PAPER OF ASTHMA CASE STUDY

Compiled to Fulfill Adult Nursing Task

Oxigenation Module

Created by :
Sitha R. Amanatunnisa G2B 009 031
Destya D. Pangestika G2B 009 044
Mitsalina Maulida Hafidz G2B 009 050
Safina Aprillia G2B 009 059

Class A092

NURSING SCIENCE PROGRAM

FACULTY OF MEDICINE
DIPONEGORO UNIVERSITY
OCTOBER, 2010
 1st CHAPTER
PREFACE

A. Background
Asthma is a worldwide health problem, both in developed and in
developing countries. In addition, asthma is a disease known in the community.
This is different about a century ago, for asthma disease was first discovered
and is still relatively rare. In the 1970s, more and more asthma sufferers are
found, this disease can be deadly even for reasons that are unclear. In the
United States for example, if heart disease and cancer are still occupying the
top position in the list of diseases spreading death, the lung disease is now
ranked third. And among the categories of lung diseases are fatal, chronic
asthma, including one of them.
WHO’s data (World Health Organization) indicates the number of asthma
sufferers in Indonesia ranges from 3-8 percent, or 6-16 million of the 200
million population. Another survey from various hospitals showed the number
of asthma sufferers in some provinces, namely Bali (2.4 percent), East Java (7
percent), Jakarta for the children (16.5 percent), Malang for children (22
percent) , East Jakarta for adults (18.3 percent), and Central Jakarta (7 percent).
Asthma is a chronic airway inflammatory disease involving various
immune cells, especially mast cells, epithelial cells, and the increased response
of the airways (bronchial hipereaktivitas) to various stimulants. Asthma can be
mild and do not interfere with the activity, but can be settled and not disturbs
daily activities and even activities reduce the quality of life.

But unfortunately, not all aspects of the pathophysiology of asthma as a whole is

understood to arise from the opinions of some doctors and the public that
asthma is a disease that is simple and easily treated, assuming that management
is the main thing is particularly bronchodilator drugs. Then show habits of
physicians and patients to overcome the symptoms of asthma are particularly
against the symptoms of shortness of breath and wheezing with drug use and
instead of managing asthma in full.

B. The Goals
This paper has eleven points to pass the goal of learning objective,
namely:
1. Students can find out the definition of asthma.
2. Students can find a variety of causes of asthma.
3. Students can find out all kinds of asthma.
4. Students can find out stages of asthma.
5. Students can find out three reactions in the pathology of asthma.
6. Students can learn how to forced expiratory.
7. Students can find pictures of X-Ray lungs
8. Students can learn the tools used in the investigation of asthma.
9. Students can learn the process of bronchial provocation test.
10. Students can find a variety of asthma medications.
11. Students can learn how to diagnose asthma and nursing interventions.
 2 nd CHAPTER
LITERATURE REVIEW

A. Definition and types of Asthma

Asthma is a chronic disease characterized by recurrent attacks of
breathlessness and wheezing, which vary in severity and frequency from
person to person. Asthma is divided into two categories, namely :

1. Extrinsic or allergies

Marked by allergic reactions caused by factors specific trigger, such as dust,

animals, influenza virus, pneumonia,Mycoplasma, food, cigarettes and
drugs.

2. Non allergic
Characterized by non-allergic reaction which reacts to triggers that are not
specific or unknown, such as cold air or can also be caused by respiratory
infections , emotion, exercise, and environmental pollution. Asthma attacks
became more severe and often in line with the passage of time and can
develop into chronic bronchitis and emphysema. Some patients will
experience asthma combined.

B. How a proper forced expiratory test is to be performed.

The function of proper force expiratory test is to know how the condition
of respiratory system then it identified how long someone can not breath and
how much the carbon dioxide volume of force respiration process. This way is
suitable for identifying asthma patient and reducing the symptom of asthma. A
kind of proper forced expiratory test is the buteyko method. The Buteyko
method has five steps, they are :
 a. Sit, relax, breathing regularly during 30 second
b. Inpiration and expiration as usuall
c. Close your nostril and start a stopwatch
d. Don’t breath until you feel oxigenation needs then breath maximally
e. See the stopwatch. How long you didn’t breath. It is you control pause time.
After we have done the buteyko method, we analysize how long we can not
breath. These are the result of proper forced expiratory test :

Control pause time The meaning of forced expiratory time

Less than 10 second Someone has respitory system disorder
10 – 25 second He/she should be more attention to check up
30 – 40 second Good respiratory system
More than 60 second It is en excellent respiratory system and its so
healthy

