Bronchial Ashthma

1
MARIANO MARCOS STATE UNIVERSITY

College of Health Sciences
Batac, Ilocos Norte
A CASE ANALYSIS:
BRONCHIAL ASTHMA
IN ACUTE EXACERBATION
Submitted to:
MRS. MAXIMA JOHANNA L. RAFOLS
MRS. RUTH T. LAYAOEN
Clinical Instructors
Submitted by:
MARY ANN C. ALLAUIGAN
JENNIFER B. AQUE
HAYDEN MAY S. BALTAZAR
CARISSA B. DAYOAN
RICHILDA S. ERLANDEZ
DANNI RICA S. GAZMEN
MADELYN C. MACADANGDANG
GERALDINE C. RAMOS
CHRISTINE V. REYES
CHATY P. SIBUCAO
ARISTOTLE S. TABIOS
RICHELLE Q. VALITE
CELSO C. VILLANUEVA
MARIA ALELI A. YANOS
BSN – IVC, GROUP III
January 27, 2005
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TABLE OF CONTENTS
Title Page - - - - - - - - - - -1
Table of Contents- - - - - - - - - -2
I. ANATOMY AND PHYSIOLOGY - - - - - -3
Respiratory System - - - - - - - -3
II. PATHOPHYSIOLOGY - - - - - - - -8
Readings- - - - - - -- - - -8
Paradigm - - - - - - - - -12
III. PERSONAL DATA- - - - - - - - -13
IV. FAMILY BACKGROUND - - - - - - - -14
V. HEALTH HISTORY- - - - - - - - -15
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Family Health History- - - - - - - -15

Past Health History - - - - - - - -16
Present Health History- - - - - - - -17
VI. DEVELOPMENTAL DATA- - - - - - - -17
VII. PATTERNS OF FUNCTIONING- - - - - - -19
VIII. LEVEL OF COMPETENCIES- - - - - - -21
IX. PHYSICAL ASSESSMENT- - - - - - - -25
X. ON GOING APPRAISAL - - - - - - - -26
XI. LABORATORY AND DIAGNOSTIC PROCEDURES- - - -29
XII. MEDICAL MANAGEMENT- - - - - - - -36
XIII. DRUG STUDY- - - - - - - - - -38
XIV. NURSING CAREPLAN- - - - - - - -43
XV. GENERAL EVALUATION - - - - - - -49
XVI. IMPLICATION OF THE STUDY - - - - - -50
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I. ANATOMY AND PHYSIOLOGY OF RESPIRATORY SYSTEM

The respiratory system contains the structures through with oxygen comes into the body to reach
the bloodstream, and through which carbon dioxide and water vapor leaves. These structures include the
lungs and the airways or air passages connected with them.
Gas exchange is the primary function of the respiratory system. The respiratory system takes
oxygen from the atmosphere, transport oxygen into the lungs, exchanges oxygen for carbon dioxide in the
alveoli, and returns carbon dioxide in the air.
Besides its major function, exchanging carbon dioxide and oxygen, the respiratory system also
supports all vital functions. The respiratory system helps maintain the body’s acid base balance to ensure
as table hydrogen ion concentration. Moreover, the system warms inhaled air, filters air thru the nasal
hairs, and distributes air through the vocal cords to allow speech.
STRUCTURES OF THE RESPIRATORY SYSTEM
UPPER AIRWAY
The upper airway consist the nose the nasal cavity, pharynx and larynx. Major functions of the
upper airway are (1) air conduction to the lower airway to the gas exchange; (2) protection to the lower
airway from foreign matters; and (3) warming filtration and humidification of inspired air.
Nose and Nasal Cavity

The term nose usually refers to the visible structure that forms a prominent feature of the face and
also can refer to the internal nasal cavity. The bridge of the nose consists of the nasal bones and
extensions of the frontal and maxillary bones, but most of the nose is composed of cartilage. The rigid
bone and cartilage are covered with connective tissue and skin.
The nasal cavity extends from the external openings in the nose to the pharynx, and it is divided
by the nasal septum into the right and left sides. The external openings to the nasal cavity are the external
nares and nostrils, and the internal openings from the nasal cavity into the pharynx are the internal nares.
The external nares lead to a cavity called vestibule. The vestibule is lined interiorly with skin and
hair (called vibrissae). The vibrissae filters foreign object and prevent them from being inhaled. The
posteriors vestibule is lined with mucus membrane. This membrane is composed of columnar epithelial
cells, which secretes mucus. Along the side of the vestibule are turbinate. The turbinate are mucus
membrane – covered projections. They contain a very rich blood supply from the external and internal
carotid arteries, and they warm and humidify inspired air.
Paranasal sinuses are open areas within the skull. They are anmed from the bones in which they
lie – frontal, ethmoid, sphenoid, and maxillary. Passageways from the paranasal sinuses drain into the
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nasal cavities. The nasolaryngeal ducts, which drain tears from the surface of the eyes, also drain into the
nasal cavity.
Pharynx
The pharynx is a funnel-shaped tube that extends from the nasal cavities to the larynx, where it
becomes continuous with the esophagus. The pharynx is the common passageway of both the digestive
and respiratory system. It receives air from the nasal cavity and air, food, and water from the mouth.
Inferiorly, the pharynx leads to the opening of the respiratory system (opening into the larynx) and the
digestive system (the esophagus). The pharynx can be divided into three regions, the nasopharynx, and
the laryngopharynx.
The nasopharynx is the superior portion of the pharynx and extends from the internal nasal cavity
to the level of the uvula, a soft process that extends from the posterior edge of the soft palate. The soft
palate forms the floor of the nasopharynx. The nasopharynx is lined with a mucus membrane similar to
that of the nasal cavity. The auditory tubes open into the nasopharynx, and the posterior portion of the
nasopharynx contains the pharyngeal tonsils, which aid in defending the body against infection. The soft
palate and uvula are elevated during swallowing, and this movement results in the closure of the
nasopharynx, which prevents food from passing from the oral cavity into the nasopharynx.
On the other hand, oropharynx extends from the uvula to the epiglottis. The oral cavity opens into
the oropharynx. Thus food, drink, and air all pass through the oropharynx. The oropharynx is lined with
stratified squamous epithelium, which protects against abrasion.
The laryngopharynx extends from the epiglottis to the lower margin of the larynx. The
laryngopharynx, like the oropharynx, is lined with stratified squamous epithelium.
Larynx
The larynx or the “voice box” is that part of the respiratory tract between the pharynx and the
trachea, containing the vocal cords. It consists of an outer casing of nine cartilages that connected to each
other by muscles and ligaments. Six of the nine cartilages form three pairs of cartillages, and three
cartillages are upaired.
One unpaired cartilage is the epiglottis, which consists of elastic cartilage rather than hyaline
cartilage. Its inferior margin is attached to the thyroid cartilage anteriorly, and the superior part of the
epiglottis projects as a free flap forward the tongue. During swallowing, the epiglottis covers the opening
of the larynx and prevents materials from entering it. The thyroid cartilage is another unpaired cartilage.
The thyroid cartilage (or Adam’s apple) is known to be the largest cartilages composing the larynx. The
unpaired cricoid cartilage is the most inferior cartilage of the larynx. It forms the base of the larynx where
the other cartilages rest.
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The six paired cartilages are stacked in two pillars, each consisting of three cartilages, between
the cricoid and thyroid cartilages on the posterior portion of the larynx.
Two pairs of ligaments extend from the posterior surface of the thyroid cartilage to the paired
cartilages. The superior pair forms the vestibular folds, or false vocal cords, and the inferior pair
composes the vocal folds, or true vocal cords. The true vocal cords are involved in voice production. Air
moving past the true vocal cords causes them to vibrate, producing sound. The force of air moving past
the true vocal cords controls the loudness and the tension of the true vocal cords controls the pitch of the
voice.
LOWER AIRWAY
The lower airway (tracheobronchial tree) is composed of the trachea, right anf left main stem
bronchi, segmental bronchi, sub segmental bronchi, and terminal bronchioles. The major functions of the
lower airway include (1) conduction of air through the many branches of airways to the alveolar level; (2)
mucociliary clearance; and (3) production of pulmonary surfactant.
Trachea
The trachea (windpipe) ia a thin-walled tube of cartilaginous and membranous tissue descending
from the larynx to the bronchi and carrying air to the lungs. It is about 1 inch wide and 4-5 inches long,
reinforced with 15-20 C-shape pieces of cartilage.
The C-shape cartilages form the anterior and lateral sides of the trachea, and they protect the
trachea and maintain an open passageway of air. The posterior wall of the trachea has no cartilage and
consists of a ligamentous membrane and smooth muscle.
The trachea is lined pseudostratified columnar epithelium that contains numerous cilia and goblet
cells. The cilia propel mucus produced by the goblet cells and foreign particles toward the larynx, where
they enter the esophagus and are swallowed.
Mainstem Bronchi
The main stem bronchi are also called primary or main brochi. They are subdivisions of the
trachea branching off from the tracheal bifurcation. One main stem bronchus enters each lung. These
tubular passages conduct air between the trachea and the pulmonary bronchi. Like the trachea, the walls
of the bronchi contain cartilaginous rings and are covered with ciliated mucous lining.
Because of the location of the heart in the thoracic cavity, the left primary bronchus is more
horizontal than the right primary bronchus. The right primary bronchus is also shorter and wider so
foreign objects that enter the trachea usually lodge in the right primary bronchus.
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Segmental and Subsegmental Bronchi

