CASE PRESENTATION: Bronchial Asthma

FATIMA UNIVERSITY MEDICAL CENTER

McArthur Highway, Marulas, Valenzuela City

In Partial Fulfillment in the Requirements in NCM 103A RLE

Submitted to:

Ms. Edna Co, RN, MAN

Submitted by:

Estares, Jaina
Fatima, Francisco
Jacinto, Alexandra Necone
Macabio, Evangeline
Manahan, Grace
Maravilla, Danica
Misajon, Maryvie
Morales, Donna
Morales, Joanna
Paguio, Catherine
Quico, Sherry
Rocha, RIcha
 BSN 3Y1- 4B S.Y. 2nd Sem 2010-2011

TABLE OF CONTENTS

I. INTRODUCTION VII. DEVELOPMENTAL DATA

II. ACKNOWLEDGEMENT A. ERIK ERIKSON

III. OBJECTIVES VIII. PATTERNS OF FUNCTIONING

IV. SCOPE AND LIMITATION VIII. LEVELS OF COMPETENCIES

V. ASSESSMENT IX. GORDON’S ASSESSMENT

1. PERSONAL DATA X. ANATOMY AND PHYSIOLOGY

2. FAMILY BACKGROUND XI. PATHOPHYSIOLOGY

3. HEALTH HISTORY XII. MEDICAL MANAGEMENT

A. FAMILY HEALTH HISTORY XIII. NURSING CARE PLAN

B. PAST HEALTH HISTORY XIV. DISCHARGE PLAN

C GENOGRAM XV. BIBLIOGRAPHY

VI. PHYSICAL ASSESSMENT

Case Presentation of Patient Diagnosed with Bronchial Asthma

I. Introduction:
The student nurse of Our Lady of Fatima University picked a case about Bronchial Asthma. As a health care provider, the student nurse has the
responsibility for planning with the patient and the family the continuation of care with eventual outcome of an optimal state of wellness.

Creating a plan of care begins with the collection of data or assessment. It consists of subjective and objective data information.

Asthma is a condition in which the airways narrow usually reversibly in response to stimuli. It is a chronic inflammatory disorder of the airways in which
many cells and cellular elements play a role, in a particular, mast cells, eosinophil, T lymphocytes, macrophages, neutrophils, and epithelial cells. In susceptible
individuals this inflammation causes recurrent episodes of wheezing, breathlessness, coughing. There are forms of asthma first is cardiac asthma, with cardiac
asthma, it is the reduced of pumping efficiency of the left side of the heart leads to a buildup of fluid in the lungs. This fluids causes airways to narrow and can
cause wheezing. Cardiac asthma is often indistinguishable from bronchial asthma. The main symptoms are shortness of breath, increase in rapid and shallow
breathing, increase in blood pressure and heart rate and a feeling of apprehension. Second forms of asthma is Bronchial Asthma, for most people bronchial
asthma is the pattern periodic attacks of wheezing alternating with periods of quite normal breathing. Strong risk of getting Bronchial asthma include being a
person genetically susceptible to asthma and being exposed early in life to indoor allergens, such as dust mites and cockroaches, and having family history of
asthma. Symptoms of bronchial asthma include a feeling of tightness of the chest, difficulty of breathing or shortness of breath, wheezing and coughing particularly
at night.
ACKNOWLEDGEMENT

First of all, we, the researchers would like to thanks to our beloved Lord Jesus Christ who guided as through the days of our duty which enables us to finish
our case study.

Second, to the family who allow us to interview about the health status of their child.

Third, to the Staff Nurses and to the Chief Nurse who let us feel their heart-warming welcome as we started duty. To the Owner of the Hospital who gave us
opportunity to learn other knowledge about in caring the patients. To the Hospital itself, who gave us another different experience that will help to our career.

To our Clinical Instructor, Ms. Edna CO, who guided us and pursued us to finish our Case Study.

Fourth, to our Family who gave us a physical and moral support.

And last but not the least, we would like to thanks ourselves because of the knowledge we shared as each of us was able to contribute and finish this Case
Study within the time frame set by our clinical instructor..

That’s all. God Bless….

OBJECTIVES
• To provide the patient a good and quality of care.

• To teach the patient in learning how to effective health and nutrition information in helping their young children to be more healthy.

• To learn and understand the disease.

• To present the case properly.

SCOPE AND LIMITATION

• The patient was admitted at the Emergency Room last Feb. 22, 2011 at around 6pm. The patient was diagnosed with Bronchial Asthma. The patient was
transferred at the Suite Room A MS Ward at the same time.

• Student Nurse Jaina Estares handled the patient from August 22-23, 2011. Jaina take care the baby. She took vital signs and monitored the condition of the
baby.

