I.

Introduction

Bronchial asthma is a disease caused by increased responsiveness of the

tracheobronchial tree to various stimuli. The result is paroxysmal constriction of the

bronchial airways. Bronchial asthma is the more correct name for the common form of

asthma. The term 'bronchial' is used to differentiate it from 'cardiac' asthma, which is a

separate condition that is caused by heart failure. Although the two types of asthma

have similar symptoms, including wheezing (a whistling sound in the chest) and

shortness of breath, they have quite different causes.

Bronchial asthma is a disease of the lungs in which an obstructive ventilation

disturbance of the respiratory passages evokes a feeling of shortness of breath. The

cause is a sharply elevated resistance to airflow in the airways. Despite its most

strenuous efforts, the respiratory musculature is unable to provide sufficient gas

exchange. The result is a characteristic asthma attack, with spasms of the bronchial

musculature, edematous swelling of the bronchial wall and increased mucus secretion.

In the initial stage, the patient can be totally symptom-free for long periods of time in the

intervals between the attacks. As the disease progresses, increased mucus is secreted

between attacks as well, which in part builds up in the airways and can then lead to

secondary bacterial infections. Bronchial asthma is usually intrinsic (no cause can be

demonstrated), but is occasionally caused by a specific allergy (such as allergy to mold,

dander, dust). Although most individuals with asthma will have some positive allergy

tests, the allergy is not necessarily the cause of the asthma symptoms.
Symptoms can occur spontaneously or can be triggered by respiratory infections,

exercise, cold air, tobacco smoke or other pollutants, stress or anxiety, or by food

allergies or drug allergies. The muscles of the bronchial tree become tight and the lining

of the air passages become swollen, reducing airflow and producing the wheezing

sound. Mucus production is increased.

Typically, the individual usually breathes relatively normally, and will have periodic

attacks of wheezing. Asthma attacks can last minutes to days, and can become

dangerous if the airflow becomes severely restricted. Asthma affects 1 in 20 of the

overall population, but the incidence is 1 in 10 in children. Asthma can develop at any

age, but some children seem to outgrow the illness. Risk factors include self or family

history of eczema, allergies or family history of asthma. Bronchial asthma causes

cough, shortness of breath, and wheezing. Bronchial asthma is an allergic condition, in

which the airways (bronchi) are hyper-reactive and constrict abnormally when exposed

to allergens, cold or exercise.

Treatment is aimed at avoiding known allergens and controlling symptoms through

medication. A variety of medications for treatment of asthma are available. People with

mild asthma (infrequent attacks) may use inhalers on an as-needed basis. Persons with

significant asthma (symptoms occur at least every week) should be treated with anti-

inflammatory medications, preferably inhaled corticosteroids, and then with

bronchodilators such as inhaled Alupent or Vanceril. Acute severe asthma may require

hospitalization, oxygen, and intravenous medications.

Decrease or control exposure to known allergens by staying away from cigarette

smoke, removing animals from bedrooms or entire houses, and avoiding foods that

cause symptoms. Allergy desensitization is rarely successful in reducing symptoms.

a. Overview of the case

Patient X is a male, a Filipino, a Roman Catholic, and was Admitted at

Polymedic General Hospital, under Dr. Joy Go last January 02, 2009. Due to shortness

of breath, cough, and fever.

b. Objective of the study

The care study was conducted for us students to dig deeply or have a thorough

understanding regarding the case of the patient. In this way, we will be able to apply our

knowledge on nursing assessment, problem identification, nursing interventions and

evaluation that is related to the disease condition of the patient. Through this study, our

understanding about the disease process will be put to application. By gathering the

subjective and objective data regarding the case, it will allow us to have a proper and

appropriate nursing care towards the condition of the patient.

c. Scope and Limitation of the study

The scope of this study focuses on health history of the patient that includes the

family history, as the history of present illness. It also involves the medical orders and

significance. And most importantly part of it are the nursing assessment, medical and

nursing management that include the drug therapy and it’s pharmacologic actions and

the discharge planning that is fused with the patient’s health teachings regarding the

disease condition.
lI. HEALTH HISTORY

a. Profile of patient

Name: X

Age: 4yrs. old

Sex: male

Address: Gracia. Tagoloan, Misamis oriental

Date of Birth: Dec. 22, 2005

Place of Birth: Gracia, tagoloan. Misamis Oriental

Nationality: Filipino

Religion: Roman Catholic

Date of Admission: Jan 02,2009

Time of Admission: 12:05 am

Hospital: Polymedic General Hospital

Informant: Mother

Attending Physician: Dr. Jocelyn Go

Chief Complaint: SOB, Cough, and Fever

Admitting Diagnosis: Bronchial Asthma

Vital signs Upon Admission:

T= 37.8 C

P= 137BPM

R= 30 CPM
Weight: 11.5 kg.

