10. ETIOLOGY 31-32

11. PATHOPHYSIOLOGY 33-34

12. CLINICAL MANISFESTATION 35-36

13. COMPLICATION 37-38

14. INVESTIGATION 39-44

15. TREATMENT/MEDICATION 45-54

16. NURSING CARE PLAN 55-67

17. HEALTH EDUCATION 68-69

18. DISCHARGE 70-71

19. FOLLOW UP 72-73

20. SUMMARY 74-76

21. CONCLUSION 77-78

 22. REFERENCE 79-80

23. APPENDIX 81-113

APPRECIATION

First of all,I am grateful to god since I can able to finished my case study on
time.Finally,I manage to complete my book of case study with the same care that I had
given to my patient.Surely not forgetting to thanks all of them that were helpful in my
case study,especially to the Lecturer and Clinical Instructor,Sister Rashidah that always
gave me support in my case study.

I also not forgotten and highly appreciation to my patient,Madam Z and her

husband that they had allowed me to treat her case as my case study.They fully gave their
cooperation to me.Also I want to thanks to the doctor,medical and surgical ward staff and
pharmacy staff who had helped me when I need their help.

Lastly but not least,I would like to thanks to my parents and my lovely friend that
always gave me support and helped me when I need their helped.
 LEARNING OBJECTIVES

At the end of the case study I will be able to :

1. State the definition of Bronchitis.

2. Explained the Anatomy & Physiology of Respiratory System.

3. List the etiology of Acute Bronchitis.

4. Explain the pathophysiology of Acute Bronchitis.

5. State the clinical manifestations of Acute Bronchitis.

6. List the complications of Acute Bronchitis.

7. State the investigation of patient

8. Identify the nursing problems & plan effective nursing intervention to care
for patients with acute Bronchitis.

9. Provide the Health Education for the patient about home care management
 INTRODUCTION
For this semester 2,I was posted to Ipoh Specialist Hospital(ISH) for my clinical
posting.So during this clinical posting ,every students in my group (32) had to choose
one case that isn related to the study of Respiratory or Cardiovascular as a case
study.Because of that,I had chosen a case about Bronchitis which is related to the study
of Respiratory Systems.I had chosen this case as my case study because for me it was a
very interesting topic and important to know more about Lower Respiratory Tract(LRT)
when had infected a large number of age group.

In this book,I wish to explained what is Acute Bronchitis,how it occur,who will

be infected,what are the sign and symptom and many more.If the patient doesn’t get
early treatment,the patient will got worse and the disease will be chronic.The patient
should be treated as soon as they got infected and to teach them how to take care of
themselves when they get the disease.

In this book,I will also explained about the investigation that is normally required
for this kind of patient and how the doctor diagnosed the disease.At the same time,a few
nursing cares that had to be carried out to the patient.

Hopefully,all of us would get more knowledgeable and understanding when read

on my book.
 PATIENT PERSONAL DATA
Name : Madam Z
I/C No : 760701-xx-xxxx
MRN No : xxxxxxx
Age : 31 years old
Sex : Female
Marital Status : Married
Race : Malay
Religion : Islam
Language spoken : English or Bahasa Malaysia
Occupation : Executive Maxis.
Address : No 99,Jalan Perpaduan 17,Taman Perpaduan
31500,Ulu Kinta,Perak Darul Ridzuan.
Phone No : 012-xxxxxxx
Consultant : Dr G

Bed No : xxx
Reason for admission: Patient complain of high fever for 1 week with
Sputum and feel dizziness and nausea.
Medical history : Migrain since 20 years old
Surgical history : Nil
Family medical history: Nil
Current medication : Own medication
Allergies : Seafood
Diagnosis : Acute Bronchitis
Date admitted : 28 September 2007
Time of admission : 2 pm
 PHYSICAL
EXAMINATION
1. Head examination :

• Hair -clean
-no infection such as dandruff.
-normal hair texture.

• Eyes -normal
-use visual aids
-conjunctivae pink
-symmetrical eyes

• Nose -nasal septum in correct alignment.

-no swelling
-symmetrical nose lobe

• Ears -normal eyes shaped

-no discharge
-no swelling

• Mouth -lip pinkish

-good oral hygiene
-no lesions at tongue

• Neck -no lymph nodes swelling or tenderness

-no swelling of the thyroid glands (enlarge)

2 . Upper limb examination :

• Skin condition -normal skin

-no lesions
-skin temperature warm

• Finger -movement of finger normal

 -good blood circulation
-no scar tissue

• Nail -nail bed pink

-no inflammation of skin the base of hand.
-no cyanosis

• Hand -good skin condition

-good joint movement.

3 . Abdominal (body) examination :

• Chest -normal respiratory pattern

(breathing pattern)
-difficult in breathing when cough
-fell pain when cough.
-cough with sputum

• Axilla -no presence of lymph nodes

-no infection of fungal.
-good skin condition

• Breast -good skin condition

-symmetrical breast.
-no lymph nodes

• Abdomen -good skin condition

-no surgical scars
-no tenderness or mass

4 . Lower limb examination :

• Leg -Musculoskeletal structure is

normal.
-no varicose vein seen
-good skin condition

• Foot -normal foot structure

-no peripheral oedema seen.

• Toe nail -clean

-no peripheral sinuses seen
-nail bed pink

5 . Private part examination :

 • Not done because patient refuse but she told me that all the private part
is clean,no discharge,skin condition also good and no abnormalities
detacted.