• Our group assigned to have a Case Presentation and focused on our patient who have been diagnosed with BAI

• The information and other gathered data by our group all came from the primary sources, the parents.

• Physical Assessment was carefully done and conducted on Feb. 23, 2011.
ASSESSMENT

I. GENERAL INFORMATION:

NAME: PATIENT X
AGE: 1 ½ months
Birthday: October 25, 2009
Place of Birth: Marulas, Valenzuela City
Sex: Male Civil Status: Single Religion: Catholic
Nationality: Filipino Weight: 12 kg Length: 62 cm

HEALTH HISTORY

FAMILY HEALTH HISTORY

Baby X is the youngest child of Mr. and Mrs. X. He is 1 1/2 yrs. old or 18 mos. old and weighs 12 kg and length of 62 cm. He was diagnosed with BAI that
makes him to have difficulty of breathing.
 According to his mother, baby X father and grandfather have asthma. Also his grandfather has hypertension while his grandmother on his mother’s side has
a history of Diabetes Mellitus. Mr. and Mrs. X have enough earnings to sustain their financial need and other expenses.

PAST ILLNESSES:
(+) cough and colds for 9days and have low grade fever.

GENOGRAM
FATHER’S SIDE MOTHER’S SIDE

Lolo 1 Lola 2 Lolo 2

HPN Lola 2
DM
ASTHM
A

Girl Girl Girl

(Aunt) (Mother) (Aunt)

Boy Boy
(Father) (Uncle)
ASTHMA

Girl (7y.o) Boy

(11mos.) BAI
 Boy
(13)

- Boy - Patient -Girl

PHYSICAL ASSESSMENT:

I. GENERAL INFORMATION:

NAME: PATIENT X

AGE: 18 months

SEX: male

II. VITAL SIGNS:

TEMP: 37. 9 °C CR: 106 RR: 33

III. GENERAL APPEARANCE:

GENERAL SURVEY
BODY PART EXAMINED NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION

Body built, height and weight in relation Proportionate height and weight, has a Upon inspection and observation the NORMAL. The pt’s weight is proportional
to the client’s age, lifestyle and health healthy lifestyle. patient is fat enough for her height. to her height.

Overall hygiene and grooming Clean and Neat As we do the inspection, we noticed that NORMAL. The pt’s hygiene is good.
the patient’s hygiene is normal because
she take a bath everyday

Attitude Non-cooperative The patient is non-cooperative every time ABNORMAL The patient is non-
we ask her some questions. cooperative.

SKULL

BODY PART EXAMINED NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION

Inspect the skull for size, shape, and Rounded, smooth skull contour The skull is normocephalic and it is smooth NORMAL. The skull is smooth in contour
symmetry in contour
Palpate the skull for nodules, masses, Smooth, uniform consistency The skull has no nodules, masses, or NORMAL. It has no nodules, masses or
or depressions depressions depressions

Note symmetry of facial movements. Symmetry in facial movement As the patient moves her face it has NORMAL. The pt’s facila movement is
symmetrical movement symmetrical.

SCALP

BODY PART EXAMINED NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION

Color and appearance Lighter that the skin color The pt’s scalp is lighter that the skin color NORMAL. The pt’s scalp is lighter that the
skin color

Areas of tenderness No signs of tenderness There is no tenderness on the pt’s scalp NORMAL. The pt’s scalp has no tenderness

HAIR

BODY PART EXAMINED NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION

Hair distribution and thickness Evenly distributed. Thick hair The hair of the patient is evenly NORMAL. The patient’s hair is evenly
distributed and thick enough. distributed and thick.
Texture and oiliness over the scalp. Silky, smooth Upon inspection the pt’s hair is silky and NORMAL. The pt’s hair is silky and smooth
smooth making it normal.

CONJUNCTIVA

BODY PART EXAMINED NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION

Palpebral conjunctiva for color, texture, Pink in color, smooth and no presence of Pt’s conjunctiva is color pink, smooth in NORMAL. The pt’s conjunctiva appears to be
and presence of lesion lesion texture and no presence of lesions pink in color, smooth and no presence of
lesion.

EARS

BODY PART EXAMINED NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION

Cerumen Dry cerumen, has presence of hair The pt’s ear has dry cerumen, and no NORMAL. Has dry cerumen, no lesion and no
follicles, no pus or blood presence of pus or blood. blood or pus

MOUTH, LIPS, GUMS

BODY PART EXAMINED NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION

Symmetry of contour, color and texture Uniform pink color, soft, moist, smoothThe patient has pink, moist, smooth lips.NORMAL. The patient has normal lips.
texture, symmetry of contour, ability toThe patient has also the ability to purse her
purse lips lips.