Height: 95 cm.

History of present illness:

A case of Pt. X a 4yr.old from Gracia, Tagoloan, Mis. Or. 8 days prior to admission .

d. Chief complain:

The chief complain of the patient is SOB. 8 days prior to admission onset of fever

with colds, fever was on and off and 4 days colds it was associated with cough given

PCM, Dizodrin night prior to admission condition associated with fast breathing with loss

of apetite, persisitence of signs and symptoms noted.

III. GROWTH and DEVELOPMENT (DEVELOPMENTAL HISTORY

Age Name Pleasure source Conflict

Mouth: sucking, biting, Weaning away from
0-2 Oral
swallowing mother's breast
Anus: defecating or retaining
2-4 Anal Toilet training
feces
Oedipus (boys),
4-5 Phallic Genitals
Electra (girls)
Sexual urges sublimated into
6- sports and hobbies. Same-
Latency
puberty sex friends also help avoid
sexual feelings.
Physical sexual changes
reawaken repressed needs.
puberty
Genital Direct sexual feelings Social
onward
towards others lead to sexual
gratification.
 Erikson’s theory of psychosocial development is one of the best-known theories

of personality. Similar to Freud, Erikson believed that personality develops in a series of

stages. Unlike Freud’s theory of psychosexual stages, Erikson’s theory describes the

impact of social experience across the whole lifespan.

One of the main elements of Erikson’s psychosocial stage theory is the

develoment of ego identity. Ego identity is the conscious sense of self that we develop

through social interaction. According to Erikson, our ego identity is constantly changing

due to new experience and information we acquire in our daily interactions with others.

In addition to ego identity, Erikson also believed that a sense of competence also

motivates behaviors and actions. Each stage in Erikson’s theory is concerned with

becoming competent in an area of life. If the stage is handled well, the person will feel a

sense of mastery. If the stage is managed poorly, the person will emerge with a sense

of inadequacy.

In each stage, Erikson believed people experience a conflict that serves as a

turning point in development. In Erikson’s view, these conflicts are centered on either

developing a psychological quality or failing to develop that quality. During these times,

the potential for personal growth is high, but so is the potential for failure.

Middle adulthood, from forty to thirty six years of age. The basic conflict is

between generativity versus stagnation and the important event is parenting. Each adult

must find some way to satisfy and support the next generation.
MEDICAL MANAGEMENT

MEDICAL ORDER
DOCTOR’S ORDER
1-02-09
• Please admit inder the service of Dr. Jocelyn Go
• Secure consent to care
• TPR every 4 hours
• Hypoallergic diet with aspirated precaution
• Labs: CBC, CXR, Urinalysis
• Start IVF with D5 0.3 NaCl 500cc at 55-66 cc/hr
• Medications:
1. Paracetamol 200g every 4 hours PRN for fever
2. Nebulization with salbutamol 1nebule now every 4 hours
• Please inform AP
• Refer accordingly

10:55 AM
• Received nebulization 1 nebule every 6 hours
• I nebule ventolin every 6 hours
• Asmanent 250 g 1 nebule every 12 hours
• Ceftriaxine (Rosephine) I gm OD ANST- to be given IV drip piggybak to
maintain. KSS after giving medications
• Give syrup Prozine 5ml OD PO
• Check 02 saturation every 4 hours and record
• IVF to follow with D5 0.3 NaCL 500 cc at 55-60 cc/hr

1-03-09
• IVF to follow with D5 0.3 NaCl 500cc at same rate x 1 bottle
Dr. Dela Serna
• IVF to ff with D5 0.3 NaCl 500 cc at same rate x 1 bottle
Dr. Dangazo
• Continue medications
• Singular 5mg 1tab OD HS
• IVF to follow D5 0.3% NaCl 500cc x 2 bottle at 50-60 cc/hr