Segmental and subsegmental bronchi are also referred to as secondary bronchi or bronchial tubes.
They are subdivisions of main bronchi and spread in an inverted treelike formation, branching through
each lung. These tubular passages convey air within the lung between the main stem bronchi and the
bronchioles.
Terminal Bronchioles
Terminal bronchioles are the last airways of the conducting system and also the smallest
subdivisions of bronchi. Segmented bronchi divide into smaller bronchioles within the broncho-
pulmonary segments. The final branches of bronchioles, i.e., respiratory bronchioles, communicate
directly within clusters of alveoli. The smooth muscles of the bronchioles are supplied by both divisions
of the autonomic nervous system, the sympathetic (promoting relaxation) and the parasympathetic
(promoting contraction).
LUNG PARENCHYMA
The lung is metabolically very active and accounts for approximately 10 percent of oxygen
consumption. The lung parenchyma is the working area of lung tissue, consisting of millions of alveolar
units. Alveoli, small air sacs at the end of the respiratory bronchioles, permit exchange of oxygen and
carbon dioxide. The entire alveolar is made up of respiratory bronchioles, alveolar ducts, and alveolar
sacs. Gas exchange actually begins in the respiratory bronchioles.
It is estimated there are 24 million alveoli at birth. By the time the person is 8 years old, the
number of alveoli has increased to the adult number of 300 million. The total working alveolar surface
area is approximately 70-80 sq.m. The large number of alveoli and the large surface area are necessary to
meet both resting and exercise oxygen requirements. Each alveolar unit is supplied with 9-11
prepulmonary and pulmonary capillaries. The blood supply for these capillaries comes from the right
ventricle of the heart. The major function of the lung parenchyma is the passage and exchange of
molecular oxygen and carbon dioxide from the pulmonary capillaries and alveoli.
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LUNGS
The lungs lie within the thoracic cavity on either side of the heart. They are light, spongy, porous,
elastic, and cone-shaped. The lungs inflate with expiration and deflate (but do not completely collapse)
with expiration. They extend from the diaphragm to just above the clavicles. The base of the lungs rests
on the diaphragm, while the apex (top) extend above the first rib. The hilus or the hilum (“root of the
lung”) is a notch or depression in the medial surface of the lung where the main stem bronchus,
pulmonary blood vessels, and nerves enter the lung. The lungs lie free within the thorax and are attached
only at the hilus.
The two
lungs are separated
by a space called
the
mediastenum. Each
lung is divided
into superior and
inferior lobes by an
oblique fissure.
The right lung is further
divided by a
horizontal fissure, which bound as middle lobe. The right lung, therefore, lies three lobes, whereas the
left lobe has only two. In addition to these five lobes that are externally visible, each lung can be
subdivided into about ten smaller units called broncho-pulmonary segments. Each broncho-pulmonary
segment represents the portion of the lung that is supplied by a specific tertiary bronchus.
Lungs are made of elastic tissue with a tendency to recoil. They are capable of stretching if a
pulling force is exerted on them from outside or if they are “blown up” (inflated) from within. Normally
the elastic fibers of the lung are partially stretched all the time, thus, filling the lung chamber. Lung
parenchyma (essential functional parts) is a network of air tubes and blood vessels, honeycombed with
air-filled sacs (alveoli).
PLEURAE
The pleurae are membranes protectively covering each lung and lining the thoracic cavity. The
two pleural layers are (1) the parietal pleural, lining the inner surface of the chest wall and covering the
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coastal, diaphragmatic, and mediastinal surfaces of the thorax, and (2) the visceral pleura, hugging the
contours of the lung tissue, including the fissures between the lobes of the lungs.
The pleura are continuous with one another and form a closed sac. Normally, there is no space
between them. A “potential space” exists called the pleural space (pleural cavity). A thin film (only a few
ml) of serous fluid (pleural fluid) is present in the pleural space acting as a lubricant. It also causes the
moist pleural membrane to adhere somewhat, the cohesion producing a tensile strength or pulling force
that helps hold the lungs in an expanded position. It is through (a) muscular energy exerted on the thorax,
and (b) changes between the relationship of intrathoracic and atmospheric pressures that gasses are able to
move in and out of the lungs.
The pressure within the lungs and thorax must be less than atmospheric pressure for inspiration to
occur. Gas flows from an area of higher pressure to one of a lower pressure. As the diaphragm and inter-
coastal muscles work to enlarge the size of the thorax, intrathoracic pressure decreases below atmospheric
pressure and air moves into the lungs. During the exhalation, inspiratory muscles relax and the elastic
recoil of the lung tissue, along with a rise in the intrathoracic pressure, causes air to move out of the lung.
The viseral pleura (which lines the lungs) adhere to the parietal pleura. As the chest wall moves,
the parietal pleura (attach to the arterial wall of the thorax) carry the visceral pleura along with it. This
mechanism simultaneously pulls the lung downward as the diaphragm descends. This counteracts the
elastic recoil of the lung tissue.
II. PATHOPHYSIOLOGY
A. Readings
A pulmonary disease characterized by reversible airway obstruction, airway inflammation, and
increased airway responsiveness to a variety of stimuli.
Airway obstruction in asthma is due to a combination of factors that include spasm of airway
smooth muscle, edema of airway mucosa, increased mucus secretion, cellular (especially eosinophilic and
lymphocytic) infiltration of the airway walls, and injury and desquamation of the airway epithelium.
Bronchospasm due to smooth muscle contraction used to be considered the major contributor to
the airway obstruction. But now, inflammatory disease of the airways is known to play a critical role,
particularly in chronic asthma. Even in mild asthma, there is an inflammatory response involving
infiltration, particularly with activated eosinophils and lymphocytes but also with neutrophils and mast
cells; epithelial cell desquamation also occurs. Mast cells seem important in the acute response to inhaled
allergens and perhaps to exercise but are less important than other cells in the pathogenesis of chronic
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inflammation. The number of eosinophils in peripheral blood and airway secretions correlates closely
with the degree of bronchial hyperresponsiveness.
Typically, all asthmatics with active disease have hyperresponsive (hyperreactive) airways,
manifest as an exaggerated bronchoconstrictor response to many different stimuli. The degree of
hyperresponsiveness is closely linked to the extent of inflammation, and both correlate closely with the
severity of the disease and the need for drugs. However, the cause of hyperresponsive airways is not
known. Structural changes in the airways may contribute to it. For example, desquamation of epithelium
(due to eosinophil major basic protein) results in a loss of epithelium-derived relaxing factor and of
prostaglandin E2, both of which reduce contractile responses to bronchoconstricting mediators. Neutral
endopeptidases responsible for metabolizing bronchoconstricting mediators (eg, substance P) are
produced by epithelial cells and are also lost when the epithelium is damaged. Another possible cause of
airway hyperresponsiveness is airway remodeling resulting in a small increase in airway thickness.
Many inflammatory mediators in the airway secretions of patients with asthma contribute to
bronchoconstriction, mucus secretion, and microvascular leakage. Leakage, a constant component of
inflammatory reactions, leads to submucosal edema, increases airway resistance, and contributes to
bronchial hyperresponsiveness. Inflammatory mediators are either released or formed as a consequence of
allergic reactions in the lungs; they include histamine and products of arachidonic acid metabolism
(leukotrienes and thromboxane, both of which can transiently increase airway hyperresponsiveness). The
cysteinyl leukotrienes, LTC4 and LTD4, are the most potent bronchoconstrictors yet studied in humans.
Platelet activating factor is no longer thought to be an important mediator of asthma.
T-cell activation of the allergic response is a key event in the inflammation that characterizes
asthma. T cells and their secretory products (cytokines) perpetuate airway inflammation. Cytokines
produced by one particular lineage of lymphocytes, the CD4Th2 (helper) T cells, promote growth and
differentiation of inflammatory cells, activate them, induce their migration into the airways, and prolong
their survival there. The principal cytokines involved include interleukin (IL)-4, which is necessary for
IgE production; IL-5, which is a chemoattractant for eosinophils; and granulocyte-macrophage colony-
stimulating factor, which is similar to IL-5 in its effects on eosinophils but less potent.
Cholinergic reflex bronchoconstriction probably occurs in the acute response to inhalation of
irritant substances; however, neuropeptides released from sensory nerves in an axon reflex pathway may
be more important. These peptides, which include substance P, neurokinin A, and calcitonin gene-related
peptide, cause vascular permeability, mucus secretion, bronchoconstriction, and bronchial vasodilation.
The pathophysiologic changes described above lead to varying degrees of airway obstruction and
to ventilation that is typically nonuniform. Continued blood flow to some hypoventilated areas causes
ventilation/perfusion imbalance, resulting in arterial hypoxemia. Early in an attack, a patient typically
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compensates by hyperventilating the unobstructed areas of the lung, resulting in a decrease in PaCO2. As
the attack progresses, the capacity for hyperventilation is impaired by more extensive airway narrowing
and muscular fatigue. Hypoxemia worsens, and PaCO2 begins to rise, leading to respiratory acidosis. At
this point, the patient is in respiratory failure.
Symptoms and Signs
The frequency and severity of symptoms vary greatly from person to person and from time to
time in the same person. Some asthmatics have occasional episodes that are mild and brief. Others have
mild coughing and wheezing much of the time, punctuated by severe exacerbations after exposure to
known allergens, viral infections, exercise, or nonspecific irritants. Psychologic factors, particularly those
associated with crying, screaming, or hard laughing, may precipitate symptoms.
Usually, an attack begins acutely with paroxysms of wheezing, coughing, and shortness of breath
or insidiously with slowly increasing manifestations of respiratory distress. However, especially in
children, an itch over the anterior neck or upper chest may be an early prodromal symptom, and dry
cough, particularly at night and during exercise, may be the sole presenting symptom. An asthmatic
usually first notices dyspnea, cough, shortness of breath, and tightness or pressure in the chest and may
hear wheezes. The cough during an acute attack sounds “tight” and generally does not produce mucus.
Except in young children, who rarely expectorate, tenacious mucoid sputum is produced as the attack
subsides.
Physical examination: During an acute attack, the patient shows varying degrees of respiratory
distress, depending on the severity and duration of the episode. Tachypnea and tachycardia are present.
The patient prefers to sit upright or even leans forward, uses accessory respiratory muscles, is anxious,
and may appear to struggle for air. Chest examination shows a prolonged expiratory phase with relatively
high-pitched wheezes throughout inspiration and most of expiration. The chest may appear hyperinflated
due to air trapping. Coarse rhonchi may accompany the wheezes, but fine crackles are not heard unless
pneumonia, atelectasis, or cardiac decompensation is also present.
During more severe episodes, the patient may be unable to speak more than a few words without
stopping for breath. Fatigue and severe distress are evidenced by rapid, shallow, ineffectual respiratory
movements. Cyanosis becomes apparent as the attack worsens. Confusion and lethargy may indicate the
onset of progressive respiratory failure with CO2 narcosis. In such patients, less wheezing may be heard
on auscultation, because extensive mucous plugging and patient fatigue result in marked reduction of
airflow and gas exchange. A quiet-sounding chest in a patient having an asthma attack is an alarm that the
patient may have a severe respiratory problem that can quickly become life threatening.
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The most reliable signs of a severe attack are dyspnea at rest, the inability to speak, cyanosis,
pulsus paradoxus (> 20 to 30 mm Hg), and use of accessory respiratory muscles. Severity is most
precisely assessed by measuring arterial blood gases.
Between acute attacks, breath sounds may be normal during quiet respiration. However, fine
wheezes may be audible during forced expiration or after exercise. Low- to moderate-grade wheezing
may be heard at any time in some patients, even when they feel asymptomatic. With long-standing severe
asthma, especially if dating from childhood, chronic hyperinflation may affect the chest wall, eg,
producing a “squared off” thorax, anterior bowing of the sternum, or a depressed diaphragm.
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B. Paradigm 13
EMOTIONAL EXERCISE ALLERGENS, RESPIRATORY

