1.

Concept of Disease
1.1 Anatomy and Physiology

ANATOMY
a. Nose
The nose or naso or nasal is the first airway, has two holes (rice cavity), separated by
nasal septum (septum nasi). Inside there are feathers that are useful for filtering air,
dust, and dirt into the nostrils.
b. Pharynx
Pharynx or pharynx is the site of the intersection between the airway and food pathway,
located below the skull base, behind the nasal cavity, and the front mouth of the neck
segment. The pharyngeal relationship with other organs is upward related to the nasal
cavity, through the hole called koana, to the front associated with the oral cavity, where
this connection is called istmus fausium, downward there are 2 holes (forward laryngeal
hole and back hole esophagus).
c. Larynx
The larynx or base of the throat is the airway and acts as a sound formation, located in
front of the pharynx to the height of the cervical vertebra and into the trachea below it.
The larynx can be covered by a throat lining, usually called the epiglottis, which
consists of cartilage that functions when we swallow food covering the larynx.
d. Trachea
 The trachea or windpipe is a continuation of the larynx formed by 16 to 20 rings
consisting of cartilage that is shaped like horse's nails (letter C) inside which is covered
by a hairy mucous membrane that is called vibrating ciliary cells, only moving outward
The trachea length is 9 to 11 cm and in the back consists of connective tissue coated by
smooth muscle.
e. Bronchus
The bronchus or branch of the throat is a continuation of the trachea, there are 2 pieces
that are at the height of the IV and V thoracic vertebrae, having a structure similar to
the trachea and coated with the same type of set. The bronchus goes down and to the
side toward the lung. The right bronchus is shorter and bigger than the left bronchus,
consisting of 6-8 rings, has 3 branches. The left bronchus is longer and slimmer than
the right, consisting of 9-12 rings having 2 branches. The bronchus branches, smaller
branches are called bronchioles (bronchioli). In the bronchioli there are no more rings,
and at the end of the bronchioli there are pulmonary bubbles or air bubbles or alveoli.
f. Lungs
The lungs are a body instrument that consists mostly of bubbles (air bubbles or alveoli).
The alveoli is composed of epithelial and endothelial cells. If stretched the surface area
is approximately 90 m². In this layer there is an exchange of air, O2 enters the blood
and CO2 is released from the blood. The number of lung bubbles is approximately
700,000,000 (left and right lungs)
The lungs are divided into two: the right lung, consisting of 3 lobes (pulmonary
hemisphere), the superior right pulmonary lobe, the media lobe, and the inferior lobe.
Each lobe is composed of lobules. The left lung, consisting of pulmonary and superior
lobes and inferior lobes. Each lobe consists of a small hemisphere called a segment.
The left lung has 10 segments, 5 segments in the superior lobe, and 5 segments
inferiorly. The right lung has 10 segments, namely 5 segments in the superior lobe, 2
segments in the medial lobe, and 3 segments in the inferior lobe. Each of these segments
is still divided into parts called lobules.
Between the lobules with each other is limited by connective tissue that contains lymph
vessels and nerves, and each lobule has a bronchiole. In the lobules, these bronchioles
branch out very much, this branch is called the alveolar duct. Each duct of the alveolus
ends in the alveolar diameter between 0.2-0.3 mm.
The location of the lungs in the chest cavity is facing the middle of the chest cavity or
the mediastinal cavity. In the middle there is a lung or hilum. At the front mediastinum
 lies the heart. The lungs are wrapped by a membrane called the pleura. The pleura is
divided into 2, namely, the first visceral pleura (wrapper membrane), which is the lung
membrane that directly wraps the lungs. Both the parietal pleura is the membrane that
lines the outer chest cavity. Between normal conditions, the pleural cavity is vacuum
(empty) so that the lungs can develop flat and there is also a small amount of fluid
(exudate) which is useful for oiling the surface (pleura), avoiding friction between the
lungs and chest wall when there is breathing movement.

