THE PATIENT WITH BRONCHIAL ASTHMA
A Case Study Presented to the Clinical Instructors AUP College of Nursing Silang, Cavite
In Partial Fulfillment of the Requirements in N301 Promotive and Preventive Nursing Care Management
Presented by: Sherilyn Magararu Ely Ren Mendoza
Date Submitted: August 20, 2009
INTRODUCTION The main function of the respiratory system is to move air into the lungs so that oxygen can enter the body and carbon dioxide can be exhaled. Several pulmonary disorders can affect the airways. Their pathophysiology differs but these diseases are characterized by limited airflow. Airflow is limited when air walls are thickened, airway lumen and is obstructed muscle of by the
secretions, airways is
increasing activated,
resistance, causing
smooth
bronchoconstriction.
Limited
airflow increases the work of breathing and residual volume of the lungs as air is trapped behind narrowed or collapsed airways. Asthma is a chronic inflammatory respiratory disorder that in children, inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness and cough, especially at night or in the early morning. These asthma episodes are associated with airflow limitation or obstruction that is reversible either spontaneously usually first begins or in with treatment. (Hockenberry, 2005) Asthma may be
childhood or adolescence, but it also adult years. While the symptoms may
appear
during
similar, certain important aspects of asthma are different in children and adults. Children born to families with history of allergies or asthma are more likely to have asthma. Children who live in urban areas, where there is a higher incidence of air pollution, or live in a home that has high levels of dust mites
or
cigarette
smoke,
are
also
at
a
higher
risk
for
asthma.
Infants born prematurely or who suffer lung damage shortly after birth are also more likely to have asthma. (Lemone, 2004) Bronchial asthma is the more correct name for the common form of asthma. The term 'bronchial' is used to differentiate it from 'cardiac' asthma, which is a separate condition that is caused by heart failure. Although the two types of asthma have similar symptoms, including wheezing (a whistling sound in the chest) and shortness of breath, they have quite different causes (http://respiratory-lung.health-cares.net/asthma-prevention.php). Bronchial asthma is usually intrinsic (no cause can be
demonstrated), but is occasionally caused by a specific allergy (such as allergy to mold, dander, dust). This case study is a thorough learning about Bronchial Asthma, which contains a study about the normal physiology of the respiratory system,
pathological physiology of the disease, a thorough assessment of the patient with said illness, applied nursing care plans to patients having this kind or disease, and discharge planning to a patient to limit the recurrence of the attack or if not proper management and care to be given during the time of asthma attack.
A.
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 knowledge of the and case study and research will gain its enough cause,
understand
Bronchial
asthma,
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. B. Objectives of the Study At the end of the case-presentation the student will be able to: 1. Know what Bronchial Asthma is all about. 2. Apply the knowledge that they have learned in the floor.
CHAPTER II PATIENT DATABASE A. Demographic Data Our patients name is Maimi. She is 3 years old. Her
birthdate is on April 29, 2006.
She lived in 273 Blk. 19 Brgy.
Addition Hills, Welfare Vine, Mandaluyong City. Her parents are Sun Ye and Jo Kwon. Black. She was They are Roman Catholic. Her doctor is Dr. 3:00 am, July 12, 2009. She was
admitted
diagnosed of Bronchial Asthma with Acute Exacerbation. B. 1. Nursing History Gordons Functional Health Pattern a. Health Perception-Health Management She is a very active and playful child. She doesnt have any allergies on any foods. b. Nutritional-Metabolic She doesnt have any special diet but she is taking Celeen for her vitamin. At home, as verbalized by the mother, she can eat all of the food served. She didnt have difficulty of swallowing, and started solid food as the main composition of the food of the patient. c. Elimination Pattern She did not experience any decrease in defecating or difficulty of urinating. Her bowel elimination pattern
is once a day even during her stays at the hospital. Her way of breathing is better than she is at home, and she could go to comfort room with assistance of mother (with IV), read books, and eat all food served. d. Activity-Exercise Pattern Our patient loves to play bahay - bahayan and running. She independently wears her dress but with assistance from her mother. She can go to the bathroom, whenever she wants to urinate and defecate but her mother still washes her anus after defecating. She goes schooling in prep-school and playing or socializing, talking,
mingling with her classmates. e. Sleep-Rest Pattern She experience difficulty of sleeping while admitted in the hospital. Before her admission, she sleeps as early as 10 in the evening and wakes at 8 in the morning. During her hospitalization, she sleeps at 10 and wakes at 8 in the morning. She also sleeps one hour in the afternoon. During night when her asthma attacks, she cant breathe normally usually having a hard time of breathing so her sleep during night is disturbed during her hospitalization period.
f.