STRESS IRRITANTS, FOODS, TRACT INFECTION
DRUGS,
Hyperemia OCCUPATION
Modification of vagal
efferent activity and Epithelial damage
activation of brain Increase minute Activation of mast
endorphines ventilation cells
Stimulation of IgE
Release of chemical
Microvasculature
mediators
engorgement
Histamine, bradykinin,
Leukotrienes
prostaglandin
Hypersecretion of
Attracts WBC (neutrophils, mucus
eosinophils and lymphocytes and
increase cellular permeability
Edema on mucus membrane
BRONCHOSPASM
BRONCHOCONSTRICTION
Increase work of breathing Use of Accessory

muscles
Restlessness
Tachypnea and dyspnea
Tachycardia
Falring of alae nasi
Diaphoresis
Cold clammy skin
Wheezing
Retractions
Pallor to cyanosis
Exhaustion
Slow, shallow respiration
Retention of CO2 Respiratory acidosis

Hypoxia, Hypoxemia s/s: headache, dyspnea, fine tremors, HPN,
tachycardia, vasodilation
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III. PERSONAL DATA
Name: Ang Khit

Age: 58 years old
Date of Birth: September 28, 1946
Place of Birth: Dingras, Ilocos Norte
Sex: Female
Civil Status: Widow
Religion: Bathle Community Church
Nationality: Filipino
Address: #4 Laoag City
Educational Attainment: High School Level
Occupation: Housekeeper
Chief Complaint: Difficulty of Breathing
Diagnosis:
Admitting: Bronchial Asthma with Acute Exacerbation
Final: Bronchial Asthma with Acute Exacerbation
Inductive period of Hospitalization:

Date of Admission: January 1, 2005
Admitting Physician: Dr. Magcalas / Dr. Catcatan
Ward & Room: Medicine – 4F, Room 409 Alley
Category: Service
Hospital Number: 754953
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IV. FAMILY BACKGROUND
Members Position Relationship Age Sex Civil Residence Occupation Religion Educational
with the Status Attainment
Head
Hi-ngal Eldest Daughter 37 F M Hong Domestic Bathle College

child Kong Helper Community Graduate
Church (Commerce)
Rharek Second Daughter 35 F M Hong Domestic Bathle High School

child Kong Helper Community Graduate
Church
Ah- Third Daughter 32 F S Hong Domestic Bathle College

nangsab child Kong Helper Community Graduate
Church (BSIT)
Uh-yhek Fourth Son 30 M M Laoag City Tricycle Bathle Vocational

child driver Community Graduate
Church
Sa-whaw Fifth Son 21 M M Laoag City Tricycle Bathle High School

child driver Community Graduate
Church
Phle-mas Sixth Daughter 15 F S Laoag City Student Bathle High School

child Community Level
Church
Approximate Income: P 10, 000.00

Main source of income: Foreign Aid (from the daughters in Hong Kong)
Ang Khit’s family is an extended type since her all her four children who are married are staying
in their family house, sharing all the resources available.
The main source of living of her family comes from her 3 children in Hong Kong working as
domestic helpers. Her married children holds their own money however, they also contributes on the
different need s in their house.
According to Ang Khit, she’s the one who budgets the money given by her children and in-laws
for all the things needed in their house including the food, groceries, electric bills, water bills,
transportation and other miscellaneous.
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In terms of decision making, she’s usually the one who makes decision when it comes with their
properties. However, it its already in terms of financial and health, its already her children with their
husbands.
V. HEALTH HISTORY
A. Family Health History
According to Ang Khit, there are only two hereditary diseases present in their family that
includes diabetes mellitus and asthma. Her husband died because of his diabetes. Her parents and
grandparents did not die of any kind of disease but due to old age as claimed by her.
Ang Khit also revealed that they had experienced having cough, colds, fever during extreme
temperatures (hot and cold weathers), headache, stomachache, toothache and body ache. They usually
manage them with over the counter drugs such as Decolgen for cough, Neozep for colds, Paracetamol
for fever, Alaxan for headache, body ache and toothache, and Kremil-S for stomachache. They also had
experienced some infectious and communicable diseases such as chicken pox, measles, mumps and
sore eyes. They manage chicken pox by applying singkamas on the vesicles to relieve irritation; for
measles, they let her wear black color clothes for they believe that this will lessen the irritation; and for
mumps, they applying “akot-akot” on the affected area. For other managements for these diseases, she
identified bedrest, enough sleep and adequate nutrition as their practices.
They also utilize herbal medicines such as oregano decoction and lagundi decoction for cough,
boiled guava leaves for cleaning wounds, “ampalaya” leaves for “an-an” and “kutsay” leaves for boils.
Ang Khit pointed out that they directly go to private clinics or to the nearest hospital for severe
cases. She stressed out that they doesn’t believe in ghost, bad spirits, witchcraft, herbolaryos, and
arbolaryos. But she stated that she often consults a hilot whenever there are sprains and dislocated
bones, and claimed to be effective.
For the immunization of the family members, Ang Khit cannot really tell if her husband had
received one. She cannot also remember if they have a complete immunization but she was very much
sure that they had received one, she just can’t remember what kind of immunization it was.
Ang Khit disclose that her in-laws are smoker consuming one pack of cigarette (hope) per day.
Ang Khit stated that they had tried to talk to them and encourage them to stop smoking but they were
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not listening to the them. Every night, they are also drinking one “cuatro cantos” of Ginebra San Miguel
but she claimed that there were no troubles that usually happens between them.
The family prefers to eat vegetables and fish, however they also buy meat when they have extra
money. The family drinks water from their well. They also drink coffee every morning sometimes
softdrinks when there’s an occasion. There were no allergies identified in the family.
B. Past Health History
According to Ang Khit, she experienced having common illnesses during her childhood days
such as fever, colds, cough, stomachache, headache, and flu. These illnesses were managed by taking
in over the counter drugs such as Paracetamol for fever, Neozep for colds, Decolgen for cough, Kremil-
S for stomachache, and Alaxan for headache. She also uses herbal plants such as oregano decoction
plus breast milk for cough, and kutsay for minor wounds.
Ang-Khit also had experienced having chicken pox, measles, and mumps. They manage her
chicken pox by applying singkamas on the vesicles to relieve irritation; for measles, they let her wear
black color clothes for they believe that this will lessen the irritation; and for mumps, they applying
“akot-akot” on the affected area.
Ang Khit doesn’t know if she had received any immunizations. She also claimed that she doesn’t
have any allergies to foods and drugs except for the dust and other allergens ands irritants present in the
environment because this triggers her asthma. Ang Khit is fond of drinking coffee with at least three
cups of day She’s also fond of drinking juice and softdrinks. Ang Khit is also fond of eating raw fishes,
salty and fatty foods, and vegetables but dislikes beef very much.
According to her, this is her second hospitalization next to her hospitalization in 1980 also in
MMMH and MC with a diagnosis of Bronchial Asthma. She was then stayed at the hospital for one
week, given due medication and was relieved. In this time, she was give Theophyllin 200 mg twice a
day as her maintenance medication and nebulization as needed.
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C. Present Health History

Ang Khit is a diagnosed case of Bronchial Asthma (since 1980) with an intake of theophylline
200 mg BID and PRN nebulization.
According to Ang Khit, her asthma usually occurs once a month depending on the situation. She
pointed out that she’s usually having asthmatic attack when exposed to dust, fumes, smoke, pollens, and
other environmental irritants and allergens. No hospitalizations or consultations to private were usually
done during these times because according to her, her maintenance medication usually relieves her
discomfort.
Three weeks prior to admission, the client started coughing accompanied by colds and difficulty
of breathing . Ang Khit self medicated with theophylline and nebulization which afforded relief.
One day prior to admission, she developed severe difficulty of breathing. She again nebulized
three times at home and afforded slight relief. However, few minutes prior to admission, difficulty of
breathing worsens prompting her for consultation, hence admission.
According to her, the attack of her asthma was caused by the smoke of the firecrackers during the
celebration of the New Year’s Eve.
VI. DEVELOPMENTAL DATA
ERIK ERICKSON
Just as physical growth patterns can be predicted, certain psychosocial tasks must be mastered in
each developmental stage. According to Erickson's theory of psychosocial development, the middle age
or adulthood stage (25-65 years old) is the stage in which our patient has to accomplish a certain task,
which is generativity, the tendency to produce or stagnation, the tendency to stand still.
Ang Khit, having the age of 58 belongs to middle adulthood. Her developmental task is
generativity where in she is expected to develop an attitude of creativity and productivity in all aspect.
Stagnation on the other hand, suggests a lack of psychosocial movement or growth. When generativity
also is not achieved, the individual may turn into self- indulgence, self-concern and lack of interest and
commitment and eventually, crisis would exist.
BSN-IVC,G3
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In addition, at this stage, she is expected to develop attitude-establishing priority of needs,

concern for others through transmitting good values to the next generation.
Relating this to our client's life in terms of creativity and concern for others, Ang Khit claimed
that she is very concerned to her family and to other people. Her secret according to her in establishing
good interpersonal relationship with other people is to be honest, trustworthy, and be good always. She
considers her family as her source of inspiration that's why she wants them to have a very good future.
She also stressed out that her source of happiness is her family, she is very supportive and caring
to her children and grandchildren Though sometimes she becomes lonely when she remember her
husband who died at the age of 52, however she said that maybe it is the will of GOD.
Ang Khit achieved certain task under generativity in the sense that she stated that she is happy
and contented with her life and willing to abreast the best that she can be for the good of his family.
ROBERT HAVIGHURST
In Havighurst theory of developmental task, biologic changes become apparent during middle
age. There is an important milestone in which both physiological and psychological adjustment must be
made for successful personal development. The following are the tasks he must achieved:
1. Achieving adult civic and social responsibility

2. Establishing and maintaining an economic standard of living
3. Assisting teenage children to become responsible and happy adults
4. Developing adult leisure-time activities
5. Relating oneself to one’s spouse as a person
6. Accepting and adjusting to the physiologic changes of middle age
7. Adjusting to aging parents
Basing from these criteria, Ang Khit is performing her tasks. In fact, as what have stated they
have good relationship with her husband when he was still living. She is responsible enough looking for
the welfare of her family that even she’s already old, she still finds a way to help her children in their
daily living.
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Aside from being a good mother of six she is also a good provider and mentor to her children.
She wanted them to be trained well and to become better individuals wherein as claimed by Phle-mas,
her mother achieved this goal.
When there are civic activities in the barangay such as Oplan Dalus, meeting of the Women’s
Organization, Bingo social, etc. she finds time to support the said activity She utilizes her leisure time
listening to AM radio specially on news and drama.
Ang Khit admitted that she is getting older, and she finds her becoming more matured and more
knowledgeable for as she believes that experience is the best teacher.
ANALYSIS:
Based on the information we gathered, we believed that Ang Khit is normally developing
analogous to Erickson and Havighurst's theories. She is doing well with the tasks he is expected to
possess and to perform.
Moreover, if he continuously carries out these tasks, most definitely, he would be able to move to
the next stage and could perform the succeeding task. Though her condition sometime gives her
problem and makes her worried, it did not serve as a hindrance to attain the different tasks expected of
her.
VII. PATTERNS OF FUNCTIONING

