INTRODUCTION REPORT NURSING CARE IN PATIENTS WITH ASMA

A. Basic Concepts of Illness

1. Definitions
Asthma is a chronic airway inflammatory disorder. Chronic respiratory tract is
hyperresponsive so that if stimulated by certain risk factors, the airway becomes
blocked and air flow is hampered by bronchial constriction, mucus blockage, and
increased inflammatory processes (Almazini, 2012).
Asthma is a condition in which the airway is narrowed due to hyperactivity to
certain stimuli, which causes inflammation, this narrowing is temporary. Asthma can
occur to anyone and may arise in all ages, but generally asthma is more common in
children under 5 and adults around the age of 30 (Saheb, 2011).
The complete asthma limit issued by the Global Initiative for Asthma (GINA)
(2010) is defined as a chronic airway inflammatory disorder with many cell plays, in
particular mast cells, eosinophils and T lymphocytes. In susceptible people this
inflammation leads to recurrent wheezing, shortness of breath, suppressed chest and
cough, especially at night or early morning. These symptoms are usually associated
with wide-ranging airway narrowing, some of which are reversible both
spontaneously and with treatment, this inflammation is also associated with airway
hyperreactivity to various stimuli

2. Signs and Symptoms

Symptoms of bronchial asthma are usually in patients who are free of attacks are
not found clinical symptoms, but at the time of asthma attacks the patient seemed to
breathe fast and deep, restless, sitting with support forwards, and without respiratory
muscles work hard. Classic symptoms of this asthma is shortness of breath, wheezing
(whezing), cough, and in some patients there is a pain in the chest. These symptoms
are not always present at the same time. In more severe attacks of asthma, symptoms
that arise more and more, among others: silent chest, cyanosis, conscious disorders,
chest hyperinflation, tachicardi and shallow superficial breathing. (Cape, 2003)
3. Cause

The stimulus or trigger factors that often cause asthma are: (Smeltzer &
Bare, 2002).
a. Extrinsic factor (allergic) Allergic reactions caused by known allergens
or allergens such as dust, powders, animal hairs.
b. Intrinsic Factors (non-allergic) Not related to allergens, such as common
cold, piratorius tract infections, exercise, emotions, and environmental
pollutants can trigger an attack.
c. Asthma combined The most common form of asthma. This asthma has
characteristics of allergic and non-allergic forms

While Lewis et al. (2006) did not specifically divide the asthma trigger.
According to them, in general asthma triggers are:

a. . Predisposing factors
Genetic
The inherited factor is the talent of the allergy, although it is not yet
known how to clearly decrease it. Patients with allergic diseases usually
have close relatives also suffer from allergic diseases. Due to the
existence of this allergic talent, the patient is very susceptible to Asthma
Bronchial disease if exposed to the trigger factor. In addition,
hypersensitivity of the respiratory tract can also be decreased.
b. . Precipitation factor
1) Allergens
Where allergens can be divided into 3 types, namely:
a) Inhalants, which enter through the respiratory tract such as dust,
animal dander, flower powder, mold spores, bacteria and
pollution.
b) Ingestants, which enter through the mouth of foods (such as fruits
and grapes containing sodium metabisulfide) and drugs (such as
aspirin, epinephrine, ACE-inhibitors, chromoline).
c) The conactant, which enters through contact with the skin.
Examples: jewelry, metal and watches

2) Sports
Most asthma sufferers will be attacked if they do physical
activity or heavy exercise. Asthma attacks due to activity usually occur
 as soon as the activity is over. Asthma can be induced by physical
activity or exercise called Exercise Induced Asthma (EIA) which
usually occurs sometime after exercise. For example: jogging,
aerobics, walking fast, or climbing stairs and characterized by
bronchospasm, shortness of breath, cough and wheezing . People with
asthma should warm up for 2-3 minutes before exercise.
3) Bacterial infections of the airways
Bacterial infections of the airway except sinusitis result in in
asthma. This infection causes an inflammatory change in the bronchial
tracheo system and alters the mechanism of mucosilia. Therefore there
is an increase in hyperresponsiveness in the bronchial system.
4) Stress
Stress / emotional disorder can trigger asthma attacks, but it can
also aggravate asthma attacks that already exist. Patients are given the
motivation to overcome his personal problems, because if the stress
has not been overcome the symptoms of asthma can not be treated.
5) Disorders of the sinuses
Nearly 30% of cases of asthma are caused by a sinus disorder, eg
allergic rhinitis and nasal polyps. Both of these disorders cause
inflammation of the mucous membranes.
6) Weather change
Humid weather and cold mountain air often affect asthma. The
sudden cold atmosphere is a trigger factor for the attacks of the asthma.
Sometimes attacks are related to seasons, such as the rainy season, the
dry season.

4. Pathophysiology
According to Wong (2009) Inflamasi plays a role in improving airway reactivity.
The mechanisms that cause airway inflammation vary considerably, and the role of each
mechanism varies and one child to another and during the course of the disease. Causes
factors such as viruses, bacteria, fungi, parasites, allergies, irritants, weather, physical
activity and psychic will stimulate bronchial hyperreactivity reaction in the respiratory
tract thus stimulating plasma cells to produce imonoglubulin E (IgE). IgE will then attach
to mast cell wall receptors called sensitized mast cells. Sensitized mast cells will
degranulasi, degranulation of mast cells will secrete a number of mediators such as
histamine and bradykinin. This mediator causes increased capillary permeability resulting
in mucosal edema, increased mucus production and contraction of smooth muscle
bronchioles. This will cause proliferation as a result of blockage and power of
consulidation on the airway so that the exchange of O2 and CO2 is inhibited as a result of
ventilation disturbance. Low O2 input to the lungs especially in the alveolus leads to an
increase in CO2 pressure in the alveoli or so-called hyperventilation, which leads to
respiratory alkalosis and decreased CO2 in the capillaries (hypoventilation) which leads
to respiratory acidosis.
5. Pathway /WOC
 6. Classification