Sexuality-Reproductive Pattern
g. Cognitive-Perceptual She neither has hearing difficulties nor eye problems. She has a like good memory for learning and her activities mother in
school
problem
solving
makes
decisions for her during medications, treatments, etc. and she also learns easily. h. Self Perception Self Concept Shes feeling better every time she is asked how she feels. Her illness makes her feel worthless because she cannot do anything. She is very anxious every time her asthma attacks. i. Role relationship She lives with her family and depends on her parents for her needs. She misses her siblings and likes to talk about them. In their house she can easily express what she wants or needs but during her hospitalization time her parents didnt knew what are the needs that she wanted or needed because of her condition. j. Coping Stress Tolerance She always wants her mother to be beside her because she provides all that she needs and she cries whenever she cant get something that she wants. She always
wanted
to
go
home
right
away
but
because
of
the
doctors order they cant go home right away, so the only thing she can do is to cry. k. Recreational Our patient and is a very playful child, she loves play with her friends almost to
explore
everyday,
usually playing for 2 hours. She does also running as her favorite sport but now that she has Asthma, her mother forbids her to run and play at the dusty places. l. Value and Beliefs They are Roman Catholic. She verbalized that she knows God loves her and He will wash her illness away so that she can go home. The parents react patiently to their daughters needs, and they supported all what their child needs.
2. a.
Developmental Tasks Sigmund Freud ( 1 to 3 years ) Anal Stage - Anus and bladder are the sources of pleasure (sensual
satisfaction, self control). Major conflict: Toilet Training. Our patient knows how to control urination in the
hospital. She tells her Mom, Ihi ako, same as when she wants to defecate. She can participate in the toilet training. The parents are happy for the improvements of the patient according to its condition. b. Erik Erikson (Early Childhood, Autonomy vs. Shame and Doubt) Self Control without loss of self esteem. Ability to
cooperate and to express oneself, compulsive self restraint and compliance, willfulness and defiance. - Our patient is a shy girl, but she can participate to her playmates as verbalized by her mother. She loves to play such as bahay bahayan, and tagu-taguan. But sometimes, her mother
would tell her that she should not run or play because she might get tired and it may cause asthma.
c.
Havighurst (Middle Childhood) - Learning physical skills necessary for essay for ordinary
games, building wholesome attitudes toward oneself as a growing
organism,
learning
to
get
along
with
age-mate,
achieving
personal independence, learning to distinguish right from wrong and develops conscience (Kozier et. al, 2008). Our patient hides from his mother whenever she does
something wrong and admits it whenever shes asked. Sometimes she would just cry in fear when her mother gets angry.
d.
Jean Piaget (Preconceptual Phase) - Uses an egocentric approach to accommodate the demands of
an environment. Everything is significant and relates to me, explores the environment. Language development is rapid and
associates words with objects. -In our patient, during the care, she always talks about her older siblings and her desire to play with them. She is able to express her thoughts already and losses evident her that egocentric she (selfish) passed
thinking
which
made
already
initiative thought phase as positive resolution.
3. a.
Health History Past and Present History History of Present Illness The patients past history of illness was said to be in the fathers side. The patient was diagnosed with bronchial asthma since 2008 given Salbutamol nebulization as necessary. 2 days prior to admission, the patient experienced non
productive cough, watery nasal discharge, and (-) fever, and decreases in appetite. 1 day prior to admission, the patient experienced
difficulty of breathing, excessively vomit once and 3 doses given Salbutamol at Tunasan Health Center every 4 hours. Few hours prior to admission, they went to Ospital ng Muntinlupa for consultation, the patient experienced
persistence of difficulty of breathing. She is a fully immunized child, complete BCG, DPT, OPV, and Hepa B immunization. When she reached 1 year of age, she disregards to drink milk but instead she started to eat solid foods like rice, etc.
CHAPTER III THE DISEASE ENTITY
A.