Patterns Before Illness During Illness During Analysis
Hospitalization
1. Eating Breakfast Breakfast Breakfast There is a change of
Time: 5-7 am Time: 6-7 am Time: 8 am the client’s food
Food content & Food content & Diet: intake during
amount: amount: Food content & hospitalization
 3-4 pcs. Pandesal  3-4 pcs. amount: because of her
 1 fried & 1 cup “pandesal”  2 slices bread & 1 asthma wherein
rice  1 fried egg & 1 banana there is a
 1 cup rice & 2 cup rice bronchospasm that
pcs. “longganisa’  1 cup rice & 2 lead to different
pcs. problems such as for
“longganisa” activity intolerance,
ineffective breathing
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Lunch Lunch Lunch pattern, etc., that

Time: 12:00 pm Time: 12:00 pm Time: 12:00-1:00 pm decreases her
Food content & Food content & Food content & appetite to eat. And
amount: amount: amount: in addition, it is very
 1 cup rice, serving  1 cup rice, serving  1 cup rice, I serving much hard to eat for
vegetable ( in any vegetable ( in any squash (“ginisa”), I the client since she’s
type) or I cup rice type) or I cup rice pc. Fish (medium having difficulty of
& 3-4 [pcs. Meat & 3-4 [pcs. Meat size)/ 2 pcs. Meat breathing and was
9matachbox 9matachbox (matchbox size) striving for oxygen.
size)/ I cup rice size)/ I cup rice
and 2 pcs. Fish and 2 pcs. Fish
(medium size) (medium size)
 1 banana  1 banana
Dinner Dinner Dinner

Time: 6:00 pm Time: 6:00 pm Time: 5:00-6:00 pm
Food content & Food content & Food content &
amount: amount: amount:
>1 cup rice, serving >1 cup rice, serving >1 cup rice, I serving
vegetable (in any vegetable (in any vegetable (in any
type), 3-4 pcs. Meat type), 1 pcs, fish type), 2 pcs. Meat
(matchbox size) 2 (medium size) (matchbox size)
pcs. Fish (medium
size)
Snack Snack Snack

Time: 9 – 10 AM / Time: 9 – 10 AM / Time: 10 AM
3 – 4 PM 3 – 4 PM Food content &
Food content & Food content & amount:
amount: amount: >1 pack sky flakes
> any home made >2-3 pcs, bread
delicacies
2. Drinking Content: water, coke , Content: water, coke , Content: water In drinking pattern
orange juice, coffe orange juice, coffe milk/coffe there is slight
>5-7 glass of water >5-7 glass of water >5-7 glass of water decrease during
>1 cup of coffe >1 cup of coffe >1 cup of milk/coffe hospitalization
>1 glass juice >1 Amount: Amount approximately because of the
Amount: approximately 1200- 1000-1200ml/day presence of ashma,
approximately 1200- 1600ml/day glass due to easy
1600ml/day juice fatigability
3. Bladder Frequency: 7times a Frequency 7times a Frequency: 5-6 times a There is a

day( 6times at day( 6times at day( 5times at daytime significant change in
daytime & once at daytime & once at & once at night) the bladder
night) night) Color : pale yellow elimination of the
Color : pale yellow Color : pale yellow Characteristic: clear client. There is a
Characteristic: clear Characteristic: clear Amount decrease in urine
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Amount Amount approximately: 1100- output as observe in

approximately: 1200- approximately: 1200- 1300ml/day the during
1400ml/day 1400ml/day hospitalization. This
is brought by the
decrease fluid intake
by the client.
4. Bowel Frequency: once a Frequency: once a Frequency: She only There is significant
day (every morning) day (every morning) defecated once on change on the bowel
Color: Brownish Color: Brownish January 3, 2005. elimination because
Consistency: semi Consistency: semi there is a lesser fluid
formed formed intake and lesser
Amount :normal Amount :normal mobility.
5. Bathing/ Frequency: Frequency: Frequency: There is a

Grooming > complete bath in > complete bath in > sponge bath every significant change in
the morning the morning morning bathing pattern
> sponge bath before > sponge bath before during
going to bed going to bed hospitalization
because patient is
not able to take a
bath by herself due
to easy fatigability.
She have her sponge
bath every morning
with the aid of her
daughter.
6. Sleeping Duration: 9 hours Duration: 9 hours Duration: 10 hours There is no change

Time of sleeping Time of sleeping and Time of sleeping and in sleeping pattern
and awaking awaking awaking except for the
>9 pm to 6 am >9 pm to 6 am >9 pm to 7 am characteristic during
Characteristic: Characteristic: Characteristic: hospitalization that
> continuous > continuous > with interruptions there is a
Nape time: 1-2 hours Nape time: 1-2 hours Nape time: 1-3 hours interruptions for
medical purposes.
But there is also a
longer sleeping and
nape time.
VIII. LEVELS OF COMPETENCIES

Patterns Before Illness During Illness During Analysis
Hospitalization
Physical Ang Khit then can At home, her In the hospital, she There is a decrease in
meet her physical activities of daily usually stayed on bed the physical
needs and active in living have been during her competency of our
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performing her limited such as hospitalization. She client due to her

activities of daily cleaning the house, claimed to us that present condition
living. At home, she dishwashing, and sometimes she able (asthma) that causes
was able to do any others. She could also to go for a walk different problems
household chore such still do these kind of along the ward. She such as difficulty of
as cleaning the house, household chores could still do proper breathing, body
dishwashing, and but then she must grooming but asks her weakness, and easy
others. After doing have to stop and daughter to assist her fatigability which
the entire household take a rest at the because she feels disables her to do her
chore, she goes to middle of her weaker when she was usual routines.
their store and activity since she already confined in
manages it. She also experiences the hospital. She also
sees to it that she was difficulty of told us that she
properly groomed breathing. She could sometimes gets tired
whenever she goes no longer also go to especially when is
out of their house and their store because coughing
before going to their she claimed to us continuously.
store. that her condition
worsens everytime
she was exposed to
smokes. Since their
store is not nearby
their house, she has
to travel then to go
to there but because
of her condition she
could no longer
manage their store.
She was also afraid
that those smokes
that she inhales
might have
triggered her
condition. Still she
made mention to us
that she was able to
maintain her proper
grooming.
Emotional Ang Khit is an At home, she is still During her stay in the A deviation of
expressive type of emotionally stable hospital, she told us emotion was noted to
person and and she is not that she gets irritated our client particularly
emotionally stable. irritable and for quite some time when she was already
She laughs and smile sensitive. She could especially when some confined in the
at things that are of still hold her temper of the hospital. Her
interest to her . She is during the presence watchers/visitors in irritability was
happy and satisfied of her illness. Even if the hospital are noisy. mainly brought about
with her life because she gets tired and This usually causes by her condition
her family is very feels weak for some her sleeping time to (frequent coughing)
supportive to her and time, she don’t still be disrupted. And as and by the noise in
BSN-IVC,G3
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she is also very open gets easily irritated. she has not slept well her environment.
to her family and However, our client during the night, she
friends. She is a type claimed that she awakes to be irritated
of person who can believes that all the during the day. She
hold her temper members of her also stated that her
whenever she got family will condition also
angry or irritated. understand her contributes to her
According to her, unexpected behavior being irritable one
whenever she had if even there might since everytime she
any misunderstanding come a time that was on the middle of
to anybody or to they’ll be having rest periods, she was
anyone on their some conflict during also easily disrupted
family, she’d rather her illness. by her frequent
go out to calm her coughing.
self and at the same
time to avoid their
problem to become
more complicated.
Social According to our During the course of In the hospital, she There is no
client, she has a lot of her illness at home, still do her best to significant change on
friends in their place. she was still able to socialize with other the social life of Ang
She also claimed that interact and make people particularly to Khit except to the
she is fond of friends especially us and her fellow fact that she can no
attending social with their patients but not that longer went house to
gatherings and loves neighbors. much anymore since house for
to interact and make However, she she feels weak for socialization. In the
friends to the people claimed to us that quite some time. hospital, though she’s
whom she come she seldom go out However, during our confined on bed, she
across with. She also already since her interaction with her, still sees to it that she
told us that there illness was triggered she frequently makes friends with
were times when she by some experiences cough the other clients and
was already in their environmental and she believes that watchers, and also to
house, some of their factors particularly this contributes to the student nurse who
neighbors needs her smokes. She still way she feels that usually interacts with
help, she always offer makes sure that sometimes she gets her.
a help for as long as whenever their tired upon long time
she’s able to give. In neighbors needs her of talking to us.
addition, she also help for as long as
participates in she’s able to give.
barangay programs Lastly, she also told
such as “clean and us that she seldom
green” and meetings. participates to
barangay programs
such as “clean and
green” and
meetings.
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Mental Ang Khit is a person At home she In the hospital, due to The mental status of
who easily already avoided the fact that she has our client has
understands / those things which already been aware/ changed. Before and
comprehend of what she was already she had already during her illness, she
is being explained/ aware that realized the effects of was oriented of what
instructed to her. She contributes to the inhaled smokes, she is happening. Her
is well oriented about worsening of her just follow what the knowledge about her
events, time, place, condition. She doctor ordered for the disease causation has
person, and what is started to avoid these betterment of her increased as a result
happening around risk factors health. She is still able of health education
her. However, even if triggering her to recall the past done by the members
she was already condition when she events that happened of the health team.
aware that those had already in her life before and She was able to
smokes triggered her submitted her self for during the course of answer the questions
condition she inhales. consultation at her disease. However, and share relevant
Sometimes she still Dingras District during the assessment, information therefore,
goes to their store and Hospital. the client was restless, she is still mentally
manages it even lethargic and slightly stable, no alteration
though she knows the confused. in the patient’s
fact that her condition mental competency.
worsens everytime The restlessness,
she goes out and lethargy and
inhales smoke confusion of the
pollutants. client during the
assessment are just
some of the
manifestations of
asthma.
Spiritual Our client strongly She still have faith in During her Her spiritual life has
believes in God and God and she didn’t hospitalization, she not changed even
has a very strong blame God for the wasn’t able to attend though she doesn’t
faith in her. She also things that are their church services attend their church
attends church happening to her, already but still didn’t services already due
services every instead she accepted forget to pray. She to her condition. She
Sunday. She also it wholeheartedly also claimed that her still has strong faith
claimed that within and pray to God to faith in God has in God. She always
their family, they help her and guide always been strong pray to Him. This is
pray to God before her everyday. She and kept on praying due to the fact that
their meals as a way believed that God is for faster recovery since she was a child,
of thanking Him for always at her side. from her illness, her parents molded
the food and blessings for her and her to be a good
blessings He had her family and for Christian which she
given. them ( her family) to carried until now that
have more patience she already old.
and strength in taking
good care of her.
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IX. PHYSICAL ASSESSMENT
Date of Assessment: January 01, 2005 @ 2 PM

