TABLE OF CONTENTS I. INTRODUCTION ............................................................................................... 1 Objectives: ......................................................................................................... 3 II. ASSESSMENT ................................................................................................. 5 A. Biographical Data .......................................................................................... 5 G.Genogram ...................................................................................................... 8 H.

Developmental Tasks.................................................................................... 9 III. LABORATORY AND DIAGNOSTIC EXAMINATION ..................................... 45 IV. REVIIEW OF ANATOMY AND PHYSIOLOGY .............................................. 52 V. SYMPTOMATOLOGY .................................................................................... 58 VI. ETIOLOGY .................................................................................................... 62 VII. PATHOPHYSIOLOGY .................................................................................. 68 VIII. NURSING CARE PLAN ............................................................................... 70 X. PHARMACOLOGICAL MANAGEMENT ......................................................... 82 IX. DISCHARGE PLAN ....................................................................................... 97 X. SYNTHESIS OF CLIENTS CONDITION ........................................................ 99 A. Conclusion .................................................................................................. 99 XI. EVALUATION OF THE OBJECTIVE OF THE STUDY ................................ 104 XII. BIBLIOGRAPHY ......................................................................................... 105

I. INTRODUCTION

Acute asthma exacerbation is commonly referred to as an asthma attack. The classic symptoms are shortness of breath, wheezing, and chest tightness. While these are the primary symptoms of asthma, some people present primarily with coughing, and in severe cases, air motion may be significantly impaired such that no wheezing is heard. Many things are considered a trigger for a bronchial asthma acute exacerbation. These things are allergens (pet hair, pollen, smoke, dust etc), air pollution and air toxins, hard physical activity and stress and anxiety. Asthma affects an estimated 300 million individuals worldwide. Evidence shows that the prevalence of asthma is increasing, especially in children. Annually, the World Health Organization (WHO) has estimated that 15 million disability-adjusted life-years are lost and 250,000 asthma deaths are reported worldwide. Approximately 500,000 annual hospitalizations (34.6% in individuals aged 18 y or younger) are due to asthma. The cost of illness related to asthma is around $6.2 billion. Each year, an estimated 1.81 million people (47.8% in individuals aged 18 y or younger) require treatment in the emergency department. Among children and adolescents aged 5-17 years, asthma accounts for a loss of 10 million school days and costs caretakers $726.1 million because of work absence. The latest data from Centers for Disease Control indicate an

asthma prevalence rate of 8.4% in the United States. Its diagnosis is usually made based on the pattern of symptoms and/or response to therapy over time. The prevalence of asthma has increased significantly since the 1970s. As of 2010, 300 million people were affected worldwide. In 2009 asthma caused 250,000 deaths globally ( William F Kelly III, MD, Assistant Professor of Medicine, Uniformed Services University of the Health Sciences; Staff Physician, Division of Pulmonary/Critical Care Medicine, Department of Medicine, Walter Reed Army Medical Center, http://emedicine.medscape.com/article/137501overview) Asthma is the third leading cause of hospitalization among children under the age of 10. Approximately 32.7 percent of all asthma hospital discharges in 2006 were in those under 10, however only 20.1% of the Philippine population was less than 10 years old. In 2005, there were approximately 679,000 emergency room visits were due to asthma in those under 10. (Region NCR Agenda - SETTING THE HEALTH RESEARCH PRIORITIES 2006.) According to the City Health Office Of Tagum there are 1.48 % children less than five year old diagnose with bronchial asthma in the year 2009, <1 for (m) 1 reported case (F) 0,Age 4 (m) 2 and for (F) 4 reported case.(city health office of Tagum CY: 2009) In Tagum Doctors Hospital, Inc. there are 17 patients who had been diagnosed with bronchial asthma in acute exacerbation in the month of June 2011. (Tagum Doctors Hospital, Inc.)

Significance of the Study Lower airway problems directly affect gas exchange and have serious consequences. Many of these problems are chronic and progressive, requiring major changes in persons lifestyles. Such airway problem includes Bronchial Asthma which is a serious problem and could probably lead to death if proper precautions are not observed. This study is made so that every reader or listener of the case study and research will gain enough knowledge and understand Bronchial asthma, its cause, manifestations, treatment, and preventions. This study points and focuses on the significance of reaching out to the awareness of every individual who may have this kind of disease and to the member of the health care team and share to them the proper ways on how to effectively care to patients suffering from this problem. Objectives: General Objectives: This study aims to deepen our knowledge about bronchial asthma. To be able to identify possible interventions that can be done to decrease the possibility of further complications and to identify the factors that lead to the occurrence of the disease. Specific Objectives: y Establish rapport to gain clients cooperation in attaining relevant information. y Gather all relevant information about the patient that will serve us our baseline data for the fulfillment of this case study,

Trace patients family history through family genogram, including the past and present health history of the patient,

Perform the head-to-toe physical assessment of the patient that will indicate the aspect of his condition,

Trace the pathophysiology of the patient who have bronchial asthma including the underlying symptoms and its predisposing and precipitating factors,

y y y

Review the anatomy and physiology of the affected organs, Enumerate those prescribed medications of the patient, Formulate nursing care plans based on the problem and evaluate the appropriate interventions to be apply, and

Create

prognosis

that

will

evaluate

patients

condition,

list

recommendations, and evaluate the overall outcome of the study.

II. ASSESSMENT

A. Biographical Data Name Age Gender Address Birth date Birthplace Race Religion Marital Status Occupation Admitting Diagnosis : Patient X : 29 years old : Male : Villa Magsanoc, Mankilam, Tagum City : May 25, 1982 : Cagayan De Oro : Filipino : Roman Catholic : Single : Encoder, Personal Collection Company : Bronchial Asthma in Acute Severe Exacerbation; CAP III Attending Physician Source of Data : Dr. Glenn Renegado : Client

B. Chief Complaint The patient is 29 years old and 2 months with complaint of cough and dyspnea. C. History of Present Illness Two days prior to admission onset of cough and dyspnea which was only tolerated? D. Past Medical History Illness Mumps Chickenpox Age 5 years old 10 years old Duration 3 days 1 week Treatment Aniel Isolation took and

medicine

(Acyclovir) Asthma 14 years old 1 week Admitted Monsanto Hospital week Table 1.1 E. Personal and family History Patient X was raised up in a Christian belief. He came from Cagayan de Oro City. He was raised up by his mother and father giving all his needs and
6

at

for

wants. His grandparents in maternal side died when her mother was still 4 years old and his grandparents on the paternal side died when his father was still 10 years old. His mother and father didnt know the cause of death of their parents due to their young age. Our patient said that he is jealous whenever he saw kids having grandparents. His mother was diagnosed with asthma since birth and since asthma is hereditary, he inherited it from his mother. His 3nd sibling also has asthma since birth and the rest still dont have manifestation for such disease. F. Socio-Economic History Patient X was born on May 25, 1982. He was the eldest among the four offspring of Mr. and Mrs. X. He studied at Southwestern University in Cebu taking up Bachelor of Science in Criminology from 1998-2002 and worked part time as an encoder in Personal Collection Company, at the same school he took up Bachelor of Science in Hotel and Restaurant Management from 2005-2007 but he wasnt able to finish the course because he chose to work in Manila as an encoder in the same company. After 1 year of working in Manila he went to his home town and applied in the same company and was assigned at Tagum City, there he met his fianc who is a daughter of the owner of the company where he worked. Patient X refused to reveal his income because they have an agreement with the company not to say it to anyone.