Color and condition, pink, moist, firm, no Pink, moist, no bleeding The pt’s teeth have no signs of bleeding. NORMAL. Has no bleeding
retraction and bleeding of gums

CHEST:

BODY PART EXAMINED NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION

Adventitious breath sounds, chest Symmetrical expansion, no presence ofThe patient has wheezing breath sounds. ABNORMAL. Has a signs of DOB
expansion chest in drawing during breathing

ABDOMEN

BODY PART EXAMINED NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION

Abdomen integrity and condition Unblemished skin, uniform in color The pt’s skin is light brown in colorNORMAL. Pt’s skin is light brown.
because abdomen is not exposing to sun.

LOWER EXTREMITIES:

BODY PART EXAMINED NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION

Condition of legs Uniformity in color and size. The pt’s lower extremities are aligned andNORMAL. The pt’s lower extremities are
have uniform color. uniform.

DEVELOPMENTAL DATA

Erik Erikson – believe that people continue to develop throughout life so he described 8 stages of development.

Erikson’s theory proposes that life is a sequence of developmental stages of levels of achievement each stage signals a task that must be accomplished.
The resolution of the task can be complete, partial or unsuccessful. Erikson believed that the more success an individual has at each developmental stage, the
healthier the person is. Failure to complete any developmental stage influences the person’s ability to progress to the next level. These developmental stages can
be viewed as a series of crises. Successful resolution of these crises supports healthy ego development. Failures to resolve the crises damage the ego.

I. PHYSICAL DEVELOPMENT

Baby X weighs 12 kg with a length of 62 cm. The rate of increase in height and weight is largely influenced by baby’s size at birth and by nutrition. His vision
is in normal function by moving eyes and follows large objects and blinks in response to bright lights. He has an intact hearing because he reacts with a startle to a
loud noise called Moro reflex. He also understands many words like “no”, “ma”. His smell and taste are functional because he was able to recognize the smell of
their mother’s milk and he respond to the smell by turning his head toward to his mother. His sense of touch is well developed because of his response to pain. His
reflexes are involuntary responses of nervous system to external and internal stimuli like rooting and sucking reflex. His motor development is also normal because
he can reach and grasp object and transfer from hand to hand.

II. PSYCHOSOCIAL DEVELOPMENT

Baby X is still depends to his parents because he is 1 ½ mos. Old that needs attention and care to fulfill his nutrition.

III. COGNITIVE DEVELOPMENT

Baby X has a concept of both space and time like his experiment to reach a goal such as a toy in a chair.

IV. MORAL DEVELOPMENT

Baby X is an infant. He doesn’t know how to feed and care himself that’s why he needs his parents support and care.

VI. SPIRITUAL DEVELOPMENT – As an infant, he has not fully developed his sense of spirituality
PATTERNS OF FUNCTIONING

Eating Pattern
Before Illness During Illness During Hospitalization Analysis
Patient can consume: Patient can consume: Breakfast:

Breakfast: Breakfast: 250mL formula milk The patient’s food intake before and during
through bottle feeding. illness doesn’t change but during
Breast Milk 2 cup of cereals hospitalization, the diet for the patient is on
Lunch: MF-SAP diet.
Lunch: 50mL of formula milk
through bottle feeding. 200mL formula milk
300mL formula milk through bottle through bottle feeding.
feeding. Lunch:
Dinner:
Dinner: 300mL formula milk
through bottle feeding. 200mL formula milk
Breast Milk through bottle feeding.
Dinner:
300mL formula milk through bottle
feeding. Breast Milk

300mL formula milk

through bottle feeding.
Drinking Pattern
Before Illness During Illness During Hospitalization Analysis

Total Intake: Total Intake:

600-800mL of milk per day 2-3 half of bottle of milk 1-1 ½ bottle of milk per day. The intake of fluid before and during illness is still the same
and 100-150mL of water per and 1-2 half bottle of water while during hospitalization the fluid intake decreased.
day. per day.

Intake:

700-950mL/day

Bowel Movement Pattern

Before Illness During Illness During Hospitalization Analysis

Frequency: 3 times a day. Frequency: 2-3 times a day. Frequency: 1-2 times a day. The patient’s bowel movement is still the same
in before and during illness while in the
hospital, the bowel movement decreased.
Bath Pattern
Before Illness During Illness During Hospitalization Analysis

Takes a bath once a day in the morning. Tepid Sponge Bath Tepid Sponge Bath The patient’s bathing pattern
changed to TSB due to his
illness.