6 . Back examination :

• Good skin condition

• Spinal core straight
• No tenderness or mass
• No scar tissue
 ASSESSMENT
Assessment done to every patient that had admitted to ward. During the assessment,
nurses have to interview patient to taken some data such as individual history and other
data. At the same time, physical assessment will be done to the patient to detect the
symptom of the disease.

On that day, 28 September 2007, I did the assessment to my patient when she was
admitted in the ward and there is the finding of the assessment:

INTERVIEW:

Every patient who had admitted to the ward in hospital will be interview by student
nurse or staff nurse. It done because it helps the nurses to plan their nursing report. With
that, we can practicing an carry out the interview skill by taking such as asking question
that we have learn in communication subject. We also can carry out the theory in the
practical. The data that should be collect during interview such as name of patient,
occupation, race, religion, reason of admission, age, sex, and others. We also can carry
collect data during interview such as:

Family History:

-For my patient, her parent or siblings doesn’t had any

disease which is related to respiratory system.

Medical History:

-My patient doesn’t have any medical history.

Surgical History:

-My patient doesn’t have any surgical history.

Current Medication:

-My patient had taken her own migraine medication.

Allergies:
-Madam Z had allergies to seafood.

Activity Daily Living :

1. Breathing:
• Madam Z had complain of high fever and cough for 1 week with
sputum.
• Madam Z had complain difficulty in breathing when cough for 1 week
• On admission, her respiratory rate is 22/min.(normal range is 15-
25/min)
• Madam Z has complained of coughing for 2 week with sputum. The
sputum is yellowish in color.

2. Eating and drinking:

• On admission, she had loss of appetite.

3. Bladder:
• Madam Z doesn’t had any problem in pass urine and do not get up
at night to pass urine.

4. Elimination:
• Madam Z have problem to pass motion.
• Madam Z had pass motion 5 day ago.
• Madam Z doesn’t take any medication to pass motion.

5. Sleeping and rest:

• On admission, she told me that she had problem in sleeping
because of her cough and sometimes she felt difficulty in
breathing.
• Although she had problem in sleeping, she never take or request
medication for sleeping.

6. Mobility:
• Madam Z can ambulate by her self.

7. Personal Hygiene:
• Madam Z always maintains her personal hygiene. She also take
her bath 2 times per day.

8. Communication:
• Madam Z understand well what ever I try to explain about her
any question or procedure that I want to carry out.
 • For her vision, she had use visual aid.
• Madam Z can hear well(normal hearing)

9. Skin condition :
• Madam Z have normal skin condition.

ADMISSION
On 28 September 2007 at 2pm,Madam Z admitted to Ipoh Specialist
Hospital(ISH).She was admitted in the 2 floor(level 2),surgical medical ward, single bed,
room 405.On admission, she looks lethargic.

During admission , Madam Z told me that she having high fever and cough for 1
weeks, difficulty in breathing when cough for 1 week, coughing with sputum 2week ago.
Sputum yellowish in color.

Madam Z looks anxious because she worried about her condition. She also had
allergic to seafood.

On admission, Madam Z looks lethargic but her husband was companies her.
Madam Z and her husband give cooperation to me when the assessment was going on.
After assessment done, I took vital signs as a baseline data. The result was below :

Temperature : 38.50C
Pulse : 76/bpm
Respiration : 22/bpm
Blood pressure :110/85mmHg
 ORIENTATION
Purpose of orientation:

• Patient will comfortable in physical and mental status during

admission.
• The way to help patient with new environment and to reduce the
fear.
• The orientation including :

Patient unit:

• Patient room number is 405

• Explain to patient and her husband how to use the call bed and
call bell.
-If you need help or anything problem, just call bell to call the
nurses.
• Locker and cupboard are preparing to keep their thing.

Ward and room:

• Patient room number is 405.

• She was admitted in level 2(old building) surgical and medical
ward (ward 5).

Rules and Regulation:

• Doctor will do round twice a day, morning and in evening. On

Friday, doctor will do round but once in the morning around
8.00 to 9.30 am and once in the afternoon around 11.30 am to
12.30 pm .On Saturday, doctor will do round once a day.

• Office hour for Ipoh Specialist Hospital(ISH) is from 8.30 am to

5.00 pm for Monday to Friday. On Saturday ,the office hour is
from 8.30 am to 12.30 pm(half day).

• Visiting hours :

8.00 am to 10.00 pm.

• Meal time :
 -Breakfast : 0800-0830 hour

-Lunch : 1200-1300 hour

-Afternoon tea : 1500-1530 hour

-Dinner : 1800-1900 hour

ANATOMY AND PHYSIOLOGY

The Respiratory systems are composed of:
• Upper Respiratory Tract to warmth and filter inspired air.
• Lower Respiratory Tract to accomplish gas exchange.
• Both are important for ventilation.
 UPPER RESPIRATORY TRACT
It consists of nose, pharynx, larynx, and the trachea.

Nose: To filter impurities, humidifier and warmth the inhaled air. We also use it as a
sense of smell.

Pharynx: Connect the nasal and oral cavity to the larynx.

It divides into 3 regions:
• Nasopharynx
• Oropharynx
• Laryngopharynx

The pharynx functions as a passage way for the respiratory and digestive tract.

Larynx: Is a cartilaginous epithelium lined structure that connect the pharynx and the
trachea.

It protects the lower airway from foreign substances and facilitates coughing.

Trachea: It mucosa lining contains gland that produce mucus to trap debris.