G.Genogram

Mr. X

Mrs. X

Patient X (29 years old)

Brother 1 (28 years old)

Sister 1 (22 years old)

Sister 2 (17 years old)

Figure 1.1 Legend: Asthma Alive

H. Developmental Tasks

THEORIST / THEORY Erik Erikson

STAGES / TASK Stage 1 INFANCY to A

NORMAL FINDINGS sense

ACTUAL FINDINGS of He grew

JUSTIFICATION

up In this stage, the his infants source primary of is

trust requires with 1 a feeling of parents. His

Psychosoci (0 al Theory

years old) Trust Mistrust

physical

parents pleasure

vs. comfort and a gave minimal amount fear infants

his sucking and the basic area of

of needs like food gratification is the and and comfort. He also by mouth. felt - A baby is very his dependent and

apprehension about future.

the loved

Trust parents. -TRUST-

can do little for his self. If babies needs properly

in infancy sets the stage for a lifelong expectation that the world will be a good and pleasant

fulfilled can move onto the next

stage but if not fulfilled baby will be mistrustful or

THEORIST / THEORY

STAGES / TASK

NORMAL FINDINGS place to

ACTUAL FINDINGS

JUSTIFICATION

over-fulfilled baby will find

live.(Demand Media, 2010)

hard to cope with a world that

doesnt meet all his/her demands. Stage 2 Early childhood After gaining He gained The control stage second of

trust in their more caregivers, over

food Eriksons theory toy of psychosocial

(18 mos.-3 infants yrs.) Autonomy to that

begin choices,

discover preferences, their and

development place early

clothings takes He during

vs. shame behavior and doubt their

is selection.

own. learns to say childhood and is focused children developing a on

They start to NO. assert sense their of

independence , or autonomy. They their realize will. If

greater sense of personal control.

10

THEORIST / THEORY

STAGES / TASK

NORMAL FINDINGS infants are

ACTUAL FINDINGS

JUSTIFICATION

restrained too much or

punished too harshly, they

are likely to develop sense shame doubt. (Demand Media, 2010) Stage 3 Play Initiative He made up During the a of and

age versus guilt is stories

with preschool years, children begin to their and

(3-5 yrs.) Initiative vs. guilt

Eriksons third superheroes, stage of toy

phones, assert

development, occurring during preschool years. As

and play baril- power barilan

with control over the world directing through play

the his friends.

and other social

11

THEORIST / THEORY

STAGES / TASK

NORMAL FINDINGS preschool children encounter widening social they challenged more when were Active, purposeful behavior needed cope these challenges. Children asked assume responsibility are to is to with than they infants. world, are a

ACTUAL FINDINGS

JUSTIFICATION

interaction.

12

THEORIST / THEORY

STAGES / TASK

NORMAL FINDINGS for bodies, their their

ACTUAL FINDINGS

JUSTIFICATION

behavior, their toys, and their pets. Developing a sense of

responsibility increases initiative. Uncomfortabl e guilt feelings may arise,

though, if the child irresponsible and is made to feel too is

anxious. (Demand Media, 2010)

13

THEORIST / THEORY

STAGES / TASK Stage 4

NORMAL FINDINGS

ACTUAL FINDINGS

JUSTIFICATION

It involves the He

was During this stage,

School age shift (6-12 yrs.) whimsical play Industry vs. Inferiority desire to

from encouraged by often called the his parents and Latency, we are a teachers to join capable for curricular of

learning, creating

achievement and

activities such and as in literacy accomplishing and numerous new and

completion. A contest child that receives praise

learns quiz bee. Boy skills he scout. parents, and teachers,

His knowledge, thus developing and sense a of

recognition for peers gave his industry. This is doing well in full support. school and also a very social stage of

completing tasks and also realizes can fail he at

development and if we experience unresolved feelings inadequacy of and

these tasks as well. (Demand

inferiority among

14

THEORIST / THEORY

STAGES / TASK

NORMAL FINDINGS Media, 2010)

ACTUAL FINDINGS

JUSTIFICATION

our

peers,

we

can have serious problems terms in of

competence and self-esteem. to this Up

stage, to

according Erikson, development mostly upon

depends what is

done to us. From here on out,

development depends primarily what we do. Stage 5 Adolescen ce The He usually Adolescence is a upon

adolescent is hangs out with stage at which his friends. we are neither a

(12-18 newly

15

THEORIST / THEORY

STAGES / TASK yrs.old)

NORMAL FINDINGS concerned

ACTUAL FINDINGS

JUSTIFICATION

He begins to child

nor life

an is

with how they court the girl adult, Identity vs. appear Role Confusion others. to he liked

in definitely getting more complex as we find attempt our to own

Ego school.

identity is the accrued confidence that the inner sameness and continuity prepared in

identity, struggle with social

interactions, and grapple moral issues. with

the past are matched by

the sameness and continuity of meaning ones for

others, where in adolescents begin to seek their true

16

THEORIST / THEORY

STAGES / TASK

NORMAL FINDINGS identities and a sense of The

ACTUAL FINDINGS

JUSTIFICATION

self. central question

of

this stage is of course, Who am (Demand Media, 2010) Stage 6 Young adulthood At this time, Our individuals face found the mutually satisfying patient This stage I?.

a covers the period of adulthood people early when are

(18-35 yrs. developmenta Old) l task

of relationship

forming Intimacy and Solidarity vs. Isolation intimate relationships with others. (Dema nd Media,

and planning to exploring build his own personal family with his relationships. fianc

17

THEORIST / THEORY

STAGES / TASK

NORMAL FINDINGS 2010) Table 1.2

ACTUAL FINDINGS

JUSTIFICATION

THEORIST / THEORY Sigmund Freud Psychosex ual Theory

STAGES / TASK Oral stage

NORMAL FINDINGS During

ACTUAL FINDINGS

JUSTIFICATION

the In this stage of The first stage of

Birth- 1 yr. oral stage, the his life, he was personality old infant's primary source interaction occurs through mouth. an oral or development where libido is in a

mouth-oriented

of such activities centered like biting,

sucking, baby's mouth. It and gets much

the bottle feeding. The

satisfaction from putting all sorts of things in its mouth to satisfy libido, and thus its id demands

mouth is vital for eating, and the derives pleasure from oral stimulation infant

18

THEORIST / THEORY

STAGES / TASK

NORMAL FINDINGS through gratifying activities such as tasting and sucking. Because infant entirely dependent upon caretakers (who are the is

ACTUAL FINDINGS

JUSTIFICATION

responsible for feeding the child), infant develops the also a

sense of trust and comfort this

through oral

19

THEORIST / THEORY

STAGES / TASK

NORMAL FINDINGS stimulation. (Kendra Cherry, 2011)

ACTUAL FINDINGS

JUSTIFICATION

Anal Stage TODDLER

During anal

the His

attention Toddlers should

stage, focused on the control a bowel anus and starts thats why they that to learn toilet should have toilet training to control urges behaviors. and

2-3 YERS Freud OLD believed the

primary training.

focus of the libido was on. controlling bladder bowel movements. The major and

conflict at this stage is toilet training--the child has to learn to

control his or

20

THEORIST / THEORY

STAGES / TASK

NORMAL FINDINGS her needs.. (Kendra Cherry, 2011) bodily

ACTUAL FINDINGS

JUSTIFICATION

Phallic Stage PRESCHO OLER 4 TO

The becomes aware

child Hes with

aware This leads to the the development of

of anatomical sex vagina envy and differences. He the wish to be a imitates his how girl. The boy

anatomical 6 sex differences,

YEARS OLD

mother resolves this by repressing for his his and the

which sets in urinates. motion conflict between erotic attraction, resentment, rivalry, jealousy fear Freud and which called the

He desires to desire be but a mother mother

realizes substituting

that he had no wish for a vagina vagina. with the wish for a baby. The boy blames his father for his 'castrated state creates and this great

21

THEORIST / THEORY

STAGES / TASK

NORMAL FINDINGS the Oedipus

ACTUAL FINDINGS

JUSTIFICATION

tension. The boy then represses

complex(in boys) and the Electra complex(in girls) This is resolved through process identification which involves the the of

his feelings (to remove tension) the and

identifies with the father to take on the male gender role.

child adopting the characteristics of the same sex parent (Kendra Cherry, 2011) LATENCY STAGE During the Most of his No further

latent period, time is spent to psychosexual

22

THEORIST / THEORY

STAGES / TASK

NORMAL FINDINGS

ACTUAL FINDINGS

JUSTIFICATION

6 -12 years the interests

libido his friends with development are the same sex. takes place

suppressed. The development of the ego and superego contribute to

during this stage (latent hidden). means The

libido is dormant. Freud Thought

that most sexual impulses are

this period of calm. stage around time The begins the that

repressed during the latent stage and energy sexual can be (re:

children enter into and more concerned with peer school become

sublimated defense mechanism) towards work,

school hobbies

and friendships.

relationships, hobbies, and

23

THEORIST / THEORY

STAGES / TASK

NORMAL FINDINGS other interests. (Kendra Cherry, 2011)

