A Case Presentation of

Bronchial Asthma In Acute Exacerbation

Mapili, Anjelika Eurelle C. Sadol, Bryan C. Zamora, Miguel Rodolfo G.

General Objectives: To fully learn and understand the underlying processes involved in Bronchial Asthma in Acute Exacerbation, its etiological process, complications and treatments for its prevention and termination.

Specific Objectives: To identify the process of Bronchial Asthma in Acute Exacerbation. To enumerate the signs and symptoms of the disease. To trace the Anatomy and Physiology of the systems involved. To trace the Pathophysiology of the disease. To identify the different ways in treating the disease.

Bronchial asthma is a chronic inflammatory disease of the airways, associated with recurrent, reversible airway obstruction with intermittent episodes of wheezing and dyspnea. Bronchial hypersensitivity is caused by various stimuli, which innervate the vagus nerve and beta adrenergic receptor cells of the airways, leading to bronchial smooth muscle constriction, hyper secretion of mucus, and mucosal edema.

An acute asthma exacerbation occurs when the symptoms of asthma worsen suddenly or over a few days.

An acute exacerbation indicates that your asthma is not well controlled. Controller medications include inhaled steroids, which work by decreasing the inflammatory response.

The symptoms of bronchial asthma includes: * a feeling of tightness in the chest * difficulty in breathing or shortness of breath * wheezing * coughing Asthma triggers may include: * Tobacco smoke * Infections such as colds, flu, or pneumonia * Allergens such as food, pollen, mold, dust mites, and pet dander * Exercise

Patients Name: Address: Age: Sex: Civil Status: Religion: Birthday: Room #: Attending Physician: Medical Diagnosis: Chief complaint:

AA REY Balagtas, Bulacan 78 Years Old Female Widow Roman Catholic December 12,1933 802 Dr Joselito Atabug CAP-MN BAIAE HASCVD-NIF Fever

History of present illness: 3 days PTA, patient complained of fever maximum of 38C with productive cough, yellowish sputum. Persistence of symptoms prompted consult hence admission.

Past Medical History: The patient said that in her childhood she never experienced any major illness and was never hospitalized before. She has a Type 2 Diabetes and Hypertension, she said that sometimes she takes some medicine but she cant recall the name of the drug because she seldom takes it because of financial problem. She has a Asthma ever since, her daughter usually buy salbutamol ventolin for her nebulization. She also said that whenever she experienced those common illnesses like fever, cough and colds, flu she just takes Paracetamol and Neozep. The patient has complete vaccines. The patient has no allergies both on food and medicines.

Family History: Patients parents both died from unknown cause. Both parents had Hypertension and in her mother side most of them had history of Bronchial asthma. The patients 2 sons are both Hypertensive. Some of her grandchildren have asthma.

Social History: The patient is non-alcoholic beverage drinker. The patient never tried cigarettes or any tobacco products but the people around her environment are smokers like her 2 sons. The patient lives with her family and relatives in 1 compound. She loves to go outside and talk to her neighbors it is a part of her daily routine. Their house is near from the highway. She is exposed to the air pollution coming from the vehicles

LYDIA HALL AND HER THEORY Lydia Hall was born in New York City on September 21, 1906. She promoted involvement of the community in health-care issues. She derived from her knowledge of psychiatry and nursing experiences in the Loeb Center the framework she used in formulating her theory of nursing. The theory contains of three independent but interconnected circles: the core, the care and the cure

The core is the person or patient to whom nursing care is directed and needed. The core has goals set by himself and not by any other person. The core behaved according to his feelings, and value system. The cure is the attention given to patients by the medical professionals The theory contains of three independent but interconnected circlesthe core, the care and the cure. According to the theory, the core is the person or patient to whom nursing care is directed and needed. The core has goals set by himself and not by any other person, and that these goals need to be achieved. The core, in addition, behaved according to his feelings, and value system.