Classification of Asthma Degrees

Degree of Asthma Symptoms of Night Symptoms

1.
Symptoms <1x / week

INTERMITEN symptoms outside attack

≤ 2 times a month
Weekly Short attack. Asymptomatic
lung function and normal
outside attack

1
Symptoms> 1x / week but
<1x / day > 2 times a week
LIGHTER LIFE
. Attacks can interfere with
Weekly activity and tidu

1.
Daily symptoms . Use the
medicine every day . Attack
> once a week
PERSISTENT IS MEDIUM disrupt activity and sleep
Daily Attack 2x / week, can be
days

Symptoms persistent.
HEAVY PERSISTENT
Physical activity is limited Often
Continuous

7. Physical Examination
a. Sputum examination
Sputum examination done to see the existence:
1) Charcot leyden crystals which are degranulations of eosinopil crystals.
2) Spiral curshmann, which is a cast cell (mold cell) from the bronchus branch.
3) Creole which is a fragment of the bronchial epithelium.
4) Netrophils and eosinopil contained in sputum, generally mukoid with high viscosity and
sometimes there is a mucus plug.
b. Blood examination
1) Blood gas analysis is generally normal but may also occur hipoksemia, hiperkapnia, or
acidosis.
2) Sometimes in the blood there is an increase of SGOT and LDH.
3) Hyponatremia and leukocyte levels occasionally above 15.000 / mm3 indicating the
presence of an infection
4) On examination of allergic factors there is an increase of IgE at the time of attack and
decreases at free time from attack
8. Diagnostic Examination / Support
a. Radiological examination
Radiologic features of asthma are generally normal. At the time of the attack showed a
picture of hyperinflation in the lungs of increased radiolucency and intercostalis cavity
melting, and a decreased diaphragm. However, if there are complications, then the
abnormalities obtained are as follows:
1) When accompanied by bronchitis, the spots in the hilus will increase.
2) If there is a complication of empisema (COPD), radiolucent image will increase.
3) If there are complications, then there is a picture of infiltrate in the lung
4) Can also cause a picture of local atelectasis.
5) If there is mediastinal pneumonia, pneumothorax, and pneumoperikardium, it can be seen
radiolusen image form in the lungs.
b. Examination of skin test
Conducted to look for allergic factors with various allergens that can cause a positive reaction
in asthma.
c. Electrocardiography
Electrocardiographic features that occur during an attack can be divided into 3 parts, and
adjusted to the image that occurs in pulmonary emphysema, namely:
1) Changes in cardiac axis, which is generally the right axis deviation and clock wise
rotation.
2) There are signs of cardiac hypertrophy, ie the presence of RBB (Right bundle branch
block).
3) Signs of hypoxemia, ie the presence of sinus tachycardia, SVES, and VES or the
occurrence of ST negative segment depression.
d. Pulmonary Scanning
By lung scanning through inhalation it can be learned that air redistribution during asthma
attacks is not exhaustive in the lungs.
e. Spirometry
To show reversible airway obstruction, the fastest and simplest way of diagnosing asthma is
to see a treatment response with a bronchodilator. Spirometer examination done before and
after pamberian aerosol bronchodilator (inhaler or nebulizer) adrenergik group.
An increase in FEV1 or FVC by more than 20% indicates the diagnosis of asthma. The
absence of aerosol bronchodilator response more than 20%. Spirometry examination is not
only important for diagnosis but it is also important to assess the weight of obstruction and
treatment effects. Benyak patient without complaints but spirometry examination showed
obstruction

9. Diagnosis / Diagnosis Criteria

a. Ineffective airway clearance b.d mucus in excessive amounts of increased mucus
production, exudate in alveoli and bronchospasm
b. Ineffectiveness of breath pattern b.d exhaustion of respiratory muscle and chest wall
deformity
c. Disturbance of gas exchange b.d retention of carbon dioxide
d. Decrease in cardiac output b.d change in contactility and volume of heart stroke
e. Activity intolerance b.d imbalance between supply and oxygen demand (hypoxia)
weakness
f. Nutrition imbalance is less than body needs b.d metabolic rate, dyspnea at meal, chewing
muscle weakness
g. Anxiety b.d state of illness in suffering

10. Medical Management Patients with gas exchange disorders should be treated promptly by
providing long-term treatment of which there are 3 factors (Nurarif & Kusuma, 2015)
a. Medications or medications aimed at treating and preventing airway obstruction symptoms
consist of controllers and relatives,
b. Treatment stages include how treatment for severe asthma, intermittent asthma, mildly
persistent asthma, persistent asthma, persistent asthma.
c. Control regularly and apply a healthy lifestyle such as improving physical fitness, quitting
or not smoking, recognizing the work environment against the triggers that cause asthma.
11. Complications Various complications that may arise (Betz & Sowden, 2002):
a. Asthmatic status is any severe asthma attack or which then becomes severe and does not
respond (refractory) adrenaline and / or aminophylline injections can be classified on asmatic
status. Patients should be treated with intensive therapy.
b. Atelectasis is partial or complete shrinkage of the lungs due to blockage of the airways
(bronchial or bronchioles) or from very shallow respiration.
c. Hypoxemia is where the body lacks oxygen.
d. Pneumothorax is the presence of air in the pleural space that causes pulmonary collapse.
e. Emphysema is a disease whose main symptom is airway obstruction (obstruction) because
the air sacs in the lungs are inflated excessively and suffered extensive damage.