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CASE PRESENTATION OF
BRONCHIAL ASTHMA
IN PARTIAL FULFILLMENT FOR OUR REQUIREMENTS IN
COMPETENCY APPRAISAL 1
PREPARED BY:
GODINEZ, Leo Patrick V M.
LUNAS, Anna Carmela L.
MONGCAL, Joe Marie R.
PALMA, Charmaine J.
REYES, Ericka Jane P.
RITUALO, Philip Gerard A.
UNIDA, Rezelle C.
VALDEZ, Merry-Lhou F.
VERGARA, Bernadeth U.
VIRAY, Jessica May C.
INTRODUCTION
Asthma is a chronic inflammatory disease of the airways that causes airway
hyper-responsiveness mucosal edema, and mucus production. This inflammation
ultimately leads to recurrent episodes of asthma symptoms: cough, chest tightness,
wheezing and dyspnea.
In 1995 the international study of asthma and allergies in children conducted
phase 1 of a worldwide study to describe the prevalence and severity of asthma, rhinitis
and eczema among school children. One hundred fifty five centers in 56 countries
participated, including the Philippines. More than 450,000 children were interviewed
using a one-page written questionnaire or a video asthma questionnaire. The study
showed that the prevalence of asthma symptoms in children varied greatly in different
populations with differences ranging between 20 and 60 fold. The highest prevalence
was found from centers in the United Kingdom, Australia and New Zealand. Three
thousand two hundred and seven children in metro manila aged 13-14 years
participated in the ISAAC. Participants accomplished a 12 month prevalence of selfreported asthma symptoms from written questionnaires and from video questionnaires.
The results showed that approximately 12% and 8% prevalence based on responses to
the written questionnaires and to the video questionnaires respectively. In a subsequent
study, 12.3% of the same population reported wheezing.
Asthma differs from the other obstructive lung disease is that it is largely
reversible, either spontaneously or with treatment. Patients with asthma may experience
symptom-free periods alternating with acute exacerbations, which last from minutes to
hours or days. Asthma can occur at any age and is the most common chronic disease
in the childhood. Despite increased knowledge regarding the pathology of asthma and
the development of better medications and management plans, the death rate from
asthma continues to increase. For most patients it is a disruptive disease, affecting
school and work attendance, occupational choices, physical activity, and general quality
of life.
Allergy is the strongest predisposing factor for asthma. Chronic exposure to
airway irritants or allergens also increases the risk for developing asthma. Common
allergens can be seasonal (e.g. grass, tree and wood pollens) or perennial (e.g. mold,
dust, roaches, or animal dander). Common triggers for asthma symptoms and
exacerbations in patients with asthma include airway irritants (e.g. air pollutants, cold,
heat, weather changes, strong odors or perfumes, smoke), exercise, stress or emotional
upsets, sinusitis with postnasal drip, medications, viral respiratory tract infections and
gastroesophageal reflux. Most people who have asthma are sensitive to a variety of
triggers. A patients asthma condition will change depending upon the environment,
activities, management practice, and other factors.
On a pregnant woman with asthma, they will have difficulty pulling in air; on
exhalation, she has too much difficulty in releasing air that she makes a high pitched
whistling sound from air being pushed past the bronchial narrowing. Asthma has the
potential of reducing the oxygen supply to a fetus leading to preterm birth or fetal growth
restriction if a major attack should occur during pregnancy, although this is not likely
with well-managed asthma. Many women find that their asthma improves during
pregnancy because of the high circulating levels of corticosteroids that are present. A
woman should check with her physician or nurse-midwife about the safety of the
medication she routinely takes for this disorder before pregnancy to be certain it will be
safe to continue using them during pregnancy and breast feeding.
PATIENTS PROFILE
NAME
C. D. R.
ADDRESS
GENDER
Female
AGE
21 years old
BIRTHDAY
CIVIL STATUS
Single
NATIONALITY
Filipino
RELIGION
Roman Catholic
FATHERS NAME :
R. C.
MOTHERS NAME :
F. R.
ADDRESS
ADMISSION DATE :
ADMISSION TIME :
10:10 PM
HOSPITAL NAME :
UPH-DJGTMC
ADMITTING DOCTOR:
Dr. P
ATTENDING PHYSICIAN:
Dra. R
DIAGNOSIS
:
Respiratory Distress
PATIENTS HISTORY
HISTORY
ADMISSION
>Upon admission, the patient
complained difficulty of breathing and
is febrile.
Family History
Obstetric History
>A Housewife.
>Shes taking cigarette.
>She does not exercise.
>Sleeps almost 8 hours a day.
>Taking medications but doesnt
remember the specific name.
