Santiago City, Philippines College of Nursing

A Case Study of Bronchial Asthma In Acute Exacerbation (BAIAE)
Submitted by: Orlando Dexter T. Rodriguez SN-NC 3rd Year Block A

Submitted to:

Clinical Instructor

A.

Significance of the study Lower airway problems directly affect gas exchange and have serious consequences.

Many of these problems are chronic and progressive, requiring major changes in 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. B. Objectives of the Study At the end of the case-presentation the student will be able to:
1. To identify what Bronchial Asthma is all about.

2. Apply the knowledge that they have learned in the floor.

11 Gordon’s Functional Health Pattern
1. Health Perception-Health Management She is a very active and playful child. She doesn’t have any allergies on any foods. 2. Nutritional-Metabolic She doesn’t have any special diet but she is taking Celeen for her vitamin. At home, as verbalized by the mother, she can eat all of the food served. She didn’t have difficulty of swallowing, and started solid food as the main composition of the food of the patient. 3. Elimination Pattern She did not experience any decrease in defecating or difficulty of urinating. Her bowel elimination pattern is once a day even during her stays at the hospital. Her way of breathing is better than she is at home, and she could go to comfort room with assistance of mother (with IV), read books, and eat all food served. 4. Activity-Exercise Pattern Our patient loves to play bahay - bahayan and running. She independently wears her dress but with assistance from her mother. She can go to the bathroom, whenever she wants to urinate and defecate but her mother still washes her anus after defecating. She goes schooling in prep-school and playing or socializing, talking, mingling with her classmates. 5. Sleep-Rest Pattern She experience difficulty of sleeping while admitted in the hospital. Before her admission, she sleeps as early as 10 in the evening and wakes at 8 in the morning. During her hospitalization, she sleeps at 10 and wakes at 8 in the morning. She

also sleeps one hour in the afternoon. During night when her asthma attacks, she can’t breathe normally usually having a hard time of breathing so her sleep during night is disturbed during her hospitalization period.

6. Sexuality-Reproductive Pattern She is a girl 7. Cognitive-Perceptual She neither has hearing difficulties nor eye problems. She has a good memory for learning activities in school like problem solving and her mother makes decisions for her during medications, treatments, etc. and she also learns easily. 8. Self Perception – Self Concept She’s feeling better every time she is asked how she feels. Her illness makes her feel worthless because she cannot do anything. She is very anxious every time her asthma attacks. 9. Role relationship She lives with her family and depends on her parents for her needs. She misses her siblings and likes to talk about them. In their house she can easily express what she wants or needs but during her hospitalization time her parents didn’t knew what are the needs that she wanted or needed because of her condition. 10. Coping – Stress Tolerance She always wants her mother to be beside her because she provides all that she needs and she cries whenever she can’t get something that she wants. She always wanted to go home right away but because of the doctors order they can’t go home right away, so the only thing she can do is to cry.

11. Value and Beliefs They are Roman Catholic. She verbalized that she knows God loves her and He will wash her illness away so that she can go home. The parents react patiently to their daughters needs, and they supported all what their child needs.

Definition
A condition of the lungs characterized by widespread narrowing of the airways due to spasm of the smooth muscle, edema of the mucosa, and the presence of mucus in the lumen of the bronchi and bronchioles. Bronchial asthma is a chronic relapsing inflammatory disorder with increased responsiveness of tracheobroncheal tree to various stimuli, resulting in paroxysmal contraction of bronchial airways which 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 or allergens 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 the symptoms. Patients are instructed to avoid the causative agents whenever possible. Knowledge is the key to quality asthma care.

Medical Management
There are two general process of asthma medication: quick relief medication for immediate treatment of asthma symptoms and exacerbations and long acting medication to achieve and maintain control and persistent asthma. Because of underlying pathology of asthma is inflammation, control of persistent 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 exerciseinduced 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 asthma symptoms, particularly those that occur during the night these agents are also effective in the prevention of exercise-induced asthma. • Quick relief medication Short acting beta adrenergic agonists are the medications of choice for relief of acute symptoms and prevention of exercise-induced asthma. They have the rapid onset of acton. Anti-cholinergic may have an added 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

Assessment Subjective: (none)

Nursing Diagnosis Risk for Activity Intolerance r/t decrease oxygenation

Planning After 8 hours of nursing intervention the patient will participate willingly in necessary/ desired activities such as deep breathing exercises.