PHYSIOLOGY
Breathing is an event of breathing air from outside that contains oxygen and exhaling air
that contains lots of carbon dioxide as a residue from oxidation out of the body. This
suction of air is called inspiration and exhalation is called expiration. So, in the lungs, an
exchange of oxygen is drawn and the air enters the blood, and CO2 is released from the
blood by osmosis. Then CO2 is released through the respiratory tract (airway) and into the
body through the pulmonary venous capillaries and then into the left ventricle of the heart
(left atrium) to the aorta then throughout the body (tissues and cells), here occurs oxidation
(combustion). As the remainder of combustion is CO2 and is released through venous
blood circulation into the heart (right foyer or right atrium) to the right ventricle (right
ventricle) and from here through the pulmonary artery to the lung tissue. Finally released
through the epithelial layer of the alveoli. The process of removing CO2 is part of the rest
of the metabolism, while the rest of the other metabolism will be released through the
urogenital tract and skin.
After the air from outside is processed, there is still a long journey in the nose to the lungs
(to the alveoli). In the larynx there is an epiglottis that is useful for closing the larynx when
swallowing, so that food does not enter the trachea, while the breathing time of the
epiglottis opens, and so on. If food enters the larynx, it will get a coughing attack, this is
to try to remove the food from the larynx.
Divided into 2 parts, namely inspiration (breathing) and expiration (exhaling). Breathing
means inspiring and inspiring alternately, regularly, rhythmically, and continuously.
Breathing is a reflex that occurs in the breathing muscles. This breathing reflex is regulated
by the respiratory center which is located in the connecting marrow (medulla oblongata).
Because a person can hold back, slow down, or speed up his breathing, this means that the
breathing reflex is also under the influence of the cerebral cortex. The respiratory center is
very sensitive to excess levels of CO2 in the blood and deficiency in the blood. Inspirai
 occurs when the diaphragm muscle has been stimulated from the phrenic nerve and then
shrinks flat.
Intercostal musculature which is located on a slant, after, gets stimulated and then shrinks
and the rib bones become flat. Thus the distance between the sternum (breastbone) and
vertebrae becomes wider and wider. Enlarged chest cavity, the pleura will be attracted,
which attracts the lungs so that the air pressure in it decreases and enter the air from
outside.
Expiration, at one time the muscles will relax again (the diaphragm will become concave,
the intercostal muscles tilt again) and thus the cavity and thus the chest cavity becomes
smaller again, then the air is pushed out. So this process of respiration or breathing occurs
because of the difference in pressure between the pleural cavity and the lungs.
Chest breathing, when someone breathes, the largest chest frame moves, this breathing is
called chest breathing. This is found in the soft chest frame, which is in young people and
in women.
Abdominal breathing, if during breathing the diaphragm goes up and down, this is called
abdominal breathing. Mostly in the elderly, because the cartilage is not so soft and concise
again caused by a lot of lime that settles in it and is found in many men.

1.2 Definition
Asthma is a chronic airway inflammation disorder. The airways that experience chronic
inflammation are hyperresponsive so that when aroused by certain risk factors, the airway
becomes blocked and air flow is blocked due to bronchial constriction, mucus obstruction,
and increased inflammatory processes (Almazini, 2012).
Asthma is a condition in which the respiratory tract is narrowed due to hyperactivity to
certain stimuli, which causes inflammation, this narrowing is temporary. Asthma can occur
to anyone and can arise in all ages, but generally asthma is more common in children under
5 years of age and adults in the age of around 30 years (Saheb, 2011).

1.3 Etiology
a. Predisposing factors
Genetic is a predisposing factor for bronchial asthma.
b. Precipitation Factor
 Allergens
Allergens can be divided into 3 types, namely:
 1) Inhalan, which enters through the respiratory tract. Examples: dust, animal
hair, pollen, mold spores, bacteria, and pollution.
2) Ingestan, who enters by mouth. Examples: food and medicine.
3) Kontaktan, which enters through contact with the skin. Examples: jewelry,
metal, and watches.
 Changes in the weather
Humid weather and cold mountain air often affect asthma.
 Stress
Stress / emotional disturbances can trigger asthma attacks. Stress can also
aggravate existing asthma attacks
 Work environment
The work environment has a direct relationship to the cause of an asthma attack.
For example, people who work in animal laboratories, the textile industry,
asbestos factories, traffic police.
 Severe physical exercise / activity
Most people with asthma will get an attack if doing physical activity or heavy
exercise.

1.4 Signs and Symptoms

Initial symptoms:
1. Cough
2. Dispnea
3. Whezzing
4. Impaired consciousness, chest hyperinflation
5. Tachicardi
6. Shallow fast breathing
Other symptoms:
1. Tachypnea
2. Restlessness
3. Diaphorosis
4. Abdominal pain due to visible abdominal muscles in breathing
5. Fatigue
6. Not tolerant of activities: eating, walking, even talking.
 7. Attacks usually begin with coughing and a feeling of tightness in the chest
accompanied by slow breathing.
8. Expiration is always more difficult and long than inspiration
9. Secondary cyanosis
10. Carbon dioxide retention movements such as: sweating, tachycardia and pulse
pressure widening.

