A CASE PRESENTATION ON

BRONCHIAL ASTHMA IN ACUTE

EXACERBATION

Roxanne Mae M. Badongen

Marie Antoinette Carreon

Ronnel Landicho

RLE 102 STUDENTS

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 person’s 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 of the Study

At the end of the case-presentation the student will be able to:

To identify what Bronchial Asthma is all about. Apply the knowledge that they have learned in

the floor. Determine the causes, predisposing and

precipitating factors that constitute the onset of the disease process.

Render series of nursing interventions for the client’s care

Improve skills and knowledge as health care providers in the clinical area.

 

OVERVIEW OF THE DISEASE A condition of the lungs characterized by

widespread narrowing of the airways due to spasm ofthe smooth muscle, edema of the mucosa, and the presence of mucus in the lumen of the bronchi andbronchioles. Bronchial asthma is a chronic relapsing inflammatory disorder with increased responsivenessof tracheobroncheal tree to various stimuli, resulting in paroxysmal contraction of bronchial airwayswhich changes in severity over short periods of time, either spontaneously or under treatment.

Causes • Allergy is the strongest predisposing factor for asthma. Chronic

exposure to airway irritants orallergens can be seasonal such as grass, tree and weed pollens or perennial under this are the molds, dust and roaches. Common triggers of asthma symptoms and exacerbations include air way irritants like air pollutant, cold, heat, weather changes, strong odors and perfumes. Other contributing factor would include exercise, stress or emotional upset, sinusitis with post nasal drip , medications and viral respiratory tract infections.

• Most people who have asthma are sensitive to a variety of triggers. A person’s asthma changes

• depending on the environment activities, management practices and other factor.

•  

Clinical Manifestation • The three most common symptoms of asthma

are cough, dyspnea, and wheezing. In some instances cough may be the only symptoms. An asthma attack often occurs at night or early in the morning, possibly because circadian variations that influence airway receptors thresholds.

• An asthma exacerbation may begin abruptly but most frequently is preceded by increasing symptoms over the previous few days. There is cough, with or without mucus production. At times the mucus is so tightly wedged in the narrow airway that the patient cannot cough it up.

Prevention • Patient with recurrent asthma should

undergo test to identify the substance that participate thesymptoms. Patients are instructed to avoid the causative agents whenever possible. Knowledge is the keyto quality asthma care.

Medical Management

• There are two general process of asthma medication: quick relief medication for immediatetreatment of asthma symptoms and exacerbations and long acting medication to achieve and maintaincontrol and persistent asthma. Because of underlying pathology of asthma is inflammation, control ofpersistent asthma is accomplish primarily with the regular use of anti inflammatory medications.

Long-acting control Medication

• Corticosteroid are the most potent and effective anti inflammatory currently available. They are broadly effective in alleviating symptoms, improving air way functions, and decreasing peak flow variability. Cromolyn sodium and nedocromil are mild to be moderate anti-inflammatory agents that are use more commonly in children. They also are effective on a prophylactic basis to prevent exercise-induced asthma or unavoidable exposure to known triggers. These medications are contraindicated in acute asthma exacerbation.

• `Long acting beta-adrenergic agonist is use with anti-inflammatory medications to control asthmasymptoms, particularly those that occur during the night these agents are also effective in the preventionof exercise-induced asthma.

Quick relief medication

• Short acting beta adrenergic agonists are the medications of choice for relief of acute symptoms andprevention of exercise-induced asthma. They have the rapid onset of acton. Anti-cholinergic may have anadded benefit in severe exacerbations of asthma but they are use more frequently in COPD.

Nursing Management

• The main focus of nursing management is to actively assess the air way and the patient response to treatment. The immediate nursing care of patient with asthma depends on the severity of the symptoms. A calm approach is an important aspect of care especially for anxious client and one’s family.

• This requires a partnership between the patient and the health care providers to determine the

desire outcome and to formulate a plan which include:

-The purpose and action of each medication

-Trigger to avoid and how to do so

- When to seek assistance

- The nature of asthma as chronic inflammatory disease

 

PATIENT’S PROFILE

•  Client’s Name: Patient Daisy Duck• Age: 63 years old• Birthday: June 5, 1947• Birth Place: Tarlac • Address: Villa Pascua, Diffun, Quirino • Civil Status: Married • Department: Medicine • Ward: Female Extension 

• Sex: Female • Nationality: Filipino • Religion: Roman Catholic • Date of admission: January 31, 2011• Time of admission: 10:00 AM• Chief complaint: Difficulty of breathing• Admitting diagnosis: BAIAE• Attending physician: Dra. De Guzman 

HEALTH HISTORY Family Health History• ( - )DM• ( +) HPN• ( +)Asthma• ( - ) Heart Disease• ( - ) Cancer

History of Present Illness• Patient was discharged from QPH this morning.

