CASE PRESENTATION: BRONCHIAL ASTHMA

INTRODUCTION A. B ACKGROUND OF THE S TUDY Asthma is a chronic disease of the airways that causes airway hyperresponsiveness, mucosal edema and mucus production. This inflammation, ultimately leads to recurrent episodes of asthma symptoms: cough, chest tightness, wheezing and dyspnea. (Medical-Surgical Health Nursing Volume 1 by Smeltzer and Bare page 587). It is a multifactorial disease process associated with genetic, allergic, environmental, infectious, emotional, and nutritional components. Because of their symptomatology the majority of individuals with asthma experience a significant number of missed work or school days. This can create a severe disruption in quality of life, often leading to depressive episodes. It also disrupts the lives of caregivers and family members of the affected individual. Asthma patients who have increased symptomatology at night (a significant portion) also tend to have disturbed sleep patterns and impaired daytime attention, concentration, and memory. B. R ATIONALE FOR C HOOSING THE C ASE Most of our patient assignments have bronchial asthma. We choose the case of bronchial asthma because it would help us to have a focus study regarding this casemore nursing care would be given. Added to that, we choose the client because of the fact that she is cooperative in the sense that she always try to answer the questions asked in her full knowledge and try to verbalize anything that she wants to say. Moreover, other patients without asthma were may go home (MGH) and was given discharge teaching by student nurses according to their respective cases C. L EARNING O BJECTIVES (1) To explore patients past health history prior to bronchial asthma (2) To review the body system involve in bronchial asthma (anatomy and physiology)

(3) To review the disordered function of the body related to bronchial asthma (pathophysiology) (4) To review the laboratory results and compare it to normal and the implication of the abnormal (5) To make a list of nursing problems (6) To prioritize listed nursing problems (7) To make Nursing Care Plan for prioritized problem (8) To make a health teaching to the client and other potential candidates regarding about bronchial asthma I. CLINICAL SUMMARY A. G ENERAL D ATA Name: B.V. y B Age: 56 years old Birth date: May 9, 1950 Birth place: Samar, Leyte Sex: Female Religion: Roman Catholic Civil Status: Married Address: K.V. D.D Occupation: vendor Room & bed #: Female Medical Ward 364B Date Admitted: November 15, 2006 Time Admitted: 11:15 pm B. C HIEF C OMPLAINT The chief complaint of the patient is difficulty of breathing

H ISTORY OF P RESENT I LLNESS A few days prior to admission, the client has on and off difficulty of breathing (DOB). She added, Bago ako isugod dito sa ospital, nakalanghap ako noon ng pamatay ng ipis tapos sa bahay nag-insenso sila kaya inatake ako ng asthma ko. Nanikip na ang dibdib ko tapos ayun na, sinugod na nila ako dito When asked about her medication whenever she has an asthma attack, she verbalized, Kapag inaatake ako ng asthma, salbutamol lang ang iniinom ko tapos nawawala naman pagkatapos. The client was admitted at President Diosdado Macapagal Memorial Medical Center last November 15, 2006 around 11: 15 in the evening According to the clients medical history, asides from bronchial asthma, she also has hypertension C. P AST M EDICAL H ISTORY 1. Childhood Illnesses --The client verbalized that she had experienced having measles, small pox, diphtheria and asthma during his childhood days 2. Immunizations --According to the client, she had completed her childhood immunizations. 3. Allergies --The client stated that whenever she smells and inhales pollutants and fume of insecticides, her asthma is triggered. She added that when she inhales these allergens, she has chest tightness at dyspnea. 4. Accidents --According to the client she doesnt have any accidents encountered 5. Hospitalization --According to the client, she never been hospitalized but she consulted health center when her asthma attacked. 6. Medicines --Her medicine is salbutamol

7. Foreign Travel --According to the client she doesnt have travels outside the country. 8. General Health Status > Adolescent --The client verbalized Bata pa lang ako may asthma na ako. Ginagamot naman ng salbutamol kaya kahit papano ayos ayos na. Tapos nawala rin siya. > Adulthood -- The client verbalized Matagal din ang panahon bago ako inatake ulit ng asthma. Ngayon na nga lang ulit sumumponmg ng ganitong katindi ang asthma ko. Bago kasi ako isugod dito sa ospital, nakalanghap ako ng pamatay sa ipis tapos sa bahay, nag-insenso sila kaya intake ako ng asthma ko. Siguro isama na rin natin na pagod din ako. Tapos nanikip na ang dibdib ko tapos sinugod na nila ako dito sa ospital. 9. Operation --According to the client, she doesnt gone any operations D. F AMILIAL H ISTORY --According to the client, they have family history of Bronchial Asthma in her fathers side

E. P HYSICAL A SSESSMENT G ENERAL A PPEARANCE 1. Posture/Gait Relaxed, erect posture; coordinated movement (pg. 531, Fundamentals of Nursing by Kozier, 7th edition) Older adults (middle age) assume a stooped forward bent posture, hips and knees are some what flexed. Arms are raised because arms are bent at the elbow. A person normally walks with arms swinging freely at the sides with head and face leading the body (pg. 519, Fundamentals of Nursing by Potter and Perry) Healthy appearance Skin color may be pink, tan, brown, Slouched/bent posture N ORMS A CTUAL F INDINGS I NTERPRETATION A NALYSIS
AND

Interpretation: Not normal Analysis: This observation is most seen with dyspnea, advance chronic lung disease and air trapping, acute and chronic (Luckmann and Sorensen MedicalSurgical Nursing, pg. 650) Slouched posture and a slow shuffling gait suggested depression or physical discomfort (Fundamentals of Nursing, 7th edition, Barbara Kozier, pg 425)

2. Skin Color

Pallor; weakness; Interpretation: Not obvious illness normal Analysis: Skin color and

G ENERAL A PPEARANCE

N ORMS olive or yellowish depends on the race. With a normal supply of oxygen, the nail beds, the tongue and the lips appear pinkish-red in color (Fundamentals of Nursing, 7th edition, Barbara Kozier, pg 538)

A CTUAL F INDINGS

I NTERPRETATION AND A NALYSIS temperature particularly that of the lips and nail beds. The color of the lips and nail beds is an indicator of tissue perfusion (passage of blood through the vessels) Pale, cyanotic, cool and moist skin may be a sign of circulatory problems (pg. 914, Fundamentals of Nursing by Kozier. 7th edition). The color and appearance of the skin and nails may reflect insufficient delivery of oxygenated blood to the tissue because of respiratory dysfunction (pg. 419, Fundamentals of Nursing by Craven and Hirnle, 4th edition) Interpretation: Normal Analysis: Personal hygiene is

3. Personal Hygiene/ Grooming

Clean, neat

No foul body odor, neat

G ENERAL A PPEARANCE

N ORMS

A CTUAL F INDINGS

I NTERPRETATION AND A NALYSIS the self care by which people attend to such functions as bathing, toileting, general body hygiene, and grooming. Hygiene is highly personal matter determined by individual values and practices. It involves care of the skin, hair, nails, teeth, oral and nasal cavities, eyes, ears, and perinealgenital areas (pg. 698, Fundamentals of Nursing by Kozier, 7th edition) Hygiene is the observance of health rules relating to these self-care activities (pg. 704, Fundamentals of Nursing by Craven and Hirnle, 4th edition) Interpretation: Not Normal Analysis: Loss of weight may be generalized as a result of inadequate