Sleeping Pattern
Before Illness During Illness During Hospitalization Analysis

Usually sleeps 8 hours and 3-4 hours nap.
Usually sleeps 8 hours and Sleep 5 hours and 1-2 The patient’s sleeping pattern
3-4 hours nap. hours nap. during hospitalization decreased
because of the Nurses that
interrupt the sleep in giving
meds and taking the vital signs.
LEVEL OF COMPETENCIES
Before Illness During Hospitalization Analysis

Physical
- Baby weighs 7.8 kg or 17.16 lbs. with - His physical appearance is still - Within all normal range.
a length of 30 cm. The weight is the same.
largely influenced by baby’s size at
birth and by his nutrition. His head
circumference is 37 cm. and chest
circumference is 35 cm. within the
normal range.
Emotional
- He needs his parents to fulfill his - Cannot be determined
needs because he can’t manage his
- He feels irritable when
taking his vital sign, that’s
own life as an infant.
why he will cry.

Social
- He expresses himself through crying
- The same in Before Illness, he

to know if he’s hungry or any

expresses himself through - Crying is the one that he
crying. used to interact to his
irritations about his body and this is
parents and other people.
Moral the way to interact with his parents.

- As an infant, he doesn’t know what’s - Cannot determine because of

going on in his world, that’s why he his age. - Cannot determine because
needs his parents to support and of his age.
 guide him.

Spiritual

- Cannot determine because of - Cannot determine because

his age. of his age.
- As an infant, he doesn’t know about
his spiritual level.
Nursing History (Gordon’s Assessment)
Name: Baby X

Address: Marulas, Valenzuela City

Age: 18 mos.

Occupation: None

Religion: Roman Catholic

Race: Filipino

Medical Diagnosis: Bronchial Asthma

Informant: Mr. and Mrs. X

I. Patient perception and expectation related to illness/ hospitalization

1. Why did you come to the hospital?

“Nahihirapan huminga anak ko”

2. What do you think caused your baby to get sick?

“Dahil sa sobrang ubo at sinisipon na din”

3. Has being sick made any difference in your baby’s usual way of life?

“Tingin ko, hindi naman”

4. What do you expect is going to happen to your baby in the hospital?

 “Ineexpect ko na magiging maginhawa ang kalagayan ng baby ko”

5. What is like for being in the hospital?

“Dahil ayoko ng lumala pa ang sakit ng baby ko.”

6. How long do you expect to be in hospital?

“Mga 3-4 days siguro”

7. Who is the most important person for your baby?

“Ako naman palagi kasama at nag aalaga ng baby ko, madalas niya ako hinahanap”

8. What effect has your coming to the hospital had on your family?

“Nag-alala syempre”

9. Are any of your family visit your baby in the hospital?

“Oo. Tulad ng kanyang mga lola at lolo tsaka mga tito at tita”

10. How do you expect to get along after you leave the hospital?

“Siguro babalik na ulit ung lakas ng baby ko”

ANATOMY AND PHYSIOLOGY OF THE LUNGS
Anatomy and Physiology

About the Lungs and Respiratory System

Breathing is so vital to life that it happens automatically. Each day, you breathe about 20,000 times, and by the time you're 70 years old, you'll have taken at least 600
million breaths.

All of this breathing couldn't happen without the respiratory system, which includes the nose, throat, voice box, windpipe, and lungs.

At the top of the respiratory system, the nostrils (also called nares) act as the air intake, bringing air into the nose, where it's warmed and humidified. Tiny hairs called cilia
protect the nasal passageways and other parts of the respiratory tract, filtering out dust and other particles that enter the nose through the breathed air.

Air can also be taken in through the mouth. These two openings of the airway (the nasal cavity and the mouth) meet at the pharynx, or throat, at the back of the nose and
mouth. The pharynx is part of the digestive system as well as the respiratory system because it carries both food and air. At the bottom of the pharynx, this pathway
divides in two, one for food (the esophagus, which leads to the stomach) and the other for air. The epiglottis, a small flap of tissue, covers the air-only passage when we
swallow, keeping food and liquid from going into the lungs.

The larynx, or voice box, is the uppermost part of the air-only pipe. This short tube contains a pair of vocal cords, which vibrate to make sounds.

The trachea, or windpipe, extends downward from the base of the larynx. It lies partly in the neck and partly in the chest cavity. The walls of the trachea are strengthened
by stiff rings of cartilage to keep it open. The trachea is also lined with cilia, which sweep fluids and foreign particles out of the airway so that they stay out of the lungs.

Trachea and Bronchi

At its bottom end, the trachea divides into left and right air tubes called bronchi, which connect to the lungs. Within the lungs, the bronchi branch into smaller bronchi and
even smaller tubes called bronchioles. Bronchioles end in tiny air sacs called alveoli, where the exchange of oxygen and carbon dioxide actually takes place. Each lung
houses about 300-400 million alveoli.