ACTUAL FINDINGS

JUSTIFICATION

GENITAL STAGE 12-19 years

During

the He

developed It is a time of sexual adolescent sexual

final stage of a psychosexual development,

relationship with

opposite experimentation, the successful of

the individual sex. develops a

resolution

strong sexual interest in the opposite sex. (Kendra Cherry, 2011)

which is settling down in a loving one-to-one relationship with another 20's or so in our

Table 1.3 THEORIST / THEORY Jean STAGES / TASK Sensori NORMAL FINDINGS Differentiates ACTUAL FINDINGS During this During this stage, JUSTIFICATION

24

THEORIST / THEORY Piaget Cognitive

STAGES / TASK motor

NORMAL FINDINGS self

ACTUAL FINDINGS

JUSTIFICATION

from stage, knowledge the world

his a

child

has little in

(Birth 2 objects. -Recognizes

of relatively is competence

Developme yrs. old) nt

self as agent limited to their representing the of action and sensory begins to act perceptions intentionally: e.g. pulls and a activities. environment using images, or An no of

motor language, He symbols. skills infant has

string to set uses mobile motion shakes in such or sucking, a looking,

as awareness

objects or people that are not

rattle to make grasping, a noise. listening learn about

and immediately to present more given the Object permanence the is at a

Achieves object permanence: realizes things continue exist to even that

moment.

environment.

awareness

that objects and people continue

to exist even if

25

THEORIST / THEORY

STAGES / TASK

NORMAL FINDINGS when no

ACTUAL FINDINGS

JUSTIFICATION

they are out of sight. In infants, when a person hides, the infant has knowledge no that

longer present to the

sense.(Athert on J S, 2011))

they are just out of sight. Pre Learns to use He is now Children develop an internal

operational (2-7 old)

language and knowledgeable represent at by symbols. and was able

yrs. to

using representation of He the world that

objects images words Thinking still egocentric: has taking viewpoint others.

to allows them to

use objects to describe people, is represent events, and

something else feelings. Children like pretending in as preoperational He stage are the

difficulty broomstick the a horse.

of liked playing

role characterized by such what Piaget

26

THEORIST / THEORY

STAGES / TASK

NORMAL FINDINGS Classifies

ACTUAL FINDINGS

JUSTIFICATION

as imitating his called egocentric or thoughts. world at The this

objects by a father single feature: mother. e.g. groups all

stage is viewed entirely from the child's perspective. Thus a child's own

together

the red blocks regardless of shape or all the blocks regardless of color.(Atherto n J S, 2011) square

explanation to an adult can be

uninformative. Children who

have not passed this stage do not know that the

amount, volume or length of an object does not change length

when the shape of the

27

THEORIST / THEORY

STAGES / TASK

NORMAL FINDINGS

ACTUAL FINDINGS

JUSTIFICATION

configuration changed. Concrete operational Can think He

is

gained Children in the concrete operational stage a better

logically about better and understanding about

(7 11 yrs. objects old) events. Classifies objects according several features can

mental have

operations and understanding of has better time and space. Children at this

to understanding abstract and hypothetical

or stage have limits to their abstract thinking, according Piaget. to

order ideas.

them in series along a single dimension such as

size. (Atherto n J S , 2011) Formal operational Can think During he this This stage

logically about stage,

is produces a new

(11 yrs and abstract

able to solve kind of thinking

28

THEORIST / THEORY

STAGES / TASK up)

NORMAL FINDINGS propositions and

ACTUAL FINDINGS

JUSTIFICATION

his problems in that is abstract, logical formal, and

test a manner.

hypotheses systematically

Hes logical. Thinking

able to quickly is no longer tied plan an to events that

Becomes concerned with

approach solve the problem.

to can be observed. the A child at this stage can think hypothetically and use logic to solve problems.

hypothetical, the and ideological problems.(Ath erton 2011) Table 1.4 I. Physical Assessment A. General Survey J S, future,

It is thought that not all individuals reach this level of thinking.

With IVF of #3 PNSS 1L @700 cc level regulated @100 gtts/min infusing well @ left metacarpal vein, intact and patent. Vital Signs taken during the assessment: July 23, 2011; 8 a.m.
29

- Temperature: 37C - Pulse Rate: 109 bpm - Respiratory Rate: 18 cpm - Blood Pressure: 120 / 80 mmHg

Interpretation The pulse rate of the patient is elevated and BP, Temperature and Respiratory rate are within normal range.

B. Review of Systems Physical assessment is done systematically using the techniques of inspection, palpation, percussion, and auscultation with the use of materials and instruments such as penlight, thermometer, sphygmomanometer, tape measure, stethoscope, percussion hammer and tuning fork, and our senses. SYSTEM ASSESSED Neurologic Status Interview -Fully alert Patient is The patients TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS INTERPRETA TION

and conscious conscious. He neurologic is oriented to status people, time, normal and When place. he is since had

asked comprehensibl

30

SYSTEM ASSESSED

TECHNIQUE NORMAL FINDINGS

ACTUAL FINDINGS

INTERPRETA TION and

asa ka nag e puyo, patients response, Villa Magsanoc, Mankilam, Tagum City. He eye has to an eye

sir? understandabl e words upon answering the questions that were asked.

contact during interview. -No defect speech No defect. can clearly can understand what we are saying. Respond speech He speak and

31

SYSTEM ASSESSED

TECHNIQUE NORMAL FINDINGS

ACTUAL FINDINGS properly to the

INTERPRETA TION

(P.M.Dillon, 2007) Integument ary System y Skin Inspection -Generally intact smooth texture. -Coloring symmetrical;

questions asked.

Upon with inspection

The skin of the client is in

skin is smooth normal and intact. Brown fair with findings.

pale pink on complexion. unexposed areas, moderately tanned exposed areas. Palpation -No rashes No skin on Tanned on

exposed area.

-Temperature: rashes. 35.5 37.5 C Within normal -Good turgor range, 37 C

32

SYSTEM ASSESSED

TECHNIQUE NORMAL FINDINGS indicated risk recoil. -Skin moist

ACTUAL FINDINGS by Good turgor. skin

INTERPRETA TION

Moist -No edema noted. No (Lynn 2009) y Hair Inspection -Generally brown Upon or inspection B. noted.

skin

edema

The hair of the client hair normal findings. is in

black, evenly black distributed over straight curly evenly

scalp, distributed or and no signs and of damage.

shiny with no signs damage. Palpation Scalp smooth is Upon with palpation of

33

SYSTEM ASSESSED

TECHNIQUE NORMAL FINDINGS no

ACTUAL FINDINGS not

INTERPRETA TION

presence lesions noted. B.

of lesions. (Lynn 2009) y Nails Inspection

-Convex nails; Upon 160 degrees inspection convex is 160. -Clear coat, Clear coat glossy

The nails of the client are in

nails normal findings.

glossy polish and present -Pink nail bed -No hemorrhage in discoloration of nails polish .

Pink nail bed. No hemorrhage noted.

surrounding tissues. -Capillary refill Upon

34

SYSTEM ASSESSED

TECHNIQUE NORMAL FINDINGS

ACTUAL FINDINGS

INTERPRETA TION

blanch test <2 palpation the seconds (P.M.Dillon, 2007) y Head/Neck Inspection Normocephali c symmetric Upon inspection The head and neck is client normal of is the in capillary refill is <2 sec

and head

normocephali c

and findings.

symmetric. No dandruff

noted. Palpation -No lesions Upon palpation not

and dandruff -Absence masses

of masses and noted.

tenderness. (Lynn 2009) y Eyes B.

35

SYSTEM ASSESSED

TECHNIQUE NORMAL FINDINGS Inspection -Eyes clear parallel alignment -No and present -Lids freely -Eyelashes are

ACTUAL FINDINGS are Upon and inspection

INTERPRETA TION The eyes clients is in

eyes is clear normal and aligned. edema findings.

lesions No edema noted. Lids move freely.

move

Eyelashes

evenly evenly distributed.

distributed and curved

outward -Palpebral Blood vessels and is

conjunctiva is present smooth, palpebra

minimal blood smooth. vessels present. -White sclera Visible white are

36

SYSTEM ASSESSED

TECHNIQUE NORMAL FINDINGS is visible. -Color consistent with color. (Lynn 2009) B. skin

ACTUAL FINDINGS sclera. is Same color

INTERPRETA TION

with the skin.

