Bronchial AsthmaA Case Presentation

IntroductionAsthma is a chronic lung

disease that affects a person's airways and makes it difficult to breathe. The airways are the breathing “tubes” that are inside of your lungs. These are called bronchial tubes.

When a person has asthma he experiences airway inflammation (reddening and swelling of the inside of the airways), airway constriction or bronchospasms (tightening of the muscles around the airways) and excessive mucous production of the mucous cells along the airways.

During an asthma flare-up, a person may experience: coughing, wheezing, shortness of breath, chest pain, chest tightness (DOB). It may feel as if you are breathing through a straw or someone was sitting on your chest.

Traditionally, doctors have divided asthma into two general categories, Extrinsic (allergic) asthma and Intrinsic (non-allergic) asthma, depending upon the types of stimuli that trigger attacks.

In Extrinsic Asthma, an "allergen" or an "antigen" is a foreign particle which enters the body. Our immune system over-reacts to these often harmless items, forming "antibodies" which are normally used to attack viruses or bacteria. Mast cells release these antibodies as well as other chemicals to defend the body.

Extrinsic Asthma

Extrinsic asthma is caused by this type of immune system response to inhaled allergens such as pollen, animal dander or dust mite particles. It was found early this century that some asthmatics had an immediate skin reaction such as swelling or redness, when an allergen was injected just under the skin.

Extrinsic Asthma

This reaction is described as "Atopic" and so extrinsic asthma is also called Atopic or "Allergic" asthma. People with allergic asthma and their families frequently have other allergy-related problems such as hay fever, rhinitis, skin rashes, hives, eczema and so on. Allergic asthma usually responds quite well to the use of inhaled steroids as these suppress the immune system, particularly in the lungs where the reaction is creating havoc.

Extrinsic Asthma

Intrinsic Asthma is caused by anything except an allergy. It may be caused by inhalation of chemicals such as cigarette smoke or cleaning agents, taking aspirin, a chest infection, stress, laughter, exercise, cold air, food preservatives or a myriad of other factors. Antibodies are not produced and even when skin tested to various antigens shows a reaction, these substances do not lead to an asthma attack. The cause may be an irritation to the nerves or muscles in the airways.

Intrinsic Asthma

Asthmatics' airways are unusually sensitive or "hyper-reactive" and the asthma presents itself in the usual manner of constricted smooth muscle, airway inflammation and increased mucus production. Treatment of intrinsic asthma is not easy as it may not be known what triggers the asthma in the first place and therefore avoiding triggers can be impossible. Avoidance of things with strong odors such as perfume or cleaning agents may be possible at home and smokes inside and outside homes.

Intrinsic Asthma

There are a lot of triggers of asthma episodes; it can be induced by the environment, physiological, psychological and physical stress.

The common allergen triggers include; dust mites (tiny bugs that live in dust), cockroaches (small indoor pests), mold (a type of fungus), and pollen (from flowers, trees, grass, and weeds). While the common animal triggers include; cats, dogs, and horses – people with asthma can be sensitive to their dander, urine, and saliva. Rabbits, hamsters, and guinea pigs can also be the cause of asthma symptoms because of their urine. Viruses are also common allergen triggers to induce an asthma attack and with the presence of cough and colds.

People who have asthma should try to avoid the triggers that can cause asthma flare-ups. They can also manage and control their asthma by taking medications; it can be a long term or short term med.

Nursing Health History

It was the 25th of March 2010 in the Out Patient Department in Mother Seton Hospital when we have the make-up duty of our group under Mrs. Sheila Tretasco, RN. Our chosen patient was Gubert Hans De Guzman, 10 months old, 14 pounds in weight and with a chief complaint of difficulty of breathing and cough and colds for 1 week. With a temperature of 36.6 degrees Celsius, the physician ordered to give Salbutamol 5ml x 2 w/in 20 minutes time interval.

During the interview the mother said that Hans experienced asthma for 1 week with cough and colds intermittently and abundant secretions. She also stated that Hans’ father is a smoker and her brother (Hans’ uncle) has chronic asthma. The nurse asked the mother to describe the place where they lived; she said that they reside along the road with various vehicles passing. She also added that they own 2 cats. The nurse also observed slight wheezing as he breath, slightly cyanotic face and extremities.

Mother often fed Hans with milk aside from breastfeeding.

Drug Study

Name Dosage Route Nursing Measures

Indications Adverse Reaction

Special Consideration

Ventolin

5ml 2x a day

Nasal(INHALATION)

Proper health teaching for administration specially if doctor orders for specific intervals for each dose

To prevent exercise-induced bronchospasm

To prevent or treat bronchospasm pt with reversible obstructive airway disease

tremor, nervousness,

dizziness, insomnia, headache,

tachycardia, palpitations, hypertension,

drying and irritation of

nose and throat,

heartburn, N/V,

hypokalemia, weight loss,

muscle cramps,

bronchospasm

Use cautiously in pts with CV disorders( including coronary insufficiency and hypertension), hyperthyroidism, DM and those unusually responsive to adrenergics

ANATOMY AND PHYSIOLOGY OF THE

RESPIRATORY SYSTEM

RESPIRATION- act of breathing• Inhaling (inspiration)

– taking in oxygen – is initiated by the diaphragm and supported by the

external intercostal muscles. Normal resting respirations are 10 to 18 breaths per minute, with a time period of 2 seconds. During vigorous inhalation (at rates exceeding 35 breaths per minute), or in approaching respiratory failure, accessory muscles of respiration are recruited for support. These consist of sternocleidomastoid, platysma, and the scalene muscles of the neck.