The lungs also contain elastic tissues that allow them to inflate and deflate without losing shape and are encased by a thin lining called the pleura. This network of alveoli,
bronchioles, and bronchi is known as the bronchial tree.

The chest cavity, or thorax, is the airtight box that houses the bronchial tree, lungs, heart, and other structures. The top and sides of the thorax are formed by the ribs and
attached muscles, and the bottom is formed by a large muscle called the diaphragm. The chest walls form a protective cage around the lungs and other contents of the
chest cavity.

Separating the chest from the abdomen, the diaphragm plays a lead role in breathing. It moves downward when we breathe in, enlarging the chest cavity and pulling air in
through the nose or mouth. When we breathe out, the diaphragm moves upward, forcing the chest cavity to get smaller and pushing the gases in the lungs up and out of
the nose and mouth.

In humans, the trachea divides into the two main bronchi that enter the roots of the lungs. The bronchi continue to divide within the lung, and after multiple
divisions, give rise to bronchioles. The bronchial tree continues branching until it reaches the level of terminal bronchioles, which lead to alveolar sacs. Alveolar sacs are
made up of clusters of alveoli, like individual grapes within a bunch. The individual alveoli are tightly wrapped in blood vessels and it is here that gas exchange actually
occurs. Deoxygenated blood from the heart is pumped through the pulmonary artery to the lungs, where oxygen diffuses into blood and is exchanged for carbon dioxide in
the hemoglobin of the erythrocytes. The oxygen-rich blood returns to the heart via the pulmonary veins to be pumped back into systemic circulation.

Human lungs are located in two cavities on either side of the heart. Though similar in appearance, the two are not identical. Both are separated into lobes by
fissures, with three lobes on the right and two on the left. The lobes are further divided into segments and then into lobules, hexagonal divisions of the lungs that are the
smallest subdivision visible to the naked eye. The connective tissue that divides lobules is often blackened in smokers. The medial border of the right lung is nearly
vertical, while the left lung contains a cardiac notch. The cardiac notch is a concave impression molded to accommodate the shape of the heart. Lungs are to a certain
extent 'overbuilt' and have a tremendous reserve volume as compared to the oxygen exchange requirements when at rest. Such excess capacity is one of the reasons
that individuals can smoke for years without having a noticeable decrease in lung function while still or moving slowly; in situations like these only a small portion of the
lungs are actually perfused with blood for gas exchange. As oxygen requirements increase due to exercise, a greater volume of the lungs is perfused, allowing the body
to match its CO2/O2 exchange requirements. Additionally, due to the excess capacity, it is possible for humans to live with only one lung, with the other compensating for
its loss.

The environment of the lung is very moist, which makes it hospitable for bacteria. Many respiratory illnesses are the result of bacterial or viral infection of the lungs.
Inflammation of the lungs is known as pneumonia; inflammation of the pleura surrounding the lungs is known as pleurisy.

Vital capacity is the maximum volume of air that a person can exhale after maximum inhalation; it can be measured with a spirometer. In combination with other
physiological measurements, the vital capacity can help make a diagnosis of underlying lung disease.

The lung parenchyma is strictly used to refer solely to alveolar tissue with respiratory bronchioles, alveolar ducts and terminal bronchioles.[4] However, it often includes
any form of lung tissue, also including bronchioles, bronchi, blood vessels and lung interstitium.

What the Lungs and Respiratory System Do

The air we breathe is made up of several gases. Oxygen is the most important for keeping us alive because body cells need it for energy and growth. Without oxygen, the
body's cells would die.

Carbon dioxide is the waste gas produced when carbon is combined with oxygen as part of the energy-making processes of the body. The lungs and respiratory system
allow oxygen in the air to be taken into the body, while also enabling the body to get rid of carbon dioxide in the air breathed out.
PATHOPHYSIOLOGY of BRONCHIAL ASTHMA
Predisposing Factor Etiologic Factor
 Intense Exposure to irritating stimuli (dust, pollutants)
 Age (11mo)
 Environmental factors (Changes in temperature)
 Gender (male)  Exercise, stressful event
 Family history of asthma
 Family history of asthma

IgE production

Re-exposure to antigen

Mass cell degranulation

Release of chemical

Airway hyper-responsiveness
(ASTHMA ATTACK)

Bronchospasm Further release of leukocytes Altered air exchange No. of mucus by goblet cells
Shortness of breath in mucosa and hypertrophy of
Wheezing Inc. airway submandibular glands
Inflammation of bronchial
Chest tightness walls resistance
Muscle & fatigue
ortness of breath exhaustion Productive cough
MEDICAL MANAGEMENT

The aims are 1) Symptom free period, 2) Maintain maximum PEFR, 3) Minimum medication a. Number, b. Doses, 4) Continuing preventive medication on long
term to reduce BHR, 5) Minimize oral steroids, 6) Cost effectiveness : As compared to developed countries where inhaled B2 + inhaled steroids form the mainstem
in therapy, we still depend a lot on oral medication because they are easily acceptable and relatively less costly.

