Beruflich Dokumente
Kultur Dokumente
On
Bronchial
Asthma
INTRODUCTION
I. Definition
Bronchial Asthma
Is a chronic disease of the respiratory system in which the airway
occasionally constricts, becomes inflamed and is lined with excessive
amounts of mucus, often in response to one or more triggers.
Bronchial asthma, an inflammation of the airways is the more correct
name for the common form of asthma. The term 'bronchial' is used to
differentiate it from 'cardiac' asthma, which is a separate condition that
develops when fluid builds up in the lungs as a complication of heart failure.
An acute exacerbation of asthma is referred to as an asthma attack. The
clinical hallmarks of an attack are shortness of breath (dyspnea) and either
wheezing or stridor.
In an asthma attack, the air passages of the lungs, known as bronchi,
overreact to substances that are ordinarily harmless. Cells in the airways
known as mast cells release histamines and leukotrienes, which induce
inflammation. These substances prompt the smooth muscles of the airways
to go into spasm and constrict. Soon, the bronchi become inflamed and
release mucus, which further blocks the passage of air. Narrowing of the air
passages is known as bronchoconstriction. When the airways are reduced in
diameter, more effort is required to move air into and out of the lungs, and
breathing becomes difficult.
Asthma can be classified into 3 types according to causative factors:
Atopic or Extrinsic asthma is due to inhaled allergens
II. Causes
Asthma attacks are caused by airway hyperresponsivenessthat is, an overreaction
of the bronchi and bronchioles to various environmental and physiological stimuli,
known as triggers. The most common causes of asthma attacks are extremely small
and lightweight particles transported through the air and inhaled into the lungs.
When they enter the airways, these particles, known as environmental triggers,
cause an inflammatory response in the airway walls, resulting in an asthma attack.
Allergenic air pollution, from nature, typically inhaled, which include waste
from common household pests, such as the house dust mite and cockroach,
grass pollen, mould spores, and pet epithelial cells;
Use of fossil fuel related allergenic air pollution, such as ozone, smog,
summer smog, nitrogen dioxide, and sulfur dioxide, which is thought to be
one of the major reasons for the high prevalence of asthma in urban areas;
Exercise
Allergenic indoor air pollution from newsprint & other literature such as, junk
mail leaflets & glossy magazines (in some countries).
Emotional stress
Atelectasis
Nursing Responsibilities:
Establish rapport to patient.
Ask pertinent questions only.
Maintain nurse-patient relationship.
Perform hand washing before and after Physical assessment
Make sure hands and stethoscope are warm before placing to patients skin
Perform physical assessment effectively.
Document only what is important.
3. Lung function tests
- for asthma include numerous procedures to diagnose lung problems. The two most
common pulmonary function tests for asthma are spirometry and methacholine
challenge tests.
Methacholine challenge test: This lung function test for asthma is more
commonly used in adults than in children. It might be performed if your symptoms
and screening spirometry do not clearly or convincingly establish a diagnosis of
asthma. Methacholine is an agent that, when inhaled, causes the airways to spasm
(contract involuntarily) and narrow if asthma is present. During this test, you inhale
increasing amounts of methacholine aerosol mist before and after spirometry. The
methacholine test is considered positive, meaning asthma is present, if the lung
function drops by at least 20%. A bronchodilator is always given at the end of the
test to reverse the effects of the methacholine.
Using a spirometer, an instrument that measures the air taken into and exhaled
from the lungs, the doctor will determine several values:
Vital capacity (VC), the maximum volume of air that can be inhaled or
exhaled.
Peak expiratory flow rate (PEFR), commonly called the peak flow rate, the
maximum flow rate that can be generated during a forced exhalation.
Forced expiratory volume (FEV1), the maximum volume of air expired in one
second.
5. Sputum eosinophils
This test looks for certain white blood cells (eosinophils) in the mixture of
saliva and mucus (sputum) you discharge during coughing. Eosinophils are
present when symptoms develop and become visible when stained with a
rose-colored dye (eosin).
Nursing Responsibilities:
Instruct patient to clear nose and throat and rinse mouth to decrease
contamination of the sputum.
Instruct patient to cough out the sputum not spit.
