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CHAPTER 1 - OBJECTIVES AND INTRODUCTION OBJECTIVES I did this case study for us to enhance my knowledge and to understand more

information about Asthma, thus to give us an idea of how I could give proper nursing care of my clients with this condition, and so that I could apply them on my future exposures as students and eventually as nurses. I also did this care study as a part of our requirement in our clinical exposure. INTRODUCTION Asthma is a disorder of the bronchial airways characterized by periods of bronchospasm. It may be extrinsic (allergic) or intrinsic (non- allergic). Extrinsic asthma usually begins in childhood and the client may be allergic to dust, pollen, insects, mold spores, smoke, medications and foods. Intrinsic asthma is triggered by internal disorders such as common colds, upper respiratory infection or exercise. There are no identified allergies and it occurs over age 35. It is considered as an inherited disorder that interacts with environmental factors causing the disease. It involves airway inflammation and periodic narrowing of airway Lumina (hyperactivity). Moreover, it is the result of individual response to a wide variety of stimuli and is therefore episodic in nature with fluctuations or worse exacerbation of symptoms. The most common form of asthma is Bronchial Asthma Atopic Type

(Extrinsic) Asthma, caused by someone who atopy caused by exposure to allergens. Allergens that enter the body through the respiratory tract, skin, gastrointestinal tract, and others will be captured by macrophages that work as antigen presenting cells (APC). Once the allergen is processed in the cell APC, then the cell, allergens presented to Th cells. Tues APC through the release of interleukin I (II-1) activate Th cells. Through the release of Interleukin 2 (II-2) by Th cells are activated, the given signal to B cells proliferate and form a cell plasthma IgE. IgE is formed will be bound by mastosit on the network and basophils were present in the circulation. This is possible because the two cells have receptors on their surface for IgE. Eosinophils cells, macrophages and platelets also have receptors for IgE but with a weak

affinity. People who already have mastosit cells and basophile with IgE on the surface are not yet showing symptoms. The person is already considered to be vulnerable or new desentisisasi When people who are vulnerable or exposed two times more with the same allergen, allergens that enter the body will be bound by the existing IgE on the surface of mastofit and basophile. Bond will cause influx Ca + + into the cell and the cell changes that decrease cAMP levels

CHAPTER II ASSESSMENT A. Nursing Health History 1. Personal Data Name Age Sex Address : Ms. J : 19 : Female : Jakarta

Civil Status : Student Nasionality Religion Birth Place Admission : Indonesian : Catholic : Jakarta :

Date : February 05, 2013 Time : 3 PM Admitting Diagnosis: Asthma Bronchial

2. Past Medical History Clients said previously had suffered the same namely asthma 3. Present Medical History At the time for the assessment date February 05, 2013 clients complain asphyxiate, especially when low temperature, for alleviating gripes asphyxiate clients sleep half sitting, asphyxiate recurring at the time of evening and morning 4. Family Health History Clients said in the members of her family were suffering from an illness that same as suffered clients such as asthma.

B. Physical Assessment 1. General Circumstances : The client is weak 2. Vital Sign Blood Pressure = 130/90 mmHg Pulse= 78x/minute 3. Cognition : Compos Metis Temperature= 370C Respiratory Rate = 28x/minute

4. Lung : a. The form of a chest symmetrical respiratory 28x per minute b. There is no pain stress c. An audible voice hipersonor d. Breath and ronchi wheezing sound 5. Abdominal : a. A shape quiet convex b. Painless press c. There is pekak abdominal d. Noisy bowels sound 7x per minute

C. Treatment 1. Long-term asthma control medications a. Inhaled corticosteroids. These medications include fluticasone

(Flovent Diskus) Flovent 110 mcg 1 puff BID b. Leukotriene modifiers. These oral montelukast (Singulair) help relieve asthma symptoms for up to 24 hours.

D. Resume of Client Ms. J, 19 years, was admitted with diagnosis of asthma. With a chief complaint of asphyxiate, especially when low temperature, for alleviating gripes asphyxiate clients sleep half sitting, asphyxiate recurring at the time of evening and morning.

Family History: Her sister had suffered asthma

E. Pathphysiology

Image: normal airway (left) and asthmatic airway (right)

CHAPTER III - IMPLEMENTATION

A. List of Prioritized Nursing Diagnosis Priority: 1. Ineffectiveness the way of the breath 2. Pain r/t surgical site, traumatic injury, ischemic process, monitoring devices, routine nursing care and/or immobility 3. A disorder of sleep pattern

