CS Baiae

Bronchial Asthma in Acute Exacerbation
College of Nursing
Angeles City
Angeles University Foundation
Group 17
Mercado, Joazelle Lorene Morales, Abigail Joy Naguiat, Caseylene Sarsagat, Paolo Salac, Timothy John
Ms. Kristine Anne S. Fernandez, RN, MN

Clinical Instructor
I. INTRODUCTION
The inspired and expired air may be sometimes very useful, by condensing and cooling the blood that passeth through the lungs; I hold that the depuration of the blood in that passage, is not only one of the ordinary, but one of the principal uses of respiration.
-Robert Boyle
Air is mainly composed of nitrogen, oxygen, and argon, which together constitute the major gases of the atmosphere. Basically air plays a vital role in life where we use this in order to breathe in order to survive and to respond in our daily activities. Breathing is one of the most important functions of the body since it is responsible for the maintenance of optimum oxidation processes in the cells and for intracellular (endogenous) respiration. Lung ventilation and gas exchange between the body cells and the atmosphere occur during the process of breathing; the cells use oxygen, which is involved in the process of cellular metabolism. Carbon dioxide formed during the oxidation is partially used by the cells and partially removed through the lungs. In order to maintain good health, to keep fit and to sustain body health reserves it is necessary to keep lungs ventilation and gas exchange in good condition. This can be achieved by means of breathing exercises that change the common breathing patterns. Bronchial Asthma is chronic inflammatory of the lungs characterized chronic inflammation causes associated increase in airways hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness and coughing particularly at night or early in the morning. It is also a chronic relapsing inflammatory disorder with increased responsiveness of tracheobroncheal tree to various stimuli, resulting in paroxysmal contraction of bronchial airways which changes in severity over short periods of time, either spontaneously or under treatment. These episodes are usually associated with widespread or variable airflow obstruction that is often reversible either spontaneously or with treatments. It may exacerbate to some individuals will have stable asthma for weeks or months and then suddenly develop an episode of acute asthma. Different asthmatic individuals react differently to various Bronchial Asthma in Acute Exacerbation 2
factors. However, most individuals can develop severe exacerbation of asthma from several triggering agents and bacterial infections of the upper respiratory tract infection. According to WHO estimates, 300 million people suffer from asthma and 255 000 people died of asthma worldwide in 2005. Asthma is the most common chronic disease among children. Asthma is not just a public health problem for high income countries: it occurs in all countries regardless of level of development. Over 80% of asthma deaths occur in low and lower-middle income countries. Asthma is under-diagnosed and under-treated, creating a substantial burden to individuals and families and possibly restricting individuals activities for a lifetime. Asthma is a common chronic disease worldwide and affects 22 million persons in the United States. Asthma is the most common chronic disease in childhood, affecting an estimated 6 million children, and it is a common cause of hospitalization for children in the United States (emedicine.medscape.com). In the Philippines, the rate of incidence of asthma is 5,519,468 million annually. (CureResearch.com) According to Center for Disease Control and Prevention (CDC) there is a recent
Statement of the American Thoracic Society estimated that approximately 15% of asthma in the adult population is attributable to occupational exposure, although other estimates have ranged from 5% to 37%. Usual signs and symptoms of Bronchial Asthma In Acute Exacerbation are shortness of breath. According to the National Institutes of Health, shortness of breath is one of the most common signs of bronchial asthma, in addition to coughing and wheezing. Shortness of breath may be most noticeable in bronchial asthma sufferers during exercise or other strenuous activity. The severity of illness may vary from mild and inconvenient to severe and life threatening. Appropriate management requires extensive history and assessment and appropriate, general supportive treatment that is often etiology specific. This case study is about Mr. Coco who was diagnosed of Bronchial Asthma In Acute Exacerbation
A. Current Trends about the Disease Condition Below are some summarized articles collected from the Internet and medical journals regarding BAIAE. 1. Study of Efficacy of Phenytoin in Therapy of Children With Bronchial Asthma Bioportfolio.com (July 15, 2010) The purpose of this study was to determine whether antiepileptic drug phenytoin is effective in the treatment of chronic asthma in children. Effective therapy of asthma still remains quite serious problem. According GINA definition,asthma is an inflammatory disorder. Consequently, modern pharmacotherapy of asthma provides wide use of anti-inflammatory drugs. But asthma also is a paroxysmal disorder: many specialists and even some guidelines underline paroxysmal clinical picture of asthma. Besides this, according to some authors, neurogenic inflammation may play important role in
asthma mechanism. It is known that some other neurogenic inflammatory paroxysmal disorders exist, and they are migraine and trigeminal neuralgia. Antiepileptic drug phenytoin is very effective in therapy of trigeminal neuralgia more than in 70-80% of cases. Other antiepileptic drugs, salts of valproic acid, are effective in the treatment of migraine. If bronchial asthma also is paroxysmal inflammatory disease, like migraine and trigeminal
neuralgia, it is possible that some antiepileptic drugs also are very effective in asthma therapy.They perform a double-blind, placebo-controlled 3-month trial for evaluation of phenytoin efficacy in therapy of bronchial asthma in children. Phenytoin is a wellknown, comparatively safe and effective antiepileptic drug with low cost. According our previous data, phenytoin is effective drug for asthma therapy.
Comparison: children will receive investigational drug in addition to their usual routine antiasthmatic treatment, compared to patients received placebo in addition to their usual routine antiasthmatic treatment.
2. c9,t11-CLA in Children and Adolescents With Allergic Asthma Bioportfolio.com (August 12, 2010)
The study was performed to investigate the effects of a dietary intervention with c9,t11-CLA on clinical and immunological parameters in children and adolescents with allergic bronchial asthma. In-vitro and animal studies strongly suggest that c9,t11CLA reduces inflammatory processes in asthma-models. Aim of this study was to determine possible beneficial effects of orally administered c9,t11-CLA in children and adolescents with allergic bronchial asthma. Thirty subjects (14 girls, 16 boys, age 6-18 years) were recruited from regular patients in the Clinic for Pediatric Allergology of the Friedrich Schiller University Jena. The study was designed as a randomized and placebo-controlled study. After a 1-week run-in period to ascertain the current state of disease and categorization of allergic sensitization by RAST, the participants were randomized and evenly distributed to receive either 3 g/d of an esterified CLA preparation free of t10,c12-CLA (75% c9,t11CLA,87%puroty) or 3 g/d of a placebo oil mixed in 100 g portions of milk fat-free yoghurt for 12 weeks. The yoghurt was freshly prepared and distributed in frequent intervals. At the beginning and at the end of the study, lung function parameters were assessed by whole body plethysmography, and venous blood and 24h-urine samples were collected for further analyses. Throughout the entire study, the participants daily recorded their peak-flow data and kept protocol about their symptoms and drug usage.
3. Acetaminophen Use in Adolescents Linked to Doubled Risk of Asthma Sciencedaily (August 13, 2010) New evidence linking the use of acetaminophen to development of asthma and eczema suggests that even monthly use of the drug in adolescents may more than double risk of asthma in adolescents compared to those who used none at all; yearly use was associated with a 50 percent increase in the risk of asthma. This study has identified that the reported use of acetaminophen in 13- and 14 year old adolescent children was associated with an exposure-dependent increased risk of asthma symptoms," said study first author Richard Beasley, M.D., professor of medicine, at the Medical Research Institute of New Zealand on behalf of the International Study of Asthma and Allergies in Childhood (ISAAC) . There was a significant association between acetaminophen use and risk of asthma and eczema. For medium users the risk of asthma 43 percent higher than nonusers; high users had 2.51 times the risk of non-users. Similarly, the risk of rhinoconjunctivitis (allergic nasal congestion) was 38 percent higher for medium users and 2.39 times as great for high users compared to non-users. For eczema, the relative risks were 31 percent and 99 percent respectively. As this was a cross-sectional study, causality could not be determined. Moreover, in an earlier study from the United States, 13 and 14-year-old children with asthma were randomized to take either acetaminophen or ibuprofen after a Augustrile illness. For those whose illness was respiratory, there was an increased risk of a subsequent outpatient visit for asthma. Given the increased risk associated with acetaminophen usage, Dr. Beasley and colleagues calculated that the population attributable risks -- the percentage of cases that might be avoided if the risk factor were to be eliminated -- were indicative of a remarkable impact from acetaminophen usage. "The overall population attributable risks for current symptoms of severe asthma were around 40 percent, suggesting that if the associations were causal, they would be of major public health significance," said Dr. Beasley. "Randomized controlled trials are now urgently required to investigate this relationship further and to guide the use of antipyretics, not only in children but in pregnancy and adult life. Bronchial Asthma in Acute Exacerbation 6
4. 'TIMely' Intervention for Asthma Sciencedaily (July 12, 2010)
One gene identified as a asthma susceptibility gene is TIM1 and now, a team of researchers, led by Paul Rennert, at Biogen Idec Inc., Cambridge, has generated data in a humanized mouse model of asthma that suggest that targeting TIM-1 protein might have therapeutic benefit in the treatment of patients with asthma. Specifically, the team found that an antibody that bound to a defined region of the TIM-1 protein (a cleft formed within the IgV domain) had therapeutic activity in the humanized mouse model of experimental asthma, ameliorating inflammation and airway hyperresponsiveness
B. Reasons for choosing such case for presentation The group has chosen the case of Bronchial Asthma In Acute Exacerbation (BAIAE) since it is one of the most common diseases in children and adults possibly because of their lifestyle or genetically. Bronchial Asthma In Acute Exacerbation (BAIAE) is a condition that can be managed with appropriate interventions and health teachings, therefore, through this case study, the student nurses will gain broader information that could help them to provide necessary health teachings to patients to help reduce the occurrence of such condition. Also, the group has chosen this case as it is fairly new to them and presumes it is challenging and very informative to the group and to the readers. B.1 Student Nurse-Centered Objectives GENERAL: After the completion of this study, the student nurses will have an increased knowledge regarding Bronchial Asthma In Acute Exacerbation (BAIAE) At the end of this case study, the student nurses are expected to
Assessment Acquire and apply classroom theories and principles into the actual situation Achieve cognitive about the past and present disease condition of the patient Understand the structure and the function of the affected system or organs and relate it in the anatomy and physiology with the manifestations of the patient. Identify patterns of daily living and lifestyle factors affecting the health status of the patient Assess and discuss the health condition of the patient Enumerate the different signs and symptoms of BAIAE
Diagnosis Formulate nursing diagnosis to the problems that emerges List accurately, analyze interpret and relate gathered data through assessment and laboratory findings. Enumerate and prioritized the identified actual and potential health problems based on the health status of the patient Plan appropriate nursing interventions based on the identified health condition
Planning Perform a comprehensive assessment of BAIAE. Discussed the pathophysiology basis of the patients manifestation Became familiar of the different diagnostic and laboratory procedures done to the patient and nursing responsibilities involved and also able to understand the results of such tests. Be updated with the latest trends and in the treatment of the Bronchial Asthma In Acute Exacerbation (BAIAE) Implementation Formulate nursing care plans utilizing the nursing process. Grasp the rationale of the medical, surgical and nursing management of the patients condition Discuss ways to prevent complications and for maintenance of health at home
Evaluation Formulate conclusions based on the findings and enumerated
recommendations concerning BAIAE Evaluate the process of the nursing interventions done in relation to the patients condition
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B.2 Patient/Family Centered Objectives
GENERAL: Upon completion of this study, the family of Mr. Coco will have an increased knowledge regarding her case and diagnosis through increase compliance with therapeutic regimen and performance of the interventions given. At the end of this study, Mr. Coco and his family will be able to: Short-term Establish and maintain rapport with the nurse researchers through hospital visits Verbalize understanding of the purpose of this case study Willingly and truthfully answer the questions of the nurse researchers and share valuable information for the completion of this case study Participate in the nursing assessment done by the nurse researchers Participate willingly with the interventions done by the nurse researchers Identify measures that could minimize the risk of occurrences of the disease/condition. Identify possible risk factors that may have contributed to the development of Bronchial Asthma In Acute Exacerbation (BAIAE) Increase awareness on the risk factors of Bronchial Asthma In Acute Exacerbation (BAIAE)
Long-term Carry out appropriate actions towards the prevention of the health problem as reflected from the nursing diagnosis Demonstrate proper health maintenance and healthy lifestyle based on the health teachings given by the nurse researchers Develop the familys support system and distinguish their respective roles in improving the patients health status and involve them in promoting the health care of the patient.
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II. NURSING ASSESSMENT
A. Personal Data Mr. Coco, a 24 year old male, single, was born via normal spontaneous delivery on September 27, 1985 in Guagua. He lives at San Basilio, Sta. Rita, Guagua with his mother Wheezy, a brother, two sisters, a sister-in-law, a brother-in-law, and two nieces. He is the 2nd youngest among the 4 children of Mr. and Mrs. Ubo and was not able to finish schooling since he started working at a very young age as a construction worker. He is a natural born Filipino and was raised as a Catholic. He was admitted last August 14, 2010 at 4:50 am due to difficulty of breathing. According to Mr. Coco himself, hes been a smoker since he was 13 and would consume half pack of cigarette although he tried to minimize the number of sticks per day for some time now. He is also an alcohol drinker since he was 13 and would consume an Emperador long neck a day. He also takes marijuana since he was 15 until now with one stick per day. Also, he used to take methamphetamine or shabu when he was 13 until he turned 16.
B. Pertinent Family History The family of Mr. Coco is an Extended type of family consisting of ten members, his two brothers, three sisters, two brothers-in-law, parents and two nieces. She was born via Normal Spontaneous Delivery within the viable age in Guagua. The obstetric history of Mother Wheezy is G4P4T4P0A0L4. Mr. Coco is the third child of Mother Wheezy. According to her, she had completed the five doses of Tetanus Toxoid during her pregnancy, however, she cannot remember the dates when these were administered. All throughout her pregnancy, Mother Wheezy did not take unprescribed medicines including herbal medicines.
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In terms of housing condition, the family is living on a compound with 5 other houses and they are crowded according to Mother Wheezy. The familys house is a concrete-wood type and about 10x20ft with four large windows of about 36x48 inches in size. The walls are concrete; the flooring is cemented, while their roofs foundation is made up of wood materials. Their neighbors own cats and dogs and there is presence of roaches in their house. They cook their foods by firing woods. They obtain their water as well as their drinking water from a water pump. In order to sustain for their living, Mother Wheezy works as a housekeeper earning Php 4,000.00/month. Mr. Coco works as a part-time construction worker and earns about Php 200.00/day at an irregular basis. His eldest brother works as an automotive mechanic earning about Php 3,000.00 a month, his sister 's husband works as a fish vendor and earns about Php 3, 000.00/month. Expenses Food Transportation Milk Electricity Bill Vices Total Amount P 8,000 P 1, 500 P P 200 600
P 4, 000 P14, 300
The Table above shows the breakdown of the familys income in a monthly basis.
The monthly budget is approximately Php 14,300.00 to be divided among all nine of the family members; it would not be enough if the criteria set by NEDA will be utilized. Each member will have a share of Php 1,588.89 which is lesser compared to the NEDAs requirement of Php 2,768.60 per individual per month.
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Mother Wheezy believes in herbolarios and according to her, she would put kerosene gas on Mr. Cocos back during asthma attacks. She also puts oregano below the rice when cooking and extract the juice to allow Mr. Coco to drink it. She also gets morning dew with one tablespoon every morning at around 6am and make Mr. Coco drink it. She believes that those managements would remove Mr. Cocos asthma.
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FAMILY DIAGRAM
Paternal Side
Legend:
Maternal Side
- Male O Female Grandfather + Abd 85 Grandmother + Tetanus, 56
+ - Deceased Abd abdominal abscess