The cure, on the other hand is the attention given to patients by the medical professionals. The model explains that the cure circle is shared by the nurse with other health professionals. These are the interventions or actions geared on treating or curing the patient from whatever illness or disease he may be suffering from. It is easy to understand from the model that in all of the circles of the model, the nurse is always presents the bigger role she takes belongs to the care circle where she acts a professional in helping the patient meet his needs and attain a sense of balance.

Pattern of Functioning Health Perception and Management

Before Hospitalization
Before hospitalization, the patient tends to walk around the house as her exercise. She thinks of health as an important issue that should not be neglected. Before hospitalization, the patient eats a lot of vegetables in her meals. Does not drink or smoke. She avoids oily foods. Before hospitalization, the patient urinates 3-4 times a day. And defecates twice a day. One in the morning and another before she goes to sleep.

During Hospitalization
During her hospitalization, patient does what she is told to do. She follows what she is told in order to get better quicker. During her hospitalization, patient eats what is given to her. The patients diet is Low Salt- Low Fat diet. During her hospitalization, patients elimination pattern did not change.

Analysis/ Interpretation
Due to her old age patient prioritized her health very seriously, but could not avoid having problems with her body. The patient is careful with what she eats and drinks and stays healthy.

Nutritional and metabolic pattern

Elimination pattern

Patient elimination pattern is normal. There is no difficulty in both urinating and defecating.

Activity and Exercise pattern

Before hospitalization, the patient normally just walks around the house, talking to her neighbours about the latest happening in their lives.
According to the patient she usually sleeps around 8 or 9 pm then wakes up around 2 am.

Due to being hospitalized patient just stays on her bed, watch tv and talks to her relatives.

Due to Patients old age she does not do too much exercise and usually just sits around.

Sleep and Rest pattern

Patient gets more Patient gets a lot of sleep. According to sleep during her stay her daughter the in the hospital. patient gets more sleep because her room is airconditioned and it has more quite environment.

Role and Relationship Pattern

According to her daughter, patient is loved by everyone in the family. She is very close to her family.

Patient was being taken care by her family. They cooperate with each other well and enjoy each others

Patient has a good relationship with her family. They love to laugh and joke around and they became closer.

Coping stress pattern

According to her daughter, when patient feels stress she just talks to the members of the family and then just forgets about what she is stressing about. According to the patients daughter she is not hard to talk to. She answers directly and with focus. Due to patients old age, she feels that she cannot do the things she used to do. Such as cleaning the house and doing chores.

During her hospitalization, patient seemed relaxed. And just uses the television to divert her attention to things that stresses her. During our interview the patient was very cooperative and answers our questions clearly. Due to being hospitalized, patient feels more of a burden because she cannot help at their house and now she has to be taken care of.

Cognitive and Perceptual pattern

Patient greatly relies to her family in coping stress. Usually she just talks to them and things get better. There is no change when it comes to coping to her stressors. Patient has a good sense of perception. She understands her situation and cooperates well with others. Patient does not feel good about being hospitalized because she feels she is giving her family more problems.

Self perception and Self Concept

Sexuality and Reproductive pattern

Patients menarche was at the age of 14 and was menopause at the age of 45.

Values and Beliefs pattern

Before hospitalization, the patient attends mass on Wednesday and Sunday. Goes to church on Monday and Saturday and pray.

During her hospitalization, due to being hospitalized she cannot go to church or attend mass. But she never fails to pray. All the time.

Patient is very religious and attends mass regularly. There will be no change in her strong faith no matter what happens.

Area Assessed

Technique

Normal Findings

Findings

Analysis

A. Skin

Color

Inspection

Light brown,
tanned skin (may vary according to race)

Light brown skin

Normal

Moisture

Inspection/ Palpation

Skin normally dry

Skin normally dry

Normal

Temperature

Palpation

Normally warm

Normally warm

Normal

Texture

Palpation

Smooth and soft

Smooth and soft slightly saggy. Presence of winkles.