4. Nutritional Status

The state of nutrition is often reflected in a persons appearance. Although the most

Malnourished; general appearance is listless, appears acutely or chronically ill

G ENERAL A PPEARANCE

N ORMS obvious physical sign of good nutrition is a normal body weight with to respect to height, body frame, and age, other tissues can serve as indicators of good nutritional status and adequate intake of specific nutrients; these include the hair, skin, teeth, gums, mucous membranes, mouth and tongue, skeletal muscles, abdomen, lower extremities, and thyroid gland. General appearance is alert and responsive (pg. 71-72, Brunner & Suddarths Textbook of Medical-Surgical Nursing, Volume 1, 10th edition by Smeltzer and Bare)

A CTUAL F INDINGS

I NTERPRETATION AND A NALYSIS caloric intake or may be seen in loss of muscle mass with disorders that affect protein synthesis. (pg. 68) Nutritional problems in the elderly often occur or are precipitated by such illnesses as pneumonia and urinary tract infections. Acute and chronic diseases may affect the metabolism and utilization of nutrients, which already are altered by the aging process (pg. 75) (Brunner & Suddarths Textbook of Medical-Surgical Nursing, Volume 1, 10th edition by Smeltzer and Bare)

5. Age

Adulthood ages

The age of the

Interpretation:

G ENERAL

N ORMS

A CTUAL F INDINGS client is 56 years old. As a middle adult, she has concern with others, talks with the patients in the same ward

A PPEARANCE Appropriateness ranges from 25 to 66 years. According to Erik Eriksons Theory, the central task is generativity versus stagnation. The indicators of positive resolution are creativity, productivity and concern for others. The indicators of negative resolution are selfindulgence, selfconcern, lack of interests and commitments. (Fundamentals of Nursing, 7th edition, Barbara Kozier, pg 357) 6. Verbal Behavior Understandable, moderate pace; exhibition of thought association; logical sequence; make sense; has sense of reality (Fundamentals of Nursing, 7th edition, Barbara Kozier, pg 531)

I NTERPRETATION AND A NALYSIS Normal Analysis: Erikson believes that the greater the task achievement, the healthier the personality of the person (Fundamentals of Nursing, 7th edition, Barbara Kozier, pg 357)

The client has logical sequence of though, has a sense of reality and able to understand

Interpretation: Normal Analysis: Verbal communication is largely conscious because people choose the words they use. The words use varies among individuals according to

G ENERAL A PPEARANCE

N ORMS

A CTUAL F INDINGS

I NTERPRETATION AND A NALYSIS culture, socioeconomic background, age and education. Countless possibilities exist for the way ideas are exchanged. An abundance of words can be used to form messages (pg. 423, Fundamentals of Nursing by Kozier, 7th edition) Interpretation: Normal Analysis: Nonverbal communication includes gestures, body movement, use of touch and physical appearance, adornment. Nonverbal behavior is controlled less consciously than verbal behavior

7. Non-verbal behavior

No distress noted in facial expression; the clients affect/mood is appropriate to situation

The clients affect/mood is appropriate in the situation.

M EASUREMENTS Temperature

N ORMS Normal adult temperature axillary: 35.8 C to 37.0 C (pg. 444, Fundamentals of Nursing by Craven and Hirnle, 4th edition)

A CTUAL F INDINGS As of November 20 2006 8:00pm 36.5 C

I NTERPRETATION A NALYSIS

AND

Interpretation: Normal Analysis: Normal adult temperature ranges from 35.8 C to 37.0 C. it is not uncommon for adult/elderly persons to have body temperature less than 36.4 C because normal temperature drops as persons ages. (pg. 414-415, Fundamentals of Nursing by Craven and Hirnle, 3rd edition) Interpretation: Normal Analysis: The normal range of the pulse in an adult is 60 to 100 beats per minute (p. 424, fundamentals of Nursing by Craven and Hirnle, 3rd edition). As the age increases, the pulse rate gradually

Pulse Rate

The normal pulse rate of an adult: 60-100 beats per minute (pg. 485, Fundamentals of Nursing by Kozier, 7th edition)

8:00pm 80 beats per minute

M EASUREMENTS

N ORMS

A CTUAL F INDINGS

I NTERPRETATION AND A NALYSIS decrease (p. 496, Fundamentals of Nursing by Kozier, 7th edition) Interpretation: Not Normal Analysis: Normal breathing is automatic and involuntary. At rest, the normal adult respiratory rate is 12 to 20 breaths per minute. Respiratory rate changes with age. Tachypnea is an abnormally fast respiratory rate (usually above 20 breaths per minute in adult) Interpretation: Normal Analysis: In adults, the trend is toward gradually increasing systolic and diastolic blood pressure with aging. In part, this trend is due to increased systematic vascular resistance, reflecting arterial narrowing

Respiratory Rate

The normal respiratory rate of an adult: 12-20 breaths per minute (pg. 444, Fundamentals of Nursing by Craven and Hirnle, 4th edition)

8:00pm 21 breaths per minute

Blood Pressure

Systolic Diastolic 90.140 60-90 (pg. 444, Fundamentals of Nursing by Craven and Hirnle, 4th edition)

8:00pm 130/70 mmHg

M EASUREMENTS

N ORMS

A CTUAL F INDINGS

I NTERPRETATION AND A NALYSIS and decreased vessel elasticity due to atherosclerotic vessel disease. The increase in systolic pressure is proportionally greater than the increase in diastolic pressure (pg. 463, Fundamentals of Nursing by Craven and Hirnle, 4th edition) I NTERPRETATION A NALYSIS
AND

B ODY P ARTS Skin

N ORMS Varies from light to deep brown; from ruddy pink; from yellow overtones to olive (pg. 538, Fundamentals of Nursing by Kozier, 7th edition)

A CTUAL F INDINGS Pallor

Interpretation: Not Normal Analysis: Pallor is the result of inadequate circulating blood or hemoglobin and subsequent reduction in tissue oxygenation (pg. 535, Fundamentals of Nursing by Kozier, 7th edition) Interpretation: Not Normal

Mouth/ Oral Cavity

-Uniform pink color -Soft, moist,

- lips has visible margins

B ODY P ARTS Lips

N ORMS

A CTUAL F INDINGS

smooth texture - symmetrical -Symmetry of - pale in color contour - no edema -Ability to purse lips (Fundamentals in Nursing, Barbara Kozier, pg. 563)

I NTERPRETATION AND A NALYSIS Analysis: Pallor is the result of inadequate circulating blood or hemoglobin and subsequent reduction in tissue oxygenation (pg. 535, Fundamentals of Nursing by Kozier, 7th edition) Interpretation: Not Normal Analysis: Dyspnea is a sign of serious disease of the airway, lungs, or heart. (www.medterms.com ) Tachypnea may be necessary for a sufficient gasexchange of the body (www.wrongdiagnosi s.com) Possible cause of air passing through a constricted bronchus as a result of secretion, swelling or tumor (Fundamentals in