Liverliver cacer Bone bone cancer
Grandfather
Grandmother
+ Liver , 25
+ Bone 71
Aunt
Uncle Father + CVA , 33
Aunt 59
Mother 55
Brother 31
Sister
Asthma, 27
Mr. Coco
BAIAE
Sister
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The genogram above shows the history of illness in the patients family. On Mr. Cocos maternal side, his grandmother, a former farmer, has died at the age of 71 due to cancer of the bone, whiles his grandfather also a former farmer, and has long been deceased at the age of 25 due to liver cancer. On Mr. Cocos paternal side, his grandmother, who was a former farmer died at the age of 85 due to abdominal abscess. His grandfather died of tetanus infection at the age of 56. Mr. Cocos father died at the age of 33 because of heart attack. His mother is 55 years old with no known complications. Mr. Coco has three more siblings, one of which, the second eldest also has asthma. The remaining two have no reports of any remarkable disease condition. Any history of disease conditions includes simple coughs, fever and colds.
D. History of Past Illness According to his mother, Mr. Coco did not have any complications after birth, but when he reached the age of 2, Coco first showed episodes of asthma attack and DOB. His mother used kerosene, morning dew and oregano as treatment for her son. He also experienced colds and coughs during his childhood years.
E. History of Present Illness Three days prior to the admission of Mr. Coco at Diosdado P Macapagal Memorial Hospital, he had been experiencing DOB. He thought it would fade away without going to the hospital. After three days of having difficulty of breathing, accompanied by chest and back pain, non-productive cough and congested nose, Mr. Coco and his family decided to seek medical management and so he was admitted on August 14, 2010 at 4:50 pm with an admitting diagnosis of Bronchial Asthma in Acute Exacerbations.
F. Physical Examination a. Initial Physical Examination: August 14 ,2010. (Lifted from the chart, assessed and accomplished by the doctor on duty) Chief complain: Difficulty of breathing Vital signs: o o o o Temperature: 37.3 C Pulse Rate: 72 bpm Respiratory Rate: 20 cpm Blood Pressure: 110/80 mmHg
Admitting Impression: Bronchial Asthma in Acute Exacerbation
b. Physical Examination: August 16, 2010 (Assessed by the Student Nurses) General Appearance: Patient Mr. Coco is a 24 year old male; with pulse rate of 84 beats per minute, respiratory rate of 24 breathe per minute, blood pressure of 130/90mmHg and a temperature of 36 C. He is conscious and coherent upon interaction and answers all the questions given.
A. INTEGUMENT a. Skin: Skin has uniform complexion on exposed areas, negative for cyanosis, pallor, jaundice and edema. Has good skin turgor. Presence of tattoos on both upper and lower extremities b. Nails: Smooth in texture, convex curved, intact tissues around nails, no clubbing, normal capillary refill (<3 sec.)
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B. HEAD AND FACE: a. Hair: Hair is black and short. Hair is thick, with fine strands and is evenly distributed
b. Skull and Face: Smooth skull contour, round, without nodules noted; Scalp is smooth and white in color, scar on left forehead upon inspection; Symmetrical facial features and facial movements
c. Eye structure Eyebrows symmetrically aligned, evenly distributed; eyelashes evenly distributed, curled slightly outward; eyelids have intact skin, lids closes symmetrically, no lesions or nodules found; Pupils constrict when diverted to light and dilates when he gazes afar.
d. Ears and Hearing: Auricles symmetrical, aligned with outer canthus of eye; ears are mobile and firm; pinna recoils after it is folded; manifest hearing ability by responding positively to watch tick test.
e. Nose and Sinuses: Nose is proportional, uniform in color, no lesions, non-tender; nasal septum is intact in the midline; Non-tender facial sinuses. Nose is congested with mucus secretion.
f. Mouth and Oropharynx: Lips are moist, proportional with the face, moist buccal mucosa, tongue is pink, moves freely, with no signs of swelling and ulceration; palates and uvula are light pink in color; uvula is positioned in midline of soft palate; oropharynx and tonsils are pink in color. four missing teeth on his upper set and missing two at the lower with minimal dental caries noted. Bronchial Asthma in Acute Exacerbation 18
C. NECK a. Neck structure: Neck is uniform in color, coordinated with movement, no enlargement of the lymph nodes upon palpation; trachea is on the midline of the neck; able to turn head from left to right and vice versa; upward and downward movement of neck without difficulty; jugular vein not distended.
D. THORAX AND LUNGS a. Thoracic and Lung structures: Full and symmetric chest expansion upon inspection; Positive for crackles. Lateral diameter of thorax is wider than the anterior-posterior diameter. There is no report of pain during the inhalation and exhalation.
E. HEART Regular heart beats upon auscultation. Presence of normal hearts sounds. Negative for murmurs and fiction rubs.
G. ABDOMEN Skin on the abdomen is uniform in color. Abdominal movements as with respiration, presence of bowel sounds are noted.No pain upon palpation of abdomen.
J. UPPER AND LOWER EXTREMITIES Arms and legs are symmetrical in shape, size, and color; there are no deformities, tenderness, lesions, or swelling noted; with the same temperature upon palpation of both upper and lower extremities.
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K. Assessment of the Genitourinary The patient has no difficulty in urination.
L. Neurological Assessment a. Behavior: Patient is quiet but answers the question asked, conscious and coherent interaction.
b. Motor Functioning: Gross motor and balance test: good posture, regular gait, free arm movements, walks unaided, negative Rombergs test, can maintain balance on toes and heels. Fine Motor Test: can repeatedly touch the nose, performs with coordination rapidly during finger to nose and nurses fingers test, can repeatedly touch each finger by the thumb of the same hand in finger to thumb test. Bones and Joints: no deformities, tenderness, swelling noted.
c. Mental Status: Language: respond very well and has good speech for her age Orientation: well oriented to person, time, date, and place Memory: can recall information and can concentrate
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c. Cranial Nerve assessment: August 17, 2010 (Assessed by the Student Nurses)
CRANIAL NERVE Name, Type and Function I. Olfactory Sensory Sense of smell ASSESSMENT TECHNIQUES NORMAL FINDING He will identify different mild aromas correctly by means of smelling of it. He will identify the picture shown to him ACTUAL FINDING
Asked Mr. Coco to close eyes and to identify different mild aromas such as fish sauce and vinegar.
He identified the mild aromas correctly
II. Optic
Instructed Mr. Coco to identify the picture shown to him
He was able to identify the picture shown to him
Sensory Vision and visual fields
III. Oculomotor
Motor Extraocular eye movement Movement of the sphincter of pupil Movement of ciliarys muscle of lens
Assessed six ocular movements and pupil reaction by instructing the patient to follow the pen not using her head. Used penlight to see the reaction of the pupil.
He will follow the pen correctly and easily. For pupil, it will perform constriction upon light and dilation when light removed. He will be able to do the six ocular movements.
He followed the pen easily and correctly. His pupil performed constriction and dilation.
IV. Trochlear Motor Moves downward and laterally
Assessed six ocular movements, like what is done at cranial nerve number three.
He perfectly performed the six ocular movements.
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V. Trigeminal
Sensory Sensation of cornea and skin of face and nasal mucosa
While the client looked upward, we lightly touch the lateral sclera of eye to elicit blink reflex. To test deep sensation, we used alternating blunt and sharp ends of a safety pin over the same area. To test light sensation, we had the client close her eyes and wipe a wisp of cotton over the clients forehead and paranasal sinuses. Assessed direction of gaze by looking at the side without using head.
We will expect Mr. Coco to blink his eyes when the cotton is being touched. For skin, he will identify the presence of cotton in her face and also identify if it is sharp or blunt. He will be able to move his eyes symmetrically.
He blinked after cotton touched to his eyes; he felt the cotton; and he also identified if the object is sharp or blunt.
VI. Abducens
He moved his eyes symmetrically.
Motor Moves eyeball laterally VII. Facial
Motor and sensory
We instructed the client to smile, raise the eyebrows, frown, puff cheeks and close eyes tightly. Asked client to identify various taste place on tip side of tongue, salt, sour, chocolate candy(sweet)
He will be able to perform all easily and symmetrically.
He definitely did all activities
He will identify what is the appropriate taste for the specific food. He will identify the whisper words.
He identified all tasted food appropriate or correctly.
VIII. Auditory
Assessed auditory by means of whispering to him.
He correctly repeated the whispered words.
Sense of hearing Sensory
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IX. Glossopharyngeal
Motor and sensory Swallowing ability Tongue movement
We instructed the client to move his tongue from side to side and up and down.
He will be able to perform side to side movement and also up and down movement. He will speak clearer and louder and will easily swallow.
He actually did all movement easily.
X. Vagus
Motor and sensory Sensation of pharynx and larynx Swallowing vocal cord movement
We assessed by instructing the client to open his mouth, speak and swallow.
He spoke clearly and did not have a difficulty in swallowing.
XI. Accessory motor head movement shrugging of shoulder
We instructed client to shrug against resistance from our hand. And turn head to side against resistance from our hands and instructed the patient to move her head side to side and up and down.
He will be able to shrug his shoulder against the resistance given and she will turn his head to all movements He will do all movements given.
He was able to shrugs her shoulder. He turned her head in all movement.
XII. Hypoglossal motor protrusion of tongue
Asked the client to protrude tongue at midline then move it side to side and up and down.
He did all movement instructed.
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G. DIAGNOSTIC AND LABORATORY PROCEDURES
COMPLETE BLOOD COUNT A screening test or a group of test for the different components of the blood Diagnostic and Laboratory Procedures Complete Count Date Ordered: Date of Result:
Indication
Results
Normal Values
Analysis and interpretation
Blood Date ordered:
This diagnostic test was done to the patient as a August 14, screening for 2010 abnormalities within the blood component. CBC is Date of Result: a routine test given to patient admitted in the August 14, hospitals. CBC was done 2010 to Mr. Coco to determine the occurrence of infection which caused her BAIAE. Also, this could determine the effectiveness of the IVF therapy and the drugs given to the patient
a. Hemoglobin (Hgb/Hb)
A hemoglobin test is performed to determine the amount of hemoglobin in a person's red blood cells (RBCs). This is important because the amount of oxygen available to tissues depends upon how much oxygen is in the RBCs, and local perfusion of the tissues.
146 g/L NORMAL
Mr. Cocos hgb is in normal value which means that there is a good flow of oxygen, knowing hemoglobin actually carries 120-180 g/L oxygen throughout the body. This may indicate that Mr. Cocos asthma attack did not alter his oxygenation. Also, this may suggest that the bronchodilators (Salbutamol) that were given were effective. . Based from the result, the hematocrit level is in the normal range. Therefore, Mr. Coco is possibly well oxygenated since his RBC are in correct proportion with his plasma level. Also, this result may present that Mr. Coco is not experiencing any signs of dehydration. Mr. Cocos status may be due to the bronchodilators and IVF therapy.
b.Hematocrit (Hct)
Hematocrit indicates the proportion of cells and fluids in the blood. It is useful in evaluating dehydration and hypovolemia. It measures the concentration of RBC within the blood volume.
0.44 g/L NORMAL
0.400.54g/L
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c. White Blood cells (WBC)
This test is done to the patient to detect if she has an existing or worsening infection process and inflammation.
9.4 x 10 g/L NORMAL
5-10 x 10 g/L
Mr. Coco has a normal WBC count. This may indicate that Mr. Coco is devoid of any possible infection and inflammation. It may also indicate the effectiveness of Mr. Cocos antibiotic therapy which is Ceftriaxone given on August 14, 2010 that is why his WBC are in a normal level.
d. Platelet Count
This test measures the amount of circulating platelets in the blood responsible in clot formation
296x103L NORMAL
150-400 x 103L
Mr. Cocos platelet result is in normal level. This may suggest that she is at low risk for having signs of bleeding
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NURSING RESPONSIBILITIES: Before the procedure: Check the doctors order Determine the prescribed test and other restrictions prior to the test Accomplish the laboratory requisition slip Explain comprehensively the procedure to the patient Inform the patient that the procedure requires blood sample to be withdrawn by the medical technologist. To avoid anxiety, inform the patient that pain will be felt upon withdrawal of blood specimen
During the procedure: (Complete blood count is usually done by a medical technologist) Use distal vein of the arm first Use patients non-dominant arm whenever possible and select a vein that is easily palpated, feels soft and full, naturally splinted by bone and large enough to allow adequate circulation around the catheter. Tell the patient to remain calm and relax when inserting the needle Assist patient when necessary Maintain sterile technique throughout the procedure If patient experiences fear during the extraction, provide emotional support and comfort by allowing patient to express her concerns and explain to the patient the importance of performing such test. After the procedure: Apply a direct pressue on the venipuncture site until the bleeding stops Send the blood sample to the laboratory immediately Instruct the patient that if hematoma develops in the venipuncture site, apply cold compress for the first 24 hours and then warm compress for the next hours.
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CHEST X-RAY Diagnostic and Laboratory Procedures Date Ordered: Date Result: Indication Results Normal Values Analysis and interpretation
Chest X-ray
Date ordered: August 15, 2010
A chest x ray is a procedure used to evaluate organs and structures within the Date of results: chest for symptoms of August 15, disease. Chest x rays 2010 include views of the lungs, heart, and small portions of the gastrointestinal tract, thyroid gland and the bones of the chest area. X rays are a form of radiation that can penetrate the body and produce an image on an x-ray film. Another name for x ray is radiograph.
Both lung fields clear. Heart not enlarged. Aorta unremarkable. Both hemidiaphragms, costophernic angles and the visualized bones are intact
Both lung fields should be clear. Heart and great vessels are within normal size. Daghragms costophrenic angles and the visualized bones are intact
Mr. Coco is not suffering from any deformities on lung structures. During asthma attack, bronchioles may constrict and may be inflamed, however, with Mr. Cocos x ray result, it is possible that the Corticosteroids and the bronchodilators that were given last August 14,2010 were effective.
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NURSING RESPONSIBILITIES: Prior:

