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I.
II.
Diagnosis or Impression
Impression: Bronchial Asthma in acute exacerbation, Hypotension Stage II uncontrolled.
III.
Pathophysiology
Chief Complaint: Chest Pain Patient is known asthmatic with last major attack last year for which he was admitted at our institution and given maintenance medication for which he is compliant, but stopped the inhaler. 1 day PTA ------------- (+) colds, (+) difficulty of breathing, (+) cold clammy skin Conscious, medium built BP: 220/120, CR: 101, RR: 25, T: 36.2 Anicteric Sclera, (+) nal discharges
Symmetrical chest expansive, (+) wheezes are on both lungs Apical beat at the 5th ECS, MCL, tachycardia, regular rhythm S1bS2 NABS (-) edema, (-) cyanosis Bronchial asthma in acute exacerbation t/c Pneumothorax and ACS HPN uncontrolled
IV.
CBC: WBC Differential Count Neutrophil Lymphocytes Monocytes Eosinophils Basophils Hemoglobin Hematocrit RBC MCV MCH MCHC RDW Platelet MPV
Result: 9.7 0.31 0.49 0.09 0.08 0.03 154 0.44 5.2 86 29.7 347 12.5 255 4.16
Normal Values: 5.0 - 10.0 x10 g/L 0.40 0.60 0.20 0.40 0.02 0.08 0.01 0.03 0 0.2 140 175 g/L 0.42 0.48 5.5 6.5 x10 g/L 88-96 27.33 300 360 g/L 12.7 22.7% 150 450 x10 g/L 4.5 7.5
Please admit to ROC lender the service of Dr. X Guevara (medicard) Secure consent for admission & mgt. TPR & Shift IVF: DBW 500cc x KVO Soft Hypoallergenic diet
V.
Diagnostic Procedures - Chest X-ray - 12 LECG - CBC TFK - ABG req. - Spirometer - Urinalysis
- Trop T, Qualitative - Crea and electrolytes - FBS, TG, TC, LDl, HDL
VI.
Medical Management
1) 2) 3) 4) 5) Salbutamol nebulization Hydrocortisone 200 mg. now then 100 mg. IV q8 Amynophilline drip at 10 gtts./min. Dolcet tablet q8 for pain Amlodipine 5 mg. 1 tab now then OD CBR with bathroom priveldges O2 at 2 LPM via nasal cannula IPO Monitor VS q1 Admitting Hx RPE c/o Complete database q0 CIC
VII.
Contraindications:
> Hypersensitivity to
adrenergic amines. > Hypersensitivity to fluorocarbons.
9. Arrhythmias 10. Hypertension 11. Nausea and vomiting 12. Hyperglycemia 13. Hypokalemia
Hydrocortisone
relieve symptoms of acute bronchial asthma and treatment of bronchospasm associated with chronic bronchitis and emphysema.
Aminophylline
relieve symptoms of acute bronchial asthma and treatment of bronchospasm associated with chronic bronchitis and emphysema.
1. Severe allergic reaction 2. Diarrhea 3. Confusion 4. Fast Breathing 5. Headaches 6. Vomiting 7. Nausea
Dolcet
1. Drowsiness 2. Nausea 3. Dizziness 4. Constipation 5. Headache 6. Vomiting 7. Diarrhea 8. Dry Mouth 9. Fatigue 10. Indigestion 11. Seizure
Amlodipine
> used to manage o hypertension, chronic stable angina, and vasospastic angina. It may be used alone or with other antihypertensives or antianginals.
1. Peripheral Edema 2. Headache 3. Flushing 4. Dizziness 5. Palpitations 6. Nausea 7. Chest Pain 8. Unusual tiredness or weakness 9. Bradycardia 10. Orthostatic Hypotension
o o o o o o o o
Scientific Explanation Inadequate oxygen in the circulation can develop weakness in our muscles. Muscles need oxygen to move and to do its function. If the patient cannot tolerate any activities because of the low oxygenation caused by the ventilationperfusion imbalance caused by the pathological minimized lung expansion.
Planning Choose: Patient will participate willingly in necessary/ desired activities such as deep breathing exercises.