Drug history - regarding intolerance to oral B2 (tremors, cramps, weakness) to xanthines (gastritis, reflux oesophagitis) should be asked for before planning.

Selection of inhaler device both relieving (B2 agonist) and preventive (DSCG, BDP, BUD) are best taken by inhaled route. This permits small quantities of drug to
be delivered directly to the site of action resulting in early action and minimising side effects to a great extent. Whilst the metered dose inhaler is the most
commonly available device, many patients can’t coordinate activation with inspiration. For these and other problems of manual dexterity a dry powder inhaler or a
spacer or a chamber device is more appropriate. Correct selection of the device and instruction on its use are almost as important as selection of the correct
treatment. However, it is observed that least attention is paid to this subject. What is needed is careful preliminary selection of the best device for that individual
patient followed by careful instructions, follow up and rechecking ofTreatment should be considered in a stepwise manner as described below, at the step most
appropriate for the initial severity of the patient’s condition and medication being continued in past, on day to day basis.

A short course of oral steroids may be needed at any time to control asthma.

Step 1 - Patients who have infrequent symptoms, without sleep disturbance, need B2 agonist preferably by MDI salbutamol 100-200 mg or terbutaline 250-500
mcg 3-4 times a day as required. The alternative is dry powder inhalation by rotahaler. In those who find this difficult, oral form of salbutamol 2-4 mg theophyllin
100-200 mg can be started.

Step 2 - Patients who need to take bronchodilators (B2 + Theophyllin) almost daily, with nocturnal symptoms and persistently low PEFR or abnormal lung
functions require regular inhaled anti inflammatory drugs. 1. Sodium cromoglycate (5-20 mg) 4 times a day (disadvantage - mild, costly, poor compliance as dose
frequently is very high), 2. Inhaled steroids beclomethasone diproprionate (BDP) or Budesonide (BUD) 100-400 mcg twice daily.

Step 2 - (Alternative) Considering the cost and difficulty in acceptance of inhaled medication, non availability of trained persons to instruct and follow inhalation
technique, a trial of theophyllin is worth a while when it has been shown to have anti inflammatory effects. Theophyllin (Anhydrous and preferably long acting) in
the dose of 10 mg/kg/day, if tolerated, increase the dose, in increments of approximately 25% at 3 day interval to 16-18 mg/kg/day. Make sure that patient has no
gastritis or reflux oesophagitis.
Step 3 - Persistent symptoms esp. at night with low peak expiratory flow rates. Add theophyllin with anti inflammatory drugs if it has not been started. A long acting
B2 agonist (salmeterol) should be added. Oral long acting salbutamol (4-8 mg) or terbutaline (5-7.5 mg) can be used as an alternative.

Step 4 - Maintenance treatment with oral corticosteroids. This is given if adequate control is not achieved in step 3. Preparation with short half life e.g.
prednisolone is preferred, esp. in alternate day regimen to minimise suppression of adrenal pituitary hypothalamic axis.

Step 5 - High dose of inhaled bronchodilators with nebuliser with special solution of salbutamol (5 mg) terbutaline (10 mg) 3-4 times/day. The use of nebuliser
without proper evaluation is not advisable. Before considering giving nebuliser bronchodilator, increased bronchodilator, increased bronchodilation without
unacceptable side effect should be demonstrated.

Step 6 - High dose of inhaled bronchodilators with nebuliser, steroids BDP or BUD should be increased to a maximum daily dose of 2 mg. A large volume spacer
device is recommended to reduce oropharyngeal candidiasis and systemic absorption. Internationally this is advocated at step 3 but because of high cost of
therapy it is not practical in India.

Step 5 and 6 should be considered depending upon patient’s economic background.

Step 7 - Treatment with short course of oral steroids : 1. Symptoms and PEFR gets progressively worse each day, 2. Sleep is disturbed by asthma, 3. Morning
symptoms persist until midday, 4. Emergency nebuliser or injectable bronchodilators are needed. Give prednisolone 2 to 40 mg daily until two days after full
recovery, when the drug may be stopped or the dose tapered.

Step down - The patient’s requirement for treatment should be reviewed from time to time. If asthma is well controlled, (asymptomatic, optimum PEFR) a step wise
reduction in the medication must be planned. In chronic asthma a 6 month period of stability should be shown before stopping anti inflammatory drugs.