1-04-09
• Received nebulization to 1 nebule ventolin every 4 hours

2:35Pm
• Zystec oral solution 4ml OD PO HS
1-05-09
 • For chest X-ray APL tomorrow AM

4:30 PM
• IVF to follow with D5 0.3 NaCl 500 cc x 2 bottle

1-06-09
• IVF D5 0.3 NaCl 500cc
• For PPD tomorrow AM provide test solution 0.1cc ID 8PM

1-07-09
• Continue medications
• Decrease IVF in to 20cc/hr
• Received ventolin nebulization to 1 nebule every 6 hours

9:10Am Dr. Ragay

6:00Pm
• IVF to follow D5 0.3 NaCl 500cc at 55-60cc/hr
Dr. Siban
1-08-09
• Dibencozine (Heraclene) 1cap BID PO; Decapsulized and mix with milk
• Decrease IVF rate to KVO
• Administer ceftriaxone at 12NN tomorrow instead of 4PM

DRUG STUDY

Generic Name Salbutamol

date ordered 1-02-09

Classification Bronchodilator
Dose/frequency/route 1neb every 4 hours (nebulization)
Mechanism of action Dilates the bronchioles and relaxes the
baronial uterine
Specific Indication To prevent or treat bronchospasm in
patients with reversible obstructive airway
diseases
Contraindication Use cautiously in patients with CV
disorders, and hyperthyroidism
Side effects/ toxic effects CNS: dizziness, headache
CV: tachycardia, palpitations
GI: nausea and vomiting, altered taste
Metabolic: Hypokalemia
 Musculoskeletal: Muscle cramps
Respiratory: Wheezing, increased
sputum
Nursing Precaution -If prescribe orders more than one
inhalation, tell patient to wait at least 2
minutes before repeating procedure
-If patient is also using a corticosteroid
inhaler, instruct him to use the
bronchodilator first and then to wait about
5 minutes before using the corticosteroid.
This lets the bronchodilator open the air
passages for maximum effectiveness
corticosteroid.

montelukast
MIMS Class : Antiasthmatic & COPD Preparations, Antihistamines & Antiallergics
Brand Names : Singulair film-coated tab Singulair chewable tab Singulair Oral
granules Kastair film-coated tab Montiget Film-coated tab Montair Chewable
tab Montair Film-coated tab Kastair EZ tab Montemax film-coated tab Montemax
chewable tab

Mechanism of Montelukast is a selective leukotriene receptor antagonist that blocks

Action the effects of cysteinyl leukotrienes in the airways.
Indication &
Dosage Oral
CHRONIC ASTHMA
Adult: 10 mg once daily in the evening.
Child: 2-5 yr: 4 mg daily; 6-14 yr: 5 mg daily; ≥15 yr: 10 mg once
daily. All doses to be taken in the evening.
SEASONAL ALLERGIC RHINITIS
Adult: 10 mg once daily in the evening.
Child: ≥2-5 yr: 4 mg daily; 6-14 yr: 5 mg daily; ≥15 yr: 10 mg daily. All
doses to be taken in the evening.
PERENNIAL ALLERGIC RHINITIS
Adult: 10 mg once daily in the evening.
Child: ≥6 mth-5 yr: 4 mg daily; 6-14 yr: 5 mg daily; ≥15 yr: 10 mg
daily. All doses to be taken in the evening.
PROPHYLAXIS OF EXERCISE-INDUCED ASTHMA
Adult: 10 mg at least 2 hr prior to exercise; do not admin additional
doses within 24 hr.
Child: ≥15 yr: 10 mg at least 2 hr prior to exercise; do not admin
additional doses within 24 hr.
Administration May be taken with or without food.
Precautions Not for the relief of acute bronchospasm. Not to be used as
monotherapy for the prevention of exercise-induced bronchospasm.
Patients in whom asthma is precipitated by aspirin or other NSAIDs
should continue to avoid aspirin and NSAIDs. Do not abruptly
substitute for oral or inhaled corticosteroids. Be alert for any signs of
Churg-Strauss syndrome. Pregnancy and lactation. Children <6 mth.
Potentially Life-
threatening
Anaphylaxis, Churg-Strauss syndrome.
Adverse Drug
Reactions
Adverse Drug Dizziness, fatigue, fever; rash; abdominal pain, dyspepsia, dental
Reactions pain, gastroenteritis; increased AST; weakness; cough, nasal
congestion. Aggression, agitation, angioedema, arthralgia, bleeding
tendency, bruising, cholestasis, diarrhoea, dream abnormalities,
drowsiness, oedema, eosinophilia, hallucinations, hepatic
eosinophilic infiltration (rare), hepatitis, hypersensitivity,
hypoaesthesia, insomnia, irritability, muscle cramps, myalgia,
nausea, palpitation, pancreatitis, paraesthesia, pruritus, restlessness,
seizure, urticaria, vasculitis, vomiting.
Interactions Metabolism may be increased with rifampicin, phenobarbital,
phenytoin. Peripheral oedema may occur with prednisone.
Click here for more Interaction Checks
Food Interaction Serum levels may be reduced with St John's wort.
MIMS Class Antiasthmatic & COPD Preparations / Antihistamines & Antiallergics
ATC R03DC03 - Belongs to the class of other systemic drugs used in the
Classification treatment of obstructive airway diseases, leukotriene receptor
antagonists.