Thorax Anterior Thorax

-Quite rhythmic and -tachypnea effortless -wheezes at right respirations lung field (Fundamentals in Nursing, Barbara Kozier, pg. 578)

B ODY P ARTS

N ORMS

A CTUAL F INDINGS

I NTERPRETATION AND A NALYSIS Nursing, Barbara Kozier, pg. 575)

F. P ATTERNS

OF

F UNCTIONING

I. Psychological Health 1. Coping Pattern According to the client, whenever she has problems, solving it right away is the solution. Gusto ko kasi kapag may problema ako nilulutas ko na kaagad hindi pinatatagal pa ANALYSIS: Coping maybe described as dealing with problems and situations, or contending with them successfully. Coping strategies varies among individuals and are often related to the individuals perception of stressful events. A persons coping strategies often change with a reappraisal of a situation. (Fundamentals of Nursing by B. Kozier, 7th edition, p 1020) INTERPRETATION: Effective Coping Pattern 2. Interaction Pattern According to the client, they are six in the familyshe, her husband and 4 siblings. Their relationship, she described, is harmonious. If there are problems in the family, they solve it all together and they communicate well to each of the family members. ANALYSIS: Interaction patterns involve ways of expressing affection, love, sorrow, anger and other feelings and thought in most significant family in person and life. Openness of communication with all family members develops the familys ability to function as a cooperative, growth producing unit. (Fundamentals of Nursing by B. Kozier, 7th edition, p 671) INTERPRETATION: Effective Interaction Pattern 3. Cognitive Pattern The highest formal education of the client was 2nd year high school. She stated that she has short term memory gap. She verbalized Madali

akong makalimot. Minsan sasabihin ko na lang makakalimutan ko pa. Matanda na kasi. Pero mabilis naman ako maka pick up kapag tiuturuan ako ANALYSIS: Changes in the cognitive function of middle adults are rare except with trauma or illness. The middle aged adults are able to continue learning new skills and can reflect on the past and current experience and can imagine, anticipate, plan and hope. (Fundamentals of Nursing by Potter and Perry, 3rd edition, Vol.1 p 821) INTERPRETATION: Proper cognitive pattern 4. Self Concept The client verbalized Matagal din bago ako intake ulit ng asthma ko. Ngayon may asthma na ako ulit, limitado na ang galaw ko kasi mahirap na baka umatake ulit at lumala. She also added that after discharge, she will continue her work as a vendor, Pero siyempre hindi na ako dapat tulad ng dati kasi nga may limitasyon na. ANALYSIS: Self concept is an individuals perception of self. It includes self esteem (an individuals perception of self worth) and body image (perception of physical self). Self concept influences individuals health behaviors in that people think highly themselves will tend to take care of themselves. On the other hand, a person with a negative self concept will engage in reckless or self destructive behaviors that endanger health. Persons with a low self concept frequently ignore their own needs because they are perceived to be less important than the needs of other people. (Nursing Fundamentals by R. Daniels p 854) INTERPRETATION: Healthy Self Concept 5. Emotional Pattern According to the client she is bored upon hospitalization but it somehow relieved by visitations of her relatives and talking to the other patients in the ward. ANALYSIS: Cooperative or friendly, expressive feelings appropriate to the situation, verbalizes positive things regarding others and the future. Express positive coping mechanism. (Nurses Handbook of Health Assessment, Janet Weber, pg. 513) Emotional states such as depression

and anger affect a clients perception and degree of risk taking behavior. These emotional states alter a clients thinking pattern and reaction time (Nursing Fundamentals by R. Daniels p 874) INTERPRETATION: Effective Emotional Pattern 6. Family Coping Patterns The client verbalized that if there are any misunderstandings, her family talks it over and the last word will be coming from the head of the family, her husband. When there are sick family members, they see to it that they attended the need of the sick member. ANALYSIS: Family coping mechanisms are the behaviors families use to deal with stress or changes imposed from either within or without. (Fundamentals of Nursing by B. Kozier, 7th edition, p 193) Because chronic illness lasts longer than acute illness, it can influence the family to a greater extent. People with chronically ill children, parents, or other family members may express negative feelings about themselves such as guilt, inadequacy, failure, rejection and helplessness. The family may be in denial initially as members struggle with the shock of the illness. (Fundamentals of Nursing by Craven and Hirnle, 4th edition, p 1282) INTERPRETATION: Effective Family Coping Pattern II. Socio Cultural Health 1. Cultural pattern According to the client, the social values she was brought up to were respect, sense of responsibility, fear of God. The traditions in her family are Christmas, Birthday, New Year and Holy week. ANALYSIS: The value placed on children and elders within a society is culturally derived. (Fundamentals of Nursing by Craven and Hirnle, 4th edition, p212) The family passes on patterns of daily living and lifestyles to offspring. Cultural rules, values, and beliefs give people a sense of being stable and able to predict others (Fundamentals of Nursing by Kozier, 7th edition p 178) INTERPRETATION: Proper Cultural Pattern

2. Significant relationship According to the client, her family is the significant persons in her life. They have harmonious relationship with her family and relatives ANALYSIS: Family influences on health care because health is defined uniquely by each clients culture. Family is often major care givers of their relatives. Lack of social support from family or significant others results in psychological and spiritual isolation, which negatively impacts a persons physiological state. Thus, it is important to help clients identify, strengthen, and use their social support systems. Sometimes, families need guidance to optimize health behaviors. (Nursing Fundamentals by R. Daniels p849-851) INTERPRETATION: Effective Significant Relationship 3. Recreational Pattern The client verbalized Kapag wala akong trabaho, nood lang ako ng TV o kaya naman naglilinis ng bahay. Iyan lang naman ang kadalasang ginagawa ko kapag nasa bahay ako. Minsan nakikipagkwentuhan sa mga kapitbahay. ANALYSIS: Leisure time is important for normal social development and adjustment (Nursing assessment and Health Promotion by Murray and Zentner, 5th edition, p 386) INTERPRETATION: Proper Recreational Pattern 4. Environment The client verbalized, Sa bahay kasi naninigarilyo din ang asawa ko. She also added Kasi ugali na kasi ng anak kong babae na maglagay ng insenso sa altar kapag gabi, di ko lang pinapansin pero nitong nakaraan kapag naaamoy ko yung usok medyo nahihrapan akong huminga tapos kapag nangyari iyon, iinom ako ng gamot. ANALYSIS: A safe environment is one which people can function safely and in one in which they obtain a sense of security. (Fundamentals of Nursing by Kozier, 7th edition p 480) INTERPRETATION: Poor Environment