PHYSICAL ASSESSMENT
GENERAL SURVEY
EYE
EAR
ABDOMINAL
Function:
1. Gas Exchange. The respiratory system allows oxygen from the air to enter the
blood and carbon dioxide to leave the blood and enter the air. The cardiovascular
system transports oxygen from the lungs to the cells of the body and carbon
dioxide from the cells of the body to the lungs. Thus, the respiratory and
cardiovascular systems work together to supply oxygen to all cells and to remove
carbon dioxide.
2. Regulation of blood pH. The respiratory system can alter blood pH by changing
blood carbon dioxide levels.
3. Voice Production. Air movement past the vocal folds makes sound and speech
possible.
4. Olfaction. The sensation of smell occurs when airborne molecules are drawn into
the nasal cavity.
5. Protection. The respiratory system provides protection against some
microorganisms by preventing their entry into the body and by removing them
from the respiratory surfaces.
Nose
A protuberance in vertebrates that houses the nostrils, or nares, which
admit and expel air for respiration in conjunction with the mouth. Behind the nose
are the olfactory mucosa and the sinuses. Behind thenasal cavity, air next
passes through the pharynx, shared with the digestive system, and then into the
rest of the respiratory system.
Nasal Cavity
Cavity between external nares and the pharynx. It is divided into two
chambers by the nasal septum and is bounded inferiorly by the hard and soft
palate.
N
asal
Cavi
ty
C
avity
betw
een
exter
nal
nare
s
and
the
phar
ynx.
It is
divid
ed
into
two
cha
mbe
rs by
the
nasa
l
sept
um
and
is
boun
ded
inferi
orly
by
the
hard
and
soft
palat
e.
T
he
nasal cavity conditions the air to be received by the other areas of the respiratory
tract. Owing to the large surface area provided by the conchae, the air passing
through the nasal cavity is warmed or cooled to within 1 degree of body
temperature. In addition, the air is humidified, and dust and other particulate
matter is removed by vibrissae, short, thick hairs, present in the vestibule.
The cilia of therespiratory epithelium move the particulate matter towards
the pharynx where it passes into the esophagus and is digested in the stomach.
Oral Cavity
The mouth; consists of the space surrounded by the lips, cheeks, teeth,
and palate; limited posteriorly by the fauces.
Pharynx
The common passageway of both the digestive and respiratory systems. It
receives air from the nasal cavity and receives air, food, and drink from the oral
cavity. Inferiorly, the pharynx is connected to the respiratory system at the larynx
and to the digestive system at the esophagus. The pharynx is divided into three
regions:
o Nasopharynx - located posterior to the choanae and superior to the soft
palate, which is an incomplete muscle and connective tissue
partition separating the nasopharynxfrom the oropharynx.
- Air passes through them to equalize air pressure between
the atmosphere and the middle ear.
o Oropharynx - extends from the soft palate to the epiglottis, and the oral
cavity opens into the oropharynx. Thus, air, food, and drink all
pass through the oropharynx.
o Laryngopharynx - extends from the tip of the epiglottis to the esophagus
and passes posterior to the larynx.
- Foods and drink pass through the laryngopharynx to the
esophagus. A small amount of air is usually swallowed
with the food and drink.
Epiglottis
A flap of elastic cartilage tissue covered with a mucus membrane,
attached to the root of the tongue. It projects obliquely upwards behind the
tongue and the hyoid bone, pointing dorsally.
The epiglottis guards the entrance of the glottis, the opening between
the vocal folds. It is normally pointed upward during breathing with its underside
functioning as part of the pharynx, but during swallowing, elevation of the hyoid
bone draws the larynx upward; as a result, the epiglottis folds down to a more
horizontal position, with its superior side functioning as part of the pharynx. In this
manner it prevents food from going into the trachea and instead directs it to
the esophagus, which is posterior.
Larynx
Is located in the anterior part of the throat and extends from the base of
the tongue to the trachea. It is a passageway for air between the pharynx and the
trachea.
Fine manipulation of the larynx is used to generate a source sound with a
particular fundamental frequency, or pitch. This source sound is altered as it
travels through the vocal tract, configured differently based on the position of
the tongue, lips, mouth, and pharynx. The process of altering a source sound as
it passes through the filter of the vocal tract creates the many different vowel and
consonant sounds of the world's languages as well as tone, certain realizations
of stress and other types of linguistic prosody. The larynx also has a similar
function as the lungs in creating pressure differences required for sound
production; a constricted larynx can be raised or lowered affecting the volume of
the oral cavity as necessary in glottalic consonants.
Trachea
Is a tube that connects the pharynx or larynx to the lungs, allowing the
passage of air. It is lined with pseudostratified ciliated columnar
epithelium cells with goblet cells, which produce mucus. This mucus lines the
cells of the trachea to trap inhaled foreign particles, which the cilia
then waft upwards towards the larynx and then the pharynx where it can either be
swallowed into the stomach or expelled as phlegm.