Examples: The mucosa lining contains gland that produce mucus to trap debris
 LOWER RESPIRATORY TRACT
Consist of which contains the pleural, pleural cavity, bronchial, and alveoli.

TRACHEA:
• Also called as windpipe.
• Located in front of the esophagus, beginning at the lower border
of cricoids cartilage of the larynx and extending to the level of
the sixth or seventh thoracic vertebra.
• The trachea is about 4 to 5 inches (12 to 15cm)and 1 inch
(2.5cm) in diameter.
• It contains 16 to 20 C- shaped rings of cartilage joined by
connective tissue.

RIGHT BRONCHUS:
• Wider, shorter and more vertical than the left bronchus and is
therefore the more likely of the two to become obstructed by
inhaled foreign body.
• It is approximately 2.5cm long.
• After entering the right lung at the hilum it divided into three
branches, one to each lobe. Each branch then subdivides into
numerous smaller branches.

LEFT BRONCHUS:
• 5cm long and is narrower than the right.
• After entering the lung at the hilum it divided into two
branches, one to each branch then subdivided into
progressively smaller tubes within the lung substance.

BRONCHIOLES:
• Absence of cartilage, the smooth muscle in the walls of the
bronchioles become thicker and is responsive to autonomic
nerve stimulation and irritation.
• Ciliated columnar mucous membrane changes gradually to
non-ciliated cuboidal-shaped cells in the distal bronchioles.
ALVEOLI:
• The alveoli are surrounded by a network of capillaries.
• The exchanges of gases during respiration take place across
two membranes, the alveolar and capillary membranes.

RIGHT LUNG:
• Divided into three distinct lobes. It is superior, middle and
inferior.

LEFT LUNG:
• It is smaller as the heart is situated left of the midline.
• Divided into only two lobes: superior and inferior
LUNG
ALVEOLI
 DEFINITION
Definition 1:

Is an inflammation of the bronchioles caused by viruses or bacteria.

Can be acute or chronic

.
(Dictionary of Nursing-Fajar Bakti)
By ELIZABETH A.MARTIN

Definition 2:

An infection of the bronchial tree (tubes that carry air from the mouth and nose to the
lungs. When these tubes get infected, they swell and mucus forms. Mucus is material
that comes up when cough.

(pulmonarychannel.com/acute bronchitis)

Definition 3

An inflammation of the lining of the bronchial tubes ,the commenest disease of the
breathing system which is caused by viruses or bacteria. It is characterized by
coughing the production of mucopurulent sputum and bronchospasm.

(A Dictionary of Symptom, 4th Edition, Bantam Books)

 ACUTE BRONCHITIS
Is an acute inflammation of the bronchioles.

Usually occurs following from viral upper respiratory tract infection.

Viruses depress normal defense mechanism, enable bacteria to present in the respiratory
tract to multiply.

Causative agent:

• Streptococcus pneumonia.

• Haemophilus influenza

• Streptococcus phyrogenes

• Staphylococcus aureus

Normal Bronchitis
-Bronchial is clear -Bronchial swollen
-More mucus produced
 CHRONIC BRONCHITIS
Is a chronic inflammation of the bronchiol mucosa resulted in hyperactivity or the
mucus-secreting glands of the bronchial mucosa in response to prolonged or frequent
recurring irritation.

It is characterized by a productive cough for at least 3 month in 2 consecutives years.

It develops mostly in middle-aged men who are chronic heavy smokers and may have
a familial predisposition.

The changes occurring in the mucous membrane of the bronchi include:

• Thickening
• Increase in the number and size of mucous glands
• Oedema
• Reduction in the number of ciliated cells
• Narrowing of bronchioles due to fibrosis following repeated inflammatory
episodes

Additional symptoms for chronic bronchitis

• Frequent respiratory infection
• Ankle, feet and leg swelling
• Blue-tinged lips
 ETIOLOGY
1. Airway infection.

2. Air pollution.
• Open burning, industrial gases.

3. Allergies.

4. Weather.

5. Hereditary

6. Occupational exposure
• Exposure to chemical fumes and dust.

5. Smoke inhalation

6. Cigarette smoking
 PATHOPHYSIOLOGY

Airway infection (influenza)

↓
Irritation of cells (bronchiol lining tissue)

↓
Inflammation process (vasodilatation)

↓
Edema of bronchial mucosa

↓
Increased mucus production/Thick secretion

↓
Mucus producing goblet cells undergo hypertrophy

↓
Ciliated epithelial cell line the respiratory tract

↓
Ciliary function impaired.

↓
Blocked airway

↓
Bronchitis
CLINICAL MANISFESTATION
• Cough
-May bring up thick white, yellow or greenish color of mucus

• Wheezing

• Dyspnea

• Chest pain

• Malaise

• Fever

• Headache

• Chills

• Hoarseness

• Sore throat

• Rhonchi

• Rales

• Distended neck veins

• Enlarge heart
 COMPLICATION
1. Chronic Bronchitis
-bronchial damage, the airways become clogged with
mucus ,bronchospams cannot relieved by bronchodilator
drugs.

2. Pneumonia
-inflammation of the lung cause by bacteria, in which the
alveoli become filled with inflammation cells and the lung
become solid.