From that test, we can know the difference between forced expiratory
volume and vital capacity. Forced expiratory volume in one second (FEV 1.0)
is the volume of air that can expiratoried during the first second expiratory vital
capacity in the determination. Then, Peak flow is the patient's maximum speed
of expiration, or also called peak expiratory flow rate (PEFR or PEF) and
normally value is 250/250. Whereas vital Capacity (VC) is maximum volume
of air that can be spent during a one-time breathing after maximum inspiration.
Vital capacity is usually about 80% of the total lung capacity (4800 ml). Vital
capacity (VC). This is the amount of air (in liters) moved out of the lung during
normal breathing. The patient is instructed to breathe in and out normally to
attain full expiration.

C. Pathophisiology of asthma

These are three primary pathologic reactions:

a. The bronchi muscles do vasoconstriction (stricture of bronchi muscle).

Because the duct of air is too narrow, so the airs have difficulty to out
 from the body. It can make wheezing voice, because the duct and air have
friction.
b. In bronchi, there is some of mucosa. If the mucosa is too much, it can
make edema so the airway is disturbed. The air will get difficulty to out
from the body in bronchi area, because there is edema. So, the person who
has this condition will be feeling congested. In edema bronchi, there is
much substance like histamine, leukotrien, and serotonin.
c. The third is cough effect. In gland of bronchial, there are so much mucosa
fluids. Because the mucosa fluids is abnormal, it can make hyper secrets.
This condition make production of mucosa has abnormal, so the cilia
difficult to move. It can make cough as effect of body from the abnormal
mucosa production.

A person who has allergy have ability to make much antibody Ig E in big
volume. This antibody can make allergy reaction if the reaction with
specification of antigen. In asthma, this antibody patch in mast cell which the
location in lung interstitial that is have relation with bronchial and small
bronchi.

If the person inhale allergen so the antibody of Ig E will be increase,

allergen will reaction with antibody in mast cell. This condition can make mast
cell will be releasing many substance like histamine, anafilaksis (acute allergy
reaction) that is slow reaction (leukotrient), and bradikinin.

The merger effect from all of this factors will be releasing local edema in
small bronchia’s wall and mucus secretion in bronchial lumen and spasm of
bronchial artless muscle so it can make person will get difficulty in breath.

D. Recognize chest x-ray changes seen with asthma

 the normal lungs the asthma lungs

In the picture above shows a picture torax in normal circumstances. In the

state of asthma torax look bigger and expanded. This is caused by
inflammation resulting in swelling. And the white shadows in the asthma lungs
are the mucus and the eudema. Beside that, the asthma patient has chest
deformity become a barrel chest. And it is the barrel chest picture :

The chest is bigger because there are

so many carbon dioxide.

E. Recognize the signs and symptoms of asthma

 To evaluate signs :

a. Chest deformity
Functional residual capacity and residual lung volume to be greatly
increased during an asthma attack due to difficulties expiratory air
out of lungs. This can cause the barrel chest.
b. Cyanosis
 Cyanosis effects is a blue color of the skin and nails may occur
from lack of oxygen.
c. Chest and stomach pain
Those happened because the abdomen and thorax’s muscle involve
during respiration process.

 To evaluate symptoms :
a. Cough
In uncomplicated asthma, cough is only noticeable when the attack
subsided and coughing helps remove accumulated secretions.
b. Dyspnea
Breathing felt tight and difficult. Functionally, an asthmatic airway
to act as if the neural beta-adrenergiknya (which helps maintain the
airway to remain patent) is not competent.
c. Orthopnea
Difficulty breathing in a state of supine
d. Phlegm (sputum) production
Bronchial gland hipersecret
e. Wheezing
Turbulence of air currents and vibrations bronchial mucus resulting
in an audible wheezing sound during an asthma attack, but the
physical signs are also seen prominently in obstructive airway
problems. In symptomatic asthma, breathing faster than normal
(although this is likely to increase resistance to air flow) due to
constriction or spasm of bronchial muscle.