Due to her old age.

Turgor

Palpation

Skin snaps back immediately

Skin snaps back immediately

Normal

B. Skin Appendages

Nails

Inspection

Transparent,

Transparent,

Normal

smooth and convex smooth and convex

Nail beds

Inspection

Pinkish

Pinkish

Normal

Nail base

Inspection

Firm

Firm

Normal

Hair distribution

Inspection

Evenly distributed

Evenly distributed

Normal

Color

Inspection

Black to light brown

Black with partly white.

White hair due to her old age.

C. Upper Extremities Arms Palpation Warm to touch and tenderness Warm to touch, no lesions Normal

Palms and dorsal surface

Inspection / Palpation

Pinkish and slightly rough

Pinkish, slightly rough

Normal

Shoulders

Inspection

Perform w/o any Can move difficulty without difficulty.

Normal

Elbows

Inspection

Perform without any difficulty

Can bend without difficulty

Normal

Inspection skull Generally round Round Normal

D. Eyes
Inspection Eyes Non protruding Visual acuity : 20/20 Eyebrows Inspection Symmetrical in size, extension, hair texture and movement Inspection Eyelashes Evenly distributed Evenly distributed Normal Symmetrical in size, extension, hair texture and movement Normal Normal

Inspection Eyelids Same colour as skin Same colour as skin Normal

Inspection Conjunctiva Transparent with Transparent with light pink color Sclera Ears Inspection Inspection Color white Free of Lesions, discharge of inflammation Hearing acuity Inspection Client normally light pink color Color white Free of Lesions, discharge of inflammation Client normally Normal Normal Normal Normal

hears words when hears words when whispered. E. Nose Inspection Nose in the midline; no discharges; no bone or cartilage deviation noted. F. Neck Inspection No mass or lumps; symmetrical; no No mass or lumps; Normal whispered. No tenderness noted; no signs of any discharges Normal

`Inspection lymph nodes

non-tender IF PALPABLE; less

Firm; non-tender and less than 1cm Normal

than 1cm in size.

Inspection thyroid Normally nonpalpable; no nodules palpable

in size

No nodules present

Normal

G. Thorax Auscultation Lungs Normal lung tissue produces resonant sound, diaphragm has dull sound. Pulsation H. Cardiovascular Pulse visible; no lift or heaves. I. Abdomen Inspection Skin colour is uniform, no lesions; some may have presence of striae or No venous engorgement; no tenderness noted; no muscles guarding Normal apical pulsations is present Normal Wheezing is present when the patient is inhaling and exhaling. Abnormal breath sounds due to bronchial asthma in acute exacerbation.

Inspection J. Lower extremities Equal in size; no Equal in size; no edema; no crepitus edema Normal

The upper respiratory tract consists of the nose, sinuses, pharynx, larynx, trachea, and epiglottis. The lower respiratory tract consists of the bronchi, bronchioles and the lungs. The major function of the respiratory system is to deliver oxygen to arterial blood and removecarbon 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 tensionguarding against hypercapnia (excessiveCO2 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 PaCO2inhibits ventilation.helping to maintain respirations (through peripheral chemoreceptor) when hypoxia occurs.

Name: AA REY Sex: Female Date: 8-14-2012 Age: 78 years old Birthday: 12-12-1933 Room #: 802 Requesting Doctor: Dr. Joselito Atabug Lab. ID: 56096
Biochem Result Normal Value Interpretation

Glucose Fasting

8.4mmol/L

3.6-6.1

Cholesterol

4.2mmol/L

Triglycerides

1.72mmol/L

AHDL Cholesterol

1.53mmol/L

Desirable 5.2 Borderline 6.2 High Borderline 2.25 High Very High 0.90 1.55

--

0-

-- 5.2-

It is high because the patient has diabetes. Cholesterol level is Desirable therefore it is within the normal range.