Explain the procedure to the client. Remove the patients clothing and jewelry above the waist and wear a hospital gown. If the patients hair is long, pin it up on the head so that no locks hang over the chest or shoulders.
During:

Position the patient against the X-ray machine. Ask the client to take a deep breath and hold it without moving until an X-ray picture is taken. Pictures are usually taken from the front and the side. Depending on the suspected problem, additional X-rays may be taken at different angles.
After:

Dress the patient. Wait for the results.
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III. ANATOMY AND PHYSIOLOGY
The primary function of the respiratory system is the supply of oxygen to the blood so this in turn delivers oxygen to all parts of the body. The respiratory system does this while breathing is taking place. During the process of breathing we inhale oxygen and exhale carbon dioxide. This exchange of gases takes place at the alveoli. The average adult's lungs contain about 600 million of these spongy, air-filled sacs that are surrounded by capillaries. The inhaled oxygen passes into the alveoli and then diffuses through the capillaries into the arterial blood. Meanwhile, the waste-rich blood from the veins releases its carbon dioxide into the alveoli. The carbon dioxide follows the same path out of the lungs when you exhale. To put it simply, the principle functions of the respiratory system are:

Ventilate the lungs Extract oxygen from the air and transfer it to the bloodstream Excrete carbon dioxide and water vapour Maintain the acid base of the blood
UPPER RESPIRATORY TRACT A. Nose The air enters through two openings, the external nares or nostrils. And just inside each nostril is an expanded vestibule containing coarse hairs. A midsagittal nasal septum divides the nasal cavity. The maxillary, nasal, frontal, ethmoid and sphenoid bones form the lateral and superior walls of the nasal cavity. The hard and soft palate forms the floor of the cavity. (the posterior part of the soft palate is the uvula). The external portion of the nose is composed of cartilage that forms the bridge and the tip of the nose. The superior, middle and inferior nasal conchae are bony shelves that project from the lateral walls of the nasal cavity. And The spaces between the conchae are the meatuses. Posteriorly the internal nares open into the nasopharynx.
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B. Pharynx It receives air from the nasal cavity and air, food , water from the mouth. A stratified squamous epithelium lines the pharynx. The throat of pharynx is divided in three regions: the Upper naso-pharynx, Middle oropharynx, and Lower laryngopharynx.
b.1 Nasopharynx The nasopharynx lies superior to the soft palate. It serves a passageway for airflow from nasal cavity. The uvula is the posterior extension of the soft palate. The auditory tubes extend from the middle ear and open into the nasopharynx. The posterior part of the nasopharynx contains the pharyngeal tonsil, which aids in defending body against infection.
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b.2 Oropharynx It extends front soft palate down to the epiglottis (base of the tongue). And it contains the palatine and lingual tonsils. Thus food, drink, and air all pass through the oropharynx.
b.3 Laryngopharynx The laryngopharynx extends from the tip of the epiglottis to the esophagus. Food and drinks pass through the laryngopharynx to the esophagus. A small amount of air is usually swallowed with the food and drink thus causing too much air in the stomach resulting in belching.
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LOWER RESPIRATORY TRACT A. Larynx It is located in the anterior throat, and is continuous superiorly with the pharynx and inferiorly with the trachea. It is consists of nine cartilage that are connected to one another by muscles and ligaments. B. Trachea The trachea or windpipe, is a membranous tube thet consists of connective tissue and smooth muscle, reinforced with 16-20 c-shaped pieces of cartilage. It projects through the mediastinum, and divides into the left and right primary bronchi at the level of the fifth vertebra. Trachea is lined with pseudo stratified ciliated columnar epithelium. C. Lungs This is a pair of cone shaped organs lining in the pleural cavity.The apex is the conical top of each lung, and the broad inferior portion is the base. Each lung has a hilus, a medical slits as the bronchial tubes, vascularization, lymphatic, and nerves reach the lungs. Each lining is divided into lobes by deep fissures. The Right lungs have three lobes and left lungs have two lobes while the left lung is divided by oblique fissure into superior and inferior lobes. It is the medium where deoxygenated blood passes to become oxygenated again.
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D. Bronchi The trachea is divided into left and right primary bronchi. Foreign objects that enter the enter the trachea usually lodge in the primary main bronchus and therefore more in direct line with the trachea. The main bronchi extend from the trachea to the lungs.
E. Alveoli It is where gas exchange occurs by the process of diffusion facilitated by its thin alveolar membrane.
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E. Pleural cavities The thoracic cavity is bounded by the ribcage and the muscular diaphragm. The mediastinum divides the region into two pleural cavities. The pleural cavity is lined with a serous membrane, called pleura. The parietal pleura line the thoracic wall, diaphragm, and mediastinum however the visceral pleura cover the surfaces of the lungs. The alveolar walls are made of simple squamous pulmonary epithelium. Scattered among epithelium are surfactant cells that secretes oil coating to prevent the alveoli from sticking together after exhalation.Also the alveolar walls are macrophages that phagocytes debris or potential pathogens. Pulmonary capillaries cover the exterior of the alveoli.
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Air from the atmosphere passes through the conducting airway until it reaches the alveoli. The walls of the alveoli are only one cell thick and this is called the respiratory surface, which is about 70 square metres, where the exchange of gases takes place. Around the alveoli are microscopic capillaries that bring carbon dioxide from the heart via pulmonary artery and delivers oxygen back to the heart via the pulmonary vein. Gas exchange happens when there is a difference in partial pressure at the semi-permeable membrane of the alveoli (diffusion). The diffusion occurs when the higher concentration of a gas moves to the lower concentration until equilibrium is achieved (Waugh & Grant 2004).
Partial Pressure of Gases Gas O2 CO2 Alveolar 105 mmHg 40 mmHg Deoxygenated Blood 40 mmHg 44 mmHg Oxygenated Blood 100 mmHg 40 mmHg
Using the table above, we can see that oxygenated blood from the alveolar will diffuse across the semi-permeable membrane and replace the lower concentration of 02 in the deoxygenated blood. The higher concentration of C02 will diffuse in the same way. This is because Daltons law states each gas exerts its own pressure in proportion to its concentration in a mixture. Inhaled Bronchial Asthma in Acute Exacerbation 37
02 has a higher percentage than exhaled 02, its pressure is higher at 100mmHg compared to the 40mmHg of lower percentage from the deoxygenated blood. The reverse of this applies to the C02 because the percentage breathed in is lower than that which is exhaled.(Waugh & Grant 2004) (West,S 2007) The act of breathing consists of two phases, inspiration and expiration
Inspiration- Diaphragm and intercostal muscles contract. The diaphragm moves downwards. The intercostals muscles make the rib cage move upwards. These two processes increase the volume of the thoracic cavity and also reduces the air pressure to below atmospheric pressure allowing air to rush into the airways then into the alveoli. (Waugh & Grant 2004).
Expiration is the opposite of inspiration as in the diaphragm and intercostal muscles relax, this allows the diaphragm to move upwards and the intercostal muscles let the rib cage relax to its resting state. The volume within the thoracic cavity now decreases. This decrease in volume now causes an increase in pressure above atmospheric pressure which forces air out up the airway (Waugh & Grant 2004).
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Central Control Breathing is clearly an involuntary process (you don't have to think about it), and like many involuntary processes (such as heart rate) it is controlled by a region of the brain called the medulla. The medulla and its nerves are part of the autonomic nervous system (i.e. involuntary). The region of the medulla that controls breathing is called the respiratory centre. The main centres are the apneustic centre, which enhances inspiration, and the pneumotaxic centre, which terminates inspiration. The respiratory centre transmits regular nerve impulses to the diaphragm and intercostal muscles to cause inhalation. Stretch receptors in the alveoli and bronchioles detect inhalation and send inhibitory signals to the respiratory centre to cause exhalation. This negative feedback system in continuous and prevents damage to the lungs Ventilation is also under voluntary control from the cortex, the voluntary part of the brain. This allows you to hold your breath or blow out candles, but it can be overruled by the autonomic system in the event of danger. For example if you hold your breath for a long time, the carbon dioxide concentration in the blood increases so much that the respiratory centre forces you to gasp and take a breath.
Peripheral Chemoreceptors A chemoreceptor, is a cell or group of cells that transduce a chemical signal into an action potential Chemoreceptors in the carotid arteries and aorta, detect the levels of carbon dioxide in the blood. To do this, they monitor the concentration of hydrogen ions in the blood, which increases the pH of the blood, as a direct consequence of the raised carbon dioxide concentration.The response is that the inspiratory control from the apneustic centre, sends nervous impulses to the external intercostal muscles and the diaphragm, via the phrenic nerve to increase breathing rate and the volume of the lungs during inhalation.
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Respiratory Terminology