 The causes of asthma

a. Children at Risk
 Children can have asthma easily because their immune still low
and sensitive.
b. Allergies
Allergies because of various allergens. Allergens can be divided in
three kinds, they are :
· Inhalan, that enter into respiratory systems (dust, bactery, and
pollution)
· Ingestan, , that enter into mouth (food and drug)
· Contactan, , that enter into skin contact (jewellery and watch)

c. Environmental Factors
From traffic pollution or high ozone levels, has been repeatedly
associated with increased asthma morbidity and has a suggested
association with asthma development that needs further research
d. Obesity
Obesity causes a 50% increase in asthma incidence. This is due to
adipose tissue (fat) diminishing respiratory function. Adipose
tissue also leads to a pro-inflammatory state which has been
associated with non-eosinophilic asthma
e. Pregnancy
During pregnancy, VC respiration still same but it happen
improvement of tidal capacity from 450 cc become 600 cc because
progesteron hormone effect toward respiratory systems resistence
so the mother has to increase ventilation.
f. Stress
Rather than stress directly causing the asthma symptoms, it is
thought that stress modulates the immune system to increase the
magnitude of the airway inflammatory response to allergens and
irritants
g. Genes
Over 100 genes have been associated with asthma in at least one
genetic association study.
F. Some of the equipment necessary for an exercise test

These are eight equiment for asthma test, such as :

1. Peak Flow

Peak Flow is probably the simplest test that you can

use to see how well your asthma is doing and will be
an integral part of your asthma care plan. Peak flows
can easily be done at home with an inexpensive
device called a peak flow meter. Peak flow measure
how quickly air can be blown out of your lungs. It is important for you to
learn how to use your peak-flow-meter appropriately.

2. Spirometry

Spirometry is slightly more complicated than peak

flow in that it is usually done in your doctors office and measures both how
much and how quickly air moves out of your lungs. It is important in both
the diagnosis and management of asthma over time.

3. Complete Pulmonary Function Testing

Your asthma care provider may want to determine your

lung volumes and diffusing capacity. This is often done if your asthma
 diagnosis is unclear. The test requires you to sit inside a special box that
helps determine how much air you breathe in and out.

 Lung Volumes: Your asthma care provider may order body

plethysmography test to determine your lung volumes. Asthma may cause
certain changes in lung volumes that will assist your asthma care provider
in diagnosing or treating your asthma.
 Diffusion Capacity: Diffusion capacity measures how well oxygen flows
from the lungs into your blood. Poor diffusion indicates damage to the
lung where the oxygen and blood meet in the lungs. Diffusion capacity is
usually normal in asthmatics.

4. Chest X-Ray

A chest x-ray is a test commonly preformed for

patients who wheeze. An asthma care provider will usually order one to
make sure there is not some other condition that may be causing your
symptoms like a lung infection.

5. Bronchoprovocation Challenge Testing

When your asthma provider orders a

bronchoprovocation test, you will inhale a specific substance through a
nebulizer, often methacholine or histamine. This is done to see if your lungs
become irritated, hyperresponsive, and lead to the development of asthma
symptoms. The test has a high negative predictive value. This means that if
the test is negative it is unlikely you have asthma.
6. Pulse Oximetry

Pulse oximetry is a non-invasive way to measure

oxygenation of blood or how well oxygen is being exchanged between the
lungs and the blood. A sensor is placed on the fingertip or other thin part of
the body with blood vessels close to the skin. The sensor measures changes
in wavelengths of light and is able to estimate oxygenation in the blood.

7. Arterial Blood Gas (ABG)

An arterial blood gas (ABG) is an arterial blood

sample used to determine how well blood is oxygenated -- a marker for
oxygen exchange between the lungs and the blood. Commonly, a blood
sample will be obtained from one of the arteries near your wrist. This test
may likely be preformed during an acute asthma exacerbation and is more
reliable than pulse oximetry.

8. Allergy Testing

The relationship between allergies and asthma has

been known for a long time. Allergens you normally breathe in can increase
the inflammatory reaction and hyperresponsiveness in your lungs. However,
your doctor cannot reliably determine if a particular allergen is responsible
 for your symptoms on clinical grounds alone. Because of this, your asthma
care provider may recommend allergy testing. Not all asthmatics are tested.
But if you have persistent asthma, your asthma care provider will probably
recommend testing.

G. The bronchoprovocation test

Bronchoprovocation tests help asthma care providers make a diagnosis of

asthma. In general, you will inhale a nebulized solution or preform exercise to
see if you develop symptoms of asthma or airflow obstruction measured by
spirometry. If you develop either, your airways are hyperresponsive. Your
asthma care provider may challenge you with methacholine, histamine, cold
air, and exercise.