3. Asthma
-narrowing of the bronchial airway.
 INVESTIGATION
Dr.G
Consultant Nephrologists
2-28,Ipoh Specialist Hospital
Ipoh

263407 50290149 F 31Y 01/10/07 09:47 01/10/07 10:36

Madam Z I/C No: 760701xxxxxx
Ward 5

Examination Result Unit Reference Range

FULL BLOOD COUNT (GP1A)

**Haemoglobin 11.2 g/dL 11.5-16.00
Red cell count 4.3 1012 /L 4.0-5.2
**Haematocrit(PCV) 32 % 36-46
**MCV 72 fl 76-103
**MCH 26 pg 26-34
MCHC 35 g/dL 31-36
**RDW 16 % 8.6-14.6
Platelet count 280 103/uL 150-450
MPV 8.2 fl 6.2-12.0
**White blood cell count 4.1 103/uL 4.3-10.5

---White blood cell differential count--

**Neutrophil 33.6 % 40-75
**Lymphocyte 50.2 % 20-45
Eosinophil 3.7 % 0-6
Monocyte 11.0 % 1-11
Basophil 1.5 % 0-2
 INVESTIGATION
Dr G
Consultant Nephrologist
2-28,Ipoh Specialist Hospital
Ipoh

263407 50289894 F 31Y 28/09/07 18:24 28/09/07 18:56

Madam Z I/C No: 760701xxxxxx

Examination Result Unit Reference Range

FULL BLOOD COUNT (GP1A)

Haemoglobin 11.7 g/dL 11.5-16.0
Red cell count 4.8 1012/L 4.0-5.2
Haematocrit(PCV) 37 % 36-46
MCV 78 fl 76-103
**MCH 25 pg 26-34
MCHC 31 g/dL 31-36
**RDW 15 % 8.6-14.6
Platelet count 202 103/uL 150-450
MPV 9.6 fl 6.5-12.0
White blood cell count 7.2 103/uL 4.3-10.5
--White blood cell differential count--
**Neutrophil 80.9 % 40-75
**Lymphocyte 15.4 % 20-45
Eosinophil 0.5 % 0-6
Monocyte 3.0 % 1-11
Basophil 0.2 % 0-2
Urea 2.1 mmol/L 2.0-6.8

SERUM ELECTROLYTES
Sodium 139 mmol/L 135-155
Potassium 3.8 mmol/L 3.5-5.5
Chloride 102 mmol/L 95-111
 MEDICATION.
Medication on hospitalization:

• Intravenous Normal Saline

• Intravenous Hartman’s solution

• Tablet Azithromycin

• Intravenous Metocloramide

• Tablet PCM

• Intramuscular Voltaran

• Syrup Sedilix

• Dyflam Lonzenges
1 . Tablet Azithromycin

Contents :Azithromycin dehydrate

Group: Antibiotics

Date on: 28 September 2007

Date off: 7 October 2007

Route:Orally

Dosage: 500mg

Frequency: Daily

Indication: Lower resp tract infections including bronchitis & pneumonia; skin &
soft tissue infections; acute otitis media; upper resp tract infections
including sinusitis & pharyngitis/tonsillitis.

Contraindication: Hypersensitivity to macrolides.

Adverse Reaction: nausea, abdominal discomfort, vomiting, dizziness, vertigo,

flatulence, arrhythmias.
2. Intravenous Metocloramide

Contents :Metoclopramide diHCl.

Group :Antiemetics& Antivertigo drugs

Date on : 28 September 2007

Date off: 1 October 2007

Route : Intravenous

Dosage :10mg

Frequency: TDS

Indication :upper GIT disorders,gastroesophageal reflux,gastritis,duodenitis.GI

upset.Digestive migraine.

Contraindication :GI haemorrhage,mechanical obstruction or digestive

perforation;previous history of tardive dyskinesia with
neuroleptics.Epilepsy

Adverse reaction: Extrapyramidal Reactions, drowsiness, vertigo, dizziness.

Headache, depression,GI disturbances,hypertension, endocrine
effects.
4. Tablet PCM

Content: Acetaminophen 500mg.

Group: Analgesics & Antipyretics drug

Date on :28 September 2007

Date off: 7 October 2007

Route:Orally

Dosage: 1g

Frequency: TDS

Indication: Relief of pain & fever

Adverse reaction: Hematological, skin reactions, other allergic reactions.

4.Intramuscular Voltaran

Content : Diclofenac sodium.

Group : Antirheumatic,anti-inflammatory,analgesic.

Date on : 28 September 2007

Date off :-

Dosage :75mg

Frequency :Stat PRN

Indication :exacerbations of inflammatory & degenerative forms of rheumatoid

arthritis,ankylosing spondylitis,osteoarthritis,spondylarthritis,painful
syndromes of the vertebral column,non-articular rheumatism.Renal
colic & biliary colic.Post-traumatic & postoperative pain,
inflammation, and swelling.

Contraindication :Gastric or intestinal ulcer.Hypersensitivity to the active

substance,or sodium metabisulfite & other excipients.
Asthma,urticaria,or acute rhinitis.

Adverse reaction :Headache,vertigo,drawsiness,rashes,epigastric pain, nausea,

vomiting,diarrhea,flatulence,anorexia.
5.Syrup Sedilix

Content :Per 5 ml : Dextromethorphan Hydrobromide 15mg

Pseudoephedrine hydrochloride 30 mg
Promethazine Hyrocloride 3.125 mg
Parabens 0.125% w/v as preservative

Group : Cough & cold remedies.

Date on : 28 September 2007

Date off : 7 October 2007

Route :Orally

Dosage : 10ml

Frequency : TDS

Indication :Relief of dry irritating cough such as those associated with common
cold or upper respiratory tract infections.