The Medical Diagnosis with chief complaints
The Expert Asthma
National on
Heart, the
Lung
and of
Blood Asthma
Institutes defined
Second
Panel as a
Management
Bronchial in
chronic
inflammatory disorder of the airway
which many cells and cellular elements play a role... (Porth 2002: 639). It is defined as a lung disease characterized by airway obstruction increased that is reversible, to airway a inflammation of stimuli. and It
airway
responsiveness
variety
occurs in about 5.4% to 7.5% (15 million to 17 million) of the population and is common among children and adults alike. Asthma is the most common chronic disease if childhood. High-risk population includes African-Americans, inner city
dwellers, and premature or low-birth weight children. (Kopstead and Banasik, 2005: 538) A number of factors can contribute to an asthmatic attack, including allergens, cold respiratory air, exercise, tract drugs and infections, chemicals,
hyperventilation,
hormonal changes and emotional upsets, airborne pollutants, and gastroesophageal reflux. Inhalation of allergens is the most common cause of asthma. Persons with allergic asthma often have other allergic disorders such as hay fever, hives, and eczema. (Porth 2002: 640). In terms of symptoms, asthma is defined as paroxysms of diffused wheezing, dyspnea, and cough, resulting from spasmodic
contractions of the bronchi. Wheezing is caused by vibration in narrowed airways which act like the vibrating reed of an
instrument, yielding a musical sound. Sputum is often thick, tenacious, scant and viscid or sticky. Physical findings vary with the severity of the attack. A mild attack may be associated with a random monophonic respiratory wheezing associated with airway narrowing. The area in which they are heard best is
indicative of the area of obstruction. Tachycardia is the early sign of hypoxemia. In the severe state, the patient may appear cyanotic, agitated, restless, and confused. (Kopstead and
Banasik, 2005: 586)
B.
Theoretical Background
The pulmonary system function to (1) ventilate the alveoli, (2) diffuse gases into and out of the blood, and (3) perfuse the lungs so that the organs and tissues of the body receive blood that is rich in oxygen and low in carbon dioxide. Each component of the pulmonary system contributes to one or more of these functions.
The central nervous system responds to neurochemical stimulation of ventilation and sends signal to the chest wall musculature. The response of the respiratory system to these impulses is influenced by several factors that impact the mechanisms of breathing and, therefore, impact the adequacy of ventilation. Gas transport between the alveoli and pulmonary capillary blood depends on a variety of
physical and chemical activities. Finally, the control of the appropriate pulmonary circulation plays a role in the
distribution of blood flow. (Huether & McCane)
CHAPTER IV THE MANAGEMENT
A. Diagnostic Test results & Significance NAME OF TEST Complete Blood Count (July 12,2009- 6:59 am) NORMALVALUE RBC: 4-6 x 10/L Hct: 0.37- 0.47 RESULTS 4.28 0.36 111 11.3 0.25 0.74 0.01 SIGNIFICANCE Increased segmenters (mature neutrophils) reflect a bacterial infection since this are the bodys first line of defense against acute bacterial invasion. Lymphocytes are decreased during early acute bacterial infection and only increase late in
Purpose: CBC is ordered to Hgb: 110- 160 gm/L aid in the detection of WBC: 5-10 x 10 /L
anemias; and as
hydration part of
status; Lymphocytes:0.25-0.35 routine Segmenters: 0.50-0.65
hospital admission test. The Eosinophil: 0.01-0.06 differential necessary for WBC is
determining
the type of infection.
bacterial infections but continue to function during the chronic phase.
Generic/Trade Name 1.Salbutamol
Classification Bronchodilator s
Indication/ Purpose Relief of bronchospasm in bronchial asthma, chronic bronchitis, emphysema and other reversible, obstructive pulmonary diseases. Also useful for treating bronchospasm in patients
Dosage Tablet: 1-2
Mechanism of Action Stimulates
Nursing Consideration Assessment Assess
mg beta-2 receptors of
3-4x/day
cardiorespiratory function: BP, heart rate and rhythm and breath sounds Determin
Syrup: bronchioles by -1 tsp. increasing levels of cAMP which relaxes smooth muscles to produce bronchodilatati on. Also cause CNS stimulation, cardiac stimulation, increase
3-4x/day
e history of previous medication and ability to self
with coexisting heart disease of hypertension.
dieresis, skeletal muscle tremors, and increased gastric acid secretion. Longer acting than isoproterenol.
medicate to prevent additive. Monitor
for evidence of allergic reaction and paradoxical bronchospas
2. one
Prednis
steroids
Allergic and inflammation conditions, i.e., in bronchial asthma and
m. 5-60 mg/ Immediately and Assessment 2-4 divided doses completely converted active prednisolone in the liver. The to - Obtain baseline weight, BP, and electrolyte
skin disorders, ophthalmic diseases, rheumatic disorders, organ transplant, neoplastic GI and nervous disorders. In conditions responsive to glucosesteroid therapy, as in adrenocortical insufficiency.