1.5 Patophysiology
Three elements involved in airway obstruction with asthma are smooth muscle spasm,
edema and inflammation of the airway mucous membranes, and exudation of intraliminal
mucus, inflammatory cells and cellular debris. Obstruction causes increased airway
resistance which lowers the volume of forced expression and flow velocity, premature
closure of the airway, pulmonary hyperinflation, increased respiratory work, changes in
elastic properties and respiratory frequency. Although the airway is diffuse, obstruction
causes a difference between one part and another, this results in insufficient ventilation of
the lungs and causes abnormalities of blood gases, especially a decrease in pCO2 due to
hyperventilation.
In allergic responses in the airways, IgE antibodies bind to allergens causing mast cell
degranulation. As a result of the degranulation, histamine is released. Histamine causes
constriction of smooth muscle bronchioles. If the histamine response is excessive, asthma
spasm can occur. Because histamine also stimulates mucus formation and increases
capillary permiability, there will also be congestion and swelling of the pulmonary itching.
Individuals who have asthma may have an overly sensitive IgE response to something
allergens or mast cells that are too degranulated. Where the inflammatory response
hypersensitivity lies, the end result is bronchospasm, mucous formation, edema and
obstruction of airflow.
1.6 Pathway

Faktor Pencetus

Alergi Idiopatik

Edema dinding Spasme otot polos Seksresi mukus kental

Bronkiolus bronkiolus di dalam lumen bronkiolus

Ekspirasi Menekan sisi luar diameter bronkiolus mengecil

Bronkiolus

Gangguan Istirahat Dispnea Bersihan Jalan Napas

Dan Tidur Tidak Efektif

Kurang pengetahuan tentang penyakit Cemas

1.7 Supporting Examination

1) Examination of sputum
On sputum examination found:
 Charcot leyden crystals which are degranulation of eosinophil crystals.
 The presence of Spiral Curschman, which is a spiral which is a cylindrical cell of
bronchial branches
 Creole which is a fragment of the bronchial epithelium
 The presence of eosinophil neutrophils
2) Blood tests
Regular blood tests are expected to increase eosinophils, while leukocytes can be
elevated or normal, even though there are complications of asthma
 Blood analysis gas
 There are variable blood flow results, but if there is an increase in PaCO2 or a
decrease in pH it indicates a poor prognosis
 Sometimes in the blood there is elevated SGOT and LDH
  Hiponatremi 15,000 / mm3 indicates infection
 On examination of allergic factors there is IgE that rises at the same time, and
decreases when the patient is free from attack.
 Examination of skin tests to look for allergic factors with various allergens can
cause a positive reaction in atopic asthma types.
3) X-ray photos
In general, normal X-ray examination in asthma. In asthma attacks, this picture shows
pulmonary hyperinflation in the form of increased radiolucency, and decreased
widening of the intercostal cavity and diaphragm. However, if there are complications,
abnormalities that occur are:
 If accompanied by bronchitis, hilum streaks will increase
 If there is a complication of emphysema (COPD) it creates an increasing picture.
 If there are complications of pneumonia, there is a picture of lung infiltrates.
4) Examination of lung function
 If the FEV1 is smaller than 40%, 2/3 of the patients show a decrease in systolic
pressure and if lower than 20%, all patients show a decrease in systolic pressure.
 Increased lung volume that covers RV almost occurs in all asthma, FRC always
decreases, while a decrease in TRC often occurs in severe asthma.
5) Electrocardiography
Electrocardiographic features during an asthma attack can be divided into three parts
and adjusted for the description of pulmonary emphysema, namely:
 Changes in the heart axis generally occur to right axis deviation and clockwise
rotation
 There are signs of cardiac hypertrophy, namely the presence of RBBB
 Signs of hypoxemia, namely sinus tachycardia, SVES, and VES or the relative
occurrence of ST depression.

