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LORMA COLLEGES

COLLEGE OF NURSING
San Fernando City, La Union

CASE STUDY
IN
Bronchial Asthma in Acute Exacerbation


Submitted by:
Gange, Neil Van
Lictao, Julie-Ann
BSN III-3

Submitted to:
Mrs. Marites Chan
Clinical Instructor

Dicelle Mariz O. Jucutan
Darleen S. Jainar

Head Nurses BSN IV-4

January 15, 2014
CHAPTER I
INTRODUCTION
Asthma is a disease affecting the airways that carry air to and from the
lungs. The inside walls of an asthmatic's airways are swollen or inflamed. This
swelling or inflammation makes the airways extremely sensitive to irritations
and increases the susceptibility to an allergic reaction.
As inflammation causes the airways to become narrower, less air can
pass through them, both to and from the lungs. Symptoms of the narrowing
include wheezing (a hissing sound while breathing), chest tightness, shortness
of breath, and coughing. Asthmatics usually experience these symptoms most
frequently during the night and the early morning.
Risk factors for acquiring asthma likely include having a blood relative (such
as a parent or sibling) with asthma, having another allergic condition, such as
atopic dermatitis or allergic rhinitis (hay fever), being a smoker, exposure to
secondhand smoke, exposure to exhaust fumes or other types of pollution,
exposure to occupational triggers, such as chemicals used in farming,
hairdressing and manufacturing. Exposure to allergens, exposure to certain
germs or parasites, and having some types of bacterial or viral infections also
may be risk factors.
Anti-inflammatory drugs, particularly inhaled steroids, are the most
important treatment for most people with asthma. These
lifesaving medications prevent asthma attacks and work by reducing swelling
and mucus production in the airways. As a result, the airways are less
sensitive and less likely to react to asthma triggers and cause asthma
symptoms.
An asthma attack can take anything from a few minutes to a few days to
develop. It can be a very frightening experience and people having an asthma
attack need help straight away.
The four-step asthma first aid is:
1. Sit the person upright and give reassurance do not leave them alone.
2. Without delay, give the person four separate puffs of their blue reliever
medication (such as Airomir, Asmol, Bricanyl or Ventolin). If using a puffer (like
Ventolin or Asmol), this should be taken one puff at a time via a spacer. Ask
the person to take four breaths from the spacer after each puff of medication.
3. Wait four minutes. If there is little or no improvement, repeat steps 2 and 3
4. If there is still no improvement, calls triple zero (000) for an ambulance
immediately. Repeat steps 2 and 3 continuously while waiting for the
ambulance to arrive.
According to World Health Survey (WHS), the global prevalence rates of
doctor diagnosed asthma, clinical/treated asthma and wheezing in adults were
4.3%, 4.5%, and 8.6% respectively, and varied by as much as 21-fold amongst
the 70 countries. Australia reported the highest rate of doctor diagnosed,
clinical/treated asthma, and wheezing (21.0%, 21.5%, and 27.4%). Amongst
those with clinical/treated asthma, almost 24% were current smokers, half
reported wheezing, and 20% had never been treated for
asthma.(http://www.ncbi.nlm.nih.gov/pubmed/22429515). According to the
latest WHO data published in April 2011 Asthma Deaths in Philippines reached
10,471 or 2.48% of total deaths. The age adjusted Death Rate is 19.48 per
100,000 of population ranks Philippines #24 in the
world.(http://www.worldlifeexpectancy.com/philippines-asthma). In San
Fernando City, asthma is one of the leading causes of morbidity with 1,125
cases reported in 2006.
(http://www.sanfernandocity.gov.ph/services/basic/health.php). At Lorma
Medical Center, 998 patients were admitted last year (2013) from January to
December.






OBJECTIVES OF THE STUDY
PATIENT-CENTERED:
That the patient will be able to:
Understand his condition/disease process
Verbalize feelings and concerns about asthma
Show willingness to participate in nursing routines especially with vital
signs monitoring
Modify behaviors to a healthy lifestyle to prevent asthma


