Ears Inspection -Intact no skin, Upon The client has no ear

drainage inspection

or lesions

skin is intact problems with presence drainage noted. no which indicate of that he has a paired hearing and can hear

-Hears

the Both ears can clearly.

sound equally hear equally. Palpation in both ears -Soft and non Non tender (P.M.Dillon, when palpated. tender

37

SYSTEM ASSESSED

TECHNIQUE NORMAL FINDINGS 2007)

ACTUAL FINDINGS

INTERPRETA TION

Nose Inspection -Nasal mucosa pink moist Upon is inspection The nose of

the client is in

and nasal mucosa normal is pink and findings.

moist. -Septum is Intact septum no

intact and at with the midline, deviation.

pink with no deviation perforation. Palpation -No lesions -No tenderness (P.M.Dillon, 2007) Respiratory System y Mouth / Inspection -Skin intact Upon The clients and Upon palpation lesions and or

tenderness not noted.

inspection the mouth

38

SYSTEM ASSESSED Throat

TECHNIQUE NORMAL FINDINGS

ACTUAL FINDINGS

INTERPRETA TION is in

skin is intact throat and symmetrical. -Pink moist -No lesion and Pink moist. No noted. -No odor -Gums bleeding unusual No odor. not No bleeding unusual lesion and normal findings.

noted. is and

-Hard and soft Palate palate pink smooth -Uvula is the and are smooth

and pink in color.

at Uvula midline rises

midline and

rises symmetrically.

symmetrically -No lesions No noted. lesions

and exudates

39

SYSTEM ASSESSED

TECHNIQUE NORMAL FINDINGS (P.M.Dillon, 2007)

ACTUAL FINDINGS

INTERPRETA TION

Respiration Inspection -Normal respiration Upon Patients may

inspection the describe themselves as having

ranges 12 - respiratory 20 cpm Palpation -No rate is 18cpm.

palpable No

masses breathing difficulties, trouble getting a deep breath or sufficient air. is With bronchial asthma, wheezes usually in in are

masses found Auscultation -Symmetrical chest excursion

palpated. Upon auscultation chest excursion equal.

-Quite, rhythmic effortless respiration

Uses and accessory

muscles when insidious breathing. Chest tightness noted. onset progressive. (P.M.Dillon, 2007)

40

SYSTEM ASSESSED

TECHNIQUE NORMAL FINDINGS -Regular

ACTUAL FINDINGS Presence of

INTERPRETA TION

breathe sound wheezes upon (P.M.Dillon, 2007) Cardiovasc ular system Palpation -Radial pulse Upon rate : The pulse rate auscultation.

60- palpation, the usually patients pulse increases rate abnormal; 109bpm. When rechecked, is response hypoxia in to since

100bpm

the patient had an airway impaired

pulse rate is secretion. 102bpm. Auscultation -Apical pulse Upon palpated at auscultation apical is (P.M.Dillon, 2007)

the 5th interco- the stals space of pulse left

sterna abnormal;

41

SYSTEM ASSESSED

TECHNIQUE NORMAL FINDINGS border. -BP range: 110/170 120/80 -No thrills abnormal palpitations -S1 lift

ACTUAL FINDINGS 102bpm.

INTERPRETA TION

Normal BP : 120/80 mmHg

or Abnormal or palpitation noted.

and S2 S1

and

S2 upon

heard, without heard splitting -No murmurs (P.M.Dillon,20 07) Reproductiv e System Interview -No penile The

auscultation. No murmurs.

client The

patient

discharge -Lesions

verbalizes no reproductive lesions discharge. and system normal there is since is

(P.M.Dillon,20

42

SYSTEM ASSESSED

TECHNIQUE NORMAL FINDINGS 07)

ACTUAL FINDINGS

INTERPRETA TION presence discharge noted. of

Gastrointest inal System Auscultation -Normal bowel movement During the The clients

assessment

gastrointestinal is in

the last bowel system movement 6am in is normal the findings.

morning. Upon cultation austhe

bowel sounds not noted. -No tenderness when palpate -No pain (P.M.Dillon,20 07) No when palpated. gastric tender

gastric No pain.

43

SYSTEM ASSESSED Genitourinar y System

TECHNIQUE NORMAL FINDINGS

ACTUAL FINDINGS

INTERPRETA TION

Interview

Urinary output During is 30cc

the The

patients

per assessment, the voided times.

genitourinary is in

hour. (P.Dillon,2007 ) Musculoskel etal system Inspection -No tremors -Coordinated movements

patient system 7 normal

findings. .

Upon inspection

The

patients

musculoskelet

tremors is not al system is in noted with normal findings.

movements coordinated. Palpation -No Upon no

tenderness or palpation swelling -No cramps (P.M.Dillon,20 07) Table 1.5 leg leg noted.

cramps

44

III. LABORATORY AND DIAGNOSTIC EXAMINATION

X-ray result Radiologic Findings:

July 20, 2011

Heart is normal in size shows infiltration in both lower lobes. Upper lung field are clear.

Impression: suggestive of pneumonia

Hematology Laboratory test Normal Values Hemoglobin Mass Concentration 135-160 g/L Actual Findings 155 g/L

July 20, 2011 Interpretation

Patients concentration

hemoglobin is within

normal range. Decreased hemoglobin concentration is seen in various

anemias, severe or

pregnancy, prolonged and fluid with intake.

hemorrhage excessive

Laboratory test

Normal Values

Actual Findings

Interpretation

Increased in polycythemia, chronic obstructive

pulmonary disease, failure of oxygenation because of congestive heart failure

and normally in people living at high altitude. Smeltzer,S.C., Bare,B.G., Hinkle,J.L., (2008) Segmenters 0,55- 0,65 g/L 0,61 10 g/L Patients within segmenter normal is Cheever,K.H.

range.

Segmenters(segmented neutrophils, or just segs) are one of the types of neutrophils, which are the most white common blood type cells. of An

elevated white count and elevated (segmenters) are segs a

46

Laboratory test

Normal Values

Actual Findings

Interpretation

suggestion that the body is attempting to fight off an infection. Smeltzer,S.C., Bare,B.G., Hinkle,J.L., (2008) Lymphocytes 0,25-0,40 g/L 0,21 Patients within lymphocyte normal is Cheever,K.H.

range.

Increased lymphocytes is seen in increased with

infectious mononucleosis, viral and some bacterial infections, and hepatitis. Decreased with aplastic

anemia, immunodeficiency including AIDS. Smeltzer,S.C., Bare,B.G., Hinkle,J.L., (2008) Monocytes 0,02-0,06 g/L 0,16 Patients above monocyte normal is Cheever,K.H.

range.

47

Laboratory test

Normal Values

Actual Findings

Interpretation

Increased

monocyte

is

seen with viral infection, parasitic disease, collagen and hemolytic disorders. Decreased with corticosteroids, infection. Smeltzer,S.C., Bare,B.G., Hinkle,J.L., (2008) Eosinophils 0,01-0,05 g/L 0,01 Patients within eosinophil normal is Cheever,K.H. use of HIV

range.

Increased in Eosinophils is seen in allery, parasitic disease, collagen disease, subacute infection.

Decrease with stress, use of some medication. Smeltzer,S.C., Bare,B.G., Hinkle,J.L., (2008) Cheever,K.H.

48

Laboratory test

Normal Values

Actual Findings 0,01

Interpretation

Basophils

0-0,005 g/L

Patients within

basophils normal

is

range.

Increased in basophils is seen in acute leukemia and following surgery or trauma. allergic Decreased reaction, with

stress,

allergy, parasitic disease, use of corticosteroids. Smeltzer,S.C., Bare,B.G., Hinkle,J.L., (2008) Leukocytes 5-10 10 g/L 11,0 10 g/L Patients above leukocyte normal is is Cheever,K.H.

range. an

Leukocytosis

abnormal increase in the number of circulating white blood cells. An increase bacterial, but not usually viral infection. Leucopenia is an abnormal decrease in

49

Laboratory test

Normal Values

Actual Findings

Interpretation

the number of white blood cells. Decrease in

leukocytes is caused by an adverse reaction, radiation poisoning, conditions. Mosby,E.(2006) Pocket Medicine, Mosbys of & or pathologic

Dictionary Nursing

Health Professions. Hematocrit Males: 42% - 0,48 52% Female: 35% - 47% Patients within hematocrit normal is

range.

