INTRODUCTION Asthma is a chronic inflammatory respiratory disorder that causes

recurrentepisodes of wheezing, breathlessness, chest tightness and cough, especially atnight or in the early morning. These asthma episodes are associated with airflowlimitation or obstruction that is reversible either spontaneously or with treatment.Asthma usually begins in childhood or adolescence, but it also may first appearduring adult years. While the symptoms may be similar, certain important aspectsof asthma are different in children and adults. Asthma affects an estimated 300 million individuals worldwide. Evidence shows that the prevalence of asthma is increasing, especially in children. Annually, the World Health Organization (WHO) has estimated that 15 million disabilityadjusted life-years are lost and 250,000 asthma deaths are reported worldwide.Approximately 500,000 annual hospitalizations (34.6% in individuals aged 18 y or younger) are due to asthma. The cost of illness related to asthma is around $6.2 billion. Each year, an estimated 1.81 million people (47.8% in individuals aged 18 y or younger) require treatment in the emergency department. Among children and adolescents aged 5-17 years, asthma accounts for a loss of 10 million school days and costs caretakers $726.1 million because of work absence. The latest data from Centers for Disease Control indicate an asthma prevalence rate of 8.4% in the United States.( William F Kelly III, MD, Assistant Professor of Medicine, Uniformed Services University of the Health Sciences; Staff Physician, Division of Pulmonary/Critical Care Medicine,

Department

of

Medicine,

Walter

Reed

Army

Medical

Center,

http://emedicine.medscape.com/article/137501-overview) Asthma is the third leading cause of hospitalization among children under the age of 10. Approximately 32.7 percent of all asthma hospital discharges in 2006 were in those under 10, however only 20.1% of the Philippine population was less than 10 years old.In 2005, there were approximately 679,000 emergency room visits were due to asthma in those under 10.( Region NCR Agenda SETTING THE HEALTH RESEARCH PRIORITIES 2006.)

According to the City Health Office Of Tagum there are 1.48 % children less than five year old diagnose with bronchial asthma in the year 2009, <1 for (m) 1 reported case (F) 0,Age 4 (m) 2 and for (F) 4 reported case.(city health office of tagum CY: 2009) The Group has chosen this Case for us to improve our skills and knowledge pertaining on caring for patients with High Risk Pedia and to be able for us to learn such case in the process of the study.

OBJECTIVES:

GENERAL: y This study aims to deepen our knowledge about bronchial asthma. To be able to identify possible interventions that can be done to decrease the possibility of further complications. And to identify the factors that lead to the occurrence of the disease.

SPECIFIC: y Gather all relevant information about the patient that will serve us our baseline data for the fulfillment of this case study, y y Perform the head-to-toe physical assessment to the patient. Trace the Pathophysiology of the patient who have bronchial asthma including the underlying symptoms and its predisposing and precipitating factors, y y Review the anatomy and physiology of the affected organs, Formulate nursing care plans based on the problem. And evaluate the appropriate interventions to be apply, y Establish rapport to gain clients/mother (pedia patient) attaining relevant information. cooperation in

Developmental history

THEORY

THEORIST

AGE

STAGE

TASK

FINDINGS

Psychosoci al theory

Erik Erikson INFANCY

Trust vs. Mistrust

Normal findings

s 0 TO 1 YEAR OLD The first stage centers on basic needs met by parents. If the parents expose the child to warmth, regularity and dependable affection they develop trust. If they are neglectful

THEORY

THEORIST

AGE

STAGE

TASK

FINDINGS

and abusive the child develops mistrust to them.

Psychosexu al theory

Sigmund Freud

Birth- 1 yr. old

Oral stage - This is related to both the physical focus and the demands being made on the child by the outside

Normal Findings

THEORY

THEORIST

AGE

STAGE

TASK

FINDINGS

world as he/she develops. For each stage, there can be two extremes in psychologic al reaction either doing too much or not enough of what is ideal.

Anatomy & Physiology of the Respiratory System

The respiratory system is responsible for gaseous exchange between the circulatory system and the outside world. Air is taken in via the upper airways (the nasal cavity, pharynx and larynx) through the lower airways (trachea, primary bronchi and bronchial tree) and into the small bronchioles and alveoli within the lung tissue. The organs of respiratory system make sure that oxygen enters our bodies and carbon dioxide leaves our bodies.