General Appearance:
Position on Bed: Sitting on bed leaning forward
Intravenous Fluid: D5NSS 1L at 700 cc level regulated to 32 gtts/min
Gadgets: with Oxygen inhalation via nasal cannula regulated 4 – 5 LPM
Appearance: with difficulty of breathing, anxious and restless
Height: 5’3” Weight: 59 kg
Body temp. 37.4oC PR: 98 bpm

RR: 30 bpm BP: 130/80 mmHg
Head to Toe Assessment:
Skin: with light brown complexion; with cold clammy skin; on diaphoresis; with fine skin turgor
(due to aging process); with minimal scars noted on upper and lower extremitites; no
open wounds noted, no edema noted.
Hair: with white and gray hairs; fine, smooth and silky; proportionally distributed; no baldness, lice
and dandruff noted.
Nails: with short and dirty nails; with pale nailbeds on both extremities; with fine capillary on both
extremities; no clubbing noted.
Head: normoephalic; round in shape; no lesion and masses noted, no scars noted.
Face: symmetrical; with few moles irregularly distributed; no masses, lesions nor irregularity noted.
Eyes: with pinkish palpebral conjunctiva; with whitish to reddish sclera, pupils normally constrict
when exposed with increasing light and accommodation; with poor visual acuity (cannot
read without corrective glasses); extraocular muscles are intact, symmetrical.
Ears: with moderately clean external canal; with good hearing acuity (can understand statements
clearly); no lesions, masses nor discharges noted.
neither blisters noted.
Nose: symmetrical, with flaring of nares noted; no lesions, masses nor discharges noted.
Lips: with pinkish lips; moist, smooth, symmetrical in contour and shape; no lesions, dryness, cracks
Oral cavity: with pinkish gums and tongue; with only 2 remaining teeth (incisors).
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Neck: with symmetrical movement; no palpable lymph nodes noted; no masses nor lesions noted.
Chest and Lungs: with symmetrical movement; with difficulty of breathing; with chest retraction;
with wheezing breath sound and rales upon auscultation (upper lobes), increase in
respiratory rate (30bpm); with use of accessory muscles.
Heart: with regular rhythm; no bigeminal heart beat noted during auscultation; increase in cardiac
rate (99).
Abdomen: with slightly convex abdomen; with normal bowel sound; no tenderness noted; no lesions
nor masses noted.
Extremities
Upper extremities: with symmetrical movement; with good muscle tone; with good fine and
gross motor; able to flex and extend, circumduct arms.
Lower extremities: with symmetrical movement; able to flex and extend legs.
CNS: Restless, lethargic and slightly confused
X. ON GOING APPRAISAL
The on going appraisal was started the day when Ang Khit was admitted at MMMH & MC
until she was discharged.
January 1, 2005
At 6:30 in the morning, the client was admitted to ER with a chief complain of difficulty of
breathing. She was seen and examined by Dr. Catcatan. After history taking and thorough
examination, she was then admitted to MMMH and MC at 7:00 in the morning.
Dr. Catcatan ordered as follows: TPR every shift and record pls; DAT; CBC typing;; chest X-
ray; 12 lead ECG; stat serum Na, K, Cl, stat BUN and creatinine. She was also for vital signs
monitoring every 2 hours and record. Also she was for oxygen inhalation at 4-5 liters per minute.
At 7:15 AM, she was admitted to fourth floor room 409-Alley in medicine department. She
was placed comfortably on bed and immediately given oxygen inhalation. Nebulization was done
twice and at 7:30, an IVF of D5NSS 1L at full level was inserted as venoclysis regulated to 16
gtts/min.
At 10:00 AM, she was seen and examined by Dr. Magcalas, however, there were no new
orders made.
All throughout the day, she complained of difficulty of breathing and was given attention
with.
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All her recorded BP and boy temperature were within the normal range except for the
respiratory rate and pulse rate which are above normal.
VS 8 AM 10 AM 12 PM 2 PM 4 PM 6 PM 8 PM 10 PM
Btemp. 37.4 37.2 36.9 37.4 36.8 37.2 37.1 37
CR 101 105 103 99 95 92 91 80
RR 35 33 30 30 29 27 30 37.1
BP 130/80 120/70 120/80 110/80 120/90 110/80 110/70 120
Urine: 6 Stool: 0
January 2, 2005
She spent most of the time lying on bed in semi-fowler’s position, awake. With an IVF of
D5NSS I L at 70 cc level regulated to 16gtts/min, infusing well. After few minutes, at 7 AM, previous
IVF was consumed and was replaced with the same IVF and regulation With no difficulty of
breathing noted.
The client was seen and examined by Dr. Catcatan during the rounds with new orders made
and carried out such as to continue medication and new medications were prescribed such as
Bambuterol 16mg/tab OD.
She was also able to eat all her meals served for breakfast, lunch and dinner.
All her vital signs are already within normal.
VS 8 AM 12 PM 4 PM 8 PM 12 AM
Btemp. 36 36.6 37 37 36.3
CR 82 88 68 76 75
RR 23 22 22 21 22
BP 130/80 120/70 120/80 110/80 120/90
Urine: 6 Stool: 0
January 3, 2005
She spent most of the time lying on bed in semi-fowler’s position, awake. With an IVF of
D5NSS I L at 500 cc level regulated to 16gtts/min, infusing well. With no reported complaint of
difficulty of breathing.
BSN-IVC,G3
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She was seen and examined by Dr. Torralba with new orders made and carried out such as
continue medications. And also the X-ray result was referred to the doctor.
She was also able to eat all her meals served for breakfast, lunch and dinner.
All her vital signs are within normal.
Btemp. 36.2 36.8 36.7 36.6 37.1
CR 88 88 72 82 68
RR 21 21 22 21 21
BP 120/80 120/80 130/80 120/80 130/80
Urine: 5 Stool: 1
January 4, 2005
The client spent lying on bed most of the time. No complaint of difficulty of breathing and other
complains.
At 9:00 in the morning, the client was seen and examined by Dr. Magcalas and ordered MGH
with home medications.
At 1:00 in the afternoon, the client went home per stretcher accompanied by relatives.
BTemp. 36.6 36.8 36.9 36.6 36.7
CR 72 76 74 79 78
RR 21 20 21 19 22
BP 120/70 120/70 120/70 110/60 80/60
Urine: 3 Stool: 0
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XI. LABORATORY AND

DIAGNOSTIC PROCEDURES
1.X-ray
Indications: As part of routine screening procedure; when pulmonary disease is suspected; to

monitor the status of respiratory disorder and abnormalities; to confirm
endotracheal or tracheostomy tube placement; after traumatic chest injury; in any
other situation in which radiographic information helps in the management of a
respiratory problem.
Result:
Date taken: January 1, 2005
Examination desired: CXR-PA
Requesting Physician: Dr. Catcatan
Result: Pneumonitis bases more on the right
Chest X-ray is a procedure done to determine if there are any abnormalities of the lungs
including the heart. It provides information about the chest that may not be available through other
assessment means. Also, they often graphically illustrate the cause of respiratory dysfunction. Chest
films may reveal abnormalities when there are no physical manifestations of pulmonary disease. In
posteanterior (PA) position, the x-ray beam penetrates from posterior.
Nursing Responsibilities:
1. Make a laboratory request and forward it to the x-ray room.
2. Explain the procedure and its importance to the patient and significant others in order to
get their cooperation.
3. Instruct the patient to remove any radiopaque objects such as jewelry or metal buttons
above the waist. Metals appear in the x-ray results and would tend to give a false result.
4. Accompany the patient to have someone that assists him.
5. Instruct the to hold his breath and to remain still when performing the procedure.
6. Follow-up result and refer to the physician to evaluate the condition of the patient.
2. Electrocardiogram
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Date Performed: January 1, 2005

Result: Available but no remarks
This electrophysiologic test is used primarily to screen for and diagnose a variety of cardiac
conditions as well as to monitor the hearts response to therapy. The electrocardiogram (ECG) is
frequently used to diagnose abnormal heart rhythms, conduction disturbances, hyperthropy of
cardiac chambers, myocardial infarction and ishemia, and pericarditis. An ECG measures
electrical flow through the heart by using electrodes applied painlessly to the chest wall and
limbs.
1.Explain the procedure to gain cooperation.
2.Assure that there is no pain with this test.
3.Remove any metal and jewelries on the client’s body.
4.Instruct the patient to lie still on his back while ECG machine is recording the heart’s
activity.
5.Explain that the chest will need to be exposed during the electrode placement. Drape
female client as much as possible during placement.
6.After the procedure, wipe off electrode paste or jelly.
7.Educate the patient and family a heart healthy diet.
3. Hematology or Complete Blood Count (CBC)

Date performed: January 1, 2005
Normal Value Found Value Analysis
Hemoglobin 110-160 127 Normal
Hematocrit 0.38-0.54 .0.40 Normal
RBC 4.5-5.5 4.2 Normal
MCV 80-100 89 Normal
MCH 27-32 30 Normal
MCHC 31-35 34 Normal
WBC 5-10 10.5 Normal
Neutrophils .50-.70 0.75 Increased
Lymphocytes .20-.40 0.23 Normal
Eosinophils 0.01 – 0.04 0.02 Normal
Platelet coutns 150 - 400 226 Normal
A complete blood count is one of the most routinely preferred test in clinical laboratory
and one of the most valuable screening and diagnostic technique. It identifies the total number of
blood cells (WBC,RBC, and platelets) as well as the hemoglobin, hematocrit (percentage of
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blood consisting of RBC’s) and RBC indices. The CBC may reveal considerable data about the
patient including diagnosis, prognosis, treatment response and recovery.
Purpose: CBC was done as a part of hospital routine to evaluate other abnormal conditions.
Procedure:
1. Perform a venipuncture and collect a blood sample in a 7 ml lavender top-tube.
2. Fill the collection tube completely and invert it gently several time to adequately
mix the sample with the anti-coagulants.
a. Hemoglobin
Hemoglobin is the main component of RBC which contains iron and which makes up
95% of the cell mass. It delivers oxygen through circulation to body tissues and returns
carbon dioxide from tissues to lungs.
A decreased in the normal value of hemoglobin indicates a decrease oxygen carrying
capacity of the blood that affects the transport of oxygen between lungs and tissues and
eventually affects cellular activities.
Indication: This test is done to determine anemia and other disease related abnormal
Hemoglobin concentrated in the blood and oxygen carrying capacity.
Analysis: Normal
b. Hematocrit:
Hematocrit is a measure of the packed cell volume of red cells, expressed as a percentage
of the total blood volume. It indicates relative proportions of plasma and RBCs (volume of
RBCs/L whole blood).
Indication: It is done to determine the space occupied by pack RBC. It is expressed as the
percentage of red cells in a volume of per blood and also to determine the
hydration of patient.
Analysis: Normal
c. Red Blood Cells (RBC)