Make sure specimen is in a sterile container and deliver it to the lab within
two hours.
Judging the Severity of Asthma
1.
Mild intermittent asthma. Symptoms occur less than twice a week, rare
exacerbation or asthma attacks and infrequent nighttime asthma symptoms. (There
are also specific findings on lung function tests.)
2.
Mild persistent asthma. Symptoms occur more than twice a week, but less
than once a day, and asthma attacks that affect activity. These people do have
nighttime symptoms of asthma more than twice a month. (There are also specific
findings on lung function tests.)
3.
4.
Severe persistent asthma. Continual symptoms occur day and night, limited
activity and frequent asthma attacks. (There are also specific findings on lung
function tests).
VII. Treatment
Medical Management
There are two general process of asthma medication: quick relief medication for
immediate treatment of asthma symptoms and exacerbations and long acting
medication to achieve and maintain control and persistent asthma. Because
of underlying pathology of asthma is inflammation, control of persistent asthma is
accomplish primarily with the regular use of anti-inflammatory medications.
Quick relief medication
Bronchodilators (Short acting beta adrenergic agonists and Anti-cholinergic)
-are the medications of choice for relief of acute symptoms and prevention of
exercise-induced asthma. They have the rapid onset of action.
You take them when you are coughing, wheezing, having trouble breathing, or
having an asthma attack. They are also called "rescue" drugs.
Long-acting control Medication
1. Corticosteroid
-are the most potent and effective anti inflammatory currently available. They are
broadly effective in alleviating symptoms, improving air way functions, and
decreasing peak flow variability. These medications are contraindicated in acute
asthma exacerbation.
2. Long acting beta-adrenergic agonist is use with anti-inflammatory medications to
control asthma symptoms, particularly those that occur during the night these
agents are also effective in the prevention of exercise-induced asthma.
3. Leukotriene Receptor Antagonists
-Direct antagonist of mediators responsible for airway inflammation in asthma.
- Used for prophylaxis of EIA and long-term treatment of asthma as alternative to
low doses of inhaled corticosteroids.
4. Mast Cell Stabilizers
- Prevent the release of mediators from mast cells that cause airway inflammation
and bronchospasm.
5. Combination Beta-Agonist/ Corticosteroid
- Advair is a unique inhaled combination medication used frequently in the
treatment of asthma.
- It consists of a long-acting beta-agonist (salmeterol) and inhaled corticosteroid
(fluticasone).
6. 5-Lipoxygenase Inhibitors
- Inhibit the formation of leukotrienes. Leukotrienes activate receptors that may be
responsible for events leading to the pathophysiology of asthma, including airway
edema, smooth muscle constriction, and altered cellular activity associated with
inflammatory reactions.
Nursing Responsibilities:
Check doctors order
Confirm right client
Assess or ask if patient has any allergies to certain kinds of drugs
Check if the patient manifests contraindications of the drug
Calculate the right dosage of drug
Explain the action of the drug
Administer drug to the right route
Observe patient if patient shows any allergies
Instruct client to report any discomforts
NURSING MANAGEMENT:
VIII. Prevention
Patient with recurrent asthma should undergo test to identify the substance that
participate the symptoms. Patients are instructed to avoid the causative agents
whenever possible. Knowledge is the key to quality asthma care.
PATIENTS PROFILE
Name:
Mrs. A.C
Age:
75 y/o
Gender:
Female
Date of Birth:
Status:
Address:
Nationality:
October 2, 1937
Widow
Balzain West. Tuguegarao City
Filipino
Religion:
Jehovas Witness
Date of Admission:
Time of Admission:
6:05 AM
Chief Complaint:
Attending Physician:
Admitting Diagnosis:
Exacerbation
Date of discharge:
Time of discharge:
8:00 am
Source of information:
NURSING HISTORY
Past History
According to the patient, she never had any of the vaccines when she was a
child because vaccines were not yet widely offered in the country that time. She
experienced having mumps, chicken pox, and measles. She also added that she was
often bitten by a dog, maraming beses na, siguro mga apat o lima. When further
asked if what were the interventions done, she said that hinuhugasan ko lang ng
maigi gamit yung sabong panlaba, pagkatapos pinapahiran ko ng bawang. When
asked if she had any allergies on food and medication, none of these were mentioned
but she verbalized that she experiences allergic symptoms when exposed to dust.