RESPIRATION- act of breathing• Inhaling (inspiration)

– When the diaphragm contracts, the ribcage expands and the contents of the abdomen are moved downward. This results in a larger thoracic volume and negative (suction) pressure (with respect to atmospheric pressure) inside the thorax. As the pressure in the chest falls, air moves into the conducting zone. Here, the air is filtered, warmed, and humidified as it flows to the lungs.

• Exhaling (expiration)– giving off carbon dioxide – generally a passive process; however, active or forced

exhalation is achieved by the abdominal and the internal intercostal muscles. During this process air is forced or exhaled out.

Functions of the Respiratory System

1. BREATHING or ventilation 2. EXTERNAL RESPIRATION - which is the

exchange of gases (oxygen and carbon dioxide) between inhaled air and the blood.

3. INTERNAL RESPIRATION - which is the exchange of gases between the blood and tissue fluids.

4. CELLULAR RESPIRATION

Other Functions

• REGULATION OF BLOOD pH - which occurs in coordination with the kidneys, and as a

• DEFENSE AGAINST MICROBES • CONTROL OF BODY TEMPERATURE - due

to loss of evaporate during expiration

Organs of Respiration

The upper respiratory tract includes the:• nose

-together with the cilia, it receives the air inhaled firsthand and filters it.

• nasal cavity -humidifies and makes the inhaled air warm

• frontal and maxillary sinus-makes the sound produced more even and clear.-decreases pressure-functions to keep the cranium lightweight

Organs of Respiration

• larynx -is also called the voice box. The vocal cords stretch across the larynx and vibrate when the air passes through them. This vibration produces various sounds.-it has several folds of elastic connective tissue called the vocal cords. They extend from the posterior end of the pharynx to the end of larynx. When air passes through the larynx, these cords vibrate and produce sound.

Organs of Respiration

• trachea -is also called the windpipe. The trachea are

held open with the help of C-shaped cartilagenous rings. The open ends of the rings are towards the oesophagus also known as the foodpipe. The trachea is situated in front of the oesophagus. The cartilages keep the larynx and trachea from collapsing even when there is no air in them. The trachea then branch into two main branches called bronchi.

The lower respiratory tract includes:• lungs

-are a pair of cone-shaped organs made up of spongy, pinkish-gray tissue.-the right lung has three lobes while the left one has only two lobes-the lungs are made up of elastic fibers that gives it the ability to handle large changes in air volume. The pleural cavity is where the lungs are located.

• alveoli -contains capillaries wherein gas exchange happens through diffusion. Carbon dioxide is excreted and oxygen is taken up by the rbc's and dissolved into the plasma.

• Bronchi-is also supported by the cartilagenous rings. The

bronchus then branches into several bronchioles. The bronchioles progressively lose the cartilages as they become narrower. The bronchioles end as fine tubules called the alveolar ducts.

-lined with ciliated epithelial cells and secretory cells (goblet cells). These secrete mucus which moistens the air as it passes through the repiratory tract and also trap any fine particles of dust or bacteria that have escaped the hairs of the nasal cavity. The cilia beat with an upward motion such that the foreign particles along with the mucus is sent to the base of the buccal cavity from where it may be either swallowed or coughed out.

Pathway of Inhaled AirAir enters the NOSTRILS

NASAL CAVITY: it is filtered by the fine hair and warms the air through its rich

supply of blood vessels

air then enters the PHARYNX

LARYNX

TRACHEA

BRONCHUS

BRONCHIOLES

ALVEOLAR DUCTS

ALVEOLI: wherein gas exchange happens.

Composition of the Air we breathe

• Nitrogen - 78% • Oxygen - 21%• Carbon dioxide - 0.03 - 0.04% • Hydrogen - traces• Noble gases - traces

Signs and Symptoms of Asthma

Emergent signs• Severe wheezing while breathing both in and out • Breathing very fast • Getting short of breath while or having difficulty

talking • A feeling of impending doom or panic • Profuse sweating • Inability to perform PEFR • Color changes in fingertips

Classic Signs and Symptoms of Worsening Asthma

As asthma worsens, the airways narrow, become inflamed, and fill with mucus.