She began to experience DOB 3hrs PTA. Recently admitted at QPH due to asthma.

• (- ) fever• (+) difficulty of breathing 

PHYSICAL ASSESSMENT

• General Appearance:

Seen lying on bed with 565 cc D5 NM + Aminophylline 250 mg regulated @ 10-15gtts/min, intact and infusing well. The patient was observed to be weak. Upon interview the patient was conscious and coherent.

• Initial Vital Signs:

Temp: 36.3° C

PR: 76 bpm

RR: 24 cpm

BP: 110/70

Body parts Technique used

findings interpretation

a. Scalp Inspectionpalpation

No lesionsNo masses and tenderness

Normal

a. Hair inspection Black with white, thick and straight

Due to old age

a. Face inspection SymmetricalFacial movement

Normal

EYES Inspection Parallel; non-protruding

normal

a. Eyebrows Inspection SymmetricalBlack in color

Normal

a. Eyelashes inspection black in color Normal

a. eyelids inspection Intact skin Normal

EAR

a. pinna inspection Symmetrical recoil after folded; bean shaped

Normal

a. ear canal inspection No discharge Normal

MOUTH

a. lips inspection Pink in color Normal

a. gums inspection Pink in color Normal

NECK Inspectionpalpation

Head centeredNo palpable lymph node

NormalNormal

UPPER EXTREMITIES inspection Can move freelysymmetrical

Normal

palpation No masses and tenderness

Normal

Chest inspection Ribs are prominent Due to thin body

auscultation Bronchial sounds normal

palpation No lumps, no masses symmetrical

normal

ABDOMEN Inspection Flat;Symmetrical movements caused by respiration

normal

AuscultationPalpation

Presence of Gurgling soundSoft

Normalnormal

LOWER EXTREMITIES Inspection Can move freelySymmetrical

Normal

Back palpation bony Due to thin body

Nails Inspection Capillary refill:2-3seconds

normal

Skin inspection Fine hair evenly distributed;Tan;Presence of wrinkles

NormalDue to old age

GORDON’S FUNCTIONAL PATTERN

HEALTH PATTERN BEFORE HOSPITALIZATION

DURING HOSPITALIZATION

Health Perception Pattern The patient said that she is healthy.

The patient is now more concern with her health.

Nutritional –Metabolic Pattern According to the pt. she eats 3x a day. She eats a lot of rice and drinks at least 8 glasses of water daily.

She still eats 3x a day but with small amount because she has a loss of appetite.

Elimination Pattern The pt voids 6 times a day and defecates once a day.

The pt voids 4 times and doesn’t defecate yet.

Sleep Rest Pattern According to the pt she sleeps @ 9pm and wakes up at 4 am because she have lots of things to do.

The pt have more time to sleep because she goes to sleep at 8pm and wakes up at 6am, she also takes naps in between.

Activity – Exercise Pattern According to the patient she cleans the house and washes clothes as her exercise and daily activities.

She cannot do anything but lay down on bed because she is weak.

Cognitive –Perception Pattern According to the pt she wasn’t able to finish her studies that is why she cannot write well and read well. She can speak Ilocano and a little Tagalog.

Still, She can speak Ilocano and a little Tagalog

Self Perception Pattern The patient is a well determined person and she thinks she is healthy.

The pt said that she thinks she is a strong person and she can survive her illness.

Role- Relationship Pattern According to the pt she is a mother of 3, and her relationship with her family is ok.

Still her relationship with her family is ok. Her 2 daughters were the once who are taking care of her in the hospital.

Coping Stress Pattern When the pt is experiencing stressful moments she just talks to her husband and kids and she also asks for God’s guidance.

She talks to her children and pray.

Sexuality- reproductive pattern she had her menarche at the age of 14 and she menopause at the age of 45

Values-belief pattern The pt is an Roman Catholic and rarely goes to mass.

The Respiratory system

Anatomy and Physiology

• 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.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.

• The normal functions of respiration O2 and CO2 tension and chemoreceptors are similar inchildren 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 .