B. Nursing Care Plan Nursing Diagnosis Ineffective Airway Clearance Possible Etiologies: (Related to) Bronchospasm Increased production of secretions; retained secretions; thick, viscous secretions Decreased energy/ fatigue Defining characteristics: (Evidenced by) Statement of difficulty in breathing Feeling of chest constriction Changes in depth/ rate of respiration; Objectives Nursing Interventions 1. Assess Short term respiratory goal: Client will status every demonstrate hour during signs of patent acute phase: airway and lung sounds, adequate respiratory rate oxygen and depth, exchange presence and within 3 days. severity of wheezing, breathing pattern, use of accessory muscles. Long term goal: Client will demonstrate behaviours to improve or maintain 2. Assist patient to airway assume to clearance and comfortable identify position, i.e. potential elevate head of complications bed, have client and initiate lean on overbed appropriate table or sit on Rationale 1. Some degree in bronchospasm is present with obstruction in airway and may be manifested with wheezing or absent breath sounds in severe asthma. Tachypnea is usually present to some degree and respiratory dysfunction is variable depending on underlying process such as allergic reaction. 2. Elevation of head of the bed facilitates respiratory function by use of gravity, however client in distress may Evaluation Client will verbalize reduction or absence in difficulty in breathing and feeling of chest constriction, respiration and cardiac rate within normal range, absence or reduction of inspiratory and expiratory wheezing, and ability to resume to activities. Client will be able to identify and avoid potential allergens or stimuli that would trigger asthma attack and be able to handle symptoms if recurrence comes,

tachypnea Tachycardia Use of accessory muscles or marked respiratory effort Abnormal breath sound, inspiratory and expiratory wheezing Cough (persistent), without sputum production Prolonged expiration

actions.

the edge of bed.

seek position that most eases breathing. 3. Precipitators of allergic type of respiratory reactions that can trigger or exacerbate onset of acute episode. 4. Provides some means to cope with or control dyspnea and reduce air trapping. 5. Hydration helps thin secretions, facilitating expectoration and using warm liquids may decrease bronchospasm. 6. Fluids during meals can increase gastric distension and pressure on the diaphragm.

3. Keep environmental pollution to a minimum according to individual situation. 4. Encourage and assist abdominal and pursed lip breathing exercises. 5. Increase fluid intake to 3000ml/ day within cardiac tolerance. 6. Provide warm liquids and recommend intake of fluids between meals, instead of during meals. 7. Administer medications as indicated.

prompt follow up check up and to always bring or have the prescribed medication/s on hand in case asthma occurs.

8. Monitor side effects of bronchodilator

7. Anticholinergic medications are the first line drugs for clients with this condition. 8. Humidity helps reduce viscosity of secretions,

facilitating expectoration and may. 9. Provide 9. Breathing supplemental exercises help humidification, enhance e.g., neutralizer diffusion, in respiratory nebulizer treatments. medications can reduce bronchospasm and stimulate expectoration. 10. Establishes 10. Monitor baseline for ABGs, pulse monitoring oximetry, progression/ chest x- ray. regression of disease process.

(tremors/ tachycardia).

Nursing Diagnosis Pain r/t surgical site, traumatic injury, ischemic process, monitoring devices, routine nursing care and/or immobility Short Term Goals / Outcomes: Patient will report pain less than 3 on 0-10 scale. Patients vital signs will be within normal limits. Intervention Rationale Assess pain A good assessment of pain will help in characteristics: the treatment and ongoing management quality (sharp, of pain. burning); severity (0 -10 scale); location; onset (gradual, sudden); duration (how long); precipitating or relieving factors Monitor vital signs Tachycardia, elevated blood pressure, tachypnea and fever may accompany pain. Assess for probable Different etiologic factors respond better cause of pain. to different therapies Assess for nonverbal indicators of pain. Facial grimacing, pulling at tubes, restlessness, resistance to passive motion and non-synchronous ventilation can all be indicators of pain. Give analgesics as Narcotics are indicated for severe pain. ordered and evaluate For acute pain, analgesics should be the effectiveness. administered intravenously and at the onset. Subsequent doses, either intravenously or orally, should be around-the-clock to ensure consistent analgesia. Assess As the patients condition improves and appropriateness of a becomes responsive he may be switched patient-controlled to PCA. (PCA) analgesia Anticipate the need The most effective way to deal with pain for pain relief and is to prevent it. Early intervention can respond decrease the total amount of analgesic immediately to required. Quick response decreases the complaints of pain. patients anxiety regarding having their needs met and demonstrates caring. Eliminate additional Outside sources of stress, anxiety and

Long Term Goal: Patient will be free of pain

Evaluation Patient reports pain as 3 on 0-10 scale; intermittent and sharp in incision area.

Vital signs within normal limits. Patient is experiencing pain from multiple traumatic injuries Patient grimaces and stiffens when turning.

Analgesics given as ordered. Patient reports pain relief after administration.

Patient awake and alert, PCA ordered

Pain medication delivered prior to dressing changes with adequate relief.