1.8 Management
1) Non-pharmacological treatment
a. Extension
This counseling is aimed at increasing client knowledge about asthma:
 Avoid trigger factors
 Physiotherapy
 b. Pharmacologic treatment
 Beta agonists. For example: Alupent, metrapel
 Methyl Xanthine. For example: Aminophilin and Theopilin
 Corticosteroids. For example: Beclometasone Dipropinate with 800 doses of
spray every day.
 Kromolin. Kromolin is an asthma prevention drug, especially for children. The
dosage ranges from 1-2 capsules four times a day.
 Ketotifen. The effect of cooperation with chromolin at a dose of 2 x 1 mg per
day. The advantage can be given orally.
 Iprutropioum bromide (Atroven). Atroven is anticolenergic, given in aerosol
form and is bronchodilator.
2) Treatment during an asthmatic status attack
a. Infusion of RL: D5 = 3: 1 every 24 hours
b. Giving oxygen 4 liters / minute through nasal cannula
c. Aminophyline bolus 5 mg / kg bw given slowly for 20 minutes followed by drip Rl
or D5 mentenence (20 drops / minute) at a dose of 20 mg / kg bw / 24 hr.
d. Terbutalin 0.25 mg / 6 hours in sub cutaneous.
e. Dexamatason 10-20 mg / 6 hours intravenously.
f. Broad-spectrum antibiotics

2. Nursing Care Plans

2.1 Assessment
2.1.1 Primary Assessment
a) Airway
 Increased respiratory secretions
 Krekles breath, ronchi, weezing
b) Breathing
 Respiratory distress: respiratory nostrils, takipneu / bradipneu, retraction.
 Using muscle respiratory accessories
 Difficulty breathing: diaphoresis, cyanosis
c) Circulation
 Decreased cardiac output: restlessness, latergias, tachycardia
 Headache
  Impaired levels of consciousness: anxiety, anxiety
 Papiledema
 Urine output decreases
d) Dissability
Knowing the general condition with a quick examination of general status and
neurology by checking or checking consciousness, pupillary reaction.

2.1.2 Secondary Assessment

a. History
History of asthma sufferers is very important, useful to gather various information
needed to develop a treatment strategy. Asthma symptoms vary greatly between
individuals and in the individual itself (at different times), from no symptoms at all
to severe tightness accompanied by impaired consciousness.
Complaints and symptoms depend on the light weight at the time of the attack. In
attacks of mild bronchial asthma and without complications, complaints and
symptoms are nothing unique. The most common complaints are: Breath sounds,
Shortness, Cough, which arises suddenly and can disappear immediately
spontaneously or with treatment, even though some continue for a long time.
b. Physical examination
Other than finding physical signs that support the diagnosis of asthma and getting
rid of other possible diseases, it is also useful to find out diseases that may
accompany asthma, including examinations:
a) General health status
It needs to be studied about client awareness, anxiety, anxiety, weakness of
speech, pulse blood pressure, increased frequency of breathing, use of cyanotic
respiratory helper muscles coughing with mucus and the client's resting
position.
b) Integumen
The presence of rough, dry surfaces, pigmentation abnormalities, skin turgor,
moisture, flaking or scaling, bleeding, pruritus, enzymes, and the presence of
marks or signs of urticaria or dermatitis in the hair are examined for hair color,
moisture and dullness.
c) Thoracic
 1. Inspection
The chest is inspected mainly the shape and symmetrical posture of an
increase in the anteroposterior diameter, the retraction of the intercostal
muscles, the nature and rhythm of the breathing and the frequency of the
role.
2. Palpation.
The palpation was studied about cosmetrical, expansion and tactile fremitus.
3. Percussion
On percussion the normal sound is obtained until hipersonor while the
diaphragm becomes flat and low.
4. Auscultation.
There is increased vesicular sound accompanied by expiration of more than
4 seconds or more than 3 times inspiration, with breathing sounds and
wheezing.
d) Respiratory system
1. The cough is initially non-productive and then becomes harder and so
becomes productive, which initially becomes runny and then becomes
thick. The phlegm is clear or white but can also be yellowish or greenish
especially if there is a secondary infection.
2. The frequency of breathing increases
3. Hypertrophy breathing aids.
4. Respiratory sounds may weaken with prolonged expiration with dry rhythm
and wheezing.
5. Expiration more than 4 seconds or 3x longer than inspiration maybe even
more.
6. In patients with severe congestion it may be found:
 Pulmonary hyperinflation seen by an increase in antheroposterior
diameter of the chest cavity which sounded hypersonor percussion.
 Breathing is increasingly fast and difficult, characterized by activation
of the breathing muscles (between ribs, sternocleidomastoid), so that it
appears suprasternal retraction, supraclavicle and ribs and nasal lobe
breathing.
 7. In more severe conditions, fast and shallow breathing can be found with
breathing sounds and wheezing is not heard (silent chest), cyanosis.
e) Cardiovascular system
a. Blood pressure increases, the pulse also increases
b. In patients with severe congestion it may be found:
 Tachycardi is more intense with dehydration.
 Pulsus paradoxus arises where there is a decrease in systolic blood
pressure of more than 10 mmHg at the time of inspiration. Normal not
more than 5 mmHg, in asthma that can weigh up to 10 mmHg or more.
f) In more severe circumstances blood pressure decreases, heart rhythm
disturbances.