Patients may experience the following symptoms:

• Chest tightness • Chronic cough • Shortness of breath • Wheezing

Early warning signs of worsening asthma:

• Increased night time cough • Cough or wheezing with physical activity • Tiredness with activities that you normally could

complete easily • Decreases in your peak expiratory flow rate (PEFR) • Restless sleep or waking up tired • Worsening allergy symptoms like persistent runny

nose, dark circles under your eyes or itchy, inflamed skin

Etiology and Symptomatology

Ineffective airway clearance r/t increased bronchial secretions

Bronchial Spasm and edema

Increased bronchial secretions

Bronchial Irritation

Constriction of airways

Severe coughing

Ineffective airway clearance

Ineffective breathing pattern r/t respiratory muscle spasm

Respiratory muscle spasm

Unpredictable occurrence of muscular constriction

Episodes of chest tightness and difficulty of breathing

Ineffective breathing pattern

Risk for Sleep Deprivation r/t prolonged discomfort : chronic coughing and shortness of breath

During sleep: Excessive coughing and shortness of breath occurs chronically

exhaustion and fatigue

Anxiety and disturbance

Sleep Deprivation

Predisposing factors precipitating factors

-Age (10 months old) - Atmospheric pollutants (smoke &perfume)

- Uncle has chronic asthma - Foods (milk)

- allergens (cat pets)

Immune Response ( interferons are produced)

Increase secretions Bronchial Irritation

(bronchial goblet cells)

(50% in asthmatic) Bronchial spasm and edema

Asthma episodes with cough and colds

NURSING CARE PLANS

Assessment NSG Diagnosis

Rationale Planning Intervention Rationale Evaluation

Subjective:- mother stated “1 week na may asthma si Hans at may abo at sipon pa”- “kada inaatake siya nagrarum paghangus niya”-“ may kaiba pa pating abo asin sipon”Objective:Age: 10 monthsWt: 14 poundsT: 36.6RR: 35With cough and colds

Ineffective airway clearance r/t increased bronchial secretions

Increased bronchial secretions cause blockage that gets massive, therefore making it difficult and ineffective for the pt to clear airway

After 4 hours of intervention, the client will:-maintain normal respiration as evidenced by absence of dyspnea and wet crackles- be able to sustain normal respiration rate of 40-50 bpm-maintain absence of bronchial secretionss

-Position the pt in high back rest or upright position

- assess the secretions. Document its amount, color and odor.

-do oronasopharyngeal suctioning limited to 5-10 second duration.

-medicate by following the doctor’s order: bronchodilators

-proper positioning lessens the difficulty of breathing- the characteristics of the secretion may indicate certain condition of the pt that maybe diagnosed by the doctor- to remove the bronchial secretions and clear the airway of the pt-to relieve dyspnea and allow the bronchioles to return to its function as the drug takes effect

After 4 hours of intervention, the client :-is able to maintain normal respiration as evidenced by absence of dyspnea and wet crackles-is able to sustain normal respiration rate of 44 bpm-is able to maintain absence of bronchial secretions

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective Data:- An episode begins with a dry cough, often at night.- DOBObjective Data:- Cyanosis present-Initial wheezing audible- Age: 10 months- Wt: 14 pounds- T: 36.6- RR: 35- With cough and colds

2. Ineffective breathing patterns r/t respiratory muscle spasm.3. Risk for sleep deprivation r/t to prolonged discomfort: chronic coughing in shortness of breath.

After 4 hours of nursing interventionPatient will:- Feel comfortable in a sitting or standing position rather than lying down.- Be relieve of dob and asthma attacksAfter 4 hours of nursing interventionPatient’s mother will:- Show willingness to listen and learn teachings to avoid allergen by environmental control. Instructing parents the side effects and cautions of the drugs.- Skin testing and hyposensitization to identify allergens.

- Put the client in an upright position as his mother held him- Administered metered dose inhalers (ventolin)- Encouraged mother to continue to drink fluids by asking about favorite beverages but avoiding milk.

After 4 hours of nursing intervention the:- Child can now breathe easily.- mother is taught and about the diet and factors that might trigger asthma - instructed mother to seek immediate help if asthma not relieved at home

DISCHARGE PLAN

Medication exercise Treatment Health Teaching Out patient Diet Spirituality

Ventolin 5ml 2x a dayAction: to prevent exercise-induced bronchospasmTo prevent or treat bronchospasm pt with reversible obstructive airway diseaseAdverse reaction: tremor, nervousness, dizziness, insomnia, headache, tachycardia, palpitations, hypertension, drying and irritation of nose and throat, heartburn, N and V, hypokalemia, weight loss, muscle cramps, bronchospasm

Allow the pt to walk with support and play but give rest to avoid getting too tired

Medications such as bronchodilators and anti-inflammatoryMild tolerable activities

Advice the parent of the pt to continue medications as prescribed by doctorTeach how to administer medications such as the nebulizerAdvice parents to keep pt away from allergens or anything that triggers asthma

Follow-up check up on March 29, 2010

Avoid those foods that causes allergyMore fruits and vegetables that could make the immune system fight foreign bodies that could be the causes of the asthma

Advice parent to pray and teach the pt on how to talk to God and ask for help