budesonide + formoterol
MIMS Class : Antiasthmatic & COPD Preparations
Brand Names : Symbicort turbuhaler
Mechanism of Budesonide is a corticosteroid that has mainly glucocorticoid
Action activity. It prevents and controls inflammation by controlling the
rate of protein syntheis, decreasing the migration of
polymorphonuclear leucocytes/fibroblasts and reversing capillary
permeability. Formoterol fumarate is a selective β2-adrenergic
agonist. It causes bronchodilation by catalysing the conversion of
adenosine triphosphate to cyclic-3', 5'-adenosine monophosphate
(cyclic AMP) resulting in bronchial smooth muscle relaxation.
Indication &
Dosage Inhalation
MAINTENANCE TREATMENT OF ASTHMA
Adult: As combination preparations in 2 strengths: Per inhalation
containing (budesonide(mcg)/formoterol fumarate(mcg)): 80/4.5 or
160/4.5: 2 inhalations bid via the orally inhaled route only. Max
daily dose: 640 mcg budesonide/18 mcg formoterol fumarate.
Child: ≥12 yr: As combination preparations in 2 strengths: Per
inhalation containing (budesonide(mcg)/formoterol
fumarate(mcg)): 80/4.5 or 160/4.5: 2 inhalations bid via the orally
inhaled route only. Max daily dose: 640 mcg budesonide/18 mcg
formoterol fumarate.
Contraindications Primary treatment of status asthmaticus or other acute episodes
of asthma.
Precautions May increase the risk of death in patients. Not to be used for
transferring patients from systemic corticosteroid treatment. May
produce paradoxical bronchospasm which is life-threatening.
Caution when used in patients with CV diseases, especially
coronary insufficiency, cardiac arrhythmias and hypertension.
Chronic use may further decrease bone mineral content when
used in patients with advanced age, osteoporosis, poor nutrition,
sedentary lifestyle or tobacco use. May reduce growth velocity
when used in paediatric patients. Caution when used in patients
with active or quiescent tuberculosis infection of the respiratory
tract, untreated systemic fungal, bacterial, viral or parasitic
infections, or ocular herpes simplex. Pregnancy and lactation.
Adverse Drug Headache, nasopharyngitis, upper respiratory tract infections,
Reactions stomach discomfort, vomiting, oral candidiasis, back pain, nasal
congestion, sinusitis.
Interactions Concomitant admin with CYP3A4 inhibitor e.g. itraconazole,
clarithromycin, erythromycin may inhibit the metabolism of
budesonide. Concurrent use with nonpotassium-sparing diuretics
may lead to ECG changes and/or hypokalaemia.
MIMS Class Antiasthmatic & COPD Preparations
ATC Classification A07EA06 - Belongs to the class of corticosteroids acting locally.
Used in the treatment of intestinal inflammation.
D07AC09 - Belongs to the class of potent (group III)
corticosteroids. Used in the treatment of dermatological diseases.
Prozinc® [syr] R01AD05 - Belongs to the class of topical corticosteroids used as
nasal
Prohealth [ Metro Drug ] decongestants.
R03AC13
MIMS Class : Vitamins & Minerals- Belongs to the class of adrenergic inhalants, selective
(Paediatric)
beta-2-adrenoreceptor agonists. Used in the treatment of
obstructive airway diseases.
R03BA02 - Belongs to the class of other inhalants used in the
treatment of obstructive airway diseases, glucocorticooids.
Contents Per 5 mL syr Zn sulfate monohydrate 55 mg (equiv to 20 mg
elemental Zn). Per mL drops Zn sulfate monohydrate 27.5 mg (equiv
to 10 mg elemental Zn).
Indications Promotes normal biochemical reactions, strengthens the immune
system, supports normal growth & development & helps prevent
growth retardation in childn & young adult.
Dosage Syr Young adult & childn 2.5-5 mL once daily. Drops Young childn
& infants 0.5-1 mL once daily.
Administration Should be taken on an empty stomach (Best taken at least 1 hr
before or 2 hr after meals. May be taken w/ meals to reduce GI
discomfort.).
MIMS Class Vitamins & Minerals (Paediatric)
ATC A12CB01 - Zinc sulfate ; Belongs to the class of zinc-containing
Classification preparations used as dietary supplements.