Decreased hematocrit in severe anemias, anemia of pregnancy, acute massive blood loss. Increased in erythrocytosis of any

cause, and in dehydration or hemoconcentration

associated with shock. Smeltzer,S.C., Bare,B.G.,

50

Laboratory test

Normal Values

Actual Findings

Interpretation

Hinkle,J.L., (2008) Table 1.6

Cheever,K.H.

51

IV. REVIIEW OF ANATOMY AND PHYSIOLOGY

Figure 1.2 The respiratory system is responsible for gaseous exchange between the circulatory system and the outside world. Air is taken in via the upper airways (the nasal cavity, pharynx and larynx) through the lower airways (trachea, primary bronchi and bronchial tree) and into the small bronchioles and alveoli within the lung tissue. The organs of respiratory system make sure that oxygen enters our bodies and carbon dioxide leaves our bodies.

Figure 1.3

Upper Respiratory system Nose- is the passageway of air and which is important for warming, moistening and filtering of air. The space inside of the nose is shaped like a triangle and

is divided into 3 parts: Nostrils - openings of the nose. Nasal Septum divides the nostrils and is important for smell

Nasal Passage the space inside of the nose Sinuses- resonating chamber of speech. Consist of four pairs of bony cavities; lined by nasal mucosa. Four pairs location y y y y Frontal Ethmoidal Sphenoidal Maxillary

Pharynx- muscular passageway commonly called throat.  y y 3 sections Nasopharynx which contains adenoids and opening to the Eustachian tubes. Oropharynx which contains palatine tonsils and also a passageway of air and food. y Laryngopharynx which extends from the epiglottis to the 6 cervical level and also allows air to enter from the nose and the mouth.

53

Larynx- a cartilaginous epithelium lined structure that connects the pharynx and trachea.  This is also known as the voice box. Sound is generated and that is where pitch and volume are manipulated.

Figure 1.5 Lower Respiratory Tract Trachea-windpipe which extends from the larynx to the 2nd costal cartilage composed of 16-20 c-shaped cartilage rings.  Carina- terminal point when trachea divides into left and right lungs.

Bronchi- two branches that arise from the trachea.  y y Consist of right and left main stem bronchus Right mainstem brochus is larger and straighter. Left maistem bronchus is shorter.

Bronchioles- are the first airway branches that no longer contain cartilage. They are branches of the bronchi. The bronchioles terminate by entering the circular sacs called alveoli. Right and Left Lungs  The main organ of respiration and lie within the thoracic cavity.

54

The right lung divides into 3 lobes and the left lung divides into 2 lobes.

Alveoli ducts- arise from the right bronchioles to the alveoli. Alveoli- the cellular unit of the lungs.  Produce surfactant that is responsible for reduce surface tension and prevents alveolar collapse.  35% alveolar gas exchange to the alveolar ducts and 65% alveolar gas exchange to the alveolar sacs.

Figure 1.6

The upper respiratory tract consists of the nose, sinuses, pharynx, larynx, trachea, and epiglottis. The lower respiratory tract consist of the bronchi, bronchioles and the lungs.

55

The major function of the respiratory system is to deliver oxygen to arterial blood and remove carbon dioxide from venous blood, a process known as gas exchange. The normal gas exchange depends on three process:


Ventilation is movement of gases from the atmosphere into and out of the lungs. This is accomplished through the mechanical acts of inspiration and expiration.

Diffusion is a movement of inhaled gases in the alveoli and across the alveolar capillary membrane

Perfusion is movement of oxygenated blood from the lungs to the tissues. Control of gas exchange involves neural and chemical process The neural system, composed of three parts located in the pons, medulla and spinal cord, coordinates respiratory rhythm and regulates the depth of respirations The chemical processes perform several vital functions such as:

 

regulating alveolar ventilation by maintaining normal blood gas tension guarding against hypercapnia (excessive CO2 in the blood) as well as hypoxia (reduced tissue oxygenation caused by decreased arterial oxygen [PaO2]. An increase in arterial CO2(PaCO2) stimulates ventilation;

conversely, a decrease in PaCO2 inhibits ventilation.



helping to maintain respirations (through peripheral chemoreceptors) when hypoxia occurs.

56

The normal functions of respiration O2 and CO2 tension and chemoreceptors are similar in children and adults. however, children respond differently than adults to respiratory disturbances; major areas of difference include:


Poor tolerance of nasal congestion, especially in infants who are obligatory nose breathers up to 4 months of age

Increased susceptibility to ear infection due to shorter, broader, and more horizontally positioned eustachian tubes.

 

Increased severity or respiratory symptoms due to smaller airway diameters A total body response to respiratory infection, with such symptoms as fever, vomiting and diarrhea.

57

V. SYMPTOMATOLOGY

Signs and Symptoms Tachycardia

Actual Symptoms

Analysis Along with an audible wheeze, the breathing cycle is longer more and effort. be

requires The

client

may

unable to complete a sentence of more than five words between the

breaths.

Examine

oral mucosa and nail beds for cyanosis. Pulse oximetry oxyden shows poor

saturation

related to the degree of dyspnea. Hypoxemia

include changes in the level of consciousness

Signs and Symptoms

Actual Symptoms

Analysis and tachycardia. (Ignatavicius, Workman, Medical-Surgical Nursing, 5th Edition,

Volume 1, page 587) Productive cough When allergens bind to the IgE on mast cells, chemicals are released that start inflammatory responses in the airway mucus Responses blood and leading vessel capillary to membranes. include dilation leak, tissue

swelling with increased secretions and mucus production.

(Ignatavicius, Workman, Medical-Surgical Nursing, 5th Edition,

59

Signs and Symptoms

Actual Symptoms

Analysis Volume 1, page 585)

Chest Tightness

Chest pain caused by respiratory diseases

usually originates from involvement of the

parietal pleura. Causes include primary pleural disorders, neoplasms inflammatory such as or disorders

affecting the pleura, or pulmonary that extend disorders to the

pleural surface, such as pneumonia. The pain

associated with irritation of the bronchi usually is substernal and dull,

rather than sharp.

(Porth, C.M., Essentials of Pathophysiology, 2nd

60

Signs and Symptoms

Actual Symptoms

Analysis Edition, page 492)

Wheezes

mild

attack

may

produce a feeling of chest tightness, a slight increase in respiratory rate with prolonged and mild

expiration,

wheezing. A cough may accompany the

wheezing. More severe attacks are associated with use of the

accessory

muscles,

distant breath sounds caused by air trapping, and loud wheezing.

(Porth, C.M., Essentials of Pathophysiology, 2nd Edition, page 499) Table 1.7

61

VI. ETIOLOGY

Predisposing Factors: Hereditary

Actual Findings

Implications It usually has its onset in childhood or

adolescence and is seen in persons with a family history of atopic allergy. Candidate genes for

predisposition to atopy and airway

hyperresponsiveness are currently subjects for

intensive research and include genes involved in antigen presentation, Tcell activation, regulation of cytokine production or function, and receptors for bronchodilating

substances.

62

(Porth, C.M., Essentials of Pathophysiology, 2nd Edition, page 496) Weakened System Immune Immune changes function during a

persons life, according to nutritional status,

environmental conditions, drugs, the

presence of disease, and age. Immune function is most efficient when

people are in their 20s and 30s and slowly

declines with increasing age. Older adults have decreased immune

function, increasing their risk for many health

problems.

(Ignatavicius, Workman,

63

Medical-Surgical Nursing, 5th Edition,

Volume 1, page 361) Precipitating Factors: Allergens Actual Findings Implications Type I reactions are

immunoglobulin E (IgE)mediated hypersensitivity reactions that begin rapidly, often within minutes of antigen challenge. These types of reactions are often referred to as allergic reactions antigens and causing the the

response as allergens.

(Porth, C.M., Essentials of Pathophysiology, 2nd Edition, page 293) Age Asthma can occur at any age. About half of adults with asthma also had the

64

disease

in

childhood.

Asthma is more common in urban settings than in rural settings.

((Ignatavicius, Workman, Medical-Surgical Nursing, 5th Edition,

Volume 1, page 587) Gender This common condition can strike at any age, half of all cases first occur in children younger than age 10; in this group, asthma affects

twice many males than females.