CHAPTER II
HEALTH HISTORY


I. Biographic Data
R.N.C. is a 44 year old male client. Married to E.N.C. and has two
children. He was born on June 26, 1969 at San Fernando, La Union. He is a
full blooded Filipino and a Roman Catholic. He has 3 siblings and he is the
middle child. He is currently working in San Fernando City Hall as a security
guard. He graduated a 2-year vocational course at DMMMSU-MLUC. He is
living with his family in Bangcusay, San Fernando La Union. His mothers
name is E.N.C. and his fathers name is F.C.
II. Reasons for Seeking Health Care
The patient was brought to Lorma Medical Center because of difficulty of
breathing and productive cough for 5 days. The patient experienced difficulty of
breathing last January 9, 2014 accompanied with cough that he couldnt
tolerate it anymore thats why he consults his physician. He was admitted at
Lorma Medical Center at 8:54 pm.
III. Family Health History
According to patient R.N.C., they have history of asthma in his mother
side on the other hand has no history of any serious illness in his father side.
IV. History of Present Health Concern
Patient R.N.C. experienced severe cough for 5 days and difficulty of
breathing prior to admission. He had been accompanied by his wife to seek
consultation to a physician the next morning and eventually had been confined
for further observation and analysis of the condition.

V. Past Health History
According to patient R.N.C., they do not experience any serious illnesses
only the common illnesses like cough, colds, fever, and headache. He also
stated that he had been admitted last April 2013 at Lorma Medical Center
because of asthma. Patients R.N.C. stated that he has no allergies.
VI. Lifestyle and Health Practices
A. Description of a Typical Day
Patient R.N.C. drinks coffee and eat bread as he wakes up in the
morning and goes to work at 7:30 am. He went home at 5:00 pm and watched
television, and sometimes goes out to check his vegetable garden at the field.

B. Nutrition and Weight Management
Patient R.N.C. eats 3 times a day. He eats meat and vegetables but
seldom eat vegetables, more on meat and frozen foods. When he is at work he
eats in the carinderia located along the premises of the city hall.

C. Activity Level and Exercise
Patient R.N.C. does push-up sometimes as his form of exercise. And
sometimes walks at the farm.
D. Sleep and Rest
Patient R.N.C. sleeps at least 3-4 hours every night. He usually sleeps at
11:30 p.m. and wakes up in the morning at 3:30 a.m. for work.

E. Medications and Substance Use
Patient R.N.C. takes simple remedies like Alaxan and Biogesic to relieve
headache and pain. They are also using herbal medicines like: Oregano for
cough and Guyabano leaves to treat stomach ache. Besides that, he also
smokes and finishes one pack of cigarette every day. He drinks occasionally,
drinking at least seven bottles of beer.
VII. Environmental Living Sanitation
Patient R.N.C. lives in a concrete type of house. It is surrounded by
different kinds of trees, plants and vegetables. They have a water sealed type of
toilet. They buy their drinking water to a purified water supplier near their
house. And their garbage is being collected every Thursday.
VIII. Developmental Tasks
The developmental task of patient R.N.C., 44 years old, according to
Erikson is Generativity vs. Stagnation. It refers to the period where the patient
strive to create or nurture things that will outlast them; often by having
children or contributing to positive changes that benefits other people.
Based on our observation especially during our interview with patient
R.N.C., he meets his developmental stage. He stated that his most priority for
now is his family. He already wants to go home and be back to work for his wife
has no job and his family depends on him. This shows his caring attitude; it
shows that his priority is for others.










CHAPTER III
PHYSICAL ASSESSMENT
DATE PERFORMED: January 11, 2014
General Survey:
During the course of interview the client was responsive and was able to give a
coherent answer. And his vital signs obtained are the following:
Temperature: 36.7C Pulse Rate: 80 bpm
Respiratory Rate: 23bpm Blood Pressure: 110/80mmHg
O2 sat.: 96%
Skin:
The skin was brown in color. Muscle tone present, skin was warm, moist, no pallor, and
no jaundice. Skin goes back in less than 2 seconds when pinched back.
Head:
The head is round in shape. The scalp is free from inflammation and is lighter in color of
that of the complexion of the skin. Hair is evenly distributed. Scalp is smooth and white in
color, minimal lesions were noted. Dandruff and lice were not seen.
Ears:
Ears were symmetrical, free of abrasions. Color is same with the rest of the body with no
pale manifestations. Patient can hear normally when spoken softly.


Eyes:
Eyes are rounded in shape. Conjunctiva was pink in color. Eyebrows and eyelashes are
evenly distributed. The scleras/pupils of both eyes were clear, equally round and reactive
to light accommodation. The eyes involuntarily blink.
Nose:
With narrow nose bridge, discharges were noted upon inspection. No swelling of the
mucous membrane and presence of nasal hairs were seen. Minimal discharges and no
flaring noted.With oxygen inhalation per nasal cannula at 1-2 LPM.
Lips:
Lips are moist dry, no pale manifestations. Cracking of lips noted.
Mouth:
He has a complete set of teeth with minimal dental caries noted. Oral mucosa and gingival
are pink in color, moist and there were no lesions nor inflammation noted. Tongue is
pinkish and is free of swelling and lesions. Lips are symmetrical, no bits noted upon
observation.
Neck:
Lymph nodes noted. Neck has strength that allows movement back and forth,
left and right. Patient is able to move his neck freely.