-- > 6.2 -- 1.7Triglyceride is in the borderline level. It is -- 5.64 within the normal -->5.65 range. Normal

LDL Cholesterol

2.10mmol/L

2.60-4.10

Normal

Test Sodium

Result 137mmoL

Normal Value 136-145

Interpretation Normal

Potassium
Chloride

3.7mmoL
99mmoL

3.5-3.1
98-107

Normal
Normal

II-Non-Fasting Blood Urea Nitrogen Creatinine Uric Acid 2.6mmol/L 75mol/L 276mol/L 2.5-6.4 53-115 155-428 Normal Normal Normal

Predisposing Factor

Precipitating Factor

Gender, Age, Family History

Viral Respiratory infection, Change in weather, Smoking and exercise and environment.

Exposure to different pathogens.

Entry of the allergen.

Release of Immunoglobulin E (igE).

Release of different chemical mediators.

Release of different chemical mediators.

Mast cell degranulation.

Release of different inflammatory chemical mediators.

Leukotrienes and other inflammatory mediators.

Prostaglandins Opening of the mucosal intrcellular junction.

Histamine, Bradykinin and other infalammatory mediators

Release of Eosinophils (To combat allergen)

Inflammatory process Mucus production

Increase vascular permeability Bronchoconstriction

Direct stimulation of the vagal efferent. Further Edema

Mucus edema

More release of other inflammatory mediators.

Epithelial damage

Decrease of ciliary function.

Increased airway responsiveness.

Mucus hypersecretion

Wheezing, Continuous coughing, Feeling of chest tightness

Dyspnea, tachypnea and anxiety.

Drug

Dosag Mechanism of Indicatio Contraindicat Adverse e Action ns ions Reaction Hydrocortison e Sodium Succinate is an adrenocortical Steroid with salt-retaining properties. Its synthetic analog form is mainly used for antiinflammatory effects in different disorders in many organ systems. -Allergic disorder -Collagen disease -Disorder of endocrine system -Disorder of eye -disorder of Gastroint estinal tract -Fungal infections, systemic; use not recommended Unless controlling a drug reaction. Hypersensitivit y to Hydrocortison e or any other component of the product. Dermatologi c: Atrophic condition of skin, impaired wound healing, sin ulcer. Endocrine Metabolic: Disorder of Protein Metabolism

Generic 100 Name: mg Hydrocort IV isone Every Sodium 8 Succinate hours Brand 1gram Name: IV SoluEvery Cortef 12 Generic hours Name: Cefuroxi me Axetil Brand Name: Zegen

Nursing Responsibilitie s -Advise patient to avoid vaccines during therapy unless approved by a Physician. -This drug may cause hyperglycemia. -Advise patients to report difficulties in glycemic control. -Instruct patients on prolonged therapy to report blurred.

Drug

Dosag Mechanism of e Action

Indications

Contraindicati ons

Adverse Reaction

Nursing Responsibili ties

Cefuroxime Axetil is a bactericidal semisynthetic cephalospori n that binds to essential target proteins, thereby, preventing the synthesis of bacterial cell walls.

-Disorder of Respiratory System -Disorder of skin -Bells palsy -Breast Cancer -Burn -Cystic Fibrosis

-Intrathecal Administrati on; Serious medical events have been reported . Hypersensiti vity to the cephalospori n group of antibiotics.

Musculosk eletal: Fracture of bone, muscle weakness, Osteoporo sis Neurologic : Headache, raised intracranial pressure

Drug

Dosag Mechanism of Indications Contraindica e Action tions

Adverse Reaction

Nursing Responsibilities

Generic Name:

1 gram IV Cefuroxime Every Axetil 12 hours

Brand Name: Zegen

Cefuroxime Axetil is a bactericidal semisynthetic cephalospori n that binds to essential target proteins, thereby, preventing the synthesis of bacterial cell walls.

-Acute bacterial exacerbat ion of chronic bronchitis -Acute otitis media Bronchitis , acute Secondar y bacterial infection

Hypersens itivity to the cephalosp orin group of antibiotics.