Total lung capacity (TC), about six litres, is all the air the lungs can hold. Vital capacity (VC) The maximum volume of air that can be expelled at the normal rate of exhalation after a maximum inspiration
Tidal volume (TV) is the amount of air breathed in or out during normal respiration. It is normally from 450 to 500 mL.
Residual volume (RV) is the amount of air left in the lungs after a maximal exhalation. This averages about 1.5 L.
Expiratory reserve volume (ERV) is the amount of additional air that can be breathed out after normal expiration. This is about 1.5 L.
Inspiratory reserve volume similarly, is the additional air that can be inhaled after a normal tidal breath in. About 2.5 more litres can be inhaled.
Functional residual capacity, (ERV + RV), is the amount of air left in the lungs after a tidal breath out.
Inspiratory capacity (IC) is the volume that can be inhaled after a tidal breath out. Anatomical dead space is the volume of the airways.
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IV. THE PATIENTS ILLNESS
A. Schematic Diagram (Book-based)
Non-Modifiable Risk Factors: a. Family history of asthma b. Gender (Male childonset; Female- adult onset) c. Age (Children - <5y/o; Adults 30s and >65y/o) d. Race common among blacks d. Born in winter months
Immunoglobulin E stimulation by B Lymphocytes
Mast cell degranulation
Modifiable Risk Factors: Extrinsic factors a. Exposure to allergens (pollen, animal fur, house dust, feather, food additives containing sulfites.) b. Irritant gasses c. Occupation-related substance d. Environmental pollution Intrinsic factors a. Emotional stress b. Changes in temperature and humidity c. Use of drugs (NSAIDs, Aspirin) e. Exercise g. low levels of vitamin D i. Viral RTI
Histamine
SRS-A
Prostaglandins
Bradykinins
Leukotrienes
Airway hyperresponsiveness
Inflammation Mucus secretion a. Lung hyperinflation b. Tachycardia e. cyanosis c. Tachypnea f. confusion d. Diaphoresis g. lethargy Bronchospasm
a. Non-productive cough b. Productive cough
a. Shortness of breath b. Chest tightness c. Wheezing d. Peak flow variability 41
A. Synthesis of the Disease (Book-based) A. Definition of the Disease Based from Medical-Surgical Nursing of Joyce M. Black Bronchial asthma is a reversible disease characterized by obstruction or narrowing of the airways, which are typically inflamed and hyperresponsive to a variety of stimuli. It may resolve spontaneously or with treatment. Bronchial asthma involves a chronic inflammatory process that produces mucosal edema, mucus secretion and airway inflammation. When people with asthma are exposed to extrinsic allergens and irritants, their airways become inflamed, producing shortness of breath, chest tightness and wheezing. Initial clinical manifestations, termed as early-phase reaction, develop immediately and last about an hour. When a client is exposed to an allergen, immunoglobulin E is produced by B lymphocytes. IgE antibodies attach to mast cells and basophils in the bronchial walls. The mast cell empties, releasing chemical mediators of inflammation, such as histamine, bradykinin, prostaglandins and slow reacting substance of anaphylaxis. These substances induce capillary dilation. About half of all asthma clients also experience a delayed reaction. These reactions do not begin until 4 to 8 hours after exposure and may last for hours or days. In both phases, the release of chemical mediator produces the airway response. In the late-phase response, however, the mediators attract other inflammatory cells and create a self-sustaining cycle of obstruction and inflammation. This chronic inflammation produces hyperresponsiveness of the airways. This causes subsequent episodes in response not only to specific antigens but also to stimuli such as physical exertion and breathing cold air.
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Atopic & Nonatopic asthma: 1. Atopic (allergic) asthma - This is the most common type. It is triggered environmental antigens (dust, pollen, food). Often the family has a positive history of atopy. This is a classic type-I IgE - mediated hypersensitivity reaction. Acute phase : There is binding of antigen by IgE coated mast causing release of primary mediators (e.g. leukotrienes) and secondary mediators (Eg. cytokines, neuro-peptides). These mediators cause broncho-spasm, edema, mucus secretion, and recruitment of leukocytes. Late phase reaction : It is mediated by recruited leukocytes (eosinophils, , neutrophils, monocytes) causing persistent bronchospasm and edema, leukocytic infiltration and loss of damaged epithelial cells. 2. Nonatopic asthma (nonreaginic): It is often triggered by respiratory infections, chemical irritants, and drugs, usually without a family history and with little or no evidence of IgE mediated hypersensitivity. The primary cause of increased airway reactivity is unknown.
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B. Predisposing/Precipitating Factors
Non- modifiable Factors: 1. Family History of Asthma - Studies show that more than half of childhood asthma cases are related to inheritance. Having one parent with asthma increases a child's risk of developing asthma threefold, while both parents having asthma increases a child's risk by six times. Similarly, a family history of asthma among adults in the family also has been shown to increase risk of developing asthma. In Arizona, a study was conducted where researchers examined 344 families to see if asthma runs in families. The results revealed the following:
Family History of Asthma Families with neither parent having asthma
Incidence of Asthma 6% of the children had asthma
Families with one parent having asthma
20% of the children had asthma
Families with both parents having asthma
60% of the children had asthma
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2.
Gender, Age and Race - Although asthma can strike at any age, half of all cases first occur in children younger than age 10; in this age group, asthma affects twice as many males as females. In the United States, 14 million adults and 6 million children have asthma. Emergency department visits, hospitalizations, and mortality from asthma have been increasing for more than 20 years, especially among children and blacks. All evidences and factors are made from statistics and incidence of asthma in United States. Asthma typically affects 7% to 10% of children and 5% of adults. It is most common in young children, least common in adolescence, and increases in frequency in adult life. Typically, childhood asthma disappears in adolescence or early adult life and has a good prognosis.
3.
Being born in winter months - Cold air, especially temperatures hovering around zero degrees, tends to be very dry. Winter winds sweep away moisture from any surface, including the skin. Inside, the air quality is not much better. The warm, heated homes also have dry air evidenced by being zapped with static electricity. In order to compensate for the dry air, lungs increase mucus production. It is the additional, thick mucus in the airways that can lead to asthma problems.
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Modifiable factors: Generally, asthma that results from sensitivity to specific external allergens is known as extrinsic while in cases in which the allergen is not obvious is referred to as intrinsic. Extrinsic Factors: 1. Exposure to allergens - Antigen or allergen induced asthma is the most common form of asthma. About one third to one half of all patients with asthma have known or suspected reactions to antigens.Most antigens are air-borne and must be present in the environment for a considerable time to induce hyperreactivity. Common allergens include pollen, animal hair or fur, and insect contamination of house dust.
2. Irritant gasses - Irritant gases, such as hydrochloric acid, ammonia, and heated plastic fumes, have a direct effect of the airways. At high doses almost all those exposed develop acute bronchitis and bronchoconstriction, where as at low doses these substances produce only bronchoconstriction in sensitive people.
3. Occupation-related substances - Asthma may be associated with inhalation of a number of occupation-related substances. More than 80 different occupations have been identified where such a substance occurs.In some instances, these substances may provoke asthma by obvious hypersensitivity mechanisms. (Eg: in animal handlers, bakers, and workers with wood and vegetable dusts, metal salts, pharmaceutical agents, and industrial chemicals). In others, the asthma may be due to release of histamine-like substances, a mechanism noted in byssinosis (brown lung), an occupational lung disease in cotton workers.Occupational exposure may directly affect the autonomic nervous system. For example, organic phosphorous insecticides act as anti-cholinesterases and produce overactivity of the parasympathetic nervous system.
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4. Environmental pollution - Environmental pollution is associated with bronchospasm, usually during episodes of massive air pollution. Usually patients with preexisting lung conditions are affected, but new cases of asthma do occur. Sulfur dioxide, oxides of nitrogen, and ozone are commonly implicated environmental pollutants.
Intrinsic factors 1. Emotional stress - Stress can be thought of as a type of exposure, though a psychological one, which can trigger asthma. Many patients find that stressful situations make them feel short of breath and wheeze, and that they need to use their quick relief inhaler for relief.Stressful life events, which are less immediate, can also lead to worsened asthma control in certain individuals. A recent study measured quality of life related to asthma in a range of individuals and found that in people with similar baseline asthma severity, asthma control was poorer in subsets of individuals who had recent stressful life events, such as divorce or moving house. Another study, in children, found that the beneficial response to sublingual immunotherapy was decreased in children with stressful lives and life events. While the mechanism by which stress and stressful life events worsens asthma control, it is clear from the clinic and research studies that the connection is clear.
2. Changes in temperature and humidity - Cold air, especially temperatures hovering around zero degrees, tends to be very dry. Winter winds sweep away moisture from any surface, including the skin. Inside, the air quality is not much better. The warm, heated homes also have dry air evidenced by being zapped with static electricity. In order to compensate for the dry air, lungs increase mucus production. It is the additional, thick mucus in the airways that can lead to asthma problems.
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3. Use of Drugs - Although drug-induced bronchospasm occurs most commonly in patients with known asthma, the agents themselves may produce asthma. The bestknown of these is aspirin, but several other anti-inflammatory agents have been implicated such as Indomethacin and Mefenamic acid.
4. Exercise - Exercise may induce attacks of asthma in patients who already have the disease; some degree of bronchospasm is usual in such subjects. Exerciseinduced asthma is related to the magnitude of heat loss from the epithelium of the airways to the intra-thoracic gas. The more rapid the ventilation (severity of exercise) and the colder and drier the air breathed, the more likely the asthma is to be precipitated.
5. Low levels of Vitamin D - According to researchers from the University of Pennsylvania, vitamin D may slow the progressive decline in lung function resulting from airway remodeling over time. In airway remodeling certain types of smooth muscle grow more prominent, cause inflammation, and can cause damage to the lungs. The researchers believe that the remodeling can possibly be prevented or slowed down if adequate amounts of vitamin D are consumed. The researchers found that vitamin D decreased growth of smooth muscle inflammation in the lungs of 12 volunteers more than other potent anti-inflammatories. While the studies are preliminary, they continue to study vitamin D as an asthma therapy. According to a press release, the authors are going to preform arandomized controlled trial to determine the effect of vitamin D supplementation on patients with severe asthma.