RBC (Red blood cell) count is a count of the erythrocytes in a specimen of whole blood.
Erythrocyte is the major cellular element of the circulating blood. It is a reddish biconcave
disk that contains hemoglobin confined within a lipoid membrane. Its principal function is to
carry hemoglobin to provide oxygen to tissues.
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Indication: This test determines the total number of RBC found in a cubic millimeter of
blood. It is an important measurement in the determination of anemia.
Analysis: Normal
d. Mean Corpuscular Volume (MCV)

This is an evaluation of the average volume of each red cell derived from the ratio of
volume of the packed red cells to the total number if RBC. It also describes the individual red
cell size. It is expressed in cubic microns.
Indication: These test determines if there is a deviation of the RBC production and important
in the determination of anemia.
Analysis: Normal
e. Mean Corpuscular Hemoglobin (MCH)

This is an estimate of the amount of Hemoglobin in an average erythrocytes, derived
from the ratio between the amount and Hemoglobin and in the number of erythrocytes
present. It is related to MCV because weight of a red blood cell increases when the amount of
hemoglobin increases and therefore its size increases.
Indication: To determine the ratio of amount of Hemoglobin and the number of erythrocytes
present.
Analysis: Normal
f. Mean Corpuscular Hemoglobin Concentration (MCHC)

This is an estimation of the concentration of hemoglobin in grams per 100 ml of packed
red blood cells, derived from the ratio of the hemoglobin to the hematocrit. This is an average
concentration of hemoglobin in RBCs. It measures the portion of hemoglobin in an average
cell. It is the ratio of the weight of hemoglobin to the volume of the red blood cells.
Indication: To determine the concentration of Hgb
Analysis: Normal
g. White Blood Cells (WBC)

This is one of the formed elements of the circulating blood system. WBC is needed to
depend against invading microorganisms through phagocytosis to produce or transport and
distribute Anti bodies to help maintain immunity. WBC count is a test that counts the total
number of WBC’s in 1cubic mm of peripheral venous blood.
BSN-IVC,G3
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Indication: This test is done to determine the presence of infection, inflammation and also
serves as a useful guide to the severity of the disease process.
Analysis: Normal
h. Neutrophils
Neutrophils are the circulating white blood cells they are the first one to launch at the site
of injured tissue. They are also essential for phagocytosis and proteolysis by which bacteria,
cellular debris, and solid particles are removed and destroyed. It is essential in preventing or
limiting bacterial infection via phagocytosis. The protective function of neutrophils include
phagocytosis where foreign particles were degraded pyrogen are released that causes fever by
acting on the hypothalamus to set the bodies thermostat at the higher level.
Indication: This test determines the presence of infection and inflammation.
Analysis: Increased because in asthma, there will be an release of chemical mediators that
attracts the neutrophils and activation of its production.
i. Lymphocytes
These are small agranulocytic leukocytes originating from fetal stem cells and developing
in the bone marrow. Lymphocytes normally comprise 25% of the total WBC count but
increase in number in response to infection. It is the integral component of immune system
and helps in the antibody production. These cells are the source of serum immunoglobulins
and of cellular immune response and play an important role in immunologic reactions.
Indication: It determines the presence of infection and inflammation.
Analysis: Normal
j. Eosinophils
A granulytic bilobed leukocyte somewhat larger than a neutrophil. It is characterized by
large numbers of coarse refractile cytoplasmic granules that stain with the acid dye eosin.
Indication: This test determines the presence of infection and inflammation.
Analysis: Normal
k. Platelet Count
It is the total number of platelets in circulation. Platelet is the smallest of the cells in the
blood. These are disk-shaped and contain no hemoglobin. They are essential for the
coagulation of blood.
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Indication: This test measures the total number of platelets in circulation.

Analysis: Normal
1. Fill up laboratory request and send to laboratory to inform the medical technologist
2. Inform patient about the type of the procedure and its purpose to gain her cooperation and
also to increase his awareness regarding the procedures that will be done to her.
3. Follow up results, attached to the chart of the patient and refer it to the Physician to
inform the abnormality of the found value and to evaluate the condition of the patient.
4. Blood Chemistry
Date Performed: January 1, 2005
Result Normal Value Analysis
Creatinine 58.9 44.2-150.3 mmol/L Normal
Urea Nitrogen 6.4 1.7 – 8.3 mmol/L Normal
Sodium 138.4 133 – 150 mmol/L Normal
Potassium 3.40 3.4 – 5.3 mmol/L Normal
Chloride 100.0 96 – 106 mmol/L Normal
a. Creatinine
This is a substance formed from the metabolism of creatine (nitrogenous compound
produced by metabolic processes in the body) commonly found in blood, urine, and muscle
tissues. Therefore, its formation and release are relatively constant and proportional to the
amount of muscle mass present. Because creatinine is filtered in the glomeruli but not
secreted into the tubules from the blood or reabsorb from the tubules into the blood, its blood
values depend closely on the GFR (glomerular filtration rate). Creatinine is the end product
of muscle energy metabolism. In normal function, level of creatinine, which is regulated and
excreted by the kidneys, remains fairly constant in the body. Serum creatinine levels reflect
the glomerular filtration rate (GFR). Serum creatinine is often used as a screening measure to
evaluate kidney/renal function.
Indication: This test measures the effectiveness of renal function. It is used to diagnose
impaired renal function.
Analysis: Normal
b. Urea Nitrogen
BSN-IVC,G3
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Urea, the end product of protein and amino acid metabolism in the liver, enters the blood
and passes to the kidneys for excretion. The blood urea nitrogen is, therefore, an indicator of
both the metabolic function of the liver and the excretory function of the kidney.
Indication: Blood urea nitrogen measures renal function and hydration.
Analysis: Normal
c. Sodium
This is one of the most abundant elements in the ECF. Consequently, sodium is the
primary determinant of ECF osmolality. Sodium ions are involved in acid-base balance,
water balance, the transmission of nerve impulses, and the contraction of muscles. Sodium is
the chief electrolyte in interstitial fluid, and its interaction with potassium as the main
intracellular electrolyte is critical to survival.
Indication: This test measures the ability of the kidneys to maintain fluid-electrolyte balance.
Analysis: Normal
d. Potassium
Potassium in the body constitutes the predominant intracellular cation, with only 2%
found in the extracellular space, helping to regulate neuromuscular excitability and muscle
contraction. It also functions in maintaining normal acid-base balance.
Indication: This test measures the effectiveness of renal function. Because the renal system
must function to maintain K balance, because 80% of the K is excreted daily from the body
by way of the kidneys; the other 20% is lost through the bowel and sweat glands. The kidneys
are the primary regulators of K balance and accomplish this by adjusting the amount of K that
is excreted in the urine.
Analysis: Normal
e. Chloride
Chloride is the major anion of the ECF. It is found more in interstitial and lymph fluid
compartments than in blood. Chloride is also contained in gastric and pancreatic juices as
well as in sweat. Na and Cl in water make up the composition of the ECF and assist in
determining osmotic pressure. The serum level of chloride reflects a change in dilution or
concentration of the ECF and does so in direct proportion to Na.
Indication: This test measures the effectiveness of renal function.
Analysis: Normal
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1. Fill up laboratory request and send to laboratory to inform the medical
technologist.
2. Inform client about the type of the procedure and its purpose to gain her
cooperation and also to increase her awareness regarding the procedures that will be done to
her.
3. Reemphasize NPO (since the client is already in NPO).
4. Follow up results, attached to the chart of the patient and refer it to the
Physician to inform the abnormality of the found value and to evaluate the condition of the
patient.
XII. MEDICAL MANAGEMENT

A. Intravenous Therapy
IVF therapy was given to the patient because it is an efficient method of supplying fluids
and electrolytes directed to the extracellular components especially the venous system. IVF was
also used to supply or provide nutrients and also a way of drug administration.
Purpose: The choice if IV solution depends on the purpose of the administration. Generally
fluids are administered to achieve one or more of the following goals:
• To provide water, electrolytes and nutrients to meet daily requirements
• To replace water and correct electrolyte imbalance
• To administer medications and blood products
IV solutions contain dextrose or electrolyte mixed in various proportion with water. Pure-
electrolyte-free water never administered IV because it rapidly enters the Red Blood Cells and
causes them to rupture.
Indication: IV is used as an avenue for IV drug administration and to supply or provide nutrients
to our patient.
1. Verify doctor’s order
2. Inform the patient about the procedure to gain cooperation
3. Know the type, amount, and indication of IV therapy
4. Always use aseptic technique when handling IV solutions to prevent further
infection
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5. Check for IVsolutions and needles for potency

6. Regulate IV flow properly to maintain proper hydration
7. Asses for infiltration on the IV site such as swelling, heat and pain around vein at
the infusion site or proximal to it may indicate thrombophlebitis
8. Change the solution container to prepare it empties to prevent embolism
9. Place the pad in proper slot to prevent needle displacement or removal during
movement
B. Diet Therapy
DAT (Diet as Tolerated)
Indication:
 it was ordered to our client to supplement necessary nutritional needs or to meet optimum
nutrition for him to function well and increase resistance
Nursing Responsibilities
1. Check the doctor’s order
2. Transcribe the order in the diet list of the patient and inform the dietician
3. Inform the patient of what is to be included in the patient’s meal, which is all
foods except those for dark colored foods and beverages
4. Encourage patient to eat foods which are not spicy to avoid gastric irritation
C. OXYGEN THERAPY
Administration of oxygen above 21% which is prescribed by the physician who specifies
the specific concentration, method, and liter flow per minute.
Oxygen – colorless, odorless, tasteless, and dry gas that support the combustion
Indications:
1. To deliver oxygen, adequate to meet the body cells needs
2. To provide high humidity
3. To allow uninterrupted delivery of oxygen while patients ingest foods/fluids.
4. It was given to client with difficulty of breathing, this will help client by supplying enough
oxygen needed by the body to facilitate efficient breathing.
BSN-IVC,G3
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Oxygen Inhalation via Nasal Cannula

- Is a method of administering oxygen
- simple device that can be inserted into the nares for delivery of oxygen and that allows
the client to breath through her mouth or nose.
- it does not interfere with the client’s ability to eat or talk.
1. Verify the order of the doctor to prevent error
2. Position the patient in moderate high back rest to allow the full expansion of the lungs and to
establish a better flow of air movement
3. Before administering the O2 equipment wash your hands- to reduce transmission of
microorganism.
4. Open source of O2 before insertion of O2 device to check if the device is functioning
5. Lubricate nares with water soluble lubricant to soothe the mucus membrane
6. Place “No Smoking Sign at the bedside to avoid possible danger like fire.
7. Provide good oro-nasal hygiene to prevent infection and promote relaxation
D. Vital Signs Taking
- Vital Signs Taking every four hours
- Frequent assessment of the vital signs provides information about the development or
progress of deterioration of patient’s condition.
1. Explain the purpose to gain cooperation.
2. Monitor vital signs including blood pressure, cardiac rate and respiratory rate for a full
minute and body temperature.
3. Record vital signs and refer for abnormalities especially if higher and lower than normal.
XIII. DRUG STUDY