Chest and Thoracic Region:
Symmetrical chest expansion, no retractions, wheezing sound and abnormal breathing
pattern noted. Color is brown, the same with the rest of the body. Breasts are symmetrical
and rounded in shape. No inflammation or deformities noted.
Abdomen:
Abdomen is rounded in shape while in sitting position and flat when in supine
position. The rest of the abdomen is of the same color and with no abrasions.
Upon palpation, no distention noted.
Back:
No inflammations and lesions observed. No abrasions are noted.
Upper Extremities:
Arms are bilaterally symmetric. No edema or prominent venous patterning. The
color is even, no mass, swelling, tenderness. The temperature is warm and
even. IVF of D5LRS IL to run for 8 hours. Regulated at 30-31 drops per minute.
Lower Extremities:
The color is even, no mass, swelling, tenderness, ulcerations, edema. Toes, feet
and legs are equally warm bilaterally. Veins are flat and barely seen.
Genitalia: Not Assessed





Chapter IV
ANATOMY AND PHYSIOLOGY

The upper respiratory tract consists of the nose, sinuses, pharynx,
larynx, trachea, and epiglottis.
The lower respiratory tract consists 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 processes:
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.



















Chapter VI
DIAGNOSTIC PROCEDURES

HEMATOLOGY SECTION
1/9/2014 09:05 AM
Examination Result Normal Value Interpretation/Significance
Hemoglobin
Hematocrit
WBC Count
Bands
Segmenters
Eosinophils
Lymphocytes
Monocytes
146
0.43
16.4
0.00
0.69

0.30
0.0
127-183 g/L
0.40-0.5
5-10X10^9 g/L
0.0-0.07
0.5-0.7
0.0-0.05
0.2-0.4
0.00-0.07
Normal
Normal
Leukocytosis
Normal
Normal

Normal
Normal









CHAPTER IX
EVALUATION
Patient R.N.C., a 44 year old male patient, was admitted at Lorma
Medical Center last January 9, 2014 under Dr. Maria Teresa Orlino due
todifficulty of breathing and cough. During the course of confinement of patient
R.N.C., the student nurses collectively with the health care team of Lorma
Medical Center rendered their optimum service with the aid of their nursing
care plans in order to deal with his present condition.
The care of the patient at the hospital lasted only for three days at our
scheduled rotation. He was diagnosed with Bronchial Asthma in Acute
Exacerbation.
The case study increased our knowledge about the disease and how to
deal with the patient's problem effectively. Through this, we taught the
necessary nursing care management to provide optimum care for the patient.
We were able to socialize with his family and rendered feasible assistance to
them. Favorably, the family showed willingness and cooperation to the
treatment provided to our patient.
We, the student nurses, have rendered nursing interventions to the
patient. We have identified the problems of the patient and made Nursing Care
Plans to aid in achieving our goals for the patient. Goal met at the end of the
nursing interventions.
In addition, we had rendered appropriate health teachings regarding
proper nutrition, coping mechanism and prevention of further infections. The
health teaching imparted include smoking cessation, avoid exposure to fumes,
or any gasses, avoid exposure to allergens like pollens, dust that might trigger
his asthma, increase oral fluid intake, and take maintenance medications
regularly. We encouraged the client to have adequate physical activity, rest,
and relaxation. We advised the patient to refrain from strenuous activities and
eat nutritious foods. Home medications prescribed: Paracetamol 500 mg 1 tab
every 4 hours for fever more than 39.8 degree Celsius, Cefuroxime 250 mg 1
tab BID, Omeprazole 20 mg 1 tab daily before meal, Levocetirizine
Dihydrochloride 5 mg per day.
At the end of the shift, the patient centered objectives were met. The
patient was able to show improvement and recovery from the illness and
demonstrate ability to perform individual self-care. We have also helped the
patient in preventing further complications that may occur during his stay in
the hospital, and administering medication per doctor's order, thus meeting his
needs and aiding in his recovery. The patient recovered from the illness and
has been discharge on January 11, 2014.