OTHER TREATMENT

Anti histaminics including ketotifen have proved disappointing in clinical practice. There is anecdotal evidence that some patients have benefitted from the use of
acupuncture, ayurvedic and homoeopathic treatment but so far there are no controlled clinical trials to justify the same. Hyponsensitization / desensitization is also
not accepted because of uncertainty about the result, cost and availability of better treatment.

5. Give sufficient doses to maintain best lung function

This is possible with regular monitoring of PEFR at home. If normal PEFR can’t be achieved, the best PEFR readings can be maintained.

6. Investigate trigger factor

This requires taking a careful history and performing skin test (pollens, fungi, animal dander, mite, dust, etc.) and in some cases provocational tests with
occupational ingested agents. Where it is practical, these trigger factors should be removed.

7. Treat aggravating conditions

Asthma is worsened by smoking, rhinitis, gastric reflux, and excessive snoring. Smoking should cease. The other conditions should be investigated and treated.

8. Write a crisis plan

A patient has to be briefed about the symptoms of exacerbation and medicines to be taken in emergency. They should be taught diaphragmatic breathing to
minimise sense of breathlessness.

9. See the patient regularly

Regular visits are needed to monitor progress, reassure the patient, check inhaler technique, and adjust doses of bronchodilators. This will prevent exacerbation
and hospitalization.

10. Minimise therapy

DRUG STUDY

Name of Drug Classification Dose Mechanism Specific Side Effects Nursing Implications
Generic Frequency of Action Indication
(Brand) Route
Acetaminophen antipyretics, 1.2 mL Inhibits the synthesis of Mild pain Hema: hemolytic anemia, BEFORE:
(Paracetamol) nonopioid q 4 hr PRN prostaglandins that Fever neutropenia, ~ Advise parents or caregivers to check concentrations
analgesics od may serve as leukopenia, of liquid preparations. Errors have resulted in
mediators of pain pancytopenia. serious liver damage.
and fever, primarily Hepa: jaundice ~ Assess fever; note presence of associated signs
in the CNS Metabolic: hypoG (diaphoresis, tachycardia, and malaise).
GI: HEPATIC FAILURE, DURING:
HEPATOTOXICITY ~ Adults should not take acetaminophen longer than
(overdose) 10 days and children not longer than 5 days
GU: renal failure (high unless directed by health care professional.
doses/chronic use). ~ Advise mother or caregiver to take medication
Derm: rash, exactly as directed and not to take more than the
urticaria. recommended amount.
AFTER:
~ Advise patient to consult health care professional if
discomfort or fever is not relieved by routine
doses of this drug or if fever is greater than
39.5°C (103°F) or lasts longer than 3 days.
 Name of Drug Classification Dose Mechanism Specific Side Effects Nursing Implications
Generic Frequency of Action Indication
(Brand) Route
Salbutamol Brochodilator Salbutamol Synthetic sympathomimetic To relieve CNS: tremors ·
Nebulizer amine and moderately Bronchospa sm associated Nervousness Position patient on high back
q8º 12nn Selective beta2- with acute or chronic asthma, Headache rest
Adrenergic agonist with bronchitis, or other Insomnia · Do back tappig after you nebulize the patient
comparatively long reversible obstructive · Do not give food immediately. It can cause
action. Acts more airway diseases. CV: Tachycardia vomiting
prominently on beta2 Also used to prevent Palpitations
receptors (particularly Exercise induced Hypertension
smooth muscles of bronchospasm
bronchi, uterus, and GI: Nausea
vascular supply to skeletal Vomiting
muscles) than on beta1 (heart) Heartburn
receptors. Minimal or Anorexia
no effect on alphaadrenergic Metabolic:
receptors Hypokamlemia
NURSING CARE PLAN

ASSESSMENT DIAGNOSIS BACKGROUND PLANNING INTERVENTION RATIONALE EVALUATION

KNOWLEDGE

SUBJECTIVE:  Ineffective Bronchial Asthma  Within 30mins INDEPENDENT:  After 30mins of

airway clearance of nursing  Monitored V/S  To obtain nursing intervention
“Nahihirapan bronchospasm baseline data
r/t bronchospasm intervention the the patient was able to
huminga ang baby  Indicative of
patient will be able  Monitor breath sounds demonstrate
ko” as verbalized by respiratory distress
increased mucus to demonstrate behaviors to improve
the mother and/or
production behaviors to airway clearance
improve airway accumulation of
OBJECTIVE:
clearance secretions
 Abnormal wheezing sounds  Suction naso/oral prn  To clear airway
breath sounds when excessive or
viscous secretion
V/S taken & are blocking airway
recorded as follows: blocking of the
bronchioles  Monitor patient for  That may
Temp: 37. 9°C feeding intolerance, compromise
CR: 106 bpm abdominal distention airways
RR: 33 cpm Ineffective airway and emotional stressor
clearance  Assist with the use of  To clear the
respiratory devices or airway
treatments
 Keep environment
allergen free  To maintain
adequate, patent
airway
DEPENDENT:
  Administer  To mobilize
medications as secretions
prescribed