Gastrointe stinal: Diarrhea, Nausea and Vomiting Reproducti ve: Vaginitis Dermatolo gic: Erythema multiforme Immunolo gic: Anaphylax is, Hypersens itivity reaction

-Obtain a careful history before giving/initiatin g therapy to determine previous use and reactions to penicillin or cephalosporin. -This drug may cause diarrhea, nausea and vomiting. The patient should be monitored by his/her watcher.

Drug

Dosage

Mechan ism of Action

Indications

Contraindicatio ns

Adverse Reaction

Nursing Responsibili ties

-Gonorrhea, Uncomplica ted

-Impetigo
-Tonsillitis Pharyngitis

-Assess patient for renal dysfunctio n and adjust accordingly . -Observe patient for signs and symptoms of anaphylaxi s (rash, pruritus, laryngeal edema and wheezing)

Drug

Dosage

Mechanism of Indications Contraindica Action tions

Adverse Reaction

Nursing Responsibili ties

Generic Name:

1 Oral Inhalatio n Salmeterol (50mcg) Xinafoate BID 12 hours Apart

Brand Name:

Seritide

Salmeterol Xinafoate is a longacting beta (2)adrenergic agonist. It stimulates adenyl cyclase resulting in increased intracellular cyclic AMP level which in turns triggers smooth muscles relaxation.

-Asthma -Chronic Obstructiv e Pulmonary Disease -Nocturnal Asthma -Allergic asthma -Cystic fibrosis

-Use for asthma symptoms without a long-term asthma control medication . Hypersens itivity to salmeterol or any componen t of the product.

Musculos keletal: Musculosk eletal pain Respirato ry: Death Asthma Exacerbati on of Asthma

-This drug may cause dizziness, headache, tremors and throat irritation. -Advise patient on proper inhalation technique, depending on the delivery device used. attack.

Drug

Dosage

Mechanism of Action

Indications Contraindica tions

Adverse Reaction

Nursing Responsibili ties

Generic Name: Ipatropium Br, Salbutamo l/ Albuterol Sulfate

Neb every 6 hours

-Blocks the action of acetylcholine at parasympath etic sites in bronchial smooth muscle causing bronchodilati on

Brand Name: Combivent , Ventolin

-Relief and prevention of bronchosp asm. -Ihalation: Treatment of acute attacks of bronchopa sm. Prevention of exercise induced bronchosp asm.

-Patients who is allergic to the drugs.

Musculos keletal: Fine tremor of skeletal -Patients muscle. with Nervous Hypertropi system: c Dizziness, obstructive Tremor, cardiomyo Nervousne pathy. ss and insomnia. - Patients Cardiovas having cular: tachyarrhy Hypertensi thmia. on, edema, palpitation s and arrhythmia

- Advise the patient to rinse mouth with water after using the nebulizer to minimize Dry mouth.

Drug

Dosage

Mechanism of Action

Indications Contraindica tions

Adverse Reaction

Nursing Responsibili ties

Generic Name: Metformin Hydrochlor ide

1 tablet 500 mg OD

Brand Name:

GlumetXR

Metformin hydrochlori de is an oral antihypergl ycemic agent. It lowers both basal and postprandi al glucose levels in type 2 Diabetes patients through several mechanis ms:

-Diabetes mellitus type 2 -diabetes mellitus: Prophylaxi s Gestationa l Diabetes mellitus -Polycystic ovary syndrome -Weight gain, Antipsycho tic therapyinduced

Hypersens itiity to metformin. -Metabolic acidosis, acute or chronic, including diabetic ketoacidos is

Gastroint estinal: Diarrhea, flatulence, indigestion and nausea and vomiting. Endocrine Metabolic : Lactic acidosis Cobalamin deficiency

-Instruct patient to report signs/sym ptoms of lactic acidosis. -Patients should take tablets with meals and extendedrelease tablets with the evening meal.