5. Economic According to the client when she was still strong, she was working. She worked as a vendor. Sapat naman ang kinikita naming mag-asawa. Nakakakain naman kami 3 beses isang araw at saka ngayong may sakit ako, nakakabili naman kami ng gamot na kailangan ko. ANALYSIS: Financial resources increase the ability to provide the necessary commodities for health and well being. (Nursing Fundamentals by R. Daniels p 855) INTERPRETATION: Adequate Economic Finances III. SPIRITUAL PATTERN 1. Religious beliefs and practices According to the client, praying is her religious practice since she is at the hospital. ANALYSIS: In middle age, people tend to be less dogmatic about religious beliefs and religion often offers more comfort to the middle aged person than it did previously. People in this age group often relies on spiritual beliefs to help them deal with illness, death and tragedy (Fundamentals of Nursing by Kozier, 7th edition p 400) INTERPRETATION: Proper practice of religious beliefs 2. Values and valuing According to the client God and family are the most important persons in her life. ANALYSIS: Values can be described as the outcome of an individuals effort to apply universal moral laws to his everyday life. Values are more personal, and provide meaning and direction. (Fundamentals of Nursing practice by Narrow and Buschle, 2nd edition p 84) INTERPRETATION: Proper valuing

G. A CTIVITIES A CTIVITIES OF D AILY L IVING Nutrition

OF

D AILY L IVING B EFORE H OSPITALIZATION The client verbalized, Kadalasan isda at gulay ang kinakain namin. Minsan may karne din. She also added that she eats 3 meals per day and drinks 7 to 8 glasses everyday D URING H OSPITALIZATION The client verbalized, Kung ano ung binibigay na pagkain dito sa hospital, un ang kinakain ko pero di ko rin nauubos. Sabi ng doktor bawal sa akin ung mga gatas at itlog kasi makati iyon. She also added that she drinks 1.5 liters of water everyday. I NTERPRETATION A NALYSIS
AND

Interpretation: Normal Analysis: The middle-aged adult should continue to eat a healthy diet, following the recommended portions of the five food groups with special attention to protein, calcium and limiting cholesterol and caloric intake. Two or three liters of fluid should be included in the daily diet. During the late middle age, they may determine that certain foods disagree with them. Clients should be advised to develop sensible eating habits and avoid fried or fatty foods (p. 1181, Fundamentals of Nursing by Kozier, 7th edition) Allergies induced by a hypersensitiveness of

A CTIVITIES OF D AILY L IVING

B EFORE H OSPITALIZATION

D URING H OSPITALIZATION

I NTERPRETATION AND A NALYSIS the individual. Allergies reaction is a process that is injuries and renders the individuals sensitivity to the antigens. (p.492, Williams, Jesse F. 1950. Personal Hygiene Applied,) Interpretation: Normal Analysis: Elimination from the urinary and intestinal tracts is essential to rid the body of wastes and materials in excess of bodily needs. Healthy adults excrete 1200ml1700ml of urine in each 24 hour period. However, this amount may vary, depending on several factors. Regular elimination of bowel wastes products is essential for normal body functioning. Because bowel function depends on the balance of several factors,

Elimination

The client verbalized that she defecates and urinates regularly and there is no burning or foul smell in her urine. She also added that she doesnt take any medications to increase her bowel movement

The client verbalized that she urinates 3 times to 6 times a day and defecates 2 times a day. She also verbalized, Buo naman ang dumi ko.

A CTIVITIES OF D AILY L IVING

B EFORE H OSPITALIZATION

D URING H OSPITALIZATION

I NTERPRETATION AND A NALYSIS elimination pattern and habits vary among individuals (p. 356 and p. 366, Fundamentals of Nursing by Eliner V. Fuerst & p. 1437, Fundamentals of Nursing by Potter and Perry, 5th edition) The normal color of the stool is brown, formed soft, and semi-solid, moist, in consistency, cylindrical in shape. (Fundamentals of Nursing by Kozier, page 1227) Interpretation: Normal Analysis: For exercise to be effective. It should be regular and sustained. Generally, exercising at least thrice a week is advised. (p. 104, Fundamentals of Nursing by Kozier). Limitations to movement may be medically prescribed

Exercise and Physical Activities

The client verbalized that walking and working is her form of exercise

The client verbalized, Wala ako masyadong exercise dito kasi lagi lang ako dito sa higaan. Minsan naglalakad ako kapag papunta ng CR. Stretching lang minsan ang ginagawa ko

A CTIVITIES OF D AILY L IVING

B EFORE H OSPITALIZATION

D URING H OSPITALIZATION

I NTERPRETATION AND A NALYSIS for some health problems (p. 1067, Fundamentals of Nursing by Kozier, 7th edition) Many middle-aged adults may not include exercise in their lifestyle because many of the activities or routine chores that provided exercise in the past have been stream lined by modern devices that save time and require little if any energy. (Fundamentals of Nursing by Kozier , p 635) Interpretation: Normal Analysis: Behaviors of mankind that produce improve and maintain health and that protects and defends health or prevent diseases are the forced and persuaded practices of hygiene. (p. 3, Principles of Hygiene by Thomas Storey,

Hygiene

The client verbalized that she takes a bath everyday, brush her teeth twice a day.

She has sponge baths everyday and brushes her teeth twice a day. The client verbalized Kaya ko naman punasan ang sarili ko pero nagpapatulong din ako sa anak ko.

A CTIVITIES OF D AILY L IVING

B EFORE H OSPITALIZATION

D URING H OSPITALIZATION

I NTERPRETATION AND A NALYSIS 1935) bathing provides relaxation and comfort and it gives most people a sense of well being (p. 704, Fundamentals of Nursing by Craven and Hirnle, 4th edition) Cleaning baths are given chiefly for hygiene purposes (p. 705, Fundamentals of Nursing by Kozier, 7th edition) Proper diet and tooth and mouth care should be evaluated and reinforced to adolescents and adults. Thorough brushing of the teeth is important in preventing tooth decay (p. 726, Fundamentals of Nursing by Kozier, 7th edition) Interpretation: Normal Analysis: Drugs or substance use is appropriately taken as prescribed

Substance Abuse

The client verbalized that she is an occasional smoker but stopped for ten years. She also drinks alcohol

She dont drink alcoholic beverages and dont smoke

A CTIVITIES OF D AILY L IVING

B EFORE H OSPITALIZATION 2 to 3 times a week consuming only 1 bottle.

D URING H OSPITALIZATION

I NTERPRETATION AND A NALYSIS or generally recommended as its intended physiological or psychological effects. (Fundamentals of Nursing by Potter and Perry pg. 1574) Interpretation: Normal Analysis: Sleep requirements and patterns vary with individual and change with age (Community Health Nursing by Stantope and Lancaster p. 607). Middle aged adult generally maintain sleep pattern established at younger age. They usually sleep 6 to 8 hours per night (Fundamentals of Nursing by Kozier, 7th edition, p. 1116)

Sleep and Rest

The client verbalized that she sleeps 4 to 5 hours. Vendor kasi ako kaya minsan puyat o kaya naman kulang sa tulog pero nababawi ko rin kapag wala ako masyado ginagawa sa bahay.