Rationale
Evaluation Patient will participate willingly in necessary/ desired activities such as deep breathing exercises. Patient will perform ADLs within clients ability and participates in desired activities. Patient will be able to increase activity tolerance AEB attendance of selfcare needs. Patient will be able to gradually increase activity within level of ability (change will to shall then shift to past tense)
1. For baseline 2. Assess data. motor 2. To function. identify 3. Note causative contributing factors. factors to 3. To fatigue. identify 4. Evaluate precipitati degree of ng deficit. factors. 4. To identify severity. 5. To identify necessity of assistive devices. 6. Stress and/or depressio n may increase the effects of illness. 7. To reduce fatigue
Patient will 5. Ascertain perform ability to ADLs stand and within move clients about. ability and 6. Assess participates emotional in desired or activities. psychologic al factors Patient will 7. Plan care be able to with rest increase periods activity between tolerance activities AEB 8. Increase attendance activity/exe of self-care rcise needs. gradually such as Patient will assisting be able to the patient gradually in doing increase PROM to activity active or within level full range of of ability motions. 9. Provide adequate rest periods. 10. Assist client in doing self
care needs 9. To replenish energy. 10. To promote independ ence and increase activity tolerance 11. Promotes venous 12. Maintains functional position
11. Elevate arm and hand 12. Place knees and hips in extended position
Assessment Subjective: (none) Objective: wheezi ng upon inspirati on and expirati on dyspne a coughin g, sputum is yellow and sticky tachypn ea, prolong ed expirati on tachyca rdia chest tightne ss suprast ernal retracti on restless ness anxiety cyanosi s loss of conscio usness
Nursing Diagnosis Ineffective airway clearance RT bronchoconstri ction, increased mucus production, and respiratory infection AEB wheezing, dyspnea, and cough
Scientific Explanation The presence of a foreign microorganism triggers the B lymphocyte to produce antibodies that are specific to that antigen. These antibodies then attach to mast cells in the lungs. The mast cells with the antibody attaches to the antigen and begins to degranulate. This degranulation causes the release of certain chemical mediators, namely, histamine, bradykinin, prostaglandin, and leukotriene. These chemical mediators cause bronchospasm leading to bronchoconstri ction, increased vascular permeability leading to fluid leakage from the lung
Planning Choose: Patient will maintain/im prove airway clearance AEB absence of signs of respiratory distress Patient will verbalize understandi ng that allergens like dust, fumes, animal dander, pollen, and extremes of temperature and humidity are irritants or factors that can contribute to ineffective airway clearance and should be avoided. Patient will demonstrate behaviors that would prevent the recurrence of the problem
Interventions 1. Adequately hydrate the pt. 2. Teach and encourage the use of diaphragma tic breathing and coughing exercises. 3. Instruct pt to avoid bronchial irritants such as cigarette smoke, aerosols, extremes of temperatur e, and fumes. 4. Teach early signs of infection that are to be reported to the clinician immediatel y. Increas es sputum product ion Change in color of sputum Increas ed
Rationale 1. Systemic hydration keeps secretion moist and easier to expectora te. 2. These technique s help to improve ventilatio n and mobilize secretions without causing breathless ness and fatigue. 3. Bronchial irritants cause bronchoco nstriction and increased mucus productio n, which then interfere with airway clearance. 4. Minor respirator y infections that are of no conseque nce to the person with
Evaluatio n Short Term: The pt shall be free from any signs of respirator y distress
Long Term: The patient shall have demonstr ated behaviors and understoo d causative factors to prevent recurrenc e of problem.
vasculature and increased mucus production. These lead to swelling of the bronchi, mucus buildup that plugs the airway and decreased bronchial diameter. This causes an increased airway resistance and a constricted pathway for air. Air cannot pass effectively and this manifests as a whistling sound. Coughing is a way to expel the obstruction (mucus plug) while dyspnea is a manifestation of the increased airway resistance.
thickne ss of sputum Increas ed SOB, tightne ss of chest, or fatigue Increas ed coughin g Fever or chills
5. If indicated, perform postural drainage with percussion and vibration in the morning and at night as prescribed. 6. Assist in administeri ng nebulizer, as indicated. 7. Administer ATX as prescribed.
normal lungs can produce fatal disturbanc es in the lungs of an asthmatic person. Early recognitio n is crucial. 5. Uses gravity to help raise secretions so they can be more easily expectora ted.