(Williams, Wilkins, nursing Approach to

L., Diseases,

and A

Process Excellent

Care, 4th Edition, page

65

427) Exercise The cause of exerciseinduced unclear. suggested It asthma has that is been during

exercise bronchospasm may be caused by the loss of heat and water from tracheobronchial the tree

because of the need for conditioning volumes of of air. large The

response is commonly exaggerated when the person exercises in a cold environment.

(Porth, C.M., Essentials of Pathophysiology, 2nd Edition, page 497) Inhaled Irritants Induce bronchospasm by way of irritant receptors

66

and

vagal to has to

reflex. parental been increase in

Exposure smoking reported asthma

severity

adults. High doses of irritant gases such as sulphur dioxide, nitrogen dioxide, and ozone may induse inflammatory

exacerbations of airway responsiveness.

(Porth, C.M., Essentials of Pathophysiology, 2nd Edition, page 497) Table 1.8

67

VII. PATHOPHYSIOLOGY

Predisposing: -hereditary -weakened immune system -age -gender

Precipitating: -allergen (dust) -inhaled irritants -exercise

Tracheal and bronchial overreact to various stimuli

Smooth- muscle spasms that that severely constrict the airway

Mucosal edema and thickened the secretions blocked the airways

Immunoglobulin (Ig) E antibodies

attached to histamine-containing mast cells and receptors on cell membranes

when exposed to antigen, IgE antibody combines with the antigen

exposure to antigen, mast cell degranulate and release mediators

causes the bronchostriction and edema of an asthma attack

expiratory airflow decreases and trapping gas in the airway

alveolar hyperinflation

Atelectasis may develop in some lung regions

Increase airway resistance initiates labored breathing.

Pathologic changes; wheezing, tightness in the chest diminished breath sounds, rapid pulse and use of Use of accessory muscle.

Hypoxemia

Respiratory failure

Status asthmaticus

Death

69

VIII. NURSING CARE PLAN NCP#1 ASSESSMENT NURSING DIAGNOSIS Subjective Cues: naglisod ko Nursing OBJECTIVE CRITERION NURSING INTERVENTION ACTION RATIONALE Some degree spasm of is After 8 hrs nursing EXPECTED OUTCOME

After 8 hours of Independent: nursing

ug Diagnosis:

Auscultate breath sounds. broncho-

ginhawa tungod sa ako ubo. as Ineffective

intervention the Note adventitious breath present with obstructions of patient will sounds like wheezes

in airway and may or intervention may not be manifested in the client will

verbalized by the airway patient clearance increase production secretion evidence

demonstrate r/t behaviors to

adventitious sounds.

breath be able to improved of

improve airway of clearance. as by

Elevate head of the bed, Elevation of the bed signs have patient lean on over facilitates respiratory relief bed table or sit on edge of function by use of gravity airways

as

ASSESSMENT

NURSING DIAGNOSIS

OBJECTIVE CRITERION

NURSING INTERVENTION ACTION the bed. Keep RATIONALE for the lung expansion

EXPECTED OUTCOME evidenced

Objective Cues: y -wheezing auscultation y y y -tachycardia -chest tightness

productive

upon cough secondary bronchial asthma. to

environmental Precipitators of allergic by: of respiratory a.)Signs of

pollution to a minimum like type

dust, smoke and feather reactions that can trigger relief pillows, according to or exacerbate onset of b.) Secretion acute episode. expectorate. c. )

-Use of accessory Scientific Basis: muscle The underlying in is and

individual situation.

y y

-Yellow sputum -Productive cough

pathology asthma reversible

Provides patient with behaviors to some means to cope improved Encourage or assist with with or control or reduce maintain abdominal or pursed lip air tapping. breathing exercises Coughing is most airway .

-V/S

taken

as diffuse airway Inflammation. The

follows:

71

ASSESSMENT

NURSING DIAGNOSIS

OBJECTIVE CRITERION

NURSING INTERVENTION ACTION RATIONALE

EXPECTED OUTCOME

T: 37C PR:109bpm RR:18cpm BP: 120/80

inflammation leads obstruction causing further and to

Assist with measures to effective in an upright improve effectiveness of position cough effort Dependent: Administer bronchodilators prescribed To reduce the viscosity as of secretions percussion after chest

narrowing; increased mucus production, which diminishes

airway size and

72

ASSESSMENT

NURSING DIAGNOSIS may entirely

OBJECTIVE CRITERION

NURSING INTERVENTION ACTION Collaborative: Instruct and For the continuous RATIONALE

EXPECTED OUTCOME

plug the bronchi. The bronchial and glands thick,

encourage relative to plan of care for the do Physiotherapy. Encourage relative to To provide nasal care to oxygenation prevent Chest client.

muscles mucus enlarge; tenacious sputum produced; the

is and alveoli

the client.

imbalances

to

the

systemic circulation of the body.

hyperinflate.

73

ASSESSMENT

NURSING DIAGNOSIS Reference: Nursing Care

OBJECTIVE CRITERION

NURSING INTERVENTION ACTION RATIONALE

EXPECTED OUTCOME

Plans edition 7 by Marilyn

Doenges. Mary Moorhouse Alice Murr Page: 131-133 Table 1.9

74

NCP #2 ASSESSMENT NURSING DIAGNOSIS Subjective Cues: punga gibati muhigda. verbalized the patient Nursing Ineffective akong breathing pag pattern as presence by secretions severe OBJECTIVE CRITERION NURSING INTERVENTION ACTION RATIONALE EXPECTED OUTCOME

After 6-8 hours Independent: of nursing Assess pt.s condition To obtain baseline Goal met data will VS monitor and record Serve to Patient track demonstrate d pursed-lip

intervention r/t Patient

of manifest signs and of decreased Auscultate sounds and

important changes

breath To check for the breathing assess presence adventitious sounds of and breath diaphragmati c breathing. minimize .

respiratory

exacerbation as effort Objective Cues: y wheezing evidenced of exacerbation absence using accessory

of airway pattern

upon productive cough Scientific Basis:

of Elevate head of the bed To

auscultation.

and change position of difficulty in breathing the pt. every 2 hours.

75

ASSESSMENT

NURSING DIAGNOSIS

OBJECTIVE CRITERION

NURSING INTERVENTION ACTION Encourage RATIONALE deep To maximize effort

EXPECTED OUTCOME

tachycardia y chest tightness

Bronchial asthma muscles. is a chronic

breathing and coughing for expectoration. exercises.

inflammatory disease airways, associated recurrent ,reversible airway obstruction with intermittent of and with of the

Demonstrate diaphragmatic pursed-lip breathing. increase in fluid intake Encourage opportunities and limit for rest

To

decrease and

air for

and trapping

efficient breathing.

To prevent fatigue.

physical

episodes wheezing

activities. Reinforce To prevent situations will aggravate

dyspnea. Bronchial

hypoallergenic diet as that

76

ASSESSMENT

NURSING DIAGNOSIS hypersensitivity is caused by various stimuli, innervate which the

OBJECTIVE CRITERION

NURSING INTERVENTION ACTION ordered. RATIONALE the condition of the patient.

EXPECTED OUTCOME

vagus nerve and beta adrenergic receptor cells of the ,leading bronchial muscle constriction, result in ineffective airways to smooth To secretions. mobilize

77

ASSESSMENT

NURSING DIAGNOSIS breathing pattern. Reference: Nursing Care

OBJECTIVE CRITERION

NURSING INTERVENTION ACTION Dependent: Bronchodilators ordered (combivent) as It dilates the RATIONALE

EXPECTED OUTCOME

Bronchioles for the patent airway.

Plans edition 7 by Marilyn Collaborative:

Doenges. Mary Moorhouse Alice Murr Page:

Instruct and encourage For the continuous relative to do exercises plan of care for the like deep breathing client. To prevent

exercises.