2.2 Nursing Diagnosis

1) Ineffective airway clearance related to Foreign body in airway
2) Impaired comfort and anxiety are related to Illness-related symptoms
3) Disturbed sleep pattern related to Feeling unrested

2.3 Nursing Interventions

No. Nursing Diagnosis Purpose Intervention Rational
1. Ineffective airway clearance Ineffective airway  Help the patient to  By giving / adjusting a
related to Foreign body in cleaning with short- position a comfortable comfortable position to
airway by being marked: term criteria: or semi-flower clean + breathe freely.
 Patients complain of  Patients can environment away  Effective coughing and
tightness. secrete secretions from pollution. breathing to expel
 Irregular breathing. easily.  Help the patient to phlegm + relieve
 Respiration: 28x /  The accumulation cough effectively and breathing.
minute. of secretions take a deep breath.  Maintain balance of
decreases.  Give information about fluid output intakes.
 Patients do not evaporation techniques  Can relieve the airway
complain of and breathe
breathing in the comfortably.
long term.
  The patient is not
congested
anymore.
2 Impaired comfort and Comfort disorders 1. Give an explanation to - Knowing the disease
anxiety are related to Illness- are overcome by the patient politely about makes it easy to include
related symptoms by being short-term criteria the disease that is being appropriate nursing.
marked:  Patients believe suffered. - Knowing disease efforts
 the patient looks worried this disease will 2. Give an explanation + healing efforts go well.
 the patient looks heal. that the disease will - Can reduce DS anxiety.
depressed  Patients know diminish little by little - Can avoid relapse of the
long-term with regular treatment. disease.
illness. 3. Give motivation and
 The patient attention to all efforts
feels calm in made by the patient for
handling the his recovery.
disease. 4. Advise the patient to
avoid triggering
recurrence of the disease.
3. Disturbed sleep pattern Disturbed sleep - Create a comfortable - Reduce noise in order to
related to Feeling unrested pattern are resolved room atmosphere. increase patient tension.
by criteria: - Tidy up and clean the - Creating rest and sleep
- Short term, bed every day. comfort.
patients can rest. - Set a safe position for - Set the dosage so that
- Long term, patients to rest and sleep. you can rest and sleep
patients can rest well.
and sleep regularly.
 BIBLIOGRAPHY

Almazini, P. (2012). Bronchial Thermoplasty Pilihan Terapi Baru untuk Asma

Berat.Jakarta: Fakultas Kedokteran Universitas Indonesia

NANDA International Nursing. (2018-2020). Diagnosis Keperawatan Definisi & Klasifikasi.

Edisi 11. Jakarta : EGC.

Purnomo.(2013). Faktor Faktor Risiko Yang Berpengaruh Terhadap Kejadian Asma Bronkial
Pada Anak. Semarang: Universitas Diponegoro

Ruhyanudin, F. (2017). Asuhan Keperawatan Pada Pasien Dengan Gangguan Sistem Kardio
Vaskuler. Malang : Hak Terbit UMM Press

Saheb, A. (2011). Penyakit Asma. Bandung: CV Medika

 REPORT INTRODUCTION
ASTHMA
PUSKESMAS PELAMBUAN BANJARMASIN

NAME : AULIA SANDRA DEWI

NRM : 1714201310003
GROUP : 2 BILINGUAL

UNIVERSITAS MUHAMMADIYAH BANJARMASIN

PROGRAM STUDI S1 KEPERAWATAN BILINGUAL
FAKULTAS KEPERAWATAN DAN ILMU KESEHATAN
BANJARMASIN
2019