A. Generic Name: Albuterol (Salbutamol)
Brand Name: Ventolin
Classification: Bronchodilator
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Dosage, Route and Frequency: 2.5 cc + NSS 1.5cc every 4 hours

Mechanism of Action:
Relaxes bronchial and vascular smooth muscle by stimulating beta - 2 receptors.
Desired Effect:
Albuterol is a short-acting, beta-adrenergic bronchodilator drug used for relief and
prevention of bronchospasm. It is also used to prevent exercise-induced bronchospasm.
Side Effect / Adverse Reaction:
CNS: tremor, nervousness, dizziness, insomnia, headache, hyperactivity, weakness, CNS
stimulation, malaise.
CV: tachycardia, palpitations, hypertension.
EENT: dry and irritated nose and throat (with inhaled form), nasal congestion, epistaxis,
hoarseness.
GI: heartburn, nausea, vomiting, anorexia, bad taste in mouth, increased appetite.
Metabolic: hypokalemia.
Musculoskeletal: muscle cramps.
Respiratory: bronchospasm, cough, wheezing, dyspnea, bronchitis, increased sputum.
Other: hypersensitivity reactions.
1. Check Doctor’s order.
2. Observe the 10 R’s.
3. Teach patient to perform oral inhalation correctly.
 Clear nasal passages and throat.
 Breathe out, expelling as much air from lungs as possible.
 Place mouthpiece well into mouth as dose from inhaler is released, and inhales
deeply.
 Hold breath for several seconds, and exhale slowly.
4. Tell patient to wash inhaler every after used.
5. Do bronchial clapping after nebulization.
6. Instruct patient to do deep breathing and coughing exercise.
7. Warn patient about possibility of paradoxical bronchospasm. Tell him to stop drug
immediately if it occurs.
B. Generic Name: Bambuterol

Brand Name: Bambec
Classification: Sympathomimetics – bronchodilator
Dosage, Route & Frequency: 10 mg 1 tab od & hs
Closely resembles the response to stimulation of adrenergic nerves, it exert a peripheral
inhibitory action on smooth muscle thus decreasing bronchial constriction.
Indication:
BSN-IVC,G3
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Bronchial asthma, chronic bronchitis, emphysema, and other lung diseases, where
bronchospasm is complicating factor.
Desired Effect:
This drug is given to our client because it decreases bronchial constriction; dilate the
bronchioles thereby allowing airway clearance.
Side Effects:
headache
tonic muscle cramps
palpitations
1. Take with food or after meal to decrease gastric irritation
2. Check for adverse reactions. Discontinue drug and notify physician.
3. Decrease irritants and increase hydration.
4. Teach the following:
a. breathing techniques
b. coughing techniques
c. nebulization
d. if it is given over a long period of time, cumulative effect
takes place takes place thus medication becomes ineffective.
C. Generic Name: Ambroxol

Brand Name:
Classification: Mucolytic
Dosage, Route and Frequency: 75 mg cap OD
Ambroxol is a metabolite of bromhexine, which liquefies and changes the structure of
bronchial secretions, reduce viscosity of sputum and promotes the expectoration of blocked-up
secretions and also eases cough.
Desired Effect:
This drug is given to the patient to relieve cough and loosens the phlegm.
Side Effect/Adverse Reaction:
- stomatitis
- nausea
- rhinorrhea
- bronchospasm
- bronchial/tracheal irritation
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- drowsiness
1. Check doctor’s order.
2. Observe the 10 R’s.
3. Patient must be taught on how to cough out effectively.
4. Check proper disposal of secretions.
5. Encourage increase in fluid intake.
6. Cough should not be suppressed if productive.
7. Observe for bronchial spasm, wheezing and increased congestion.
8. drug must always be found at hand in case of bronchospasm.
D. Generic Name: Theophylline

Brand Name:
Classification: Bronchodilator
Dosage, Route, and Frequency: 200 mg BID
Inhibits phosphodiesterase, the enzyme that degrades cAMP, resulting in relaxation of
smooth muscle of the bronchial airways and pulmonary blood vessels.
Desired Effect:
This drug is given to the patient to treat acute bronchospasm and relaxes the muscles
surrounding the airways.
Side effects/Adverse Reaction:
CNS: restlessness, dizziness, headache, insomnia, irritability, seizures, muscle twitching
CV: palpitations, sinus tachycardia, flushing, marked hypotension, arrhythmias
GI: nausea, vomiting, diarrhea, epigastric pain
Respiratory: tachypnea, respiratory arrest
1. Monitor vital signs; measure and record fluid intake and output. Expect improved quality of
pulse and respirations.
2. Inform elderly patient that dizziness is common at start of therapy.
3. Tell patient o relieve GI symptoms by taking oral drug with full glass of water after meals,
although food in stomachache delays absorption.
4. Instruct patient to take drug regularly, only as directed. Patients tend to want to take extra
“breathing pills.”
E. Generic Name: Hydrocortisone
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Brand Name:
Classification: Corticosteroids
Dosage, Route, and Frequency: 100mg IVP q 6o
Decreases inflammation, mainly by stabilizing leukocyte lysosomal membranes;
suppresses immune response; stimulates bone marrow; and influences protein, fat, and
carbohydrate metabolism.
Desired effect:
This drug is given to the patient to relax the airway muscles that constrict during
bronchospasm and it reduces asthma symptoms by suppressing the immune response.
Side Effects/Adverse Reaction:
CNS: euphoria, insomnia, psychotic behavior, vertigo, headache, paresthesia, seizures
CV: heart failure, hypertension, edema, arrhythmias
EENT: cataracts, glaucoma
GI: irritation, nausea, vomiting
1. Check Doctor’s order.
2. Determine whether patient is sensitive to other corticosteroids.
3. Do skin testing.
4. Instruct patient/ watcher to report any hypersensitivity reactions.
5. Monitor patient’s weight, blood pressure, and electrolyte levels.
6. Inspect patient’s skin for petechiae.
E. Generic Name: Levofloxacin

Brand Name:
Classification: Anti-biotic
Dosage, Route, and Frequency: 500 mg i tab OD
Inhibits bacterial DNA gyrase and prevents DNA replication, transcription, repair, and
recombination in susceptible bacteria.
Desired effect:
This drug is given to the patient to prevent infection most specially on the respiratory
system.
Side Effects/Adverse Reaction:
CNS: headache, insomnia, dizziness, encephalopathy, paresthesia, seizures.
CV: chest pain, palpitations, vasodilation.
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EENT (ophthalmic solution): transient decreased vision, foreign body sensation, transient
ocular burning, ocular pain, photophobia, pharyngitis.
GI: nausea, diarrhea, constipation, vomiting, abdominal pain, dyspepsia, flatulence,
pseudomembranous colitis.
GU: vaginitis.
Hematologic: eosinophilia, hemolytic anemia, lymphopenia.
Metabolic: hypoglycemia.
Musculoskeletal: back pain, tendon rupture.
Respiratory: allergic pneumonitis.
Skin: rash, photosensitivity, pruritus, erythema multiforme, Stevens-Johnson syndrome.
Other: pain, hypersensitivity reactions, anaphylaxis, multisystem organ failure, fever.
1. Tell patient to take drug as prescribed, even if symptoms disappear.
2. Advise patient to take drug with plenty of fluids and to avoid antacids, sucralfate,
and products containing iron or zinc for at least 2 hours before and after each dose.
3. Warn patient to avoid hazardous tasks until adverse CNS effects of drug are
known.
4. Advise patient to avoid excessive sunlight, use sunblock, and wear protective
clothing when outdoors.
5. Instruct patient to stop drug and notify doctor if rash or other signs or symptoms
of hypersensitivity develop.
6. Tell patient to notify doctor if he experiences pain or inflammation; tendon
rupture can occur with drug.
7. Instruct patient to notify doctor if loose stools or diarrhea occurs. Inspect
patient’s skin for petechiae.
XIV. NURSING CARE PLAN
1. Nursing Diagnosis: Ineffective airway clearance related to bronchospasm and increased

production of secretions as manifested by deep breathing, increased
respiratory rate (30 bpm), use of accessory muscles in breathing, with
abnormal breath sounds (wheeze and rales), with chest retractions, coughing
and the verbalization of “kasla lang adda nakasullat ditoy karabukob ko”.
Nursing Inference: In asthma, there will be an ineffective airway clearance brought about by the
bronchospasm and increased production in secretions. Bronchospasm can be
defined as constriction of the air passages of the lung by spasmodic
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contraction of the bronchial muscles caused by the different factors such as

emotional stress, exercise, respiratory infection, allergens, irritants, foods,
drugs, and occupation. Increased mucus production also happens when there
is a release of leukotrienes of the mast cells which the main role is to activate
mucus production of the mucus membrane.
Nursing Goal: After 30 minutes to 2 hours of rendering nursing interventions, the client’s
airway will be cleared as will be manifested by the absence of deep
breathing, respiratory rate within normal range, breathing without the use of
accessory muscles, no abnormal breath sounds, no chest retractions and the
verbalization of “nalag-an iti panaganges kon”.
Nursing Interventions:
Interventions Rationale
1. Admi - To deliver adequate O2
nister O2 inhalation as ordered and needed by the body cells in normal
regulate it accurately. amount
2. Admi - Bronchodilators
nister bronchodilators as ordered stimulate the relaxation of smooth
muscle of the irritated bronchioles.
- For better lung

3. Positi expansion
on the client in high or semi-fowlers
position or in orthopneic position
- To liquefy secretions
4. Incre thereby easier expectoration.
ase fluid intake unless contraindicated
- To aid in the gradual