A common scenario for asthma care providers to order

bronchoprovocation testing is if you have symptoms that suggest asthma, but
normal spirometry testing and no response to rescue medications. Obstruction
of airflow in your lungs can be provoked by inhaling aerosols known to elicit
asthma symptoms and cause airway narrowing and irritation.
The procedure to do bronchoprovocation tests are you will begin by
inhaling a nebulized aerosol with one of the previously mentioned agents as if
you were taking a normal breathing treatment. The nebulized treatments will be
repeated at specific time increments. You will preform spirometry before and
after each nebulized treatment, and your asthma care provider will look at the
decrease in FEV1.
A decline in FEV1 of 20% from your baseline reading is considered a
positive test. If your asthma care provider suspects asthma, you may be started
on an asthma treatment. Hyperresponsiveness reliably discriminates between
patients with asthma from patients without asthma. Bronchoprovocation testing
has a high negative predictive value. Thus, if you have a negative test, it is
unlikely you have asthma.

H. The values are most often used when testing for asthma
 The value, it means that what are the point should we get to identify
asthma. The values are peak flow, heart beat, respiratory beat, the sign and
symptom of asthma, and may be we have to know about blood pH, ABG
values, PCO2, PO2, and Sa O2. Those addition value used to diagnose the
probability to gets hiperventilation, alcaliosis respiratoric condition, or other
obtructive respiration diseases.

I. The appropriate nursing diagnosis of an asthmatic patient for chronic treatment

or for an acute attack

Asthma is clinically classified according to the frequency of symptoms and

peak expiratory flow rate. These are the classification of asthma stadium :

Studium Frequency of symptoms Peak Flow (PF)

Intermiten Less than twice a month PF > 80 %
Mild persisten More than once a week PF > 80 %
Moderate persisten Every day PF 60 – 80%
Severe persisten Continually PF < 60 %

If the patient suffer asthma until the most dangerous studium, especially in
severe persisten, so he/she gets accute asthma. But if the patient gets asthma
in long time, it means he/she gets cronic asthma. The medication is a kind of
treatment ways to help the patient. The medication of asthma divided in two
group, namely :
1. Reliever medicine: obat pereda, pelega, atau obat serangan.
2. Controller medicine : obat pengendali, obat pencegah, obat profilaksis.
This medicine is used for reducing cronic repiratoric inflamation. In other
reference, we found the different name :
1. Quick relief medication -> accute
 bronkodilator (antikolenergik, metilksantin); kortikosteroid oral (sistemic)

2. Long term medication -> chronic

inhalasi steroid, long action beta-2-agonis, sodium kromoglikat,

nedokromil, etc.

J. The commonly used nursing interventions

A number of nursin interventions are commonly used throughout all

community settings and more often than in acute care settings. Mc Closkey and
Bulechek identified nursing intervention such as :

1. Medication administration : preparing, giving, and evaluating the

effectiveness of prescription and nonprescription drugs.
2. Health education : developing and providing instruction and learning
experiences to facilitate voluntary adaptation of behaviour conductive to
health in individuals, families, groups, or communities.
3. Health system guidance : facilitating a patient’s location and use of
appropriate health service.

K. The evaluation related to the implementation in asthma

It is a table that explain the intervention to evaluate the bronchospasme

condition in asthma patient.

No. Independent Rational

1. Auscultation of breath sounds, Some degree of spasm
 record the sound of breath. bronchus occurs with
e.g wheezing airway obstruction and
can / does not manifest
the breath advertisius.

2. Review / monitor frequency Tachipnea usually exist in

respiratory, record the ratio of a few degrees and can be
inspiration / expiration. found on the acceptance
or during stress / a

No. Independent Rational

3. Write down the degree of Respiratory dysfunction is
dyspnea, variable that depends on
anxiety, respiratory distress, acute stage of the process
drug use aids. cause treatment
Place a comfortable position hospital.
in patients, for example:
elevate head of bed,
sitting on the back bed.

4. Place a comfortable position Elevation head place

in patients, for example: facilitate sleep function
elevate head of bed, breathing with
sitting on the back bed. using gravity.
5. Maintain environmental Type allergy triggers
pollution breathing can trigger
minimum, eg dust, smoke etc. acute episode.

6. Increase fluid intake Hydration help

up to 3,000 ml / day lower viscosity
 appropriate cardiac tolerance secretions, the use of liquid
provide warm water. warm can reduce
viscosity of secretions,
the use of warm fluid
to reduce spasm
bronchus.