Upper Respiratory system Nose- is the passageway of air and which is important for warming, moistening and filtering of air.  The space inside of the nose is shaped like a triangle and is divided into 3 parts: Nostrils - openings of the nose Nasal Septum - divides the nostrils and is important for smell Nasal Passage the space inside of the nose Sinuses- resonating chamber of speech.  Consist of four pairs of bony cavities; lined by nasal mucosa.  Four pairs location y y y y Frontal Ethmoidal Sphenoidal Maxillary

Pharynx- muscular passageway commonly called throat.  3 sections y Nasopharynx which contains adenoids and opening to the Eustachian tubes. y Oropharynx which contains palatine tonsils and also a passageway of air and food. y Laryngopharynx which extends from the epiglottis to the 6 cervical level and also allows air to enter from the nose and the mouth. Larynx- a cartilaginous epithelium lined structure that connects the pharynx and trachea.  This is also known as the voice box. Sound is generated and that is where pitch and volume are manipulated.

Lower Respiratory Tract Trachea-windpipe which extends from the larynx to the 2nd costal cartilage composed of 16-20 c-shaped cartilage rings.  Carina- terminal point when trachea divides into left and right lungs. Bronchi- two branches that arise from the trachea.  Consist of right and left main stem bronchus y y Right mainstem brochus is larger and straighter. Left maistem bronchus is shorter.

Bronchioles- are the first airway branches that no longer contain cartilage. They are branches of the bronchi. The bronchioles terminate by entering the circular sacs called alveoli. Right and Left Lungs  The main organ of respiration and lie within the thoracic cavity.  The right lung divides into 3 lobes and the left lung divides into 2 lobes. Alveoli ducts- arise from the right bronchioles to the alveoli. Alveoli- the cellular unit of the lungs.  Produce surfactant that is responsible for reduce surface tension and prevents alveolar collapse.  35% alveolar gas exchange to the alveolar ducts and 65% alveolar gas exchange to the alveolar sacs.

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.

 

Pathophysiology

File name: pathophysiology of brochial asthma by jayster

Chief complaint: Cough EENT: (+) sunken eyeballs Neck: thyroid, lymph nodes (+), dry lips Lungs: (+) crackles Impressions: URTI; BA in AE

X-ray result Chest APL: Heart is normal in size. Patchy infiltrates are noted in both lungs fields. Impression: suggestive of bilateral pneumonia LAB TEST: Salmonella typhi Igb & IgM negative/ probably not typhoid Hematology Segmentres (0,55-0,65) = 6 AM Basophils (0-0,005) = 255 Hematocrit = 0.35 Dengue Igb & IgM Negative Urinalysis Color: yellow Appearance: clear Sugar: Negative Reaction: acidic Fecalysis: Color: yellow Consistency: 100 IE Pus cells: 0-1 Specific gravity: 1-005 Albumin: Negative Epithelial cells: few Pus cells: 2-3

Hematology: Hemoglobin Female (120-150):125 Leukocyte: (5-10) 7,7 Segmentres: (0,55-0,65) 0.67 Lymphocytes: (0,25-0,40) 0,27 Monocytes: (0,02-0,06) 0,05 Eosinophils: (0,01-0,05) 0,01 Thrombocyte: (150-300) Hematocrit: 0,38

Intravenous Fluid Date 1/22/11 1/22/11 1/23/11 1/24/11 1/25/11 1/26/11 Shift 73 117 311 73 117 311 73 # of Fluid 1 2 3 4 5 6 7 Fluid D5 0.3 NaCL D5 0.3 NaCl D5 IMB D5 IMB D5 IMB D5 IMB D5 IMB Volume 500cc 500cc 500cc 500cc 500cc 500cc 500cc cc/ 45 cc/ 45 cc/ 45 cc/ 45 cc/ 45 cc/ 45 cc/ 45 cc/