Encourage relative to oxygenation provide nasal care to the imbalances client. systemic to the

circulation

of the body. Table 2.1

78

NCP #3 ASSESSMENT NURSING DIAGNOSIS Subjective Cues: Nursing Diagnosis: OBJECTIVE CRITERION NURSING INTERVENTION ACTION RATIONALE EXPECTED OUTCOME

After 6 hours of Independent: nursing Provide for adequate Although prolonged After 6 hrs and mental of nursing

Sig e ra kog Disturbed sleep intervention the rest. Restrict daytime rigid katulugon kay wala pattern koy tarong tulog persistent r/t patient will sleep as appropriate activity

results

in intervention

demonstrate behaviors

;increase to between

interaction fatigue , which can the client will client and increase confusion, be able to

kay ga ubo-ubo coughing man gud ko inig secondary kagabii Objective Cues: Yawning Dozing during bronchial asthma. Scientific basis:

to sleep or rest family /staff during day, programmed between disturbances and report to then reduce mental without overstimulation promote sleep.

activity improved signs of behaviors of sleep rest

activity late in the day.

increase sense Adhere

regular Reinforces that it is between and disturbances.

of well- being bedtime schedule and bedtime

79

ASSESSMENT

NURSING DIAGNOSIS

OBJECTIVE CRITERION

NURSING INTERVENTION ACTION RATIONALE

EXPECTED OUTCOME

the day Eye bags

and feeling well rituals. Tell client that it maintains stability of Decrease rest. is time to sleep environment . dozing sensory time by decrease out the yawning. day and

Reduce noise, provide Reduces . soft music . stimulation blocking

environmental sounds Increased that could interfere sense of well being feeling Reference: Nursing Care Dependent: Administer bronchodilators To reduce the viscosity as of secretions rested and

with restful sleep.

Plans edition 7 by Marilyn

80

ASSESSMENT

NURSING DIAGNOSIS Doenges. Mary Moorhouse Alice Murr Page: 131-133

OBJECTIVE CRITERION

NURSING INTERVENTION ACTION prescribed RATIONALE

EXPECTED OUTCOME

Collaborative: Instruct and encourage For the continuous relative to do Chest plan of care for the Physiotherapy. client. prevent

Encourage relative to To provide nasal care to oxygenation the client. imbalances

to

the

systemic circulation of the body. Table 2.2

81

X. PHARMACOLOGICAL MANAGEMENT Date/s hift 07-092011 Name drug Generic name: of Classificati on y Antihistami ne Indication Contraindication Hypersensitivit Use y Reaction type1 including Mechanism of action CNS:dizziness, drowsiness, poop coordination, Side effects Nursing responsibilities May drowsiness cause use

un High sedative;anti

childrens years age

Diphenhydr y Second amine generation

of cholinergic and and antiemetic

caution until drug effects realize. 30 mins

hydrochlori y Ethanol de mine

younger.

fatigue, anxiety, Take euphoria, aresthesia confusion, neuritis, seizures. EENT: vision,

perennial and Use seasonal

of effects.

before travel to prevent sickness. Use sugarless to dry motion

oral OTC

allergic rhinitis diphenhy Brand name: Benadryl and sneezing dramine caused by products

gum/candy blurred diminish dilated mouth effects.

common cold, the other allergic products

82

Date/s hift

Name drug

of Classificati on

Indication

Contraindication

Mechanism of action

Side effects

Nursing responsibilities

Dosage/tim e/route IM Adult;10-50 mg up to

conjunctivitis caused inhalant allergies food,

containin

pupils,

tinnitus, Assess respiratory status:

by g diphenhy and dramine , mild including topical

dry nose, GI:

nausea, rate, rhythm, and increase bronchial in

anorexia, diarrhea GU:

100mg/day If needed

uncomplicated allergic

retension, secretion. Monitor I & o ratio be alert for

skin products.

dysuria, frequency. HEMA: thrombocytopen

manifestations of and angioedema amelioration of allergic urticarid

urinary frequency, dysuria,

ia, agranulasis, Assess the cough hemolytic anemia. characteristics. Including type

83

Date/s hift

Name drug

of Classificati on

Indication

Contraindication

Mechanism of action

Side effects

Nursing responsibilities

reaction blood plasma Motion sickness

to or

INTEG: photosensitive MISC: anaphylaxis RESP;

frequency, thickness of the secretions, evaluate response to this and

Parkinsonism Nighttime sleep aid Antitussive Table 2.3

wheezing chest medication. tightness

84

Date/s hift

Name drug

of Dosage/tim Indication e/ route

Contraindication

Mechanism of action

Side effects

Nursing responsibilities

07-2111

Generic name:

250mg 6-12-6 PO

To suppress Hypersensi Short acting CNS: undesirable inflammatory response. tivity to synthetic ateroid both glucocorticoi d depression, with flushing, sweating, head ache,

Establish baseline and data continuing on Bp,

glucocortic oids, idiopathic thrombocyt openic

hydrocortiso ne

weigth, fluid and electrolyte balance, blood glucose Report any signs of hypersensitivity such as itching for and

and CV; hypertention, embolism, tachycardia,

mineracortic oid

Brand name:

purpura,

psychoses, properties acute glomerulo that nearly systems

affect edema,

all EENT: fungal Watch of infection,

Classificatio

nephritis,

palpitation and if +

85

n:

viral bacterial

or the body

blurred vision, GI:

refer to CI or NOD for

diarrhea, Assess tachycardia, nausea,

Skin mucous

and

disease of skin infection not controlled by antibiotics

nausea, abdominal distention, HEMA; thrombocytop enea

membrane agent, antinflamato ry

hypocalcemia and refer Monitor U/O.

INTEG: achne, wound healing, MS: fractures, osteoporosis, poor

86

weakness. Table 2.4

87

Date/s hift 07-2111

Name drug Generic name: Lenox

of Dosage/ti me/route 750 mg OD PO

Indication

Contraindication

Mechanism of action

Side effects

Nursing responsibilities for any of and

Treatment adult mild,

of Hypersens with itivity

Inhibits DNA CNS: anxiety, Watch depression, signs

to topoisomera se

Levofloxac

more GI:

nausea, unusualities

moderate and in. severe infection caused Brand name: susceptible

commonly referred

vomiting, as diarrhea, abdominal pain,

signs of nausea vomiting, diarrhea, skin rash, chest pain

Patient w/ DNA gyrase. by history tendon of

DNA gyrase GU;

oliguria, Assess previous hypersensitivity reaction. Assess for

for

strains if the disorders designated Classificatio n: Anti bacterial microorganis ms for r/t Fluovorqui

is necessary protenuria, for bacterial hematuria, DNA replication. HEMA: anemia, increase

the nolone therapy.

any

following

allergic reaction.

88

conditions; Acute bacterial sinusitis, Complicated skin and skin structure infections, community acquired pneumonia and nosocomial pneumonia. Table 2.5

bleeding time, Identify bone marrow output

urine if

depression, META: hyperkalemia, alkalosis, hypernatremia , MISC: pain, tenderness, and fever, local

decreasing notify the prescriber. It may toxicity. monitor indicate Also increase

BUN, creatinine.

89

Date/s hift

Name of drug Dosage/ Time Route Generic 1 /

Indication

Contraindication

Mechanism of action

Side effects

Nursing responsibilities

Neb., Indicate the

for Contraindic Ipatropium ated patient to bromide; produce local, specific

CNS: tremors, Encourage patient anxiety, insomnia, to increase OFI.

7/ 11

21/ name:

10am2pm,

management of

Ipratropium 73 bromide Salbutamol Sulfate

nebulaziti + on-

reversible with hypersensi

site headache, dizziness, on restlessness, larger CV: palpitation, tachycardia, hypertension, angina,

Monitor respiratory status.

brochospasm

inhalation associate with tivity obstructive airway dse. In patient who more

to effects the central airways including

combivent

Watch bronchospasm, laryngospasm, pharyngeal

for

Brand name:

require

than a single Combivent bronchodilator

bronchodilat or

edema, and throat dry irritation. If

and EENT:

90

. Classification :

prevention of nose, irritation positive, brochospas

refer

of nose and STAT to C I or NOD.

m salbutamol throat, sulfate

acts GI: heartburn, Do not break or crush the tablet. Give PO with

Bronchodilat or

more on beta nausea, 2 receptor vomiting,

than on beta MISC: 1. Continuous flushing, sweating,

meals to decrease gastric irritation.

used of the 2 anorexia, bad produces great on bronchodilati on. RESP: cough, taste, muscle

effect MS:

cramps,

91

wheezing, dyspnea, bronchospas m Date/s hift 7/ /11 Generic name: Cefuroxime sodium Name of drug Classifica Indication tion Antiinfective cephalos porin Contraindication Treatment for Diarrhea, acute bacterial exacerbation of chronic nausea and vomiting. Mechanism of action It interferes CNS: Side effects Nursing responsibilities Assess previous sensitivity pt.

with bacterial headache, biosynthesis insomnia,

of protein by hallucinations, reaction. competitive antagonism of PABA. depressions, vertigo, fatigue, anxiety, Assess signs symptoms infections pt. for and of

bronchitis and secondary bacterial Brand name: infections.