Patient appears relaxed, is

stressors when possible. Provide rest periods, sleep and relaxation. Institute nonpharmacological approached to pain (detraction, relaxation exercises, music therapy, etc) If patient is on continuous intravenous analgesics, a daily interruption should occur if the patient: has adequate pain control is not receiving neuromuscular blocking agents is hemodynamically stable is stable on the ventilator If patient is on patient controlled analgesia (PCA): Dedicate an IV line for PCA only 2. Assess pain relief and the amount of pain the patient is requesting. 3. Educate patient and significant others on correct use of PCA.
1.

lack of sleep all may exaggerate the patients perception of pain.

sleeping throughout the night.

Non-pharmacological approaches help distract the patient from the pain. The goal is to reduce tension and thereby reduce pain.

Patient is relaxing with radio playing.

Daily interruption of continuous infusions of intravenous analgesics results in a decreased number of days on the ventilator and decrease in the length of stay

Daily interruption of continuous analgesia held for 60 minutes, patient awake and alert during interruption.

Drug interaction may occur, if dedicated line is not possible consult pharmacist before mixing drugs. If demands for the drug are frequent the basal or lock-out dose may need increased to cover the patients pain. If demands for the drug are very low, the patient may need further education of use of the PCA. The patient and significant others must understand that the patient is the only one who should control the PCA.

PCA infusing without complications. Patient and family understand purpose and use of PCA. Patient is getting adequate pain relief with current dose.

For PCA: Keep Narcan readily available. 2. Place No


1.

In event of respiratory depression reversal agent must be available.

Narcan on unit if needed. Sign placed in room for safety.

additional analgesia sign over head of bed.

This prevents inadvertent analgesia overdosing.

Nursing Diagnosis Disturbed Sleep Pattern r/t environment, patient care activities, discomfort, medication, withdrawal Short Term Goals / Outcomes: Patient will appear rested or verbalize feelings of rest Patient will show an improvement in the sleep pattern Intervention Rationale Document Lack of sleep can cause changes in observation of metabolism, immune response and sleeping and respiratory dysfunction. These may lead wakeful behaviors. to delayed healing and prolonged need Record number of for mechanical ventilatory support. It sleep hours. Note may also be a factor in the development physical and/or of ICU psychosis. There are many physiological factors in the critical care environment circumstances that that can interrupt sleep. interrupt sleep. Modify the The environment must be conducive to environment by sleep. decreasing noise, comfortable temperature, darkness, closed door. Provide a relaxing A back rub, providing pillows for activity before comfort, calming music, or reading can bedtime. all help the patient relax before sleeping. Administer Any medications prescribed for sleep hypnotics or should be short course of therapy and sedatives as ordered. only used if less aggressive means are ineffective. Organize nursing It takes at least 60 -90 minutes to care to provide complete one sleep cycle. The minimal completion of an entire sleep cycle is interruptions and necessary to benefit from sleep. allow for at least two hours of uninterrupted sleep.

Long Term Goal: Patient will achieve optimal amounts of sleep

Evaluation Patient sleeping 30 -45 minutes at a time. Wakes up every time caregiver enters room or monitor alarms.

Light dimmed and curtain drawn. Patient requested extra blanket and is sleeping.

Back rub given and patient listening to CD player prior to falling asleep. Patient requested medication for sleep.

Patient sleeping a least 1 a time.

C. Discharge Planning M - MEDICINE Advice patient to continue taking his prescribed medicines E- ENVIRONMENT AND EXERCISE 1. Maintain a quiet, pleasant, environment to promote relaxation. 2. Provide clean and comfortable environment T- TREATMENT 1. Continue home medications 2. Teach the patient to use an inhaler 3. Encourage the patient to drink warm 4. Teach the patient the things that need to be avoided: allergen factors, stress, excessive cold weather activity H- HEALTH TEACHING Provide written and oral instructions about asthma care, activity, medications and follow-up visits O- OUT PATIENT FOLLOW-UP 1. Patient will be advised to go back in the hospital in a specific date to have a follow-up check up after discharge or during an asthma attack 2. Consul doctor for are any problems or complications encountered D- DIET 1. Encourage patient to monitor oral intake, if not enough add

parenteral nutrition 2. Eat small or favorite meals but often S- SPIRITUALITY 1. Encourage patient to communicate with God 2. Encourage patient to communicate with other people

CHAPTER IV CONCLUTION

Several possibilities were considered in this patient at admission. It should be noted that Asthma was not on the card. Asthma is a disorder of the bronchial airways characterized by periods of bronchospasm. It may be extrinsic (allergic) or intrinsic (non- allergic). Extrinsic asthma usually begins in childhood and the client may be allergic to dust, pollen, insects, mold spores, smoke, medications and foods. It is considered as an inherited disorder that interacts with environmental factors causing the disease. It involves airway inflammation and periodic narrowing of airway Lumina (hyperactivity). Moreover, it is the result of individual response to a wide variety of stimuli and is therefore episodic in nature with fluctuations or worse exacerbation of symptoms. The patients of asphyxiate, especially when low temperature

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