5. Teac movement of secretions or
h client to cough effectively expectoration
- To improve chest
6. Enco expansion for further distribution of
urage deep breathing and coughing O2 and easier expectoration of
exercises. secretions.
- To conserve energy.
7. Enco
urage the client to have enough rest and
BSN-IVC,G3
46
sleep. - Precipitators of
allergic type of respiratory
reactions that can
8. Keep trigger/exacerbate onset of acute
environmental pollution to a minimum, episode.
e.g., dust, smoke, and feather pillows,
according to individual situation.
Nursing Evaluation: After one hour of rendering nursing interventions, the client’s airway was
cleared as manifested by the absence of deep breathing, respiratory rate
within normal range, breathing without the use of accessory muscles, no
abnormal breath sounds, no chest retractions and the verbalization of
“mayat iti panaganges kon”.
2. Nursing Diagnosis: Impaired gas exchange related to altered oxygen supply secondary to
obstruction of airway as manifested by difficulty of breathing, slight
confusion, restlessness, irritability, inability to move secretions, deep rapid
breathing (RR = 30) and the verbalization of “agkakapsutak”.
Nursing Inference: In asthma, airway obstruction is main problem. The impaired gas exchange is
caused by the airway obstruction that disables the oxygen to enter the lungs
for ventilation thereby altering the oxygen supply.
Nursing Goal: After 30 minutes to 2 hours of rendering nursing interventions, the client
will manifest signs of increased oxygen supply such as absence difficulty
of breathing, slight confusion, restlessness and irritability, able to move
secretions, respiratory rate within normal and the verbalization of “limaag-an
panaganges kon”.
1. Reduce airway obstructions by: - To increase
- Increasing patients oral fluid oxygen supply.
intake unless contraindicated
- Administer steam inhalation
- Teach patient to cough
effectively
- Administer nebulization as
ordered
BSN-IVC,G3
47
2. Increase oxygen supply to the lungs - To facilitate gas

by: exchange in the lungs because to the
- Ask patient to be in presence of abundant oxygen
sitting/fowlers/semi-fowlers
position this provides greater area
for optimum chest expansion
- Administer oxygen as
ordered. This provides greater
concentration of O2 than that in
normally inhaled air
- Instruct breathing
exercise. This increase alveolar
ventilation reduces the amount of
dead air in the lungs.
Nursing Evaluation: After one hour of rendering nursing interventions, the client
manifested signs of increased oxygen supply such as absence difficulty
of breathing, slight confusion, restlessness and irritability, able to move
secretions, respiratory rate within normal and the verbalization of “nalag-an
panaganges kon”.
3. Nursing Diagnosis: Ineffective breathing pattern related to bronchoconstriction as manifested by

rapid deep breathing, use accessory muscles in breathing, flaring of nares,
chest retraction and the verbalization of “marigatangak nga aganges”.
Nursing Inference: In asthma, bronchoconstriction is always present and is the main problem.
Because of the narrowing of the airways, it is a comsensatory mechanism of
the body to strive hard in order to inspire the needed amount of oxygen of the
body. In this compensatory mechanism, the normal breathing pattern of the
client will be altered.
Nursing Goal: After 30 minutes to 2 hours of rendering nursing interventions, the client’s
breathing pattern will be improved as will be manifested by the absence of
rapid deep breathing, breathing without the use of accessory muscles, no
flaring of nares, no chest retraction and the verbalization of “nalag-an iti
panaganges kon”.
BSN-IVC,G3
48
1. Teac - Helps patient prolong

h patient diaphragmatic and pursed-lip expiration time and decreases air
breathing. trapping. With these techniques,
patient will breathe more efficiently
and effectively
- Pacing activities permit

2. Enco patient to perform activities without
urage alternating activity with rest excessive distress.
periods.
- Strengthens and
conditions the4 respiratory muscles.
3. Enco
urage use of an inspiratory muscle trainer
Nursing Evaluation: After 2 hours of rendering nursing interventions, the client’s breathing
pattern was improved as manifested by the absence of rapid deep breathing,
breathing without the use of accessory muscles, no flaring of nares, no chest
retraction and the verbalization of “mayat iti panaganges kon”.
4. Nursing Diagnosis: Activity intolerance related to ineffective breathing pattern and altered
oxygen supply as manifested by weakness, inability to do usual routines,
easy fatigability, and the verbalization of “alistuak nga mabannog”.
Nursing Inference: The present condition of the client (asthma) wherein there is a bronchospasm
and increase mucus production that both leads to bronchoconstriction causes
her to have an ineffective breathing pattern and altered oxygen supply. These
conditions causes activity intolerance by a) ineffective breathing pattern
because of the lost of energy exerted to inspire oxygen and b) altered
oxygen supply because oxygen is needed in the cellular level for its normal
functioning.
Nursing Goal: After 30 minutes to 2 days of rendering appropriate nursing interventions, the
client will be able to tolerate physical activity within level of capabilities as
will be evidenced by having enough energy to maintain usual routine,
absence of weakness and verbalization of “haanak alisto nga mabannogen”.
BSN-IVC,G3
49
1. Admi - To meet the oxygen
nister oxygen per nasal cannula at 5 LPM needed by the body
2. Enco - To reduce cardiac

urage adequate rest periods especially workload.
before ambulation, diagnostic procedures
and meals.
3. Assis
t with ADL as indicated. - To reduce energy
expenditures
4. Enco
urage active ROM exercises such as - To maintain muscles
dangling and deep breathing exercises. strength and join range of
motion.
5. Invol
ve the client and significant other in setting - Setting small
the plan of care. attainable goals can increases self
confidence and self esteem
6. Avoi - To increase her self

d doing for client what she can do for esteem
herself
Nursing Evaluation: After 2 hours of rendering appropriate nursing interventions, the client was
able to tolerate physical activity within level of capabilities as evidenced by
having enough energy to maintain usual routine, absence of weakness and
verbalization of “haanak alisto nga mabannogen”.
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XV. GENERAL EVALUATION
Ang Khit, 58 years old, widow, residing in # 4, Laoag City, was admitted to emergency room last
January 1, 2005 at 6:30 in the morning with a chief complaint of difficulty of breathing. After thorough
history taking and physical examination done by Dr. Magcalas and Dr. Catcatan, she was admitted to
Mariano Marcos Memorial Hospital and Medical Center (MMMH & MC) at 7:00 in the same morning.
Ang Khit had an admitting diagnosis of Bronchial Asthma in Acute Exacerbations. After a continuous
management and examination, the same diagnosis was found out.
After four days of nursing interaction, assessment, planning, and interventions, the client’s
condition had improved in many ways.
Difficulty of breathing was felt during the date of admission and immediately treated. No series
of difficulty of breathing was reported on the last three days stay in the hospital.
As the client went home, new orders were given by the physician, proper instructions and
health teachings had imparted to our client and to her relatives. And Ang Khit affirmed that they
will comply particularly with the medications and the follow up OPD check up after five days.
The also appreciated the care and concern bestowed by the student nurses especially those from
MMSU.
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51
XVI. IMPLICATION OF THE STUDY
A. Nursing Practice
This case study will provide student nurses as well a staff nurses a clearer view of the disease
process, its pathology, treatment as well as management. Through the knowledge of the different
nursing responsibilities, the nurse would be able to deal with the client logically whenever she will meet
one of such disease.
This will also serve as a guide for students for the care and supervision of patient with such
disease. It will also serve, as background knowledge for students to give the quality nursing care of
patient and that student nurses should take note of the signs and symptoms as well as prevention of the
disease.
B. Nursing Education
This case study will serve as a basis for nurses in improving the care of patient suffering from
BRONCHIAL ASTHMA IN ACUTE EXACERBATION. This would give a better understanding of the
patient; likewise it provides courage for the students to study more of this case and be able to determine
the possible needs of the patient in that certain disease. This will also facilitate a clearer view of such
disease, the management of every problems encountered, on how to deal with them, and to implement a
plan and evaluate afterwards. This case study is beneficial to the students not only as a basis but also a
way of enlightenment such as in gaining knowledge.
C. Nursing Research
This study is a tool to develop more thesis and researches on the said disease. The nature,
incidence, predisposing factors, management and treatments are important to develop a good study of
this certain disease. Willing and able nurses and researches are needed to study more of the disease to
be able to come up with higher quality nursing care. This study is not just merely a research but also an
application of plans and intervention and evaluation of results based on what is really happening to the
patient.
BSN-IVC,G3

Bronchial Ashthma

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1

MARIANO MARCOS STATE UNIVERSITY

January 27, 2005

Family Health History- - - - - - - -15

IX. PHYSICAL ASSESSMENT- - - - - - - -25

X. ON GOING APPRAISAL - - - - - - - -26

XI. LABORATORY AND DIAGNOSTIC PROCEDURES- - - -29

XII. MEDICAL MANAGEMENT- - - - - - - -36

XIII. DRUG STUDY- - - - - - - - - -38

XIV. NURSING CAREPLAN- - - - - - - -43

XV. GENERAL EVALUATION - - - - - - -49

XVI. IMPLICATION OF THE STUDY - - - - - -50

I. ANATOMY AND PHYSIOLOGY OF RESPIRATORY SYSTEM

STRUCTURES OF THE RESPIRATORY SYSTEM

Nose and Nasal Cavity

Segmental and Subsegmental Bronchi

Symptoms and Signs

EMOTIONAL EXERCISE ALLERGENS, RESPIRATORY

Edema on mucus membrane

Increase work of breathing Use of Accessory

Slow, shallow respiration

Retention of CO2 Respiratory acidosis

III. PERSONAL DATA

Name: Ang Khit

Final: Bronchial Asthma with Acute Exacerbation

Inductive period of Hospitalization:

IV. FAMILY BACKGROUND

Hi-ngal Eldest Daughter 37 F M Hong Domestic Bathle College

Rharek Second Daughter 35 F M Hong Domestic Bathle High School

Ah- Third Daughter 32 F S Hong Domestic Bathle College

Uh-yhek Fourth Son 30 M M Laoag City Tricycle Bathle Vocational

Sa-whaw Fifth Son 21 M M Laoag City Tricycle Bathle High School

Phle-mas Sixth Daughter 15 F S Laoag City Student Bathle High School

Approximate Income: P 10, 000.00

B. Past Health History

C. Present Health History

VI. DEVELOPMENTAL DATA

In addition, at this stage, she is expected to develop attitude-establishing priority of needs,

1. Achieving adult civic and social responsibility

VII. PATTERNS OF FUNCTIONING

Lunch Lunch Lunch pattern, etc., that

Dinner Dinner Dinner

Snack Snack Snack

3. Bladder Frequency: 7times a Frequency 7times a Frequency: 5-6 times a There is a

Amount Amount approximately: 1100- output as observe in

5. Bathing/ Frequency: Frequency: Frequency: There is a

6. Sleeping Duration: 9 hours Duration: 9 hours Duration: 10 hours There is no change

VIII. LEVELS OF COMPETENCIES

performing her limited such as hospitalization. She client due to her

IX. PHYSICAL ASSESSMENT

Date of Assessment: January 01, 2005 @ 2 PM

Body temp. 37.4oC PR: 98 bpm

Head to Toe Assessment:

XI. LABORATORY AND

Indications: As part of routine screening procedure; when pulmonary disease is suspected; to

Date Performed: January 1, 2005

3. Hematology or Complete Blood Count (CBC)

c. Red Blood Cells (RBC)

d. Mean Corpuscular Volume (MCV)

e. Mean Corpuscular Hemoglobin (MCH)

f. Mean Corpuscular Hemoglobin Concentration (MCHC)

g. White Blood Cells (WBC)

Indication: This test measures the total number of platelets in circulation.