Contraindication :Liver disease,asthma;MAOls

Adverse Reaction: Drowsiness, dizziness & constipation;GIT discomfort

6.Dyflam Lonzenges

Content: 1) Active: Benzydamine hydrochloride 3 mg

2) Inactive: Isomalt,saccharin sodium

Group: Anti-Inflammatory analgesic.

Date on: 28 September 2007

Date off : Continue until discharge

Route : Orally

Dosage : 1 tablet

Frequency: Every 6 hourly

Indication:Painful & inflammatory mouth & throat conditions including

tonsillitis,sore throat,radiation mucositis,aphthous ulcer,post
orosurgical & post-periodontal procedures.

Contraindication : Nil

Adverse reaction : Oral numbness;dryness or thirst,tingling,warm feeling in

mouth,altered sense of taste.
 NURSING CARE PLAN

1. INEFFECTIVE AIRWAY CLEARANCE RELATED TO INCREASED

PRODUCTION OF MUCUS.

2. ALTERATION IN COMFORT; COUGH RELATED TO PRODUCTIVE

SECRETION

3 .ALTERATOIN IN BODY TEMPERATURE; FEVER RELATED TO THE

PRESENCE OF INFECTION

4. ALTERATION IN SLEEPING PATTERN RELATED TO PRODUCTIVE COUGH.

5. KNOWLEDGE DEFICIT REGARDING DISEASE PROCESS AND HOME CARE

MANAGEMENT.
Date: 28th September 2007

Time: 1700hour

Nursing Diagnosis: Ineffective airway clearance related to increased production of

mucus.

Supporting data: 1) Patient has productive cough

2) Patient verbalized having difficulty to clear his throat of secretion

Goal: Patient will be able to maintain a patent airway within 2 – 3 hours after nursing
intervention given and during hospitalization.

Nursing Intervention:

1. Assess patient general condition such as her breathing pattern, sputum colour,
consistency and amount, respiration rate and sound.
R: As a baseline data for further nursing intervention.
I: I did an assessment to Madam Z such as by counting her respiration rate,
observed her breathing pattern and sound of her breathing.

2. Monitor vital sign every 4hourly especially respiration rate.

R: To detect any abnormalities especially respiration rate.
I: I checked Madam Z respiration rate every 4hourly for detect any abnormalities.

3. Advice patient to sit in fowler’s position.

R: To assist in breathing pattern and for better lung expansion.
I: I advised Madam Z to sit more in fowler’s position so that it could assist her
breathing pattern.

4. Teach patient deep breathing and double coughing exercise.

R: For easier to cough out and expectorant out.
I: I demonstrated to Madam Z to do proper deep breathing and coughing exercise
and ask her to follow me step by step.

5. Advice patient to drink a lot of water such as 1.5-2 liter per days.
R: To liquefy secretion and facilitate clearing the phlegm
I :I advised Madam Z to drink a lot of water about 1.5-2 liter per days to keep her
mucus (secretion) thin.
6. Provide mouth gargle (Thymol gargle) to patient.
R: To promote comfort after cough out sputum many time.
I : I ensure Madam Z to gargle her mouth after having cough many times.

7. Advice patient to rest in bed.

R: To reduce oxygen consumption
I : I advised Madam Z to rest more in bed so that she would not waste her energy.

8. Provide good ventilation and conducive environment.

R: To promote relaxation and comfort for patient.
I : I ensure that Madam Z room is well ventilated and the surroundings is clean, neat
and tidy.

9. Administer medication as ordered by doctor e.g IV Metaclopramide.

R :To loosen the mucus (secretion).
I :I administer medication observed by staff nurse to Madam Z as prescribed by
doctor ordered.

10.Inform doctor or nurse in-charge if patient is still uncomfortable.

R: For further treatment.
I : I didn’t informed doctor or nurse in-charge because Madam Z seems to be
comfortable after nursing intervention given to her.

Date: 28 September 2007 @ 1900hour

Evaluation: Patient able to maintain her clear airway and able to facilitate the removal
of mucus plugs.

Date: 29 September 2007@ 1900hour

Evaluation: Patient able to maintain her clear airway and able to facilitate the removal
of mucus plugs.

Date: 30 September 2007@ 1900hour

Evaluation: Patient able to maintain her clear airway and able to facilitate the removal
of mucus plugs.

Date: 1 October 2007@ 1900hour

.
Evaluation: Patient able to maintain her clear airway and able to facilitate the removal
of mucus plugs.

Supporting data :1)Patient didn’t complain difficulty in breathing.

2) Her respiration rate was within normal range – 20 breath/min.

Date: 28 September 2007

Time: 1500hour

Nursing Diagnosis: Alteration in comfort; cough related to productive secretion.

Supporting data: 1) Patient’s having cough for 2 weeks

2) Patient’s sputum yellowish in colour.

Goal: Patient’s cough will be able reduce after 2-3 hours and be more comfort within 3
days after nursing intervention given and during hospitalization.

Nursing Intervention:

1 .Assess patient’s general condition example type of cough, nature, frequency,

productive and non productive.
R: As a baseline data and to plan an appropriate nursing intervention.
I : I assess Madam Z when she cough and she have yellowish colour of sputum.

2. Promote comfortable position as patient desire example fowler’s position.

R: For better lung expansion and make Madam Z easy to cough out the secretion.
I: I put Madam Z in fowler’s position and she easy to cough out the secretion.

3. Teach patient’s to do deep breathing and cough exercise.

R: To promote lung expansion and to make my patient’s easy to cough out the
secretion
I: I teach Madam Z how to do deep breathing and coughing exercise and asked her to
follow me step by step.