Zyrtec® [Oral soln]

UCB [ Zuellig ]
MIMS Class : Antihistamines & Antiallergics

Contents Cetirizine diHCl

Indications Perennial & seasonal allergic rhinitis eg rhinorrhea, nasal pruritus &
sneezing, non-nasal symptoms associated w/ conjunctivitis; pruritus
& chronic idiopathic urticaria.
Dosage Adult 10 mg once daily. Childn >6 yr 5 mg bid or 10 mg once daily,
2-6 yr 2.5 mg bid or 5 mg once daily. Oral drops Childn 1-2 yr 2.5
mg bid (5 drops bid).
Overdosage For action to be taken in the event of accidental overdose ... click to
view
Administration May be taken with or without food
Contraindications History of allergy to hydroxyzine or piperazine derivatives; severe
renal impairment (CrCl <10 mL/min). Rare hereditary problems eg
galactose intolerance, Lapp-lactase insufficiency, glucose-galactose
malabsorption should not take the film-coated tab. Those w/ rare
hereditary fructose intolerance should not take the oral soln.
Pregnancy & lactation.
Special
May affect ability to drive or operate machinery.
Precautions
Adverse Drug Sedation, somnolence fatigue, dizziness & headache. Isolated
Reactions cases of micturition difficulty, accommodation disorders & dry
mouth. Abnormal hepatic function w/ elevated bilirubin w/c resolves
upon discontinuation of treatment.
Click to view ADR Monitoring Website
Drug Interactions Alcohol.
Click here for more Interaction Checks
Pregnancy
Category (US
FDA) Category B: Either animal-reproduction studies have not
demonstrated a foetal risk but there are no controlled studies in
pregnant women or animal-reproduction studies have shown an
adverse effect (other than a decrease in fertility) that was not
confirmed in controlled studies in women in the 1st trimester (and
there is no evidence of a risk in later trimesters).
Storage For special storage condition to ensure optimal shelf-life of
medicine... click to view
Side Effects click to view
Mechanism of For Details of the mechanism of action, pharmacodynamics and
Action pharmacokinetics ... click to view
MIMS Class Antihistamines & Antiallergics
ATC R06AE07 - Cetirizine ; Belongs to the class of piperazine derivatives
Classification used as systemic antihistamines.
Poison Schedule tab:Non-Rx; soln:Non-Rx; drops oral:Non-Rx
Combivent® [Metered dose inhaler]
Boehringer Ingelheim [ Metro Drug ]
MIMS Class : Antiasthmatic & COPD Preparations

Contents Per metered dose Ipratropium Br 20 mcg, salbutamol 120 mcg.