NURSES NOTES 1/22/11 6 am-Received and admitted this 1 yr.old,F, in due to cough and fever, under the service of Dr. Mae Dalisay, VS checked and recorded. Dr. Delos Reyes resident on duty orders laboratory and requested, started with IVF of D5 0.3 NaCl 500cc @ 40 cc/ , infusing well @ left metacarpal vein; Salbutamol nebulisation as ordered, transported per wheelchair cuddled by mother; endorsed to ward NOD----------------------------------------------------------------Received lying on bed; awake and responsive, on hypoallergenic diet, on going IVF # 1D5.3 NaCl 500 cc @ 40cc/ infusing well and regulated. VS checked and recorded. Lab results attached to chart seen and examined by Dr. M.Dalisay with orders made and carried out. Due meds given as ordered. Endorsed to NOD.--Received patient on bed awake and responsive, with watchers @ bedside with on going IVF #1 D5.3 NaCl 500cc @45cc/ ; infusing well and regulated accordingly. VS checked ad recoreded. On hypoallergenic diet with aspiration precaution. Due meds given as prescribed. Endorsed.-----------------------------Received patient on bed asleep on HAD with IVF #2 D5.3 NaCl 500cc @ 45 cc/ . VS checked and recoreded. Due meds given as ordered. Still for repeat hematocrit and platelet, dengue serology requested. Cared for continuously.--@ 7:10 am received on bed awake; on HAD; with on going IVF #2 D5 0.3 NaCl 500cc@ the level of 300cc regulated @ 45 cc/ . Attach and infusing well 2 left metacarpal vein. VS checked and recorded within normal range. Endorsed-----Received on bed asleep on HAD. With lon going IVF #3 D5 IMB 500cc @ 45cc/ . Attached and infusing well and regulated @ desired rate. VS taken and recorded. Nebulisation follow up chest X-ray. Due meds given as ordered. Comforted with cool and comfortable env t. Endorsed to NOD.------------------Received patient on bed, asleep, with mother at the side, on HAD, with aspiration precaution, with on going IVF of #3 D5 IMB 500cc@ 45cc/ . Infusing well and regulated accordingly. VS checked and recorded. Provided with restful env t. Due meds given as prescribed. Endorsed to NOD.--------------Received on bed awake, on HAD with aspiration precaution; IVF #4 D5 IMB 500cc@ 45cc/ , infusing well @ left metacarpal vein; VS checked and recorded; due meds given as ordered. 12:40 pm seen and examined by AP with new orders made and carried out.-----------------------------------------------------Received on bed, resting on bed, on HAD with aspiration precaution with on going IVF #4 D5 IMB 500cc@ 45cc/ . Infusing well and regulated @ desired rate. VS taken and recorded. Due meds given as ordered. Endorsed to NOD.----

117

73

311

117
1/23/11

73 311

117

1/24/11

73

311

117

1/25/11

73

311

117
1/26/11

73

Received lying on bed, awake and responsive, on HAD, with on going IVF #5 D5 IMB 500cc @ 45cc/ , infusing well and patent. VS checked and recorded, due meds given as ordered. Endorsed to NOD.---------------------------------------------7am received patient on low fowler s position, asleep with watcher @ bedside, with on going IVF #5 D5 IMB 500cc @45cc/ infusing well @ left metacarpal vein with the level received @ 15occ, assessment done, very cooperative, skin is intact without any lesion. Placed on HAD, @ 8 AM VS checked and recorded. Bedside care done @ 9am above IVF consumed and followed with the same fluid #6 D5 IMB 500cc@ 45cc/ @ 12pm VS rechecked and recorded with the result, due Ambroxol HCl 15/5 25ml TID given, due Salbutamol nebulisation 22cc q 6 given, due Xylitol 5% teething gel checks inner palate and tongue, health teachings recorded as follow: instruct watcher to give meds on time with correct dosage and schedule @ 3pm due Budesomide 250 ml in 2 ml nebule given as ordered, I & O summed up and recorded, left on bed asleep with watcher @ bedside, with same IVF still on, no untoward unusualities noted, endorsed to NOD.------------------------------------------------------------------@ 3:10 PM received on bed awake, responsive, with on going IVF #6 D5 IMB 500cc@ 45cc/ hooked and infusing well; patent and dry; VS checked and recorded; afebrile; due meds given as ordered. All needs attended, bedside care done; watched and cared for.---------------------------------------------------------Received lying on bed, awake and responsive, on HAD, with on going IVF #6 D5 IMB 500 cc@ 45cc/ , infusing well and patent. VS checked and recorded, due meds given as ordered. Endorsed.---------------------------------------------------------Received on bed. On HAD, with on going IVF #6 D5 IMB 500cc@ 45cc/ , infusing well and regulated accordingly. @ 8 am, above IVF consumed and followed up with #7 D5 IMB 500 cc@ 45cc/ regulated accordingly. VS checked within normal range. Medicated as ordered, watched and cared for.--------------

DATE/SHI FT

NAME OF THE DRUG

DOSAGE/TIM E ROUTE

INDICATION

CONTRAINDICATION

MECHANISM OF ACTION

SIDE EFFECT

NURSING RESPONSIBILITIE S

GENERIC NAME Ambroxol BRAND NAME AmbroLex CLASSIFI CATIONl: Expectorant DRAWIN G:

TSP. BID.

Acute & chronic disorders of the patient associated with pathologically thickened mucus & impaired mucus transfer.

HypersensiTivity to ambroxol.

It acts by increasing the respiratory tract secretion of lower viscosity mucus& exerting a positive influence on the alveolar surfactant system which leads to improve mucus flow and transport.

-allergic skin reaction.

-assess for any

signs of allergy. -report any signs of unusualities after giving the medication.