4. Assist Physiotherapist in chest percussion and deep breathing exercise.

R: To facilitate the movement of secretion help to cough out secretion.
I: I assist Physiotherapist do chest percussion and deep breathing exercise to
Madam Z.

5. Encourage patient to drink a lot of plain water especially warm water at least 2 or 3
liters per days
R: To loosen the secretion and to soother the throat.
I: I encourage Madam Z to drink a lot of plain water at least 2 or 3 liter per day to help
loosen the sputum.

6. Advice patient to avoid any cold or oily food.

R :To reduce throat irritation.
 I :I advise Madam Z to reduce or do not take any cold or oily food.

7. Promote clean and conducive environment such as encourage my patient not to be in

the room while nurses changing the linen.
R :To reduce cough reflex and promote comfort.
I :I ensure Madam Z in clean and conducive environment.
8. Administer medication as ordered by doctor such as Syrup Sedilix
R :To reduce and stop irritation that cause coughing and also reduce the
secretion(sputum).
I :I serve medication that has ordered by doctor to Madam Z such as Syrup Sedilix.
I also told her about the medication, the indication, side effect and others.

9. Inform doctor or nurse in-charge if patient’s still having coughing and the treatment is
not persist.
R :For further treatment.
I :I didn’t inform doctor or nurse in-charged because Madam Z cough are reduce.

Date: 28 September 2007@ 1800hour.

Evaluation: Patient’s verbalize that her cough has been reduce after 3 hours medication
and nursing intervention given

Date: 29 September 2007@ 1800hour.

Evaluation: Patient’s verbalize that her cough has been reduce after 3 hours medication
and nursing intervention given

Date: 30 September 2007@ 1800hour.

Evaluation: Patient’s verbalize that her cough has been reduce after 3 hours medication
and nursing intervention given

Date: 1 October 2007@ 1800hour.

Evaluation: Patient’s verbalize that her cough has been reduce after 3 hours medication
and nursing intervention given

Date :2 October 2007@ Time :1000hour.

Evaluation: Patient’s verbalize that her cough has been reduce after medication given
and nursing intervention given to her in 3 days during hospitalization.

Supporting data: Patient told me that her cough has been reduce after 1 week admitted in
the hospitalization.
Date : 28 September 2007.

Time : 1700hour

Nursing Diagnosis: Alteration in body temperature; fever related to presence of infection.

Supporting data: 1) Patient having body temperature 38.50C

2) Patient facial expression looks lethargy.

Goal: Patient body temperature will be reduced after 2 hour medication and nursing
intervention given during hospitalization.

Nursing Intervention:

1. Assess patient general condition such as patient facial expression.

R :As a baseline data and for further nursing intervention.
I :I looks at patient facial expression and she looks lethargy and she cover her body
with blanket.

2. Monitor vital signs every hourly especially temperature.

R :To detect any abnormalities especially patient body temperature.
I :I do an observation to Madam Z and she having body temperature 38.5oC

3. Encourage patient body temperature after 30 minutes patient taken a bath.

R :To reduce patient body temperature.
I :I encourage Madam Z to take a bath with cold water to reduce her body
temperature.

4. Recheck patient body temperature after 30 minutes patient taken a bath.

R :To recheck whether patient body temperature are reduce or not.
I :I recheck Madam Z body temperature and her temperature had gone down to 380C

5. Encourage patient to wear a thin clothes.

R :To reduce patient body temperature.
I :I ensure Madam Z wear thin clothes.

6. Provide patient in a good ventilation room such as switch on air-condition.

R :To promote comfort and help reducing patient’s body temperature.
I :I switch the air-condition at a suitable temperature.

7. Encourage patient to drink a lot of plain water example 1.5-2 liter per day.
R :To prevent dehydration and reduce patient body temperature.
 I :I advised Madam Z to drink a lot of water to prevent dehydration and reduce her
body temperature.

8. Administer medication as ordered by doctor such as Paracetamol(PCM) 1g.

R :To help reduce patient body temperature.
I :I administer as ordered by doctor such as Paracetamol(PCM) 1g to Madam Z.

9. Inform doctor if patient body temperature still not reduce.

R :For further treatment.
I :It is not necessary to the doctor since Madam Z body temperature had stabilized
within normal range(36-37)0C.

Date :28 September 2007@1900 hours.

Evaluation: Patient body temperature reduce from 38.50C to 36.90C after 2 hours
medication and nursing intervention given to my patient.

Date: 29 September 2007@1900 hours.

Evaluation: Patient body temperature reduce from 38.50C to 36.90C after nursing
intervention given during hospitalization.

Date: 30 September 2007@1900 hours.

Evaluation: Patient body temperature reduce from 38.50C to 36.90C after nursing
intervention given during hospitalization.

Supporting data :1)Patient body temperature are within normal range(36-37)0C

2)Patient facial expression looks more cheerful.

Date: 28 September 2007.

Time: 2100hour.

Nursing Diagnosis: Alteration in sleeping pattern related to productive cough.

Supporting data: Patient told me that she can’t sleep because of coughing.

Goal: Patient will be able to sleep atleast 5 hours every night after medication and
nursing intervention given during hospitalization.

Nursing Intervention :

1. Assess patient sleeping pattern by asking the patient such as why she can’t sleep, her of
duration sleep and what is her sleeping time.
R: As baseline data and to plan an appropriate nursing intervention.
I :I asked Madam Z some question such as why she can’t sleep, her duration of
sleep and what is her sleeping time.