Lungs
The Lungs are paired organs in the chest that perform respiration. Each
human has two lungs. Each lung is between 10 and 12 inches long. The two
lungs are separated by a structure called the mediastinum. The mediastinum
contains the heart, trachea, esophagus, and blood vessels. A protective
membrane called the pulmonary pleura covers the lungs.
The lungs oxygenate the body because air is breathed in via the nose or
mouth. When a person breathes in, the lungs expand and need assistance from
other muscles in order to function properly. When a person breathes out, or
exhales, the lungs do not need assistance.
Gas Exchange
Oxygen and Carbon Dioxide in partial pressure diffusion gradients between the
alveoli and the pulmonary capillaries and between the tissues and the tissue capillaries
are responsible for gas exchange.
5. As a result of diffusion at the venous ends of tissue capillaries, the PO2 in the
blood is equal to the PO2 in the tissue and the PCO2 in the blood is equal to the
PCO2 in the tissue.
a. Higher centers of the brain (speech, emotions, voluntary control of breathing and
action potential in motor pathways).
b. Medullarychemoreceptors pH, CO2
c. Carotid and aortic body chemreceptors O2.
d. Hering-Breuer reflex (stretch receptors in lungs).
e. Proprioceptors in muscles and joints.
f. Receptors for touch, temperature and pain stimuli.
PATHOPHYSIOLOGY
Non-modifiable Factors:
Age
Gender
Immunity
Hereditary
Modifiable Factors:
Environmental Factors
Pollution
Smoking
Cliamte
Alleregens
Occupation
Lifestyle
Exercise
SleepingPattern
ADL
Diet
Prostaglandins are
released.
Increased vascular
permeability of the
bronchioles.
Narrowing of bronchioles
(vasoconstriction).
Wheezing sound
Secretions
Increase Respiratory
Rate
Dyspnea
MEDICAL MANAGEMENT
During pregnancy
Independent
Consider intubation earlier than usual and call an expert if intubation is required
as it can be more difficult in pregnant women owing to the edema of the
oropharyngeal mucosa
Postpartum Period
Education
DIAGNOSTIC EXAMINATIONS
URINALYSIS
-Is an array of tests performed on urine and one of the most common methods of
medical diagnosis. Using urine dipsticks, in which the results can be read as color
changes, can perform a part of a urinalysis.
Date:
TEST
a. Color
b.
Transparency/
Turbidity
PATIENTS
RESULT
Light Yellow
Clear
NORMAL
VALUE
Straw to Dark
Yellow
Clear to
Slightly Hazy
INTERPRETATION SIGNIFICANCE
Normal
Normal
Normal
Normal
Acidic
4.6- 6.5
Acidic
1.010
1.016- 1.022
Normal
May be caused
by excessive
dietary intake of
purines
---
Normal
------Normal
Normal
------Normal
c. Reaction
d. Specific
Gravity
e. Protein
f. Glucose
g. Pus Cells
h. RBC
Negative
14
few
i. Epithelial
Cells
0-2
0-1
Small
amounts of
Hyaline,
coarse fine
granular,
RBC, WBC,
waxy casts
DIAGNOSTIC HEMATOLOGY
- to check for blood diseases and disorders, infections in blood, oxygen levels in blood,
diabetes, kidney, and liver disease and a host of ailments.
Department of Pathology and Laboratory Hematology
July 02, 2012
COMPONENTS GENDER
Hemoglobin
Hematocrit
Red Blood
Cells
Erythrocyte
Sed Rate
White Blood
Cells
Platelets
M
F
M
F
M
F
M
F
NORMAL
VALUE
120- 150 gm/L
110- 140 gm/L
0.40- 0.54
0.37- 0.47
4.5-6 x10
4.5-5 x10
0- 10 mm/hr
0-20 mm/hr
5.0- 10 x 10
150- 400 x10
HbsAg: ( - )
PATIENTS
SIGNIFICANCE
RESULT
120 gm/L
Normal
0.36
Normal
4.1
Normal
---
---
8.4
Normal
204
Normal
Basophils
0- 0.01
Normal
Eosinophils
0- 0.04
0.01
Normal
Stabs
0- 0.04
Normal
0.50- 0.70
0.84
0.20- 0.40
0.15
0- 0.05
COMPONENTS
Segmenters
Lymphocytes
Monocytes
May due to
inflammatory
diseases
Normal
Normal
1. Simple Disorders
a. Respiratory Acidosis
-
b. Respiratory Alkalosis
- An abnormal condition in which there is a primary increase in alveolar ventilation
relative to the rate of CO2 production.
- PaCO2 is below the expected level and indicates that the ventilation is exceeding
the normal level.