She said that when she encounters sickness like headache and toothache, she just
took a rest but if she cant tolerate it anymore she takes OTC drugs. She added that
whenever she experiences having cough her mother would let her drink her excreted
urine in the morning. When further asked if how could this help her, she just
answered by believing that it would relieved her cough. She added that she had a
history of occasional smoking in her teenage years. She also acknowledged that she
was 47 years old when she was diagnosed of having hypertension and 55 years old
when first diagnosed of having asthma. She added that she copes with it by using her
puff and nebulizer (Symbicort, Ventolin respectively).
puff and nebulizer (Symbicort, Ventolin respectively). On the day prior to admission,
the patient again experienced difficulty of breathing (dyspnea) which prompted her
to seek immediate medical attention. She was then told that she will be needing
confinement as said by the attending physician, Dr. Zinggapan at PGH. She then had
an admitting diagnosis of Bronchial Asthma in Acute Exacerbation. The physician
ordered for the administration of oxygen via nasal cannula to aid the patient in
respiration and nebulization every 4 hours with CPT (Chestphysio Therapy) during
and after nebulization to loosen and expel secretions. The physician prescribed
cefuroxime 750mg, hydrocortisone 100mg and requested the patient to undergo
Diagnostic Tests such as CBC (Complete Blood Count) with APC , Na,K, and Chest XRay.
Family History
FATHER
(
(
(
(
(
(
MOTHER
) Cancer
/) Asthma
) TB
) DM
) Heart Disease
) Hypertension
( ) Cancer
( ) Asthma
( ) TB
( ) DM
( ) Heart Disease
(/) Hypertension
Social History
According to the patient, she stays at home most of the time. Their family
attends mass on Sundays to worship. According to her, she has a good relationship
with her family. And also manages to have a good relationship with her neighbors.
Because of her age and condition (that is having bronchial asthma), her family let her
do simple chores like folding clothes and sometimes washing the dishes . The patient
finished her Elementary Education but wasnt able to continue her H.S and College
education due to financial constraints.
OB History
The patient had her menarche at the age of 13 and usually consumes 2-3
pads per day and it typically last for 4 days. She had her coitarche as soon as she got
married at the age of 20. She then had an OB score of G5P5 (4105). She had her
menopause at the age of 50.
FUNCTIONAL
PATTERN
BEFORE HOSPITALIZATION
DURING HOSPITALIZATION
She considers herself
unhealthy due to her
underlying condition. For her,
she is a bit useless because
she cant do her daily routine of
doing the chores, she easily
gets tired. One more reason
Nutritional Metabolic
Pattern
Elimination
Pattern
Activity Exercise
Pattern
Sleep - Rest
Pattern
Cognitive
Perceptual
Pattern
SelfPerception
Self-Concept
Pattern
Role
Relationship
Pattern
Sexuality
Reproductive
Pattern
Coping
Stress
Tolerance
Pattern
Value Belief
Pattern
Respiration is the process of taking in oxygen, producing energy with it, and
excreting gaseous waste products.
Nose & nasal cavity: The function of this part of the system is to warm,
filter and moisten the incoming air.
Pharynx: Here the throat divides into the trachea (wind pipe) and esophagus
(food pipe). There is also a small flap of cartilage called the epiglottis which
prevents food from entering the trachea.
Trachea: Also known as the windpipe this is the tube which carries air from
the throat into the lungs. The inner membrane of the trachea is covered in
tiny hairs called cilia, which catch particles of dust which we can then remove
through coughing. The trachea is surrounded by 15-20 C-shaped rings of
cartilage at the front and side which help protect the trachea and keep it
open. They are not complete circles due to the position of the esophagus
immediately behind the trachea and the need for the trachea to partially
collapse to allow the expansion of the esophagus when swallowing large
pieces of food.
Bronchi: The left bronchi is narrower, longer and more horizontal than the
right. Irregular rings of cartilage surround the bronchi, whose walls also
consist of smooth muscle. Once inside the lung the bronchi split several
ways, forming tertiary bronchi.