antiinflammatory effects due inhibition prostaglandin synthesis. also the of It maybe to of
levels and monitor periodicall y during therapy. - Assess patients condition before therapy and regularly thereafter to monitor drug effectivene ss. - Monitor
inhibits migration leukocytes
and macrophages to the site of inflammation as well inhibits phagocytosis and lososomal as
enzyme release. The immunosuppressa nt effect maybe due reduction to in
for possible drug induced adverse reactions.- Monitor
the number of T Lymphocytes, monocytes eosinophils. and
plasma cortisol levels during long term therapy.
3. drocortisone
Hy
Anti pyretic
Treatment of primary or secondary adrenal cortex insufficiency, rheumatic disorders, collagen diseases, dermatologic disease, allergic states, allergic and inflammatory ophthalmic processes,
IM/IV 0.186-1
Glucocorticoid with anti
-
Assess
patients condition before starting therapy and reassess regularly. Monitor
mg/kg 2- inflammatory 3x/day effect because
of its ability to inhibit
prostaglandin synthesis, inhibit migration macrophages, leukocytes, and fibroblasts sites inflammation, phagocytosis and lysosomal at of of
patients weight, BP, glucose and electrolyte levels. Monitor
weight, input and
respiratory disease, hematologic disorders, neoplastic diseases, edematous states, GI, multiple sclerosis, tuberculous meningitis, trichinosis with neurologic or myocardial involment.
enzyme release. It cause reversal increased capillary permeability. can also the of
output ratio, urine output and increasing edema. Report hypertension , edema, cardiac symptoms or weekly weight gain of >5 lbs. Assess
carefully for signs of infection
especially fever and WBC count because the drug masks infection symptoms. 4. ikacin Am Anti-pyretic Treatment of infection caused by susceptible strains of microorganisms , especially gram negative bacteria. IV/IM 15 mg/kg/da y in 2 or 3 divided doses Binds to bacterial ribosomal subunit to cause misreading of the genetic code which leads to inaccurate-
Assess
patient for signs and symptoms of infection, including characterist ics of wounds, sputum,
peptide sequence of protein synthesis and bacterial death.
urine, stool, WBC >10,000/mm3, earache, temp; obtain baseline information before and during treatment.-
Assess
for allergic reaction: rash, urticaria, pruritus, and
hypotension. for overgrowth of infection: perineal itching, fever, malaise, redness, pain, swelling, drainage, rash, diarrhea, change in Assess
cough, sputum
CHAPTER IV THE MANAGEMENT
B. Course in the Ward
Date, Time, and Hospital Day July 12, 2009 2:45 am
Doctors Order
Nurses Observation and Management
Please admit to the pedia ward A Ensure consent for admission and assistance TPR every shift NPO/TFV Laboratory:
Admitted a 3 yr old girl carried by mother. With a chief complaints of difficulty of breathing Vital Signs taken and recorded - patient have increase respiratory rate caused by constricted airways
CBC to be follow up to know whether the illness is caused by an infection/ microorganism or
3:25 am
not. Chest x-ray to be
follow up - theres a blockage in the bronchus that causes bronchoconstriction that leads to airway trapping. IVF: D5 0.3 NaCl
that causes difficulty of breathing. S/E by Dra. Gahol with orders made Consent for admission signed
1 D5 0.3 NaCl
350 cc/ml to run at 39-40 mcgtts/min Hydrocortisone
#50cc at 39-40 mcgtts/min hooked and regulated at desired route Follow up route Rendered Afebrile Medication prescription NPO TFV TPR every
95-IV every 6 hours 3:30 am
Salbutamol
nebulized, 1 neb every 2 hours
Combivent
nebulized, neb every 6 hours I&O every
shift
shift
Oxygen
Oxygen inhalation at 3-5 LPM via face mask
inhalation at 3-5 LMP via face mask Inform prior to admission 4:20 am Watch out for invert signs and symptoms
Hydrocortisone