 

DOCTOR’S ORDER RATIONALE

1-31-2011

Please admit to FMW

Secure consent

D5NM 1 L+ Aminophylline 250mg

to run for 24 hrs

Hydrocortisone 200mg IV

Salbutamol 1neb q6

Omeprazole 40mg 1 cap OD

v/s q 2

high back rest or inhalation @ 2-

3LPM

refer

For further management and

treatment of condition

For legal purposes

To provide access for

intravenous medications and for

the treatment of the disease

To help for fast recovery and for

the treatment of the disease

For monitoring and to have

baseline data

To prevent difficulty of breathing

and To help for fast recovery

DOCTOR’S ORDER RATIONALE

02-1-11Continue medicationsTF with D5 NM 1 L @ SR 9:35pmMGH @3pm tomorrow feb. 2,2011Home meds:-cardiomax 1 cap TID x 10 days-dexone 500mg BID x 15daysOPD after 2 wks 

To help for fast recoveryTo provide access for intravenous medications. Preparation for going home .  For follow up check up  

Name of drug

Classification

Action Indication Contraindic

ation

Adverse

Effects

Nursing

Considerations

Cardiomax antihypertensi

ve

cardiovascular

system drug

inhibits ACE,

preventing

conversion of

angiotensin I to

angiotensin II, a

potent

vasoconstrictor;

less angiotensin

II decrease

peripheral

arterial

resistance,

decrease

aldosterone

secretion, which

reduces Na &

H2O

>

hypertension

> left

ventricular

dysfunction

> Px

hypersensitiv

e to the drug

> CNS –

dizziness,

fainting,

headache,

malaise,

fatigue, fever

> CV –

tachycardia,

hypotension,

angina pectoris

> GI –

abdominal pain,

anorexia,

constipation,

diarrhea, dry

mouth,

dysgeusia,

nausea,

vomiting

> monitor Px’s BP &

PR frequently

> assess Px for signs

of angioedema

> monitor WBC &

differential counts in

Px with impaired renal

fxn or collagen

vascular dse before

starting Tx, q 2 weeks

for the first 3 mos of

therapy, &

periodically thereafter

Name of drug Classification Indication Side effects Nsg consideration

Generic name:aminophillin

Anti-asthma

bronchodilator

Stock dose: 250 mg/10ml

relaxes brochial smooth muscles causing brocho dilation and increasing vital capacity

irritability restlessness dizziness severe depression stammering speech

Observe 11 rights in giving medication

Observe side effects that occur

Provide TLC

Watch out for any allergic reaction

GENERIC NAME

INDICATION ACTIONCONTRAINDIC

ATION

PRECAUTION/ ADVERSE REACTION

NURSING CONSIDERATI

ON

Salbutamol Reversible airway obstruction including bronchial asthma, chronic bronchitis

Facilitates/ potentiates the inhibitory activity of GABA at the limbic system and reticular formation to reduce anxiety, promote calmness and sleep

Hypersensitivity PRECAUTION:Hyperthyroidism,DM, cardiovascular diseaseADVERSE RXNFine tremor of skeletal muscle, feeling of tension, a compensory small increase in heart rate, headache, muscle cramps

> drug may be decrese sensitivity of spirometry used for diagnosis of asthma>syrup may be taken as young as age 2>monitor for evidence of allergic rxn

CUES NURSING DIAGNOSIS

RATIONALE PLANNING NURSING INTERVETION

RATIONALE EVALUATION

OBJECTIVES:>Wheezes on both lung fields>uses intercostal muscles upon respiration

Ineffective Airway

Clearance

related to retained

secretions

Normally the lungs are free from secretions. Pneumonia bacteria are invading the lung parenchyma thus, producing inflammatory process. And these responses leading to filling of the alveolar sacs with exudates leading to consolidation. The airway is narrowed thus wheezes is being heard. DOB in some cases orthopnea is observed.

Short term:After 1 hour of nursing intervention, the client will be able to maintain airway patency, clear breath sounds.Long Term:After 1 day of nursing intervention, the client will be able to expectorate retained secretions and maintain normal breathing pattern.

> monitor VS> suction secretions PRN> Elevate HOB> Encourage deep breathing > give bronchodilator as ordered> refer for any abnormal changes in the body

> to obtain baseline data> to decrease secretion retained in the bronchi>to maintain patent airway>to take advantage of the gravity decrease pressure on the diaphragm.> to mobilize secretion> to moisten secretions for easy expectoration> to medically manage any complications.

The client shall have maintained airway patency, clear breath sounds(goal partially met)The client shall have expectorated retained secretions and maintained normal breathing pattern(goal met)

DISCHARGE PLANNING

Medication• Patient will be compliant to take cardiomax 1

cap three times a day for 10 days and Dexone 500mg two times a day for 15 days

Exercise• Patient will verbalize need importance of

exercise and demonstrate proper initiation of appropriate exercise and needs to rest in between periods of activities

Treatment• Patient will know appropriate treatment like

using nebulization

• Hygiene

The patient must take a bath daily and know the proper oral hygiene

Outpatient• Patient must come back after 2 weeks at the

OPD

Diet• Low salt low fat diet

Spiritual• The patient should go to mass and know how

to pray to God