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS BACKGROUND PLANNING INTERVENTION RATIONALE EVALUATION

KNOWLEDGE
 SUBJECTIVE:  Risk for Upper respiratory tract  After 8 hrs of INDEPENDENT:  After 8 hrs of
Activity infection nursing intervention  Monitored V/S  To obtain nursing
“Hindi masyado Intolerance r/t baseline data
the patient will be intervention the
nagkikilos ang anak presence of  To develop
able to participate  Implement patient was able to
ko” as verbalized by circulatory bronchospasm alternative ways to
in program to physical therapy participate in
the mother responsive remain active.
enhance clarity to program to enhance
problems perform  Note presence  To determine clarity to perform
OBJECTIVE: collection of mucus
of medical the abilityto
secretion perform at a desired
 The patient diagnosis or
manifested low therapeutic level of activity
level of activity. Productive cough regimens.  To promote
 Identify and wellness.
V/S taken and discuss to mother
recorded as follows: Blocking of the bronchioles the symptoms o the
illness.  To sustain
Temp: 37. 9°C
 Refer to appropriate activity level
CR: 106 bpm DOB
RR: 33 cpm resources for
assistance or
Risk for Activity equipments as
Intolerance needed.

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS BACKGROUND PLANNING INTERVENTION RATIONALE EVALUATION

KNOWLEDGE
 SUBJECTIVE:  Imbalanced Pneumonia  Within 3 hrs of INDEPENDENT:  After 3 hrs of
Nutrition: les than nursing intervention  Determine patients  All factors that can nursing
“Nahihirapan dumede body requirements ability to chew, affect ingestion
the patient will be intervention the
ang baby ko” as r/t inability to Bacteria in the lungs swallow food
able to swallow and/or digestion of patient was able to
verbalized by the ingest/digest food food
food swallow food
mother
 Note age, body build,  Helps determine
Weakened immune system
OBJECTIVE: strength, rest level nutritional needs
 Evaluate total daily  Changes that could be
 weakness food intake made in patient’s
nausea may
experience intake
 Promote pleasant &  To enhance food
relaxing environment intake
V/S taken and
recorded as follows: inability to ingest/digest
food  Monitor nutritional
Temp: 37. 9°C  To enhance food
CR: 106 bpm satisfaction
RR: 33 cpm Imbalanced nutrition
:

NURSING CARE PLAN

 ASSESSMENT DIAGNOSIS BACKGROUND PLANNING INTERVENTION RATIONALE EVALUATION
KNOWLEDGE

SUBJECTIVE:  Ineffective Upper respiratory tract  Within 30 mins INDEPENDENT:  After 30 mins
airway clearance infection of nursing  Monitored V/S  To obtain baseline of nursing
“May ubo ang baby data
r/t cough intervention the intervention the
ko” as verbalized by  To maintain
patient will be able  Monitor patient patient was able to
the mother adequate airway
to maintain airway on small feeding maintain airway
Cough  To maintain open
OBJECTIVE: patency  Position the patient patency
at Moderate high airway in at-rest
 Productive cough back rest
to non-productive Non productive cough  Increase fluid intake  To liquefy viscous
cough secretion & improve
secretion clearance
V/S taken and  Assist with the use  To
Productive cough
recorded as follows: of respiratory acquire/maintain
devices or treatments adequate airways
Temp: 37. 9°C
CR: 106 bpm DEPENDENT:
Accumulated secretion
RR: 33 cpm  Administer
medications as  To improve lung
prescribed function
Blocking of the bronchioles

Ineffective airway
clearance

DISCHARGE PLAN
After patient has been hospitalized. He needs an attention and monitoring

AREA CONTENT

MEDICATION Give medication on scheduled time and when the symptom of DOB
occurs.

EXERCISE

HYGIENE Maintain his cleanliness, must render TSB if the patient feel that he is
irritable to improved his comfort.

TREATMENT Maintain his proper ventilation, must maintain clean surroundings to avoid
sudden attacks of his condition about his illness

HEALTH TEACHING

OUT PATEINT The patient should have a monthly check-up for further monitoring and
evaluate his condition about his illness.

DIET Provide milk formula especially breast feed to improve growth and
nutrition.

BIBLIOGRAPHY

 Nurse’s Pocket Guide 11th Edition

 Lippincott’s Nursing Drug Guide 2010 Edition
 Kozier and Erb’s Fundamentals of nursing, 8th edition vol 1
 http://kidshealth.org/parent/general/body_basics/lungs.html#