 Per unit dose vial Ipratropium Br anhydrous 500 mcg, salbutamol
base 2.5 mg
Indications Management of reversible bronchospasm associated w/ obstructive
airway diseases in patients who require more than a single
bronchodilator.
Dosage MDI Adult 2 puffs tid-qid. Max 12 puffs/day. Unit dose vial Adult &
childn >12 yr 1 vial every 6-8 hr. Childn 2-12 yr 3 drops/kg/dose
(max: 2500 mcg of salbutamol) every 6-8 hr.
Contraindications Hypertrophic obstructive cardiomyopathy or tachyarrhythmia.
History of hypersensitivity to soya lecithin or related food products
(for MDI only).
Special Insufficiently controlled diabetes mellitus, recent MI, severe organic
Precautions heart or vascular disorders, hyperthyroidism, pheochromocytoma,
risk of narrow-angle glaucoma, prostatic hypertrophy or bladder-
neck obstruction; cystic fibrosis. Pregnancy, lactation.
Adverse Drug Fine tremor of skeletal muscle; palpitations; headache, dizziness,
Reactions nervousness; dryness of mouth, throat irritation; urinary retention.
Click to view ADR Monitoring Website
Drug Interactions Other β-adrenergics, anticholinergics, xanthine derivatives,
glucocorticosteroids, diuretics; digoxin, β-blockers; MAOIs, tricyclic
antidepressants, halogenated hydrocarbon anesth.
Click here for more Interaction Checks
Pregnancy
Category (US
FDA) Category C: Either studies in animals have revealed adverse
effects on the foetus (teratogenic or embryocidal or other) and
there are no controlled studies in women or studies in women and
animals are not available. Drugs should be given only if the
potential benefit justifies the potential risk to the foetus.
MIMS Class Antiasthmatic & COPD Preparations
ATC R03AK04 - Salbutamol and other drugs for obstructive airway
Classification diseases ; Belongs to the class of adrenergics and other inhalants
used in the treatment of obstructive airway diseases.

LABORATORY RESULT:
HEMATOLOGY REPORT

TEST RESULT NORMAL VALUE IMPLICATION

WBC 8.10 5.0-10 Within normal range

RBC 3.60 4.0-5.0 Below normal.

Hemoglobin 12.1 12.0-16.0 Within normal

range

Hematocrit 37.9 37.0-47.0

Below normal

Differential count

Lymphocytes 14.2 17.4-48.2

Within normal range
Neutrophils 74.5 43-76

Within Normal
range
Monocytes 8.0 5.0-10.0
Within normal range
Eosinophils 1.9 1.0-3.0

Within Normal
range
Basophils 0.3 1.0-2.0

Within normal range

Platelets 22.3 15.0-40.0

1-02-09

Chest X-Ray
 • There are streaky and hazy opacities seen involving both inner lungs with fecal
wedge opacity at the right suprahilar area

IMPRESSION:

Consider pneuomonia bilateral with focal beginning consolidation

V. Anatomy and Physiology

The Respiratory System

The respiratory system is an intricate arrangement of spaces and passageways

that conduct air from outside the body into the lungs and finally into the blood as well as

expelling waste gasses. This system is responsible for the mechanical process called

breathing, with the average adult breathing about 12 to 20 times per minute.

When engaged in strenuous activities, the rate and depth of breathing increases in

order to handle the increased concentrations of carbon dioxide in the blood. Breathing is

typically an involuntary process, but can be consciously stimulated or inhibited as in

holding your breath.

Nostrils/Nasal Cavities

During inhalation, air enters the nostrils and passes into the nasal cavities where foreign

bodies are removed, the air is heated and moisturized before it is brought further into

the body. It is this part of the body that houses our sense of smell.
Sinuses

The sinuses are small cavities that are lined with mucous membrane within the bones of

the skull.

Pharynx

The pharynx or throat carries foods and liquids into the digestive tract and also carries

air into the respiratory tract.

Larynx

The larynx or voice box is located between the pharynx and trachea. It is the location of

the Adam's apple, which in reality is the thyroid gland and houses the vocal cords.

Trachea

The trachea or windpipe is a tube that extends from the lower edge of the larynx to the

upper part of the chest and conducts air between the larynx and the lungs.

Lungs

The lungs are the organ in which the exchange of gasses takes place. The lungs are

made up of extremely thin and delicate tissues. At the lungs, the bronchi subdivides,

becoming progressively smaller as they branch through the lung tissue, until they reach

the tiny air sacks of the lungs called the alveoli. It is at the alveoli that gasses enter and

leave the blood stream.

Bronchi

The trachea divides into two parts called the bronchi, which enter the lungs.

Bronchioles

The bronchi subdivide creating a network of smaller branches, with the smallest one

being the bronchioles. There are more than one million bronchioles in each lung.
Avleoli

The alveoli are tiny air sacks that are enveloped in a network of capillaries. It is here

that the air we breathe is diffused into the blood, and waste gasses are returned for

elimination.