92

ceftin

CV:

allergic including characteristic wound, of

myocarditis. Dosage/time/r oute: 750mg

q8

sputum,

GI:

nausea, urine, and stool.

vomiting, abdominal pain, anorexia. GU: failure. Monitor INTEG: rash, bleeding; dermatitis, urticaria, erythemia. ecchymosis, bleeding gums. for Assess allergic for reaction;

IVTT 6-2-10

rash, chills, fever, renal joint pain.

93

Date/sh ift 7/ /11

Name drug Generic name:

of Classific ation broncho dilator

Indication

Contraindication

Mechanism of action to Cysteinyl leukotrienes and

Side effects

Nursing responsibilities

Prophylaxis

Use

CNS;

headache, -Monitor ECG at baseline periodically and to

and chronic reverse treatment of bronchospa asthma adult children,

dizziness, sommolence. C.V; chest hypertension, bradycardia, GI; abdominal

Montelukast

in sm in acute leukotriene and asthma attacks, including receptor occupation are associated with

palpitations, determine drug pain, effectiveness.

Monitor I & O and

Brand name:

Relief

of status

nausea, ratio pain, electrolytes.

symptoms of asthmaticus Dosage/time seasonal . Use

to symptoms of vomiting, diarrhea.

94

/route: 10mg 1 tab OD, PO

allergic rhinitis adults children.

abruptly in substitute and for or

asthma, including

GU;

sexual

-Monitor

liver

dysfunction, difficult function. urination, dysuria, -Monitor cardiac

inhaled airway oral edema,

urinary retention. MISC;

corticosteroi smooth ds. muscle contraction and inflammation .

sweating, rate, respiratory rate, rhythm, and

musculoskeletal pain, drug

fever, character

blurred vision, dry chest pain. Drug mouth, RESP; should dyspnea, discontinue. be

hyperventilation, apnea, asthma, -Monitor toxicity; tremors, dizziness, for find

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lethargy, hypotension conduction disturbance. Table 2.7

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IX. DISCHARGE PLAN

Medication  Inform the patient and family of the prescribed medication including the name, purpose, schedules, doses and side effects.  Instruct the patient not to change any medication that the patient is taking, adding or stopping drugs without consulting the physician.  Instruct the patient not to take other over the counter drug without the physicians advised.

Exercise  Instruct the patient to maintain all the activities and restrictions that can affect her condition.

Treatment  Instruct the family and patient to religiously comply follow up checkups of the patient with the physician to ensure full recovery.

Hygiene  Instruct the patient to maintain hygienic measures like taking a bath every day and perform daily oral care.  Instruct patient to maintain a clean surrounding free from allergens.

Outpatient Orders  Instruct the patient to follow regular medical checkups to monitor her progress and for further management.   Provide adequate rest and sleep including calm and quiet environment. Encouraged patient to strictly follow medications and diet.

Diet   Instruct client to eat nutritious food to help in the recovery process. Instruct patient to increase fluid intake.

Spiritual  Encouraged the patient and the family members to always keep God almighty in their midst and pray for good health and safety.  Advised the patient and family to make God as the center of their activity.

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X. SYNTHESIS OF CLIENTS CONDITION

A. Conclusion Based on the aforementioned result, the overall prognosis of the client is good since the client reveals eminence of health and wellness. Therefore, the client achieved a state of good care providence by the health care team. B. Patients Prognosis CRITERIA GOOD 3 Onset Illness of FAIR 2 POOR 1 Patient is aware of his condition, but he seldom seeks medical He attention. seeks attention JUSTIFICATION

only

medical

when the condition was severe. The patients family Family support is residing in

Cagayan de Oro, but his fianc and

her family visit him. Although there are times patient watcher. where have the no

Environment

The patient lives along the road in which it is dusty. Asthma that results from sensitivity to specific external

allergens is known as Allergens cause asthma pollen, mold, extrinsic. that extrinsic include dust or

feather

pillows and etc. (Diseases. Lippincott Williams & Wilkins.)

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Willingness to take treatment regimen

The

patient

was

willing to take and purchase prescribed medicines. the

Nutrition

The

patient

is of

knowledgeable

the foods that are contraindicated to

his condition. And does not eat foods that he is allergic to.

Duration illness

of

The

patient

recovered fast from his illness. He was hospitalized for 3 days.

Age

Asthma can strike at any age, half of these cases first occur in children

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younger than age 10. (Diseases. Lippincott Williams & Wilkins.)

Gender

Bronchial affects many

asthma as as

twice males

females. (Diseases. Lippincott Williams & Wilkins.) Race Bronchial asthma

affects of all races. Table 2.9 Computation: Good: 4x3= 12 Fair: 3x2= 6 Poor: 1x1= 1 19 19/ 8 = 2.4 (Good Prognosis) Legend:

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Good: 3 pts. Rating:

Fair: 2 pts.

Poor: 1 pt.

Good: 2.4 3.0

Fair: 1.7 2.3

Poor: 1 1.6

Recommendations The group has listed the following recommendations to improve the patients state of health. y Avoid potential environmental asthma triggers, such as smoke, dust, mold and etc. y y Increase oral fluid intake to loosen secretions and maintain hydration. Be sure you know the proper technique and correct sequence when you when you use metered dose inhalers. y y y Be sure to take adequate rest and sleep. Reduce stress and anxiety; learn relaxation techniques. Seek immediate emergency care when uncontrollable asthma attack occurs.

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XI. EVALUATION OF THE OBJECTIVE OF THE STUDY

Having this case presentation, each member of the group involved to the said study was able to establish rapport and gained the clients cooperation in attaining relevant information. The group have assessed properly every single data, thoroughly assessed every system involved regarding the patients condition and mapped out and traced the pathophysiology of bronchial asthma. On the latter part, the students were able to come up with a nursing care plan that is very helpful in restoring the clients present condition. We were able to trace the patients family history through family genogram, gathered all possible resources and relevant datas regarding the past and present history of Patient Xs illness. With the data gathered, we are able to identify vital informations such as predisposing and precipitating factors that greatly contribute to Patient Xs present illness The group was able to identify, determine and understand the underlying general health problems of our client. The study improves our skills and knowledge pertaining on caring patients with such changes. Without anticipation, we are looking forward that this output may give additional knowledge to other student nurses in order for them to extend their cognition made upon it and finally improve their service.

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XII. BIBLIOGRAPHY

Bickley, L.S.,2009, Guide to Physical Examination and History Taking, 10th Edition, page 321. Carpenito-Moyet, L.J., 2006, Handbook of Nursing Diagnosis, 11th Edition, page 453-457. City Health Office of Tagum CY: 2009) Ignatavicius and Workman,2006, Medical-Surgical Nursing, Critical Thinking for Collaborative Care, 5th Edition, 585-594. Doenges,M.E.,Moorhouse,M.F.,Murr, A.C., 2006,Nursing Care Plans, Guidelines for Individualizing Clients Care Across the Life Span, 7th Edition, page 131-133 Porth,C.M.,2007, Essential of Pathophysiology, Concepts of Altered Health States, 2nd Edition, page 495-501. Skidmore-Roth, L.,RN, MSN, MP, Mosbys Drug Guide for Nurses, 7th Edition. Smeltzer,S.C., Bare,B.G., Hinkle,J.L., Cheever,K.H. (2008) Textbook of Medical Surgical Nursing 11th Edition vol.2., Wolters Kluwer and Lippincott Williams & Wilkins, page 2579-2580. Tagum Doctors Hospital, Inc Williams, L., and Wilkins, Diseases, A Nursing Process Approach to Excellent Care, 4th Edition, page 426-430. Williams, L., and Wilkins, 2007, Manual of Nursing Practice Series of Pathophysiology, page 95-97

Williams, L., and Wilkins,2006, Straight As in Pathophysiology, page 67-69.

Website: Medscape, 2011, Drugs, Diseases and Procedures,

http://emedicine.medscape.com/article/137501-overview). Retrieved of May 26, 2011. . .

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