6. Viral respiratory tract infections - Viral respiratory tract infections trigger attacks in young asthmatics and may cause the first attack. In children under the age of 2 years the respiratory syncytial virus is the usual agent, whereas in older children rhinovirus, influenza , andparainfluenza organisms. are the common inciting
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C. Signs and Symptoms
An asthma attack may begin dramatically, with simultaneous onset of many severe symptoms, or insidiously, with gradually increasing respiratory distress. It typically includes progressively worsening shortness of breath, cough, wheezing and chest tightness or some combination of these signs or symptoms. During an acute attack, the cough sounds tight and dry. As the attack subsides, tenacious mucoid sputum is produced except in young children who dont expectorate. Characteristic wheezing may be accompanied by coarse rhonchi, but fine crackles are not heard unless associated with a related complication. Between acute attacks, breath sounds may be normal. The intensity of breath sounds in symptomatic asthma is typically reduced. A prolonged phase of forced expiration is typical of airflow obstruction. Evidence of lung hyperinflation is particularly common in children. Acute attacks may be accompanied by tachycardia, tachypnea and diaphoresis. In severe attacks, the patient may be unable to speak more than a few words without pausing for breath, Cyanosis, confusion and lethargy indicate the onset of respiratory failure. Status asthmaticus is a long-lasting and severe asthma episode that does not respond to standard treatment. It occurs when asthma symptoms - difficulty breathing, wheezing, and coughing - fail to improve with emergency medication treatment. Status asthmaticus is a medical emergency that can lead to death.
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Signs and Symptoms
Mild intermittent Asthma no more than twice a
Mild persistent asthma 3 to 6 days a week
Moderate persistent asthma Daily daytime symptoms
Daytime Symptoms
week
No more than twice a Nighttime symptoms month
3 to 4 times a month
At least weekly
Lung function testing
80% of predicted value or higher
80% of predicted value or higher
60% to 80% of predicted value
Peak expiratory flow
Varies no more than 20%
Varies between 20% and 30%
Varies more than 30%
Diagnostic results: 1. Pulmonary Function studies reveal signs of airway obstruction. Decreased vital capacity, increased total lung and residual capacity. May be normal between attacks 2. decreased arterial oxygen saturation 3. Arterial blood gas provides the best indications of an attacks severity. In acutely severe asthma, the partial pressure of arterial oxygen is less than 60mmHg, partial pressure of arterial carbon dioxide is 40 mmHg or more and pH is usually decreased 4. eosinophil count 5. hyperinflation with areas of focal atelectasis Chest x-rays may show Complete blood count increased Pulse oximetry may reveal
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D. Health Promotion and Preventive Aspects of the Disease Primary prevention is introduced before exposure to risk factors known to be associated with a disease. The goal is to prevent the onset of disease in susceptible (at-risk) individuals. This is not yet possible in asthma. Increasing evidence indicates that allergic sensitization is the most common precursor to the development of asthma. Since sensitization can occur antenatally, much of the focus of primary prevention will likely be on perinatal interventions. Secondary prevention is employed after primary sensitization to allergen has occurred, but before there is any evidence of disease. The aim is to prevent the establishment of chronic, persistent disease in people who are susceptible and who have early signs of the disease. This is currently being investigated in asthma. Secondary prevention of asthma is likely to focus very specifically on the first year or two of life. Tertiary prevention involves avoidance of allergens and nonspecific triggers when asthma is established. The goal is to prevent exacerbations or illness that would otherwise occur with exposure to identified allergens or irritants. It is considered that tertiary prevention should be introduced when the first signs of asthma have occurred. However, increasing evidence would suggest that the histopathology of the disease is fully established by the time asthma symptoms occur. Preventing asthma attacks is a part of tertiary prevention. Asthma attacks can be prevented by avoiding environmental pollutants and allergens. Use of masks can help to prevent the inhalation of gas irritants such as carbon monoxide and nitrates. Limiting the use of objects such as rags, feathered pillows, flowers and plants and avoiding pets and regulating the temperature can decrease the risk for the occurrence of unwanted asthma attacks. Vigorous physical exertion should also be avoided to avoid the drying of airways which could induce
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asthma exacerbation. Being psychologically well by being open to emotions and feelings may also help to avoid aggravating asthma. Also, using inhaled corticosteroids, antihistamines, decongestants, cromolyn powder by inhalation, leukotriene modifier and oral or aerosol bronchodilators can reduce or subside asthma attacks. B. Schematic Diagram (Patient-based)
Non-Modifiable Risk Factors: a. Family history of asthma b. Gender (Male child-onset) d. Age (2y/o onset of pts asthma)
Immunoglobulin E stimulation by B Lymphocytes
Mast cell degranulation
Modifiable Risk Factors: Extrinsic factors a. Exposure to allergens - animal fur(cats and dogs) b. Irritant gasses Kerosene gas c. Occupation-related substance construction worker d. Environmental pollution - Smoker since 13y/o - Use of marijuana since 15 y/o - Use of methamphetamine - Exposure to vehicular smoke - use of wood for cooking Intrinsic factors - Emotional stress excitatory state during alcohol drinking and drug use.
Histamine
SRS-A
Prostaglandins
Bradykinins
Leukotrienes
Airway hyperresponsiveness
Inflammation Mucus secretion Bronchial Asthma in Acute Exacerbation Bronchospasm 52
a. Non-productive cough and congested nose( 08-14-10)
a. Tachypnea (08-14-10) 29 cpm (08-15-10) 25cpm (08-16-10) 26 cpm (08-17-10) 25cpm
(08-14-10) a. Difficulty of breathing b. Chest tightness
B. Synthesis of the Disease (Patient-centered) A. Definition of the Disease Bronchial Asthma is a medical term that refers to a chronic respiratory illness that entails inflammation of air passageways. The common symptoms of bronchial asthma, which is more commonly known as asthma, include wheezing, shortness of breath, coughing and even chest tightening.
B. Predisposing/Precipitating Factors
Non- Modifiable: 1. Family History of asthma - Asthma has been greatly connected with familial predisposition. Although there is no such thing as asthma gene, the genes of the family line are more susceptible to allergens and are more sensitive to pollutants. In Mr. Cocos case, his great grandparents as well as his parents do not have the disease condition; however, her second sister, ate dos also has asthma since childhood.
2. Gender and Age - Mr. Coco is a male and his manifestations of asthma appeared at 2 years of age. According to studies, half of all cases first occur in
children younger than age 10; in this age group, asthma affects twice as many males as females.
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Modifiable Extrinsic 1. Exposure to allergens a. Animal fur - Mr. Coco live in a compound and almost all of their neighbors have dogs and cats, inducing Mr. Cocos exposure to animal fur which is considered as an allergen.
2. Irritant gasses - According to Mother wheezy, one of her management to Mr. Cocos asthma is by applying kerosene gas on Mr. Cocos back when he was still in his childhood years. Kerosene is irritating to the airway and may have direct effects on the respiratory tract
3. Occupation-related substance - Mr. Coco previously worked as a construction worker wherein his major job is too mix sand and cement powder. Sand can cause irritation to mucosal lining and airway leading to an increase risk for an asthma attack
4. Environmental pollution -Mr. Coco revealed that he started smoking when was 13 years old and he has been using marijuana and methamphetamine since 15 years of age. According to Mr. Coco, he inhales such substances or uses fire to create smoke and fumes. Also, the location of Mr. Cocos house is highly exposed to smoke from vehicles and he also stated that his family, as well as his neighbors in the compound uses wood instead of a stove to cook their meals Bronchial Asthma in Acute Exacerbation 54
Intrinsic 1. Emotional stress - According to Mr. Coco, he usually feels delighted and he always perform physical activities together with his friends especially whenever they drink alcohol and every time they use marijuana.
C. Signs and Symptoms Mr. Coco experienced difficulty of breathing, tachypnea, and chest tightness on August 14, 2010. His respiratory rate is elevated from August 14 to August 17, 2010.
D. Health promotion and preventive aspects of the disease Base from the patients history, during his childhood, from 2 to 7 years of age, his mother, Mother wheezy managed Mr. Cocos asthma by providing herbal medicines such as oregano, by allowing Mr. Coco to drink morning dew of plants and by applying kerosene gas on Mr. Cocos back. At present, Mr. Coco do not take any precautions or preventive measures to manage his asthma.
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V. THE PATIENT AND HIS CARE
A. Medical Management a. INTRAVENOUS FLUIDS
MEDICAL MANAGEMENT/ TREATMENT
DATE ORDERED/ DATE PERFORMED/ DATE CHANGED
GENERAL DESCRIPTION
INDICATION(S) OR PURPOSE
CLIENTS RESPONSE TO THE TREATMENT
This medication is a solution D5 W 500 cc x KV August 14, 2010 given by vein (through an IV). It is also used as a mixing solution (diluent) for other IV medications. Dextrose is a natural sugar found in the body and serves as a major energy source. When used as an energy source, dextrose allows the body to preserve its muscle mass.
> It is used to supply water and calories to the Mr Cocos body. Physical exertion due to coughing and chest tightness may increase the patients metabolic demand. This IVF therapy is also ordered in KVO to promote administration of medications through IV
Clients body responded positively to the said treatment as manifested by the positive result of good skin turgor (08.16.10) and good capillary refill (08.16.10) as well as the normal hematocrit level of the patient. (08.14.10)
GENERAL DESCRIPTION
D5LRS 1L x 20-21gtts/min
August 16, 2010 9:20 am (started)
Each 100 mL of 5% Dextrose in Lactated Ringer's Injection contains: Hydrous Dextrose USP 5 g; Sodium Chloride USP 0.6 g, Sodium Lactate 0.31 g; Potassium Chloride USP 0.03 g, Calcium Chloride Dihydrate USP 0.02 g, Water for Injection USP qs , 5% Dextrose in Lactated Ringer's Injection is sterile, nonpyrogenic and contains no bacteriostatic or antimicrobial agents. This product is intended for intravenous administration.
This IV solution is given to the patient to maintain his hydration status and to compensate for his increase metabolic demand due to exertion during coughing and asthma attacks.
The pt. did not show any hypersensitivity reaction to the IVF and remains to have a good hydration status AEB he did not manifests any signs of dehydration or weakness.
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GENERAL DESCRIPTION
D5 D5W 500cc KVO + 2amps aminophylline
August 16, 2010 9:25(started)
Aminophylline is a bronchodilator, it relaxes bronchial smooth muscle causing bronchodilator and
The following are the reasons why such IVF is given to the pt:
>Symptomatic relief increasing vital capacity, which or prevention of bronchochial asthma has been impaired by and reversible bronchospasm and air bronchospasm trapping, in higher > It is used to supply concentration, and it also water and calories to inhibits the release of slow the body. reacting substance of anaphylaxis and histamine and >Supplies body water for hydration. suppresses the response of airways to stimuli. D5 D5W is a solution given by vein (through an IV). It is also used as a mixing solution
Bronchial Asthma in Acute Exacerbation 59
Mr. Coco responded positively to the IVF therapy since he was relieved from chest tightness and bronchoconstriction (08-17-10). He also manifested good skin turgor (08.16.10) and good capillary refill (08.16.10) which are indicators of good oxygenation status.