Drug

Dosage

Mechanism of Action

Indications Contraindica tions

Adverse Reaction

Nursing Responsibili ties

Decreases hepatic glucose production , decreases intestinal absorption and increases peripheral glucose uptake and utilization by improving insulin sensitivity.

- Renal impairmen t Pregnancy -Hepatic impairmen t

-Advise patient to maintain adequate hydration to prevent renal dysfunctio n.

-Patient should not drink alcohol while taking this drug.

Assessmen t Subjective: ok naman ako kaso inuuubo pa rin ako at minsan nahihirapan ako huminga as verbalized by the patient. Objective: -Presence of wheezing sound at auscultation -RR of 25bpm

Diagnosis Ineffective airway clearance as evidenced by wheezing breath sounds.

Planning
After 8 hours of effective nursing intervention the patient will maintain patent airway with clear breath sound and the patient will demonstrate behaviors to improve airway clearance like coughing effectively and expectorate

Intervention Rationale Independent: -Monitor Vital signs. -Auscultate breath sounds, note areas with presence of adventitious breath sounds. -Adequately hydrate the patient. -For baseline data. -Crackles indicate Accumulatio n of secretions and inability to clear airways. -Systemic hydration keeps the secretion moist and easier to expectorate.

Evaluation After 8 hours of effective nursing intervention the patient had maintained patent airway with clear breath sound and the patient had demonstrate d behaviors that improved her airway. Goal was met.

her secretions.

Assessme nt

Diagnosis

Planning

Interventio n

Rationale

Evaluation

Assessme nt

-Teach and encourage the use of diaphragm atic breathing and coughing exercises.

-If there is no fluid restriction, Increase fluid intake up to 3000ml/da y.

-These techniques help to improve ventilation and mobilize secretions without causing breathless ness and fatigue.

-Hydration helps viscosity of secretions, facilitating expectorati on

Assessme nt

Diagnosis

Planning

Interventio n

Rationale

Evaluation

Assessme nt

Collaborati ve: -Assist in administeri ng nebulizer as indicated. Administer antibiotics as prescribed . -These ensure adequate delivery of medication to the airway. -Antibiotic may be prescribed to treat the infection.

Assessmen t Subjective: None

Diagnosis Activity Intolerance related to decrease oxygenation.

Planning After 8 hours of effective nursing intervention the patient will participate willingly in necessary / desired activity such as deep breathing exercises.

Intervention Rationale -Monitor Vital Signs -Note contributing factors for fatigue. -Assess emotional or psychologica l factors. -For Baseline data. -To identify precipitating factor. -Stress depression may increase effect of illness. -To reduce fatigue.

Evaluation After 8 hours of effective nursing intervention the patient had participated willingly in the activity such as deep breathing exercises. Goal was met.

Objective: -Weakness -Immobility

-Plan care with rest periods. -Assist patient to assume comfortable position. -Provide quiet

-To maintain functional position.

-To reduce stress.

Medication Metformin Hydrochlori de 1tablet 500mg OD Seritide 1puff BID

Exercise Treatment Health teaching Encoura ge to do exercises daily such as brisk walking for 30min. Instruct to do deep breathing exercises and do chest up tapping Combiven t every 6hours(Ne b) Encourag e oral fluid atleast 8 to 10 glasses a day Encourag e pt to sit up straight when there is a DOB Encourag e to avoid persons with respiratory infections such as cold,cough ,pneumoni a and many others.

OPD Instruct the patient to visit the physician on the scheduled date of visit Provide photocopy of all laboratory test taken during hospitaliza tion

Diet Low salt Low fat Eat high fiber foods such as fruits and vegetables Avoid salty foods such as dried fish, canned goods and bagoong. Eat fruits with Vit C such as oranges, guava and apple.

Spiritual Encourag e not to lose hope and pray to God o a regular basis asking Him for his constant guidance and blessing continue to have strong faith.