Pathophysiology:

Predisposing factor:
-environment
-lifesytle

Precipitating factor:
Viral, bacterial, parasitic aspiration

Exposure to allergens and Causative factors

↓
Immunoglobulin E stimulation

↓
Mast cell degranulation

↓
Histamine, Leukotrienes, Prostaglandins, Bradykinins

↓
Mucus secretion Inflammation bronchospasm

↓
 wheezing and narrowing of airways

↓
Airway obstruction

VII. NURSING MANAGEMENT

a. IDEAL NURSING MANAGEMENT

 Outcome/Discharge Criteria the patient will:

 Have improved respiratory function

 Tolerate expected level of activity

 Have no signs and symptoms of complications

 Identify ways to maintain respiratory health

 Nursing/Collaborative Diagnoses

¬ Impaired respiratory function

a. Ineffective breathing pattern

b. Ineffective airway clearance

c. Impaired gas exchange

¬ Risk for deficient fluid volume

¬ Acute pain: chest

Nursing Diagnosis: Impaired Respiratory Function

ϖ Ineffective breathing related to:

1. Decreased depth of respirations associated with:

a. weakness, fatigue, and reluctance to breathe deeply because of chest pain

b. Decreased lung compliance if pleural effusion is present

2. Increased rate of respirations associated with:

a. Compensation for hypoxia that results from impaired gas exchange

b. The increase in metabolic rate that occurs with an infectious process

ϖ Ineffective airway clearance related to:

1. tracheobronchial inflammation and increased production of mucus associated with

the accumulation of mucus and consolidation of lung tissue

2. Stasis of secretions associated with decreased activity, poor cough effort resulting

from fatigue and chest pain, and impaired ciliary function

ϖ Impaired gas exchange related to decrease in effective lung surface associated

with the accumulation of mucus and consolidation of lung tissue.

NURSING ACTIONS:

• Assess for and report signs and symptoms of impaired respiratory function

1. Rapid and shallow respirations

2. dyspnea and orthopne

3. Use of accessory muscles when breathing

4. Abnormal breath sounds (e.g., diminished, bronchial, crackles, rales and

wheezes)

5. Asymmetrical or limited chest excursion

6. Cough (usually a productive cough of rust colored, purulent or blood tinged

sputum)

7. Restlessness and irritability

8. Confusion and somnolence

9. Significant decrease in oximetry results

10. Abnormal blood gases

• Implement measures to improve respiratory status

1. Maintain client on bed rest as ordered during the acute phase to reduce oxygen

needs

2. Place client to breathe slowly if hyperventilating

3. If client must remain flat in bed, assist with position change at least every 2 hours

4. Place client in semi-fowlers position unless contraindicated, position with pillows to

prevent slumping

5. Instruct client to deep breath or use incentives pyrometer every 1-2 hours

Nursing Diagnosis: Risk for deficient fluid volume related to decrease oral intake

and excessive fluid loss

• Assess for and report signs and symptoms of deficient fluid volume

1. Decreased skin turgor

2. Membranes, thirst

3. Weight loss of 25 or greater in a short period

4. Postural hypotension

5. Weak and rapid pulse

6. Capillary refill time greater than 2-3 seconds

7. Flat neck veins when supine

8. Change in mental status

9. elevated BUN and Hct

10. Decreased urine output with increased specific gravity

 • Implement measure to prevent deficient fluid volume:

1. Perform actions to improve oral intake

2. Actions to reduce fever and resolve the infectious process

3. Fluid intake of at least 2500ml/day unless contraindicated

Nursing Diagnosis: Acute pain: chest related to:

ϖ Extension of the inflammatory/ infectious process to the pleura

ϖ Muscle strain associated with excessive coughing

Nursing actions:

• Assess for signs and symptoms of pain

• Assess client’s perception of the severity of pain using a pain intensity rating scale