(diluent) for other IV medications. Dextrose is a natural sugar found in the body and serves as a major energy source. When used as an energy source, dextrose allows the body to preserve its muscle mass.
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NURSING RESPONSIBILITIES Before: During: Read doctors order carefully to determine type of fluid and regulation Identify patient and establish good working relationship with the SO and patient. Explain the procedure to the SO Carry out hand hygiene & put on disposable non latex gloves Prime the tubing before insertion Apply a tourniquet 4-6 inches above the sites apply identify a suitable vein.
Explain to the SO what you are going to do, why is it necessary & how can she cooperates. Question the SO regarding patient sensitivity of latex; use blood pressure cuff instead of latex tourniquet if the patient is positive for latex sensitivity. Apply new tourniquet for each patient & palpate for pulse and distal tourniquet With hand holding the veins access device, steady patients arm & use the finger to pull skin taut Holding the needle bake up and at 5-25 degree angle depending on the depth of vein If backflow of blood is visible, straighten and advance the needle. Cover & tape the small loop of IV tubing on the dressing Calculate infusion rate and regulate flow of infusion Calculate if IV is infusing well After: Document date and time of therapy Discard needles, stylets, guardrives into a puncture resistant needle container Perform a detailed follow up based findings that deviated from expected or normal for the patient Place splint to support the IV needle Regulate IV as prescribed Document reaction of the patient toward this management.
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b. DRUGS
GENERIC NAME (BRAND NAME)
DATE ORDERED DATE D/C
ROUTE DOSAGE FREQUENCY
GENERAL ACTION
INDICATION / PURPOSE
CLIENTS RESPONSE
Generic Name: Salbutamol August 14, 2010 3 doses q 4o min intervals
Brand Name: Ventolin neb.
It is used for relief of bronchospasm in patients with reversible obstructive airway disease and relaxation of uterine smooth muscle to delay threatened abortion.
Salbutamol was given to the patient to relieve his bronchospasm since asthma attacks involve the constriction of the bronchioles which could impair oxygenation.
Mr. Coco manifested a normal Hgb count of 146g/L (08-1410) which may indicate his good oxygenation status. He was also relieved from chest-tightness and difficulty of breathing (08-1710)
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GENERIC NAME (BRAND NAME)
DATE ORDERED DATE D/C
ROUTE DOSAGE FREQUENCY 1 gm q12 o min intervals
GENERAL ACTION
INDICATION / PURPOSE
CLIENTS RESPONSE
Generic Name: Ceftriaxone
August10, 2010
Brand Name: Rocephin
Effective against urinary tract infections, lower respiratory tract infections, infections of the skin and soft tissue, adnexitis, typhus, as well as in the prevention of infections in neutropenia and perioperative infections (single dose). It can be used for endocarditis or septicemia if there are sensitive germs. Ceftriaxone is not always effective against syphilis and chancroid (Haemophilus ducreyi). It is only insufficiently active in pseudonomas .
The patient is given Ceftriaxone to eradicate infections which could cause the inflammation of his airways.
Patient did not manifest any signs of infection and his WBC is within normal level 9.4 x 103 g/ (08-14-10) He was also relieved from chest-tightness and difficulty of breathing (08-1710)
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GENERIC NAME (BRAND NAME) Generic Name: Hydrocortisone
DATE ORDERED DATE D/C August 10, 2010
ROUTE DOSAGE FREQUENCY q12 o min intervals
GENERAL ACTION Corticosteroid (short acting), which enter the target cells and binds to cytoplasmic receptors. Initiates many complex reactions that are responsible for its anti inflammatory, immunosuppressive and salt retaining actions. Some action may be undesirable, depending on drug use.
INDICATION / PURPOSE Hydrocortisone was given to relieve patient from inflammation which is the cause of bronchoconstriction and increase mucus production.
CLIENTS RESPONSE The patient was relieved from chest-tightness and difficulty of breathing (08-1710) which could suggest the relief of patient from the inflammation of his airways.
Brand Name: A-Hydrocort SoluCortef
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NURSING RESPONSIBILITIES: Before: Check 10 rights of administration of drugs Check doctors order three times & verify the patient Check the label of the drug, Its name & its expiration date Explain the importance of compliance in medication regimen Obtain history of previous use & reaction to medication Wash hands before handling the medication
During: Administer as ordered Administer with aseptic technique. Aseptic technique is employed to maximize and maintain asepsis, the absence of pathogenic organisms, in the clinical setting. The goals of aseptic technique are to protect the patient from infection and to prevent the spread of pathogens. After: Instruct SO to notify prescriber about rash or evidence of superinfection to patient. Observe for drug side effects to the patient Evaluate the effect of medication to the patients condition
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c. DIET Date Ordered Date Performed Date Changed General Description Indication Or Purposes Specific Foods Taken Clients response and/or reaction to the diet
Type of Diet
Nothing per Date Ordered: orem July 12, 2010
Nothing per orem or NPO is a type of diet performed by withholding oral foods and fluids for various reasons such as to avoid aspiration and for diagnostic procedures After NPO, pt. may shift to liquid diet or SFF
NPO was ordered to avoid aspiration since he is experiencing coughing and increase mucus production. Eating could block the airway causing respiratory distress and arrest.
Because of NPO, Mr. Coco did not experience aspiration or any unwanted blockage of the airway.
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NURSING RESPONSIBILITIES:
Before: Check the doctors order. Explain to the SO the importance and purpose of placing pt on NPO Emphasize to the SO that strict compliance should be done until further orders on shifting to another diet is done
After: Advice the SO to religiously comply with the diet as prescribed. Provide oral hygiene. Monitor patients reaction and compliance with the diet.
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Type of Diet
Date Ordered Date Performed Date Changed 08-15-10
General Description
Indication Or Purposes
Specific Foods Taken
Clients response and/or reaction to the diet Mr. Coco did not experience aspiration or any unwanted blockage of the airway.
Soft diet
a diet that is soft in texture, low in residue, easily digested, and well tolerated. It provides the essential nutrients in the form of liquids and semisolid foods, such as milk; fruit juices; eggs; cheese; custards; tapioca and puddings; strained soups and vegetables; rice; ground beef and lamb; fowl; fish; mashed, boiled, or baked potatoes; wheat, corn, or rice cereals; and breads
Soft Diet was ordered to avoid aspiration since Mr. Coco is experiencing cough, chest tightness, DOB and increase mucus production.
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NURSING RESPONSIBILITIES:
Before: Check the doctors order. Explain to the SO the importance and purpose of placing pt on Soft Diet Emphasize to the SO that strict compliance should be done until further orders on shifting to another diet is done
After: Advice the SO to religiously comply with the diet as prescribed. Provide oral hygiene. Monitor patients reaction and compliance with the diet.
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ACTIVITY
Activity
Date Ordered Date Performed Date Changed Date Performed: 08-17-10
General Description
Indication
Clients Reaction to Activity
Chest Physiotherapy
A Nursing intervention where in it is assisting the patient to move airway secretions from peripheral airway to more central airway for a more effective expectoration.
Due to the inflammation Patient was able to of his airway, the pt expectorate retained experienced an increase secretions. in mucus secretion. This is done to mobilize secretion of the patient to maintain a patent airway.
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Before: Check the doctors order. Identify the patient. Ask the SO for proper identification. Explain to the SO the purpose of order. During: Assist the SO in allowing pt to perform the prescribed activity. Reinforce to the SO the importance of having such activity. After: Monitor patients response Provide safety measure such as by raising side rails or stretching of bed linens. Monitor clients reaction and SOs compliance with the activity.
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NURSING MANAGEMENT 1. Nursing Care Plans
Ineffective Airway Clearance Assessment Nursing diagnosis Ineffective airway clearance related to presence of retained secretions AEB productive cough Scientific explanation Maintaining a patent airway is vital to life. Coughing is the main mechanism for clearing the airway. However, the cough may be ineffective in both normal and disease states secondary to factors such as pain from surgical incisions/ trauma, respiratory muscle fatigue, or neuromuscular Planning Interventions Rationale Expected outcome
S= O O= the pt manifest > productive cough > rales heard upon auscultation on both lung fields >nasal secretions > difficulty vocalizing
Short term:
> Establish rapport
> To gain patient and SOs trust and cooperation
Short term:
After 4 of NI, the pt will be able to maintain airway patency AEB absence of nasal secretions, gradual relief of DOB
> Monitor and record V/S
> To obtain baseline data for reference
After 4 of NI, the pt shall have maintained airway patency AEB absence of nasal secretions, gradual relief of
> Asses patients general condition
> To ascertain status and DOB note progress and note progress
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> restlessness
The patient may manifested: > decreased exercise tolerance > prolonged expiration >adventitious breath sounds > cyanosis
weakness. Other mechanisms that exist in the lower bronchioles and alveoli to maintain the airway include the mucociliary system, macrophages, and the lymphatics. Factors such as anesthesia and dehydration can affect function of the mucociliary system. Ineffective airway clearance is inability to clear secretions or obstructions from the respiratory tract to maintain airway patency. Likewise,
Long term: > To assess for presence of adventitious sounds Long term:
After 2 days of Ni, the pt.secretions are mobilized and airway is maintained free of secretions, AEB clear lung sounds, eupnea, and ability to effectively cough up secretions after treatments and deep breaths.
>Auscultate breath sounds
>Elevate HOB
> To take advantage of gravity decreasing pressure on the diaphragm
> To prevent further complication >Keep pts back dry > To maintain open airway in a patient at rest or compromised individual
After 2 days of Ni, pt shall have improved a healthy living condition AEB clear lung sounds, eupnea, and ability to effectively cough up secretions after treatments and deep breaths.
>Position head midline with flexion appropriate for age or condition
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conditions will cause increased production of secretions due to irritation upon inhalation then there will be infammtory response which results to increase production of secretions so the there will airway constriction that will cause dyspnea that make it difficult to keep a patent airway AMB DOB, productive cough and difficulty in vocalizng.
>Instruct SO to >To help liquefy increase pts fluid secretions intake
>Assisst in performing nebulization
>To moisten respiratory tract mucosa
>Instruct SO to perform bronchial tapping after each nebulization
>To improve lung function and mobilize secretions
> Observe for signs and symptoms of infection such as fever, (+)pus, foul >To identify infectious process or promote
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odor
timely intervention
> Explain effects of wearing restrictive clothing
>Provide opportunities for rest
> Respiratory excursion is not compromised and may reduce the oxygen supply in the ody
>To prevent fatigue and conserve energy > Teach and supervise effective coughing techniques >In order to provide proper expectorationof secretions.
>Administer bronchodilators as ordered