Alveoli: Individual hollow cavities contained within alveolar sacs (or ducts).
Alveoli have very thin walls which permit the exchange of gases Oxygen and
Carbon Dioxide. They are surrounded by a network of capillaries, into which
the inspired gases pass. There are approximately 3 million alveoli within an
average adult lung.
Breath Sounds
Crackles
Crackles are discontinuous, explosive, "popping" sounds that originate within the
airways. They are heard when an obstructed airway suddenly opens and the
pressures on either side of the obstruction suddenly equilibrates resulting in
transient, distinct vibrations in the airway wall. The dynamic airway obstruction
can be caused by either accumulation of secretions within the airway lumen or
by airway collapse caused by pressure from inflammation or edema in
surrounding pulmonary tissue.
Wheezes
Wheezes are continuous musical tones that are most commonly heard at end
inspiration or early expiration. They result as a collapsed airway lumen
gradually opens during inspiration or gradually closes during expiration.
Wheezes may be monophonic (a single pitch and tonal quality heard over an
isolated area) polyphonic (multiple pitches and tones heard over a variable
area of the lung).
Rhonchi
IMMUNE SYSTEM
Immune Response
The immune response is how your body recognizes and defends itself against
bacteria, viruses, and substances that appear foreign and harmful.
Innate Immunity
Innate, or nonspecific, immunity is the defense system with which you were born. It
protects you against all antigens. Innate immunity involves barriers that keep
harmful materials from entering your body. These barriers form the first line of
defense in the immune response.
Cough reflex
Skin
Stomach acid
Acquired Immunity
Passive Immunity
Passive immunity is due to antibodies that are produced in a body other than
your own. Infants have passive immunity because they are born with
antibodies that are transferred through the placenta from their mother. These
antibodies disappear between ages 6 and 12 months.
Immune System Cells and their Primary Functions
Phagocytosis and inflammation;
usually the first cell to leave the
blood and enter infected tissues.
Monocyte
Leaves the blood and enters the
tissues to become a macrophage.
Macrophage
Most effective phagocyte; important
in later stages of infection and tissue
repair; located throughout the body
Neutrophil
Basophil
Mast cell
Eosinophil
Chemical Mediators
Interferons are proteins produced by most cells, thet interfere with virus
production and infection.
Blood Components
The immune system includes certain types of white blood cells. It also includes
chemicals and proteins in the blood, such as antibodies, complement proteins, and
interferon.
Antibody
IgM
5-10
IgA
15
IgE
0.002
IgD
0.2
Description
It can cross the placenta
and provide immune
protection to the fetus and
newborns.
It is responsible for
transfusion reactions in
the ABO blood system.
Secreted into saliva, into
tears, and onto mucous
membranes to provide
protection on body
surfaces; found in
colostrums and milk to
provide immune
protection to newborns.
Binds to mast cells and
basophils and stimulates
the inflammatory
response.
Functions as antigen
binding receptor on B
cells.
Precipitating Factors
-age
pollutants
-gender
-obesity
-race
-history of allergies
-family history
-Psychological stress
-weather
-Hygiene
-Antibiotic use
-Socioeconomic factor
-GERD
-Exercise
-Emotional expression
Stimulation of B lymphocytes
Production of IgE
Attachment of IgE to mast cells and basophils
A
Release of chemical mediators
Inflammation
cAMP
Imbalanced stimulation of beta and alpha
adrenergic receptors
mucous production
Capillary dilation
bronchospasm
bronchodilation
Cough
Wheezing
Hyperventilation
Tachycardia
Elevated Blood pH
Tachypnea
Respiratory Alkalosis
hypoventilation
Compensating mechanism failed
Respiratory failure
Fatigue
Hyperinflation of alveoli
D
B
B
Hypoxemia
breakdown of fats
E
C
Hypoxia
Cellular Ischemia
Tissue necrosis
Vital Organ Failure death
Death
increased fatigue
Hyperventilation
Lactic Acid production
Production of fats
Ketone formation
Metabolic acidosis
metabolic acidosis
Hypoventilation Headache Mental dullness Kussmauls breathing Hyperkalemia