The client verbalized, Nakakatulog naman ako ng mataga-tagal. Nagigising ako minsan tuwing gabi pero nakakatulog din naman ako kaagad

H. P ATIENT S C ONCEPT OF H EALTH, I LLNESS AND H OSPITALIZATION The ideal health status is one in which people are successful in achieving their full potential regardless of any limitations they might have. The person with a chronic illness or disability may still be able to achieve a desirable level of wellness. The key to wellness is to function at the highest potential within the limitations over which there is no control.

The client views her role as a sick person as a vulnerable person who seek help and proper care. She expects support and proper care management and calmness to those people who care for her. She said that her illness should be treated with the help of medicines and proper care management. She wants to know the things that are necessary for her and health promotion. She also verbalized, Alam ko naman na may asthma ako kasi simula pa bata ako meron na ako noon. Mahirap nga lang kasi ngayon limitado na ang gagawin ko kasi baka atakihin ulit ako. Marami na namang bawal. Her hospitalization now at Pres. Diosdado Macapagal Memorial Medical Center is her major hospitalization because shes been staying there for almost a week and her past check ups in health center are not a form of hospitalization. ANALYSIS: The patients expect the nurse to be thoughtful, understanding and accepting of him. Patients are critical of behavior that is primitive or judgmental. He expects the nurse to orient him in the health agency. Nearby everyone is afraid of the unknown and to be left alone without orientation can be a frightening experience. He also expects the nurse to provide an explanation of his care. Health practitioners who ignore this aspect of care are often referred to as cruel and unkind (Fundamentals of Nursing, 7th edition, pp. 277-278) I. L ABORATORY D IAGNOSTIC E XAM Urinalysis
AND

D IAGNOSTIC E XAMINATION N ORMS A CTUAL R ESULTS Actual Findings Color: Yellow Appearance: slightly hazy Odor: aromatic pH: acidic Specific Gravity: 1.015 Protein: trace Glucose: I NTERPRETATION
AND

A NALYSIS

Reference Values Color: light straw to dark amber Appearance: clear Odor: aromatic pH: 4.5-8.0 Specific Gravity:

Interpretation: The urine color, appearance, pH and microscopic examination are considered not normal while the odor, specific gravity, protein and glucose are considered normal. Analysis: Color of the urine

D IAGNOSTIC E XAM

N ORMS 1.005-1.030 Protein: 2-8 mg/dl; negative reagent strip test; trace Glucose: negative Ketones: negative (Handbook of Laboratory and Diagnostic Test with Nursing Inplication, 5th edition, pg. 343) Microscopic Examination: RBC: 0-2/high power field WBC: 0-5/high power field Epithelial cells: 0-5/high power field (Handbook of Diagnostic Test, 3rd edition, pg. 329)

A CTUAL R ESULTS negative Microscopic Examination: RBC: 2-3/hpf Pus: 3-5/hpf Epithelial cells: many Mucus threads: light Bacteria: few

I NTERPRETATION

AND

A NALYSIS

changes can results from diet, drugs and many diseases (pg. 395, Diagnostic Test). Color is affected by concentration of urine. Tea colored urine is due to blood in the urine. Bright yellow urine may be secondary to vitamin intake. Dark yellow urine is a sure indicator that there is dehydrated indicated and that the fluid consumption must be increased. When water loose from the body exceeds water intake, the kidneys need to consume water making the urination more concentrated with waste products and subsequently dark in color. Yellow colored urine is possible of pyuria, and infection. (Medical Surgical Nursing by Bare and Smeltzer pg.1263) Turbid urine may contain red or white cells, bacteria, fat or chyle and may reflect renal infection (pg. 395, Diagnostic Test, 2004 by Lippincott Williams and Wilkins). Urine turbidity may result from urinary tract infections (pg. 180, A

D IAGNOSTIC E XAM

N ORMS

A CTUAL R ESULTS

I NTERPRETATION

AND

A NALYSIS

Manual of Laboratory and Diagnostic Test, 7th edition). A normal pH is 7. A pH < 7 indicates acid urine and > 7 indicates alkaline urine. Acid urine ph is associated with renal tuberculosis, pyrexia, phenylketonuria, alkaptonuria and acidosis. (Diagnostic Tests, A Prescribers Guide to Selection and Interpretation by Lippincott Williams and Wilkins, p.395) Due to carbohydrate malabsorption, fat malabsorption and disaccharides deficiency. (A Manual of Laboratory and Diagnostic Tests, 7th edition by Lippincott William and Wilkins, p.279)Normally, freshly voided urine has a faint odor owing to the presence of volatile acids. It is not generally offensive. Fresh urine from most persons has a characteristic aromatic odor (pg. 396, Diagnostic Test). Specific gravity is an indication of the relative proportions of dissolved

D IAGNOSTIC E XAM

N ORMS

A CTUAL R ESULTS

I NTERPRETATION

AND

A NALYSIS

solid components to the total volume of the specimen and reflects the relative degree of concentration or dilution of the specimen. (www.intensivecaring.com) In a healthy renal and urinary tract system, urine contains no protein or only trace amount (pg. 191, A Manual of Laboratory and Diagnostic Test). Sugar, usually absent from the urine, may appear under normal conditions (pg. 329, Handbook of Diagnostic Test, 3rd edition) Red blood cells in the urine can be due to vigorous exercise or exposure to toxic chemicals. Bloody urine can also be a sign of bleeding in the genitourinary tract as a result of systemic bleeding disorders, various kidney diseases, bacterial infections, parasitic infections including malaria, obstructions in the urinary tract, scurvy, subacute bacterial endocarditis, traumatic

D IAGNOSTIC E XAM

N ORMS

A CTUAL R ESULTS

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A NALYSIS

injuries, and tumors. A high number of white blood cells in the urine is usually a symptom of urinary tract infection. A large number of cells from tissue lining (epithelial cells) can indicate damage to the small tubes that carry material into and out of the kidneys. (www.healthatoz.com) Hematology Reference Values: Neutrophils: 0.40-0.60 Lymphocytes: 0.20-0.40 (Diagnostic Testing and Nursing Implications, 4th edition) Actual Findings: Neutrophils: 0.79 Lymphocytes: 0.13 Interpretation: Not normal Analysis: Increase in Neutrophils: severe bacterial disease, diabetic acidosis, infarctions, increase in acute, severe inflammation, malignancies (Diagnostic Testing and Nursing Implications, 4th edition) Decreased in Lymphocytes: indicates lymphopenia. (Medical Surgical Nursing by Bare and Smeltzer pg. 876) Possible cause of sepsis and immunodeficiency disease. (Fundamentals of Nursing by Kozier pg. 759)

J. I MPRESSION/D IAGNOSIS The admitting diagnosis is Bronchial Asthma in Acute Exacerbation K. C OURSE IN THE W ARD The patient was admitted in Female Medical Ward 364 bed letter B. She has intravenous fluid (Balanced Multiple Maintenance Solution 5% Dextrose) hooked, laboratory works up done (urinalysis, hematology and radiological report). She was given salbutamol as nebulizer and Cefuroxime Sodium as antibiotics II. CLINICAL DISCUSSION OF THE DISEASE A. E COLOGIC M ODEL (1) Hypothesis There are many unanswered questions about the role of host factors in disease. A potentially harmful change in any of the components of the system may not lead to detectable diseases. Predisposing Factors Host a. Age: 54 years old b. Sex: Female c. Race: Asian d. Nationality: Filipino e. Behaviors: f. Heredity: they have family history of Bronchial Asthma in her fathers side Agent Allergenspollutants and fume of insecticides Environment Physical: exposure and inhalation of pollutants and fume of insecticides; exposure to smoke from cigarette

(2) A.