- One of the common causes of Respiratory Alkalosis is Pulmonary Fibrosis.
c. Metabolic Acidosis
- Identified when the plasma HCO3- or base excess falls below normal.
- Can occur when buffers are not produced in sufficient quantities or when they are
lost excessively.
- One of the common causes of Metabolic Acidosis is Ketoacidosis.
d. Metabolic Alkalosis
- Identified by an elevation of the plasma HCO3- above normal.
- Occurs whenever HCO3- ions in the blood or when an abnormal number of H + ions
are lost from the plasma.
- One of the common causes of Metabolic Alkalosis is Loss of gastric fluid (e.g.
Vomiting).
ABG RESULT
PATIENTS
RESULT
pH
7.27
7.35 7.45
Acidemia / Acidosis
PaCO2
78 mmHg
35 45 mmHg
Respiratory Acidosis
HCO3-
26 mEq/L
22 26 mEq/L
Normal
PaO2
71 mmHg
80 100 mmHg
Mild Hypoxemia
SaO2
87%
>95%
---
DRUG STUDY
DRUG
NAME
BRAND NAME
INDICATION
ACTION
NURSING CONSIDERATION
Solucortef
Solucortef
Endocrine,
hematologic,
rheumatic and collagen
disorders;
dermatologic,ophth
GI,
resp
and
neoplastic
diseases. Allergies. Acute
exacerbations
of
TB
meningitis
with
subarachnoid
block,
trichinosis.
Multiple
scelorosis.
Generic Name
hydrocortisone Na
succinate
Frequency
q 6 hrs.
3 days
Route
IV
Dosage
100mg
DRUG
NAME
BRAND NAME
INDICATIONS
Tums
Tums
Generic Name
Ca carbonate
Frequency
OD
Route
Oral
Dosage
2 Tab
ACTION
NURSING CONSIDERATIONS
DRUG
NAME
BRAND NAME
INDICATION
Bricanyl
Bricanyl
Brochospasm
in
bronchial
asthma,
chronic
bronchitis,
emphysema,
other
lung diseases where
bronchoconstriction is
a complicating factor.
Generic name:
terbutaline sulfate
Frequency:
OD (given at ER)
q 6 hours (given
at OB ward)
Route:
SC (ER)
Nebulization (OB)
Dosage:
0.25mg (SC)
ACTION
NURSING CONSIDERATION
DRUG NAME
BRAND NAME
INDICATIONS
Aminophylline
drip
Atlantic
Aminophylline
Symptomatic
treatment
of
bronchial
asthma,
bronchitis,
bronchospasm and
status asthmaticus.
Relieve
periodic
apnea. Adjunct in
treatment
of
pulmonary
edema
and
paroxysmal
nocturnal
dyspnea
caused by left heart
failure.
Generic Name
aminophylline
Frequency
--
Route
IV
Dosage
2 ampules D5W
gtts/min
ACTION
NURSING CONSIDERATION
Competitive
nonselective
phosphodiesterase inhibitor Monitor for S&S of toxicity (generally
which raises intracellular
related to theophylline serum levels
cAMP,
activates
PKA,
over 20 mg/mL). Observe patients
inhibits TNF-alpha and
receiving parenteral drug closely for
leukotriene synthesis, and
signs of hypotension, arrhythmias,
reduces inflammation and
and
convulsions
until
serum
innate
immunity
and
theophylline stabilizes within the
nonselective
adenosine
therapeutic range.
receptor antagonist. Less Note: High incidence of toxicity is
potent and shorter-acting
associated with rectal suppository use
than theophylline. Its most
due to erratic rate of absorption.
common use is in the Monitor & record vital signs and I&O.
treatment
of
bronchial
A sudden, sharp, unexplained rise in
asthma.
heart rate may indicate toxicity.
Lab tests: Monitor serum theophylline
levels.
Note: Older adults, acutely ill, and
patients with severe respiratory
problems,
liver dysfunction, or
pulmonary edema are at greater risk
of toxicity due to reduced drug
clearance.
DRUG
NAME
Clusivol
OB
BRAND NAME
Clusivol OB
Generic Name
Multivitamins
Frequency
OD
Route
Oral
Dosage
1 tablet
INDICATION
ACTION
Vitamin
and
mineral A dietary supplement.
supplement for use during
pregnancy,
post-partum
and lactation.
NURSING CONSIDERATION
DRUG
NAME
BRAND NAME
INDICATION
ACTION
NURSING CONSIDERATION
Pulmoxel
Pulmoxel
Specific beta 2
receptor
stimulant,
resulting
to
bronchodilation
and
relaxation of peripheral
vasculature. Minimum
beta 1 activity.
Action resembles that
of isoproterenol.
Generic Name
terbutaline sulfate
Frequency
q 4 hrs.
Route
Nebulization
Dosage
1cc + 2cc NSS