2. Administer medication as ordered by doctor such as Syrup Sedilix 10ml.

R :To promote relaxation ,reduce cough and enable patient easy to sleep.
I :I serve medication to my patient as ordered by doctor such as Syrup Sedilix 10ml to
promote relaxation, reduce cough and easier for her to sleep.

3. Encourage patient to sleep in semi-fowler’s position.

R :To make her comfortable and able to sleep.
I :I encourage Madam Z to sleep in semi-fowler’s position .So that she will finds it
easier to breath and sleep.

4. Encourage patient to drink a lot of warm water such as 1.5 to 2 liter per days
R :To reduce throat irritation.
I :I encouraged Madam Z to drink a lot of warm water such as 1.5 to 2 liter per day to
reduce throat irritation.

5. Inform doctor or nurse in-charge if patient still cannot sleep.

R :For further treatment
I :I didn’t inform doctor or nurse in-charge because Madam Z verbalized that she was
able to sleep after taken the medication.

Date :29 September 2007@0900 hours

Evaluation :Patient able to sleep atleast 5 hours every night after medication and nursing
 intervention given during hospitalization.

Date :30 September 2007@0900 hours

Evaluation :Patient able to sleep atleast 5 hours every night after medication and nursing
intervention given during hospitalization.
Date :1 October 2007@0900 hours

Evaluation :Patient able to sleep atleast 5 hours every night after medication and nursing
intervention given during hospitalization

Date :2 October 2007@0900 hours

Evaluation :Patient able to sleep atleast 5 hours every night after medication and nursing
intervention given during hospitalization

Supporting data :Patient told me that she able to sleep after taken the medication.
Date:7 October 2007.

Time :0900hour.

Nursing Diagnosis: Knowledge deficit regarding disease process and home care
management.

Supporting data :Madam Z asked me about her disease, how it occur and how to prevent
it.
Goal :Patient will gain an understanding about her disease and knew how to prevent it
after 1 or 2 hour nursing intervention given to her and during hospitalization.

Nursing Intervention :

1.Assess patient level of knowledge about her disease such as asking her what she
already knew and what she wanted to knew about her disease.
R :To plan further nursing intervention.
I :I asked my patient what does she wanted to knew about her disease.

2.Reinforce doctor’s explanation.

R :For better understanding.
I :I re-explain doctor’s explanation to Madam Z by summarizing it.

3.Give explanation and appropriate health education to patient.

R :To provide more information to my patient.
I :I give education about the disease that I know will be helpful in helping the patient
to control and prevent her disease.

4.Provide pamphlet that is related to patient such as pamphlet on bronchitis.

R :For better understanding and help patient to managed her disease.
I :I gave Madam Z pamphlet that I got from internet.

5.Teach patient effective deep breathing and coughing exercise.

R :To help patient when she felt sick.
I :I demonstrated to Madam Z about deep breathing and coughing exercise and asked
her to follow me step by step.

6.Advice patient to drink a lot of water such as 1.5 to 2 liter per days.
R :To help and keep the mucus (secretion)thin.
I :I advised Madam Z to drink a lot of plain water such as 1.5 to 2 liter per days.

7.Advice patient to avoid exposure to dust,air pollutants and others.

R :To prevent transmission of infection.
I :I advised Madam Z not to be exposed to dust,air pollutant and others.
8.Advice patient to avoid people who are smoking and air –conditioner in her office.
R :To prevent disease.
I :I advised Madam Z not to be exposed to people who are smoking and air-condition
in her office.

9.Advised patient to take and finished the medication on time.

R :To prevent infections ,assist in healing and avoid recurrence of the disease.
I :I explain to Madam Z the important of taking and finishing the medication and
advised her to taken the medication at the right time and dose.

10.Explain to patient the important of follow up and advice her to come on time.
R :To ensure patient know about the important to follow up and remind her not to
forget the follow up.

11.Advice patient to come and see the doctor whenever she feels the symptom and if
complication occurs.
R :For further treatment.
I :I advise to Madam Z to come to see doctor whenever she feels the symptom and if
she find any complication occurs.

Date :7 October 2007@1100 hour.

Evaluation :Patient had been made to understand about her disease and how to prevent it
after nursing intervention given to her and during hospitalization.

Supporting data :I asked patient to re-explain what I had explained to her before.
 HEALTH EDUCATION
ACUTE BRONCHITIS :

• I had re- explained doctor explanation to Madam Z and her husband about her
disease,how it’s occur, the sign and symptom and other enable them to
understand more about the disease.It is also can helped her able to control and
prevent the disease.
• I also gave her a pamphlet of her disease that I had taken from internet to gave
her more knowledge about her disease.

PREVENTION OF ATTACK:

• I asked my patient to maintain cleanliness and hygiene in her office and her
house.
• I asked my patient and her husband to remove dust particles that settle on
furniture,rack and other in her house.
• I asked my patient to avoid direct exposure to air-conditioner and avoid
mingle with people who are smoking in her office.
• I asked my patient to informed her employed to check the air-condition
system.eg:by removing and replace the air-conditioner filter if necessary to
prevent the dissemination of dust and particulate matter in the office.

MEDICATION :

• I explained to my patient about the important of following medication

medication regime and complete course. I also explained to her regarding her
medication,purpose and side effect to enable her to understand more about
her medication.