B. C.

B. Ecologic Model The Epidemiological Triangle

Host (susceptible host)

Agent: (Allergens)

Environment: Exposure to indoor and outdoor allergens

Analysis In medicine, we focus on the human and the forces within him and within the environment that influence his state of health. From this viewpoint, the human is the host organism; other organisms are considered only as they relate to human health. However, the organism alone is not sufficient to account for the outbreak and cannot therefore be considered the cause. An additional set of factors, environmental conditions, also determine whether effective transmission of disease can occur in any given situation. These factors include degree of contact, level of hygienic practices, and presence of other organisms. When a factor must be present for a disease too occurs, it is called the agent of that disease. Many, but not all, of he known agents of disease are located in the biologic environment. In keeping with the ecological view presented above, an agent is considered to be a necessary but not sufficient cause of disease because suitable conditions of the host and environment must also be presented for disease to develop. It is customary to divide the factors affecting the development of disease into two groups, host factors (intrinsic) and factors in the environment (extrinsic). Host factors affect susceptibility to disease; factors in the environment influence exposure and sometimes indirectly affect susceptibility as well. The interactions of these two sets of factors determine whether or not disease develops. . (Mausner and Bahn EpidemiologyAn Introductory Text by Judith Mausner and Shira Kramer, 2nd edition pages 27-28) Specific substances that cause allergic responses can affect respirations, sometime severely. The body attempts to rid itself of substances perceived as harmful by releasing chemical mediators that cause an inflammatory response. Substances that trigger an inflammatory response are called allergens. Almost any substance can be allergen: pollens, dust, and foods are common allergy triggers. The allergic response precipitates a series of events that lead to tissue damage. Hay fever is the result of allergies confined to the nose and upper airways. Symptoms include dripping nose, itchy eyes and swollen mucous membrane; they are annoying and uncomfortable but not lifethreatening. When allergic responses take place in the lungs, breathing

difficulties are far more severe. Small airways became edematous, mucous production increases, and inflammatory chemical mediators cause bronchospasm. These are the hallmarks of common allergic asthma. Severe and uncontrolled allergic asthma can be fatal. (Fundamentals of Nursing by Craven and Hirnle, 4th edition page 813)= Healthy people exposed to air pollution often experience stinging of the eyes, headache, dizziness, coughing and choking. People who have a history of existing lung disease and altered respiratory function experience varying degrees of respiratory difficulty in a polluted environment. Some are unable to perform self-care in such an environment. (Fundamentals of Nursing by Kozier, 7th edition page 1295-1296) C. Conclusion and Recommendations Reducing exposure to allergens that can trigger bronchoconstriction and inflammation is an important preventive measure. Nurses can be instrumental in working with the client and family to identify individual asthma triggers and motivate the family to restructure the environment to limit allergen exposure. (Fundamentals of Nursing by Craven and Hirnle, 4th edition page 826) L. A NATOMY AND P HYSIOLOGY The respiratory system is situated in the thorax, and 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 respiratory system is an intricate arrangement of spaces and passageways that conduct air from outside the body into the lungs and finally into the blood as well as expelling waste gasses. This system is responsible for the mechanical process called breathing, with the average adult breathing about 12 to 20 times per minute. When engaged in strenuous activities, the rate and depth of breathing increases in order to handle the increased concentrations of carbon dioxide in the blood. Breathing is typically an involuntary process, but can be consciously stimulated or inhibited as in holding your breath.

Nostrils/Nasal Cavities During inhalation, air enters the nostrils and passes into the nasal cavities where foreign bodies are removed, the air is heated and moisturized before it is brought further into the body. It is this part of the body that houses our sense of smell. Sinuses The sinuses are small cavities that are lined with mucous membrane within the bones of the skull. Pharynx The pharynx or throat carries foods and liquids into the digestive tract and also carries air into the respiratory tract. Larynx The larynx or voice box is located between the pharynx and trachea. It is the location of the Adam's apple, which in reality is the thyroid gland and houses the vocal cords. Trachea The chest and conducts air between the larynx and the lungs. Lungs The lungs are the organ in which the exchange of gasses takes place. The lungs are made up of extremely thin and delicate tissues. At the lungs, the bronchi subdivides, becoming progressively smaller as they branch through the lung tissue, until they reach the tiny air sacks of the lungs called the alveoli. It is at the alveoli that gasses enter and leave the blood stream. The lungs are divided into lobes; The left lung is composed of the upper lobe, the lower lobe and the lingula (a small remnant next to the apex of the heart), the right lung is composed of the upper, the middle and the lower lobes. Bronchi The trachea divides into two parts called the bronchi, which enter the lungs. Bronchioles The bronchi subdivide creating a network of smaller branches, with the smallest one being the bronchioles. There are more than one million bronchioles in each lung. Alveoli

The alveoli are tiny air sacks that are enveloped in a network of capillaries. It is here that the air we breathe is diffused into the blood, and waste gasses are returned for elimination. M. P ATHOPHYSIOLOGY/S CHEMATIC D IAGRAM OF THE D ISEASE The underlying pathology of asthma is reversible and diffuse airway inflammation. The inflammation leads to obstruction from the following: swelling of the membranes that line the airways (mucosal edema), reducing the airway diameter; contraction of the bronchial smooth muscle that encircles the airways (bronchospasm), causing further narrowing; and increased mucus production, which diminishes airway size and may entirely plug the bronchi. The bronchial muscles and mucus glands enlarge; thick tenacious sputum is produced; and the alveoli hyperinflate. Some patients may have airway subbasement membrane fibrosis. This is called airway remodeling and occurs in response to chronic inflammation. The fibrotic changes in the airway lead to airway narrowing and potentially irreversible airflow limitation. Cells that play a key role in the inflammation of asthma are mast cells, Neutrophils, eosinophils, and lymphocytes. Mast cells, when activated, release several chemicals called mediators. These chemicals, which include histamine, bradykinin, prostaglandins and leukotrienes, perpetuate the inflammatory response, causing increased blood flow, vasoconstriction, fluid leak from vasculature, attraction of white blood cells to the area and bronchoconstriction. Regulation of these chemicals is the aim of much of the current research regarding pharmacologic therapy for asthma. Further, alpha- and beta2-adrenergic receptors of the sympathetic nervous system are located in the bronchi. When the alpha-adrenergic receptors are stimulated, bronchoconstriction occurs; when the beta2adrenergic receptors are stimulated, bronchodilation results. The balance between alpha and beta2 receptors is controlled primarily by cyclic adenosine monophosphate (cAMP). Alpha-adrenergic receptor stimulation results in a decrease in cAMP, which leads to an increase of chemical mediators released by the mast cells and bronchoconstriction. Beta2receptor stimulation results in increased levels of cAMP, which inhibits the release of chemical mediators and causes bronchodilation. (MedicalSurgical Nursing Volume 1 by Smeltzer and Bare page 588)