Interventions 1. Monitor VS. 2. Assess motor function. 3. Note contributing factors to fatigue. 4. Evaluate degree of deficit. 5. Ascertain ability to stand and move about. 6. Assess emotional or psychological factors 7. Plan care with rest periods between activities 8. Increase activity/exercise gradually such as assisting the patient in doing PROM to active or full range of motions. 9. Provide adequate rest periods. 10. Assist client in doing self care needs 11. Elevate arm and hand 12. Place knees and

Rationale 1. For baseline data. 2. To identify causative factors. 3. To identify precipitating factors. 4. To identify severity. 5. To identify necessity of assistive devices. 6. Stress and/or depression may increase the effects of illness. 7. To reduce fatigue 8. Minimizes muscle atrophy, promotes circulation, helps to prevent contractures 9. To replenish energy. 10. To promote independence and increase activity tolerance 11. Promotes venous 12. Maintains functional position

Evaluation

Goal met Patient participated willingly in necessary/ desired activities such as deep breathing exercises.

Objective: • • Immobility Weakness

hips in extended position

Assessment Subjective: “Nahihirapan akong huminga” as verbalized by the patient

Nursing Diagnosis Ineffective breathing pattern r/t presence of secretions AEB productive cough and dyspnea

Planning After 4-5 hours of nursing intervention Patient will manifest signs of decreased respiratory effort AEB absence of dyspnea

Interventions 1. Establish rapport. 2. assess pt.’s condition 3. VS monitor and record 4. Auscultate breath sounds and assess airway pattern 5. Elevate head of the bed and change position of the pt. every 2 hours. 6. Encourage deep breathing and coughing exercises. 7. Demonstrate diaphragmatic and pursed-lip breathing. 8. Encourage increase in fluid intake 9. Encourage opportunities for rest and limit physical activities. 10. Reinforce low salt, low fat diet as

Rationale 1. To gain pt.’s trust. 2. To obtain baseline data 3. Serve to track important changes 4. to check for the presence of adventitious breath sounds 5. To minimize difficulty in breathing 6. To maximize effort for expectoration. 7. To decrease air trapping and for efficient breathing. 8. To prevent fatigue. 9. To prevent situations that will aggravate the condition 10. To mobilize secretions.

Evaluation Goal met Patient demonstrated pursed-lip breathing and diaphragmatic breathing.

Objective: • wheezing upon inspiration and expiration dyspnea tachycardia chest tightness suprasternal retraction restlessness

• • •

ordered.

Assessment Subjective: “Nahihirapan akong huminga” as verbalized by the patient

Nursing Diagnosis Ineffective airway clearance RT bronchoconstri ction, increased mucus production, and respiratory infection AEB wheezing, dyspnea, and cough

Planning After 5-6 hours of nursing intervention the Patient will maintain/impro ve airway clearance AEB absence of signs of respiratory distress

Interventions 1. Adequately hydrate the pt. 1. 2. Teach and encourage the use of diaphragmatic breathing and coughing 2. exercises. 3. Instruct pt to avoid bronchial irritants such as cigarette smoke, aerosols, 3. extremes of temperature, and fumes. 4. Teach early signs of infection that are to be reported to the clinician immediately. • Increases sputum production 4. • Change in color of sputum • Increased thickness of sputum • Increased SOB, tightness of chest, or fatigue • Increased coughing • Fever or chills 1. If indicated, perform postural drainage with percussion and vibration in

Rationale Systemic hydration keeps secretion moist and easier to expectorate. These techniques help to improve ventilation and mobilize secretions without causing breathlessness and fatigue. Bronchial irritants cause bronchoconstriction and increased mucus production, which then interfere with airway clearance. Minor respiratory infections that are of no consequence to the person with normal lungs can produce fatal disturbances in the lungs of an asthmatic person. Early recognition is crucial.

Evaluation Goal met By verbalization of the patient of “Ok na po ang aking paghinga, hindi na ako nahihirapan”

Objective: • wheezing upon inspiration and expiration dyspnea tachycardia chest tightness suprasternal retraction productive cough

• • •

the morning and at night as prescribed.

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 in children and adults. however, children respond differently than adults to respiratory disturbances; major areas of difference include: •

Poor tolerance of nasal congestion, especially in infants who are obligatory nose breathers up to 4 months of age Increased susceptibility to ear infection due to shorter, broader, and more horizontally positioned eustachian tubes. Increased severity or respiratory symptoms due to smaller airway diameters A total body response to respiratory infection, with such symptoms as fever, vomiting and diarrhea.

• •

Patient’s Profile

Name: Age: Sex: Location: Admitting diagnosis: Chief complaint: Date of admission: Attending Doctor:

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