7. Collaboration to give the Relaxes smooth muscle and

medication in accordance with reduce spasm road
indication of bronchodilators. breath, wheezing, and production
mucosa.
3 rd CHAPTURE
DISCUSSION OF CASE STUDY

A 37 y/o black female with a history of asthma, presents to the Emergency

Rate (ER) with tachypnea, and acute shortness of breath with audible
wheezing. Patient has taken her prescribed medications of Cromolyn Sodium
and Ventolin at home with no relief of symptoms prior to coming to the ER. A
physical exam revealed the following: HR 110, RR 40 with signs of accessory
muscle use. Auscultation revealed decreased breath sounds with inspiratory
and expiratory wheezing and pt was coughing up small amounts of white
sputum. SaO2 was 93% on room air. An arterial blood gas (ABG) was ordered
with the following results: pH 7.5, PaCO2 27, PaO2 75.

An aerosol treatment was ordered and given with 0.5 cc albuterol with 3.0
cc normal saline in a small volume nebulizer for 10 minutes. Peak flows done
before and after the treatment were 125/250 and auscultation revealed loud
expiratory wheezing and better airflow. 20 minutes later a second treatment
was given with the above meds. Peak flows before and after showed
improvements of 230/360 and on auscultation there was clearing of breath
sounds and much improved airflow. RR was 24 at this time and HR 108.
Symptoms resolved and patient was given prescription for inhaled steroids to
be used with current home meds. Instruction was given for use of inhaled
steroids and the patient was sent home.

Diagnosis 1 :

 HR 110 -> 60 – 100 : takikardi RR 40 -> 16 – 24

 Peak flows 125/250 -> 250/250
 Asthma studium : severe persisten PF < 60 % and symptoms continually

:: classified patients in severe acute asthma (severe persisten) ::

Diagnosis 2 :

VALUES TEST RESULT NORMAL

pH 7,5 7,34 – 7,44

PCO2 27 35 - 45
PO2 75 85 - 116
Sa O2 93 % 95 – 98 %

Viewed from the table above, show that patients experienced hyper
ventilation. Low levels of CO2 make the exchange with O2 gas becomes
less. As a result patients have tachypnea (rapid breathing and deep) as the
body's attempt to restore blood pH to normal. Beside that, the patient’s
blood is alkaline pH and PCO2 and PO2 below normal so that carbon
dioxide levels in the blood becomes low.
So, the patient also suffers respiratory alkaliosis.

Intervention / Treatment :

From the case we can conclude about the nursing intervention is

medication administration that :
 a. Patient get medication of asthma : 0,5 cc albuterol and 3,o normal saline in
nebulizer with small volume during 10 minutes, albuterol is belong to
pharmacology therapy and quicker-relief type.

b. Albuterol can relax the muscles in respiratory duct so the respiratory duct
will be wider than before and the patient can breath easier. Then after 20
minutes, the patient get that medicine. Next the peak flow meter measures
that the peak flow condition become normal 230/360, before is 125.250.

c. So, we can see the nursing intervention was given is right. That patient can
be better.

Management :

 Management: Describe Medication Roles

1. How Medications work

a. Long-term medications reduce inflammation
b. Short-term medications rescue from bronchospasm
2. Emphasize Long-term medications as key to control

 Management: Skill Training

1. Inhaler use
2. Monitoring methods
a. Symptom monitoring
b. Peak Flow meter
c. Early recognition of exacerbation
3. Written action plan
a. Stepwise plan for exacerbations
b. When and how to take Rescue medications

 Management: Control Measures for Environmental Allergens

See Environmental Allergen and avoid them, such as :

1. Animal Dander
1. Remove animal from house
2. Keep animal out of patient's bedroom
3. Install Filter on bedroom air duct
2. House-Dust mites
1. Encase mattress and pillow in impermeable cover
2. Wash bedding weekly in hot water
3. Reduce indoor humidity <50%
3. Cockroaches
1. Set traps
2. Preventative measures
4. Indoor Mold
1. Fix leaks and other water sources of mold growth
2. Reduce indoor humidity to <50%
3. Clean

4 th CHAPTER

CLOSING

A. Conclusion
Oxigenation need is so important in the life. One of a respiratory disorder
kind is asthma. Asthma is a worldwide health problem. It happened in
whole the world and can be suffered by children until elders. From
pathophisiology of asthma, we can see how dangerous asthma occurs. It
disturbs the repiration process. Nowdays, the health provider have used
many ways to help patient asthma to identify, to cope, and to management
asthma. If their ways is right so the patient can be helped.

B. Recommendation

However medical practice have known how to diagnose, give intervention,

and management asthma, we as nursing science students should be able to
do the researches so that asthma problem can be reduced. Beside that,
nursing intervention not only is published to the asthma patients and their
family, but also give health education to public. If we can do the best and
collaboration with nursing profession or other health provider, it is not just
a dream to decrease asthma problem.