Figure 1-1 Pathophysiology of Asthma

Predisposing Factors Atopy Female Gender Causal Factors Exposure to indoor and outdoor allergens Occupational sensitizers Contributing Factors Respiratory infections Air pollution Active/passive smoking Other (diet, small size at birth)

Inflammation

Hyperrensponsiveness of airways

Airflow limitation

Risk Factors for exacerbations Allergens Respiratory infections Exercise and hyperventilation Weather changes Exposure to sulfur dioxide Exposure to food, additives, medications

Symptoms Wheezing Cough Dyspnea Chest tightness

N. D RUG S TUDY
G ENERIC N AME A CTION B RAND N AME C LASSIFICATION I NDICATION C ONTRAINDICATIONS S IDE E FFECTS / A DVERSE R EACTIONS Body as a Whole: Hypersensitivi ty reaction. CNS: Tremor, anxiety, nervousness, restlessness, convulsions, weakness, headache, hallucinations . CV: Palpitation, hypertension, hypotension, bradycardia, reflex tachycardia. Special Senses: Blurred vision, dilated pupils. GI: Nausea, vomiting. Other: N URSING R ESPONSIBILITY Assessment & Drug Effects Monitor therapeutic effectivenes s which is indicated by significant subjective improvemen t in pulmonary function within 60 90 min after drug administrati on. Monitor for: S&S of fine tremor in fingers, which may interfere with precision handwork; CNS

ALBUTEROL

Synthetic sympathomim etic amine and moderately selective beta2adrenergic agonist with comparatively long action. Acts more prominently on beta2 receptors (particularly smooth muscles of bronchi, uterus, and vascular supply to skeletal muscles) than on beta1 (heart) receptors. Minimal or no

Salbutamol

autonomic nervous system agent; betaadrenergic agonist (sympathomimet ic); bronchodilator (respiratory smooth muscle relaxant)

To relieve bronchospas m associated with acute or chronic asthma, bronchitis, or other reversible obstructive airway diseases. Also used to prevent exerciseinduced bronchospas m.

Pregnancy (category C), lactation. Use of oral syrup in children <2 y.

G ENERIC N AME

A CTION effect on alphaadrenergic receptors. Inhibits histamine release by mast cells.

B RAND N AME

C LASSIFICATION

I NDICATION

C ONTRAINDICATIONS

S IDE E FFECTS / A DVERSE R EACTIONS Muscle cramps, hoarseness

N URSING R ESPONSIBILITY stimulation, particularly in children 26 y, (hyperactivit y, excitement, nervousness , insomnia), tachycardia, GI symptoms. Report promptly to physician. Lab tests: Periodic ABGs, pulmonary functions, and pulse oximetry. Consult physician about giving last albuterol dose several hours before bedtime, if drug-

G ENERIC N AME

A CTION

B RAND N AME

C LASSIFICATION

I NDICATION

C ONTRAINDICATIONS

S IDE E FFECTS / A DVERSE R EACTIONS

N URSING R ESPONSIBILITY induced insomnia is a problem. Patient & Family Education Review directions for correct use of medication and inhaler Avoid contact of inhalation drug with eyes. Do not increase number or frequency of inhalations without advice of physician. Notify physician if albuterol fails to provide relief

G ENERIC N AME

A CTION

B RAND N AME

C LASSIFICATION

I NDICATION

C ONTRAINDICATIONS

S IDE E FFECTS / A DVERSE R EACTIONS

N URSING R ESPONSIBILITY because this can signify worsening of pulmonary function and a reevaluation of condition/th erapy may be indicated. Note: Albuterol can cause dizziness or vertigo; take necessary precautions. Do not use OTC drugs without physician approval. Many medications (e.g., cold remedies) contain drugs that

G ENERIC N AME

A CTION

B RAND N AME

C LASSIFICATION

I NDICATION

C ONTRAINDICATIONS

S IDE E FFECTS / A DVERSE R EACTIONS

N URSING R ESPONSIBILITY may intensify albuterol action.

CEFUROXIME SODIUM

Semisynthetic secondgeneration cephalosporin antibiotic with structure similar to that of the penicillins. Resistance against betalactamaseproducing strains exceeds that of first generation cephalosporin s. Antimicrobial spectrum of activity resembles that of cefonicid. Preferentially

Kefurox, Zinacef

antiinfective; antibiotic; secondgeneration cephalosporin

Infections caused by susceptible organisms in the lower respiratory tract, urinary tract, skin, and skin structures; also used for treatment of meningitis, gonorrhea, and otitis media and for perioperative prophylaxis (e.g., openheart surgery), early Lyme disease.

Hypersensitivity to cephalosporins and related antibiotics; pregnancy (category B), lactation

Body as a Whole: Thrombophle bitis (IV site); pain, burning, cellulitis (IM site); superinfectio ns, positive Coombs' test. GI: Diarrhea, nausea, antibioticassociated colitis. Skin: Rash, pruritus, urticaria. Urogenital: Increased serum creatinine and BUN, decreased creatinine clearance.

Assessment & Drug Effects Determine history of hypersensiti vity reactions to cephalospor ins, penicillins, and history of allergies, particularly to drugs, before therapy is initiated. Lab tests: Perform culture and sensitivity tests before initiation of therapy and periodically during

G ENERIC N AME

A CTION binds to one or more of the penicillinbinding proteins (PBP) located on cell walls of susceptible organisms. This inhibits third and final stage of bacterial cell wall synthesis, thus killing the bacterium. Partial crossallergenicity between other betalactam antibiotics and cephalosporin s has been reported.

B RAND N AME

C LASSIFICATION

I NDICATION

C ONTRAINDICATIONS

S IDE E FFECTS / A DVERSE R EACTIONS

N URSING R ESPONSIBILITY therapy if indicated. Therapy may be instituted pending test results. Monitor periodically BUN and creatinine clearance. Inspect IM and IV injection sites frequently for signs of phlebitis. Report onset of loose stools or diarrhea. Monitor for manifestatio ns of hypersensiti vity. Discontinue drug and report their appearance

G ENERIC N AME

A CTION

B RAND N AME

C LASSIFICATION

I NDICATION

C ONTRAINDICATIONS

S IDE E FFECTS / A DVERSE R EACTIONS

N URSING R ESPONSIBILITY promptly. Monitor I&O rates and pattern: Especially important in severely ill patients receiving high doses. Report any significant changes.

Patient & Family Education Report loose stools or diarrhea promptly. Report any signs or symptoms of hypersensiti vity

III.