>To relax the respiratory tractt and tol easily mobilize secretions.
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Ineffective Breathing Pattern Assessment Nursing Diagnosis Scientific Explanation Objectives Short term: S= Medyo nahihirapan akong huminga Ineffective breathing pattern r/t presence of secretions AEB productive cough and DOB 2 BAIAE Impaired gas exchange is the excessiveness or deficiency of oxygenation and/or carbon dioxide elimination at the respiratory system. The retained secretions in the lungs will occlude the respiratory membrane thus causing them to Nursing Interventions > Establish rapport Rationale > To gain patient and SOs trust and cooperation Expected Outcome Short term:
O= The patient manifested:
> with productive cough > rales heard upon auscultation on both lung
After 4 hours of nursing interventions, the patient will be able to verbalize understanding of causative factors and appropriate interventions.
The patient shall have > To obtain baseline verbalized data for reference understanding and to asses for rapid of causative alteration in V/S factors and appropriate interventions . > To note for etiology and precipitating factors regarding patients condition
Long term:
> To evaluate degree of compromise and > prompts recognition

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fields >nasal secretions
> The patient may manifest:
> restlessness > irritability > depth of breathing > nasal flaring > cyanosis
consolidate. Therefore the function of the alveoli capillary membrane will be altered. This result in the implant of oxygen and carbon dioxide exchange can further lead to hypoxemia.
After 2 days of nursing interventions, patient will demonstrate improved ventilation and adequate oxygenation of tissues and absence of DOB
> Note respiratory rate and depth, use of accessory muscles and areas of pallor/cyanosis
of deteriorating respiratory function can decrease potentially lethal outcomes
Long term:
> To ascertain status and note progress of the patients condition
The patient shall have improved ventilation and adequate oxygenation of tissues and absence of DOB
> Auscultate breath sounds, note areas of decreased/adventitious > To maintain airway breath sounds and promote lung expansion
> Elevate head of bed/position patient appropriately

> For mobilization of secretions and helps to thin secretions for
better expectoration > Maintain adequate intake of fluids
> Helps limit oxygen needs/consumption which will at least alleviate pts condition
> Encourage SO to have patient adequate rest > To reduce irritant periods effect on airways and prevent further complication > Keep environment allergen/pollutant free
> To promote prevention and management of risk in order to endorse wellness
> Review risk factors, particularly the

> For the patient to
environmental and socio economic condition
adhere to the medical regimen
> Instruct SO importance of compliance to medical regimen
>To treat the underlying condition
> Administer medications as needed and prescribed
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Risk for aspiration Assessment Nursing Diagnosis Scientific Explanation Objectives Interventions > Establish rapport Rationale > To gain patient and SOs trust and cooperation Expected Outcomes
S=
Risk for aspiration r/t production of secretion
> with productive cough
> rales heard upon auscultation on both lung fields
At risk for entry of gastrointestinal secretions, oropharyngeal secretions, or solids or fluids into tracheobronchial passages because of Increased production of secretions is a defense mechanism of the body to expel invading pathogens in the
Short Term:
Short Term:
After 4 hrs. of nursing intervention the patient SO will identify causative/risk factors of aspiration and maintain patent airway
> To ascertain status and note progress and note progress
The patient shall have identified causative/risk factors of aspiration and maintain patent airway
Long Term: > To assess for presence of adventitious sounds
Long Term: >Auscultate

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>nasal
The patient shall have decreased
secretions
> The patient may manifest: >wide eyes >protrusion of tongue >hypoxia >dyspnea
lungs. Overproduction of secretion depresses the gag reflex which poses the patient at risk in aspiration.
breath sounds After 2 days of nursing intervention the patient will be able to decreased risk of aspiration with the help of proper assessment and early intervention > Provides information about respiratory pattern changes caused by aspiration
risk of aspiration with the help of proper assessment and early intervention
> Assess respiratory status for rate, depth and ease, breath sounds before and after feeding
> To determine patient susceptibility or aspiration
> Assess amount and consistency of respiratory secretions and strength of gag/ cough reflex
> Assess for

> Predisposes to aspiration of contents of reflux which is precipitated by
vomiting and activity intolerance
factors associated with feeding
> Prevents reflux and minimizes symptoms
> Offer frequent, > For possible small feedings clogging of secretion in patients airway > Maintain operational suction equipment at hand
> To remove secretion and promote patent airway and tissue
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> Suction patient oxygenation as needed > To prevent aspiration of milk to the lungs
> Patient should be propped at the right side after feeding
> To prevent aspiration and minimizes risk for reflux
> Feed the patient with head elevated
> For the patient to adhere to the medical regimen
> Instruct SO importance of compliance to

>To treat the underlying
medical regimen
condition
> Administer medications as needed
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Risk for infection Assessment S= Nursing Diagnosis Risk for infection r/t ineffective pulmonary clearance 2 BAIAE Scientific Explanation Objectives Nursing Interventions > Establish rapport Rationale > To gain patient and SOs trust and cooperation Expected Outcome Short term:
O= The patient manifested: > with productive cough > rales heard upon auscultation on both lung fields > nasal secretions >Temp. of 37.5C
At increased Short term: risk for being invaded by pathogenic After 4 hours of organisms. nursing interventions, Pulmonary patients SO hygiene is will be able to needed to rid remain free of the lungs of infection, AEB secretions. normal vital When there is signs and constriction decreased and thickening cough of the production bronchioles ciliary function is impaired resulting to reduction in Long term: mucus
The patients SO shall have remained free of infection, AEB normal vital signs and decreased cough production
> Stress to patient the importance of hand washing after

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> Hand washing is the primary defense against the spread of infection
Long term:
> The patient may manifest: > restlessness > irritability > hyperthermia > increase WBC count >increased dyspnea >chills
clearance. There is a further increase in mucus production as the affected bronchioles are inflamed. Mucus secretions are retained in the lungs resulting to increase susceptibility to infection.
After 2 days of nursing interventions, patient will demonstrate techniques to promote safe environment AEB health promotion behaviors and awareness of manifestation of pulmonary infection
contact with potentially infectious material
The patient shall have > For mobilization of secretions and helps to thin secretions for better expectoration demonstrated techniques to promote safe environment AEB health promotion behaviors and awareness of manifestation of pulmonary infection
> Maintain adequate intake of fluids
> Teach the pt about the manifestations of pulmonary infections (change in color or volume of sputum, fever, chills, malaise, productive cough, confusion, increased dyspnea) self-care and when to call physician
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> Early recognition of manifestations can lead to a rapid diagnosis. Self-care with preplanned interventions (eg antibiotics) should be understood. Notification of the physician can provide for early treatment.
> To prevent
exposure to possible infection and further complications > Monitor and limit pts visitor > For mobilization of secretions and helps to thin secretions for better expectoration > Encourage deep breathing exercises, position change and coughing exercises
> Helps limit oxygen needs/consumption which will at least alleviate pts condition
> Encourage patient to have adequate rest periods
> To promote prevention and management of risk in order to endorse wellness
> Review risk factors, particularly

the environmental condition
> For the patient to adhere to the medical regimen
> Instruct patient about the importance of compliance to medical regimen
> Administer medications (such as antibiotics) as needed and as prescribe
> Antibiotics inhibits bacterial multiplication and alleviate the underlying condition
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Hyperthermia Assessment Nursing Diagnosis Hyperthermia Scientific Explanation Hyperthermia is a state in which the individuals temperature is above the normal range. Due to the presence of microorganisms or inflammation, endotoxins will reach the brain affecting the thermoregulatory center of the brain which is the hypothalamus causing alteration in the hypothalamic thermostat Objectives Nursing Interventions Short term: >Establish rapport >To gain pt. and SOs trust and cooperation. Rationale Expected Outcome Short term:
S=
> with productive cough > rales heard upon auscultation on both lung fields >flushed skin >skin is warm to touch
After 4 hrs of NI, pts temperature >Monitor and will decrease record VS from 37.5C to 36.8C. >Assess pts general condition
>To obtain baseline data
Pts temperature shall decrease from 37.5C to 36.8C
Long term:
After 2 days of NI, pt. will maintain a temperature within normal

89
>To note for etiology or precipitating factors that can lead to hyperthermia
Long term:
>To promote heat loss
The pt. shall maintain temperature within normal range (36.537.2C) and will
> nasal secretions >increased in body temp 37.5 (08-14-10)
leading hyperthermia.
to range (36.537.2C) and will not develop complications such as convulsions.
>Perform TSB
through evaporation.
not develop complications such as convulsions.
>To promote heat loss by radiation and conduction. >Instruct SO to remove excess clothing
> The patient may manifest: > restlessness > irritability > hyperthermia > increase WBC count >fatigue >increased dyspnea >chills
>To reduce metabolic demands
>Encourage SO to provide adequate rest periods for pt.
>To support the circulating volume and tissue perfusion
>Instruct SO to increase oral fluid intake of pt.