DATE/SHI FT

NAME OF THE DRUG

DOSAGE/TIME ROUTE

INDICATION

CONTRAINDICATION

MECHANISM OF ACTION

SIDE EFFECT

NURSING RESPONSIBILITIES

GENER -IC NAME Paracetamol BRAND NAME Tempra CLASSI FICATI ONl: Analges ics DRAWI NG:

TSP. TID.

Fever & minor aches, pains associated with common Colds.

-renal hepatic impairment.

Decreases fever by inhibiting the effects of pyrogens on the hypothalamic actions leading to sweating and vasodilatation relieves pain by inhibiting prostaglandin synthesis at the CNS but does have antiinflammatory action on peripheral prostaglandin synthesis.

-Skin rashes & other allergic reaction.

-assess for
any signs of allergy such as itching. -assess for the history of hepatic impairment. -Closely monitor the patients condition and immediately report to the CI or NOD of any signs of unusualities.

Symptomatology

Signs and Symptoms Dyspnea

actual symptoms 

Analysis Anything that interferes with breathing leads to too little oxygen and too much carbon dioxide in the blood. Dyspnea is often felt when the airway passage is constricted thus air is not adequate to meet the demands of the system. http://firstaid.about.com/od/shortnessofbreat1/Brea thing_Emergencies_Airway_Injuries_Obstructions_ and_Disorders.htm

Wheezing

 Wheezing results from the airways of the lungs narrowing as a result of inflammation, making it more difficult for air to flow through the lung. http://asthma.about.com/od/adultasthma/a/adult_ar t_whz.htm Cough is appropriate as your body tries to expel

Productive Cough

infection, mucus and other foreign material from your body. Productive cough is caused by

increase eosinophil in the area causing Increase mucous production.

http://asthma.about.com/od/asthmabasics/a/basic_ chroniccough.htm

Chest tightness

As your airways become more inflamed, filled with mucus, and the smooth muscles in your airways constrict, chest tightness may be experienced as the inability or perception of not being able to move air in and out of your lungs. http://asthma.about.com/od/asthmabasics/a/basic_ chesttightness.htm

Etiology

Predisposing

Actual findings

Implications

Factors

Hereditary

Research on genetic mutations casts further light on the synergistic nature of multiple mutations in the pathophysiology of asthma, particularly as it is related to the role of platelet-activating factor hydrolyses, an intrinsic neutralizing agent of platelet-activating factor in most humans. (ALA Utah, 2000), (http://www.articlesbase.com/health-

articles/bronchial-asthma-symptoms-and-causes-of-bronchialasthma-396837.html)

Weakened Immune System

On initial exposure to an allergen, the immune system stimulates B cells that then synthesize IgE. The IgE migrates through the body and inserts into Mast cells. Upon second exposure, the allergen binds to the IgE, causes the Mast cells to degranulate and dump a collection of substances called the mediators of inflammation. The ensuant

reaction can be violent and life-threatening. So the immune system recognizes self-proteins and begins to attack the body's own tissues, setting the stage for autoimmune diseases. (http://www.microbiologytext.com/index.php?)

Age

5y.o

No one really knows the exact reasons why more and more children are developing asthma. Some experts suggest that children spend too much time indoors and are exposed to more and more dust, air pollution, and secondhand smoke. Some suspect that children are not exposed to enough childhood illnesses to direct the attention of their immune system to bacteria and viruses.

and below

Gender

According to the Asthma and Allergy Foundation of America, asthma is more common in male children than it is in female children. However, in adults, asthma tends to be more common in women than in men.

Precipitating Factors

Actual findings

Implications

Allergens or infections elicit an infectious reaction of the bronchial Allergen (dust)  mucous membrane. In allergic asthma, an IgE-induced reaction of the immediate type (Type 1 reaction) occurs immediately after inhalation of the allergen. The mast cells in the mucous membrane degranulate and thereby release inflammation mediators like histamine, ECF-A,

bradykinin and leukotrienes ("immediate reaction") (http://www.flexikon.com/Bronchial_asthma#2._Bronchial_hyperreactivit y)

Respiratory Infection

An unspecific bronchial hyperreactivity can be detected in almost all asthmatics. In case of the inhalation of irritants, the hyperreactivity

manifests as a very strong constriction of the bronchial tubes. (http://www.flexikon.com/Bronchial_asthma#2._Bronchial_hyperreactivit y) Air Pollution/ environm ental factors  Air pollution triggers inflammation and irritation of the bronchial tubes leading to the lungs. The bronchial tubes swell up and create mucus, making it hard to breathe, causing coughing and the wheezing sound that is characteristic of an asthma attack. (http://www.ehow.com/facts_5206854_air-pollution-causingasthma.html)