NURSING PROCESS

A. P ROBLEM L IST

D ATE

OF

O NSET

N URSING P ROBLEM Ineffective airway clearance related to diffuse airway inflammation Ineffective airway clearance related to secretions in the bronchi

D ATE I DENTIFIED November 15, 2006

D ATE R ESOLVED November 15, 2006

D ATE I NACTIVE November 15, 2006

November 15, 2006

November 20, 2006

November 20, 2006

November 20, 2006

November 20, 2006

R ATE 1

N URSING P ROBLEMS I DENTIFIED Ineffective airway clearance related to diffuse airway inflammation

C UES INTERACTION: The client verbalized Bago ako isugod dito sa ospital, nakalanghap ako noon ng pamatay ng ipis tapos sa bahay naginsenso sila kaya inatake ako ng asthma ko. Nanikip na ang dibdib ko tapos ayun na, sinugod na nila ako dito OBSERVATION: On and off difficulty of breathing (DOB). Patient looks restlessness, pale weak MEASUREMENT Respiratory Rate: 23 breaths per minute

J USTIFICATION This is an actual problem that requires immediate attention. It is the chief complaint of the patient and the other nursing problems occur in relation to the presence of this problem.

R ATE 2

N URSING P ROBLEMS I DENTIFIED Ineffective airway clearance related to secretions in the bronchi

C UES INTERACTION The client verbalized, Hindi ko mailabas ang plema ko ngayon Nakakahinga naman ako pero medyo hirap OBSERVATION Difficulty vocalizing Wheezes at right lung field Pale MEASUREMENT Respiratory Rate: 21 breaths per minute

J USTIFICATION This is an actual problem which is an effect of the prioritized problem above. Interventions are available and possible for this problem

B. N URSING C ARE P LAN

C UES INTERACTION The client verbalized, Hindi ko mailabas ang plema ko ngayon Nakakahinga naman ako pero medyo hirap OBSERVATION Difficulty vocalizing Wheezes at right lung field Pale MEASUREMENT Respiratory Rate: 21 breaths per minute N URSING D IAGNOSIS Ineffective airway clearance related to secretions in the bronchi A NALYSIS / H EALTH I MPLICATION IMMEDIATE CAUSE Secretions in the bronchi INTERMEDIATE CAUSE Contraction of the bronchial smooth muscle that encircles the airways (bronchospasm) ROOT CAUSE Diffuse airway inflammation HEALTH IMPLICATION Retained secretions increased the work breathing and may contribute to atelectasis and hypoxemia. (Fundamentals of G OALS AND O BJECTIVES GOAL: After 8 hours of shift, Mrs. Ventura will be able to expectorate/ clear secretions readily OBJECTIVES (1) Provide and teach the client the importance of adequate hydration a. Encourage fluid (2,0003,000ml/day) within level of cardiac tolerance Adequate hydration thins secretions, which prevents mucus from plugging airways. (Fundamentals of Nursing by Craven and Hirnle, 4th edition page 861) Evaluate hydration status of client (Fundamentals EFFECTIVENESS 1. Was the client able to promote systemic fluid hydration? yes __no why? 2. Was the client able to cough to mobilize the secretions yes __no why? 3. Was the client able to be monitor regarding to his respiratory functioning? yes __no why? N URSING I NTERVENTIONS R ATIONALE E VALUATION

b. Monitor clients input and output

C UES

N URSING D IAGNOSIS

A NALYSIS / H EALTH I MPLICATION Nursing by Craven and Hirnle, 4th edition page 828) Shallow respirations inhibit both diaphragmatic excursion and lung distensibility. The result of inadequate chest expansion is pooling of respiratory secretions, which ultimately harbor microorganisms and promote infection (Fundamentals of Nursing by Kozier, 7th edition page 1301) Mucus that is hard to expectorate promotes infection because the bacteria it traps have time to multiply.

G OALS AND O BJECTIVES

N URSING I NTERVENTIONS

R ATIONALE of Nursing by Craven and Hirnle, 4th edition page 861)

E VALUATION EFFICIENCY Was the interventions done within the time frame? yes __no why? APPROPRIATENESS Were the interventions suitable to the client? yes __no why? ACCESSIBILITY Were the interventions acceptable to the client? yes __no why? ADEQUACY Were the interventions adequate to meet the clients needs? yes __no why?

c. Avoid milk and milk products (2) Position and encourage client to cough to promote mobilization of secretions a. Deep breathing every 2 hours

Milk products tend to thickens secretions To facilitate lung aeration, thereby preventing atelectasis and pneumonia (Fundamentals of Nursing by Kozier, 7th edition page 903) Prevent airway collapse (Fundamentals of Nursing by Craven and Hirnle, 4th edition page 861) This technique helps keep your

b. Huff coughing

C UES

N URSING D IAGNOSIS

A NALYSIS / H EALTH I MPLICATION Mucous plugs in the airways can lead to atelectasis and decreased oxygenation (Fundamentals of Nursing by Craven and Hirnle, 4th edition page 827)

G OALS AND O BJECTIVES

N URSING I NTERVENTIONS

R ATIONALE airway open while moving secretions up and out of the lungs. (Fundamentals of Nursing by Kozier, 7th edition page 1303)

E VALUATION

c. Assist client to a sitting position with head slightly flexed, shoulders relaxed, and knees flexed

Lying flat causes the abdominal organs to shift toward the chest, crowding the lungs and making it more difficult to breathe (Fundamentals of Nursing by Kozier, 7th edition page 1327) Permits deep inspiration and forceful abdominal contractions necessary for coughing

C UES

N URSING D IAGNOSIS

A NALYSIS / H EALTH I MPLICATION

G OALS AND O BJECTIVES

N URSING I NTERVENTIONS

R ATIONALE (Fundamentals of Nursing by Craven and Hirnle, 4th edition page 861)

E VALUATION

(3) Respiratory monitoring

a. Monitor rate, rhythm, depth, and effort of respirations

Provide basis for evaluating adequacy of ventilation (Fundamentals of Nursing by Kozier, 7th edition page 1327) Respiratory tract infections alter the amount and character of secretions. An ineffective cough compromises airway clearance and prevent mucus from being expelled (Fundamentals of Nursing by

b. Monitor clients ability to cough effectively

C UES

N URSING D IAGNOSIS

A NALYSIS / H EALTH I MPLICATION

G OALS AND O BJECTIVES

N URSING I NTERVENTIONS

R ATIONALE Kozier, 7th edition page 1327)

E VALUATION

c. Institute respiratory therapy treatments (e.g. nebulizer) as needed

A variety of respiratory therapy treatments may be used to open constricted airways and liquefy secretions (Fundamentals of Nursing by Kozier, 7th edition page 1328)

C. D ISCHARGE P LANNING M EDICATION Continue medications prescribed by the physician Salbutamol: Adult: PO 24 mg 34 times/day, 48 mg sustained release 2 times/day Inhaled 12 inhalations q46h E XERCISE Deep breathing and Coughing Exercise T REATMENT Continue medications prescribed by the physician. Provide adequate rest periods H EALTH T EACHINGS Teach the client to do purse-lip breathing and relaxation techniques Maintain a dust-free environment Reduce exposure to pollen O UT P ATIENT F OLLOW- UP Notify the health care provider when respiratory infection occurs Make appropriate referrals to home health agencies for assistance in obtaining medical and assistive equipment D IET Hypoallergenic Diet Increased fluid intake to thin bronchial secretions