>To meet increased
metabolic demands >Instruct SO to give high calorie diet
>To increase resistance
>Instruct SO to >To reduce increase pts Vit. fever by its C intake central action to the hypothalamus. >Administer antipyretic as ordered
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Risk for Nutrition Imbalanced, Less than body requirements Assessment Nursing Diagnosis Scientific Explanation Adequate nutrition is necessary to meet the bodys demands. Nutritional status can be affected by disease or injury states Nutrition Imbalanced, less than body requirements occurs when intake of nutrients is insufficient to meet metabolic Objectives Interventions Rationale Expected Outcome Short term:
Short term:
S=Mepayat ku pin eh. O= Pt. manifested the following: - poor appetite -poor muscle tone -productive cough -restlessness
Risk for Nutrition: Imbalanced, less than body requirements r/t the disease condition BAIAE
>Establish rapport
After 4 hrs. of NI, pt. will manifest behavior to regain weight such as increased >Monitor and in appetite. record VS
> To gain patient and SOs trust and cooperation
The patient shall have manifested behavior to regain weight such as increased in appetite.
Long term:
>Assess pts general condition
Long term:
>patient may manifest:
After 2 days of NI, pt. will demonstrate wt. gain towards

92
The patient shall have demonstrated wt. gain towards
>fatigue >malaise >cyanosis
needs. Due to the inflammatory process occurring and due to the brochial secretions in the lungs , which made the patient not to eat the adequate amount of food.
goal.
>To evaluate pt. nutritional status and obtain baseline wt. >Assess pts nutritional status
goal.
>To enhance intake
>To prevent aspiration >Give fluids to pt. as tolerated >To emphasize importance of >Give slow well- balanced frequent feeding diet and nutritional intake >Provide SO with information >To promote regarding pts
93
nutritional needs
adequate nutritional intake.
>Encourage SO to give Vit. rich foods
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2. Actual Soapies S > O >received on sitting position, conscious and coherent, good skin turgor, capillary refill time of 3seconds; the ffg VS taken and recorded as follows: T= 36 C, PR= 84bpm, RR=24cpm, BP= 130/90mmHg A > Ineffective airway clearance related to increased production of secretions P > after 4 hours of nursing interventions, the patient will demonstrate behaviors to improve airway clearance. I >established rapport >Auscultated breath sounds. >Assessed general condition >Monitored and regulated IVF >Elevated head of the bed have patient lean on over bed table or sit on edge of the bed. >Maintained proper ventilation >Encouraged adequate rest periods to conserve energy >Encouraged abdominal or pursed lip breathing exercises. >Assisted with measures to improve effectiveness of cough effort. >Regulated IVF accordingly >Further needs attended >Endorsed E > after 4 hours of nursing interventions, the patient will demonstrate behaviors to improve airway clearance AEB stable VS
S > O >received on sitting position, conscious and coherent, good skin turgor, capillary refill time of 3seconds; the ffg VS taken and recorded as follows: T= 36 C, PR= 84bpm, RR=24cpm, BP= 130/90mmHg A > Ineffective breathing pattern r/t increase mucus secretion and bronchoconstriction P > after 4 hours of nursing interventions, the patient will demonstrate behaviors to achieve effective breathing pattern I >established rapport >Assessed general condition >Monitored and regulated IVF accordingly >Auscultated breath sounds >Elevated head of the bed have patient lean on over bed table or sit on edge of the bed. >Maintained proper ventilation > discussed pursed-lip breathing > Performed chest physiotherapy >Encouraged adequate rest periods to conserve energy >Assisted with measures to improve effectiveness of cough effort. >Regulated IVF accordingly >Further needs attended >Endorsed E > after 4 hours of nursing interventions, the patient will demonstrate behaviors to improve airway clearance AEB stable VS
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VI. CLIENTS DAILY PROGRESS IN THE HOSPITAL
A. Clients Daily Progress Chart

DAYS ADMISSION (08-14-10) 2 (08-15-10) 3 (08-16-10) 4 (08-17-10)
Nursing Problems 1.Ineffective Airway clearance 2.Ineffective breathing pattern 3.Risk for aspiration 4.Risk for Infection 5.Hyperthermia 6. Risk for Imbalanced nutrition: less than body requirement
Vital Signs Temp: PR: RR: BP: 37.5 87 22 110/80 36.4 86 23 120/80 36.5 84 24 120/80 36.5 84 24 120/80
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OXC/Lab. Procedures 1. CBC
Medical Management
1.D5W 500ml KVO 2.D5LRS x20-21gtts 9:20(started) 3.D5W 500cc KVO + 2amps aminophylline 9:25(started)
x x
x x x
4. D5LR 1L x5h FTF x
DRUGS 1.Salbutamol Q4 2.Hydrocortisone IV Q6 20mg 3.Ceftriaxone 1gm Q12 4.Aminophylline2amps X x x
500cc D5W x 10ugtts/min
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DIET
NPO
Soft diet w/ SAP
Soft diet w/ SAP
Soft diet w/ SAP
ACTIVITY/EXERCISE
Chest Physiotherapy
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. Discharge planning a. General condition of client upon discharge Student Nurses failed to assess and to meet the patient upon his discharge.
b. METHODS
Exercise: Encouraged adequate rest and sleep
Health Teachings: Instructed to keep environment free from smoke and allergens Encouraged to observe proper positional measures in feeding the pt Encouraged to elevate head to 30 degree angle to promote lung expansion Encouraged SO to always monitor pt especially when feeding since pt is at risk for aspiration. Encouraged SO to increase fluid intake of pt Discussed and taught the proper way in performing chest physiotherapy Instruct to eat before nebulization to avoid aspiration
Diet: Instructed to eat foods high in CHO, CHONm vitamins and minerals Increased fluid intake of pt.
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VII. SUMMARY
Upon the completion of the study, the researchers were able to: Identify and differentiate risks for BAIAE. Be updated with the latest trends and in the treatment of the BAIAE Perform a comprehensive assessment of BAIAE. Enumerate the different signs and symptoms of BAIAE. List down the different diagnostic procedures that would help in the diagnosis of BAIAE including the normal values, indications, and results of the pts laboratory test. Identify and understand different types of medical treatment necessary for the treatment of BAIAE. Formulate nursing care plans utilizing the nursing process. Formulate conclusions based on the findings and enumerated
recommendations concerning BAIAE. Have critical thinking necessary for providing safe and effective nursing care. Have a comprehensive assessment and implement care based on our knowledge and skills of the condition. Have familiarized us with effective inter-personal skills to emphasized health promotion and illness prevention. Increased awareness on the risk factors of BAIAE. Develop the familys support system and distinguish their respective roles in improving the patients health status and involved them in promoting the health care of the patient.
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VIII. CONCLUSIONS
The researchers were able to accomplish the task given to them. They were able to established rapport and achieve trust with the patient and his significant others. They were able to show patients data with the information gathered and interpret the data. The workload is properly distributed with the patient and the task is completed on time.
VIII. RECOMMENDATIONS:
The study can be recommended for the following persons: To the physicians. They can acquire base line knowledge about the condition of the patient. They can help with the prognosis of the patient. They can perform appropriate interventions and surgical operations for the betterment of the patient. To the nurses. Acquiring this information can equip the nurse to render proper nursing intervention for the prognosis of the patient. To the clinical instructors and nursing students. This study will be helpful to increase awareness regarding several conditions and that they can give appropriate health teachings to the people for the prevention of the occurrence of such condition.
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X. LEARNING DERIVED
Having the case of Bronchial Asthma in Acute exacerbation gave us more understanding and knowledge of the disease condition. We wanted to contribute in some ways in order to minimize the increasing number of people who are diagnosed with such disease through the interventions and health teachings that we provided. Suppressing the fact thought of hunger, stiffening our neck and enduring our back pain as we face our computer, trying to figure out on how to make a scholarly and a well written case study. It was a blast. It caused more severity of our daily bad headaches, however we are very much thankful with this case study because of the added knowledge that was imparted. These little pieces of knowledge, when combined will surely guide and light our way towards becoming a competent and responsible nurses someday.
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BIBLIOGRAPHY
Joyce M. Black, J. H. (2008). Medical-Surgical Nursing: Clinical Management for Positive Outcomes. Winsland House I: Elsevier. Karch, A. M. (2011). 2011 Lippincotts Nursing Drug Guide. Ambler City: Lippincott Williams & Wilkins. Marilyn E. Doenges, M. F. (2007). Nurses Pocket Guide, Diagnoses, Prioritized Interventions, and Rationales (2007) Edition 11 . Bangkok: iGroup Press Co, Ltd. . http://www.scribd.com/doc/16170708/Bronchial-Asthma-III-IIILectures http://www.healthcentral.com/asthma/c/55/7614/stress-asthma http://health.ezinemark.com/bronchial-asthma-mysteries-revealed-4f2be6caac9.html http://asthma.about.com/od/preventioncontrol/a/prev_asthmaRF.htm http://www.histopathology-india.net/BrAs.htm http://www.suite101.com/article.cfm/asthma/56505#ixzz0xOOoKp7c
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Bronchial Asthma in Acute Exacerbation

Angeles University Foundation

Ms. Kristine Anne S. Fernandez, RN, MN

Bronchial Asthma in Acute Exacerbation

Bronchial Asthma in Acute Exacerbation

Bronchial Asthma in Acute Exacerbation

4. 'TIMely' Intervention for Asthma Sciencedaily (July 12, 2010)

Bronchial Asthma in Acute Exacerbation

Bronchial Asthma in Acute Exacerbation

Bronchial Asthma in Acute Exacerbation

Evaluation Formulate conclusions based on the findings and enumerated

Bronchial Asthma in Acute Exacerbation

B.2 Patient/Family Centered Objectives

Bronchial Asthma in Acute Exacerbation

II. NURSING ASSESSMENT

Bronchial Asthma in Acute Exacerbation

P 4, 000 P14, 300

Bronchial Asthma in Acute Exacerbation

Bronchial Asthma in Acute Exacerbation

- Male O Female Grandfather + Abd 85 Grandmother + Tetanus, 56

+ - Deceased Abd abdominal abscess

Uncle Father + CVA , 33

Admitting Impression: Bronchial Asthma in Acute Exacerbation

Bronchial Asthma in Acute Exacerbation

Bronchial Asthma in Acute Exacerbation

K. Assessment of the Genitourinary The patient has no difficulty in urination.

Bronchial Asthma in Acute Exacerbation

He identified the mild aromas correctly

Instructed Mr. Coco to identify the picture shown to him

He was able to identify the picture shown to him

Sensory Vision and visual fields

IV. Trochlear Motor Moves downward and laterally

He perfectly performed the six ocular movements.

Bronchial Asthma in Acute Exacerbation

Sensory Sensation of cornea and skin of face and nasal mucosa

He moved his eyes symmetrically.

Motor Moves eyeball laterally VII. Facial

Motor and sensory

He will be able to perform all easily and symmetrically.

He definitely did all activities

He identified all tasted food appropriate or correctly.

Assessed auditory by means of whispering to him.

He correctly repeated the whispered words.

Sense of hearing Sensory

Bronchial Asthma in Acute Exacerbation

Motor and sensory Swallowing ability Tongue movement

He actually did all movement easily.

He spoke clearly and did not have a difficulty in swallowing.

XI. Accessory motor head movement shrugging of shoulder

XII. Hypoglossal motor protrusion of tongue

He did all movement instructed.

Bronchial Asthma in Acute Exacerbation

G. DIAGNOSTIC AND LABORATORY PROCEDURES

Analysis and interpretation

Blood Date ordered:

146 g/L NORMAL

0.44 g/L NORMAL

Bronchial Asthma in Acute Exacerbation

c. White Blood cells (WBC)

9.4 x 10 g/L NORMAL

Bronchial Asthma in Acute Exacerbation

Bronchial Asthma in Acute Exacerbation