DIET :

• I asked my patient to adequate fluid intake 1.5 to 2 liter/day to keep

mucus(secretion)thin and easier to cough out the phlegm.
• I asked her to avoid cold and oily food to reduce her throat irritation.
• I also asked her to eat more fruits and vegetable to enable her to be more
health
IMPORTANCE OF FOLLOW UP :

• I had reminded my patient the date and the purpose of follow up to ensure
my patient understand and came to hospital for her follow up.

I told my patient to get adequate rest to conserve energy and used of oxygen.

I teach my patient deep breathing and coughing exercise.

 DISCHARGE
On 7 October 2007,at 1400 hours,Madam Z was discharge from hospital.Her
husband was accompanied her.Madam Z has been discharge by Dr G after Dr G has
comes to review Madam Z condition at about 0945 hours.Dr G prescribed Tablet
Azithromycin 500mg daily,Tablet PCM 1g TDS,Syrup Sedilix 10ml TDS,and Dyflam
Lonzenges every 6 hours 4 times per day.

Dr G advised Madam Z to make sure she take and finished all the medication that
has been given and remember to come to hospital for follow up treatment on 14 October
2007.

At the moment,I also gave her a health education to help her to maintain healthy and
avoid to sick.
 FOLLOW UP
On 14 October 2007 at 1230 hour,Madam Z comes to hospital for follow up
treatment with Dr G.She came with her husband.

Madam Z looked happy and cheerful.She say she felt comfortable now and her
cough now are reducing.She say thanks to me because I take care of her when she was
admitted in hospital.

On her follow up,her blood pressure is 110/80mmHg,pulse rate is 73/bpm,respiration

is 22/min,and her weight is 72kg.Dr G had checked up on Madam Z and give some
advise and health education to Madam Z and her husband.

Dr G told Madam Z that she do not need to come for further follow up unless she had
any problem related to her condition.Dr G also told Madam Z to come back for treatment
if she felt sick again.
 SUMMARY
Madam Z was admitted to Ipoh Specialist Hospital (ISH),in Ipoh,Perak on 28
September at 1400 hour.She came with her husband to the hospital after complaining of
high fever and continuosly coughing for 2 week,difficulty in breathing for 2 days,fell
pain when coughing for 1 week.

Madam Z was suspected as having Bronchitis signs.After all the medical check up
carried out to her,doctor had finally diagnosed her as having Acute Bronchitis.She was
under Doctor G.

During the Admission from Accident and Emergency Department,she was wheeled
in to the ward and accompanied by A&E staff.During that time,her vital signs are :

Temperature :38.50C
Pulse :76/bpm
Respiration :22/bpm
Blood Pressure :110/85mmHg

On that day,Dr G had explained to Madam Z and her parent about Madam z disease
and all of them are able to understand it.In the ward,I also did as Doctor was done and
gave a health education to remind Madam Z and her husband how to take care of herself
and prevent the disease.

After 2 days admitted in the ward,she doesn’t complained about difficulty in

sleeping,fever,difficulty in breathing,but cough are still there and her phlegm is much
more reduced.

After 4 days admitted in the ward,she looks better and healthier than before.She was
discharge on 7 October 2007 around 1230 hour.She was given medication to continue her
treatment at home such as :

• Tablet Azithromycin 500mg daily

• Tablet PCM 1g TDS
• Syrup Sedilix 10ml TDS
• Dyflam Lonzenges every 6 hours 4 times per day.
 Before she was discharge,I had reminded her to take her medication strictly
according as doctor ordered.I also gave a health education to her to avoid her to avoid the
disease contracting again.She was very happy to be discharged.

Her follow up was on 14 October 2007 at 1230 hour.On that days,she looks cheerful
and more healthier.

CONCLUSION
First of all,I would like to thanks to all those who had helped and guided me in doing
this case study.My patient and her husband gave me a very good cooperation in making
my case study easier.

Before doing my case study,I initially that I could not o this case study because I had
no experience in doing a case study and also difficult to find a case that is related to the
study of Respiratory or Cardiovascular in Ipoh Specialist Hospital(ISH),Perak.But after
all the encouragement given by Clinical Instructor and my lovely friends,I feld more
confident to do and finished my case study.

After finishing doing my case study,I realized that I had learned a lot about taking
care of patient with Bronchitis.I take care of Madam Z from first day of her admission
until she was discharged.I gained information and knowledge about how to take care of
patient with Bronchitis.I also teached my patient about health education for her disease
and how to prevent it.

Lastly,I would like to says thanks again to all those who had helped me and spend
time for me to finished my case study.
 REFERENCE
WEBSITE :

1. http://www.yahoo.com.my/bronchitis

2. http://www.msn.com.my/bronchitis

3. http://nlm.nih.gov/medlineplus/bronchitis.html

4. http://pulmonarychannel.com/bronchitis

5. Official drugs referent of the Malaysian medical association,

MIMS, 97TH MEDIMEDIA (www.mims.online.com

BOOK :

1.) Anatomy and Physiology in Health and Illness Ross and Wilson,Ninth Edition.
Churchill Livingstone,Anne Waugh and Allison Grant.

2.) Dictionary Of Nursing Malaysian Edition,Fajar Bakti

Editor:Elizabeth A.Martin.

3.) Smeltzer S C and Bare B G, (2004), Brunner & Suddarth’s Textbook of Medical
Surgical Nursing, Lippincott Williams and Wilkins.

4.) A Dictionary of Symptom, 4th Edition, Bantam Books

Dr.Gomez,J(1968)United States Of America,Centaur Press.