• Assess the clients pain pattern

• Implement measures to reduce chest pain

1. Perform actions to reduce fear and anxiety about the pain

2. Administer analgesics prior to any painful procedures

3. Instruct and assist client to splint chest with hands deep breathing, coughing or

changing position to promote rest

4. Provide or assist with non pharmacologic methods for pain relief

5. Perform actions to decrease excessive coughing

b. Actual Nursing Management

S • No subjective cues ( 4yrs., old

cannot verbalized feeling)
O • objective cues:
-increased respiration( 30 bpm)
-chest retractions
A • Ineffective breathing pattern
related to increased rate
respiration associated with
compensation for hypoxia that
• result from impaired gas exchange
secondary to pneumonia.
P • At the end of 1 hour of nursing
intervention, the patient will
experience adequate respiratory
function.
I INDEPENDENT
• Assessted respiratory rate and
depth every 2 to 4 hours to have
proper monitoring if impaired
respiratory function results.
• Maintained patient on bed rest to
reduce oxygen needs
• Instructed SO to Change patient’s
position al least every 2 hours to
mobilize secretions and allow
aeration of lung fields.
• Provided hydration to ensure
adequate hydration and loosen
secretions unless contraindicated
DEPENDENT:
• Provided nebulizer treatment
(salbutamol) and provide chest
pain tapping to liquefy secretions
and to facilitate removal of
secretions.
Patient experienced adequate
respiratory function after 2 hours
as evidenced by improved breath
sounds.

E After 1 hour the patient was able to

experience adequate respiratory function.

S • No Subjective cues: (4 yrs old)

O • Objective cues:
-facial grimacing
-restlessness

A • Acute pain: chest related to

muscle strain associated with
excessive coughing secondary to
pneumonia as evidenced by facial
grimacing and restlessness

P • After 2 hours of nursing

intervention, patient will
experience reduce of chest pain
I • Assisted patient to splint chest with
hands or pillow when coughing or
changing position to reduce chest
pain
• Encouraged to perform actions to
promote rest in order to reduce
fatigue and subsequently increase
the client’s threshold and tolerance
of pain.
¬ Minimize environmental activity and
noise
¬ Organize nursing care to allow for
periods of uninterrupted rest
¬ Limit the number of visitors and their
length to stay
• Provided with non pharmacologic
methods like position change,
relaxation techniques, and restful
environment for pain relief.
Protect patient from exposure to irritants
such as smoke and powder to prevent
stimulation of excessive coughing
Evaluation • The patient experienced reduced
chest pain after 2 hours as
evidenced by relaxed facial
expression and body positioning.
VIII. REFERRALS AND FOLLOW-UPS

Medications • Stress out to the patients the

importance of compliance to home

 medication regimen

• Discuss the action of the

medication ordered

• Emphasize the significance of the

following the right timing when

administering
Exercise • Demonstrate passive range of

motion exercises and explain why

is it necessary for the patient

Treatment • Educate the mother of patient on

the prevention of recurrence of the

disease.

• Emphasize the importance of good

rest
Out patient • Emphasized the significance of

follow-up checkup at OPD

Diet • The importance is increased fluid

intake.

IX EVALUATION AND IMPLICATION

The patient was diagnosed of respiratory disease condition called pneumonia.

The patient should be compliant to follow the medication regimen ordered for the

complete treatment of the patient. Health teachings are also of great help for the family

members to have an idea on what comfort measures they could provide to the patient

whenever they observe any experienced by the patient. They must also be

knowledgeable enough on the mode of transmission and preventions of the said

disease condition to avoid recurrence. A follow up check up should also be stressed to

the patient so that the proper monitoring on the current health condition.

X. BIBLIOGRAPHY

Conale: Nursing Care Planning Guide 6th ed;Elsivier USA 2005

Black, joyce: Medical and Surgical Nursing 7th ed; Elsivier Inc. USA 2005

Smeltzer, Suzzane: Medical and Surgical Nursing. Lippincott-Raven publishers.

Pennysylvania 2005.

Papalia.diane: Human Development: 8th Ed; Mcgraw-hill, inc.2001

Thmpson: Clinical Nursing: 4th Ed; Mosby year- Book, Inc 1997

http//www.yahoo.com

Liceo De Cagayan University

Carmen, Cagayan De Oro City
College of Nursing
NCM501204

In partial fulfillment of the course requirement of the subject

RELATED LEARNING EXPERIENCE
CASE PRESENTATION

SUBMITTED TO

MR. MC MICHAEL CHAN, RN

SUBMITTED BY

Caballes, Ma. Kristal Jade C.

Lavanza, Gulliver C.
Mayol, Jezreel Jane I.
Renoir, Orio

January 2009