45 mg given TIV Please inform prior of admission Note for any introduced signs and symptoms and refer Please refer Fixed and brought to Pedia Ward A Endorsed Received patient for pedia carried by her mother and allowed by ND with ongoing IVF
at 320 ml Conscious
Ongoing oxygen
inhalation at 3-5 LPM via Face mask
Follow up CBC
Follow up chest x-ray
Rendered
nebulization Admission care rendered Placed comfortably on bed Vital Signs taken and recorded Medication given at PER Never attended Ordered
Received patient on bed with IVF at 150 cc level Conscious On NPO TFV
With ongoing
oxygen inhalation at 3-5 LMP via face mask
Follow up CBC
Follow up chest x-ray
Rendered
nebulization S/E by Dr. Orea with orders made and carried out Needs attended Endorsed
Received
4:20 am 6:59 am
patient in bed Please follow up CBC with Platelet count Continue medication and management Refer to the Doctor. Dx: CBC May start regular soft diet. Please refer accordingly. NPO TFV
with 80 cc level of #1 D5 0.3NaCl 350 at 39-40 mcgtts/min Conscious
With ongoing
oxygen inhalation 5:20 pm at 3-5 LMP via face mask
Follow up
chest x-ray
Rendered
nebulization July 13, 2009 7:40 am 3:30 am Continue regular diet for age. IVF to 1L D5MB to run at 45-50 S/E by Castro within moderate bed rest
Hooked #2 D5
mcgtts/min Follow up x-ray result
IMB 800 cc at 4950 mcgtts/min
Continue medication and management Please refer Continue diet for age
Soft diet D5-IMB 80 cc to be run at 4950 mcgtts/min
July 14, 2009 8:45 am
Oxygen
Please follow up
inhalation ongoing Chest x-ray Nebulization D5-IMB 800cc at 49-50 mcgtts/min S/E by doctor Afebrile Endorsed Received patient with IVF with 70 cc level of #2 D5 IMB 800 cc at 49-50 mcgtts/min
chest x-ray result
Start ampicillin
250 mg TIV every 6 hours with ANST (-) Decrease Salbutamol
neb to every 6 hours Decrease combivent
neb to every 8 hours May discontinue
Hydrocortisone Start prednisone
10mg/5ml 3 ml BID x 1 day 3ml OD x 1 day taken DIC 4:10 pm Please refer
Conscious Regular soft diet #3 D5 IMB 1L WITH 49-50 mcgtts/min
accordingly IVF to be follow:
D5IMB 1L to run at 43July 15, 2009 7:35 am 44 mcgtts/min Continue Salbutamol nebulization Discontinue
Hooked Medications given
Endorsed
Combivent age CPT after Continuediet for
nebulization Continue present
medication and management 8:30 am
Refer accordingly May start Amikacin
80 mg TIV every 12 hours (ANST)
May start Immuzinc
syrup 1 tsp. per orem 11:30 am Please refer
accordingly IVF to follow D5IMB to run at 43-44
July 16, 2009
mcgtts/min Increase
7:25 am
nebulization of Salbutamol every 4 hours Repeat CBC with
Platelet count May give Prednisone
3 ml p.o. accordingly Continue present
medication and management If with normal
result and still afebrile, possible, 9:25 am CPT after neb Please refer
accordingly Decrease Salbutamol nebulization to every 6 hours Start Combivent neb
every 6 hours Hold Prednisone Refer
Discharge Summary
Nursing Goals Medication Patient will be compliant to continued medication regimen Exercise Patient will verbalize need importance of exercise and demonstrate proper initiation of appropriate exercise. Treatment Patient will know appropriate treatment regimen and verbalize compliance. Hygiene Outpatient Diet Spiritual
Orders
Rationale Compliance to medications will enhance fast recovery from illness. Exercise enhances blood circulation, proper body alignment and improves sense of well being. Together with medication, treatment will speed up development of patients condition.
BIBLIOGRAPHY Doenges(2006). Nursing Care Plans 7th Edition. Gulanick, Klopp, Galanes, Gradishar, Puzas(1994). Nursing Care Plans 3rd Edition. Cahill, Matthew(1994). Illustrated Manual of Nursing Practice 2nd Edition. Timbly, B.R. & Smith, N.E.(2005). Essentials of Nursing Care of Adults and Child Lippincott Williams & Wilkins, Co. Behrman, Richard E.(1992). Textbook of Pediatrics 14th Edition W.B. Saunders Company Nurses Pocket Guide 11th Edition, 2008 PPDs Nursing Drug Guide 2nd Edition, Malan Press, Inc., 2008 http://www.drugs.com http://www.proteases.org
