A CASE STUDY ON BRONCHIAL ASTHMA IN ACUTE EXACERBATION

Presented to Level II Clinical Instructor of Saint Anthony College of Roxas City Nursing Department

In Partial Fulfillment of the Requirements in Related Learning Experience

Submitted to: Mrs. Mabel Alona Macahilig, R.N. Clinical Instructor

Submitted by: Charmie Lou D. Celestial Nio de Prada Ward BSN-2B Group 4

TABLE OF CONTENTS
I. Introduction II. Objectives III. Vital Information IV. Clinical Assessment A. Nursing History 1. History of Present Illness 2. Past Health History 3. Family Health History B. Clinical Inspection V. Case Discussion VI. Anatomy VII. Pathophysiology VIII. Drug Study IX. Nursing Care Plans X. Discharge Planning

I. INTRODUCTION Bronchial asthma is a disease caused by increased responsiveness of the tracheobronchial tree to various stimuli. The result is paroxysmal constriction of the bronchial airways. Bronchial asthma is the more correct name for the common form of asthma. The term 'bronchial' is used to differentiate it from 'cardiac' asthma, which is a separate condition that is caused by heart failure. Although the two types of asthma have similar symptoms, including wheezing (a whistling sound in the chest) and shortness of breath, they have quite different causes. Bronchial asthma is a disease of the lungs in which an obstructive ventilation disturbance of the respiratory passages evokes a feeling of shortness of breath. The cause is a sharply elevated resistance to airflow in the airways. Despite its most strenuous efforts, the respiratory musculature is unable to provide sufficient gas exchange. The result is a characteristic asthma attack, with spasms of the bronchial musculature, edematous swelling of the bronchial wall and increased mucus secretion. In the initial stage, the patient can be totally symptom-free for long periods of time in the intervals between the attacks. As the disease progresses, increased mucus is secreted between attacks as well, which in part builds up in the airways and can then lead to secondary bacterial infections. Bronchial asthma is usually intrinsic (no cause can be demonstrated), but is occasionally caused by a specific allergy (such as allergy to mold, dander, dust). Although most individuals with asthma will have some positive allergy tests, the allergy is not necessarily the cause of the asthma symptoms. Symptoms can occur spontaneously or can be triggered by respiratory infections, exercise, cold air, tobacco smoke or other pollutants, stress or anxiety, or by food allergies or drug allergies. The muscles of the bronchial tree become tight and the lining of the air passages become swollen, reducing airflow and producing the wheezing sound. Mucus production is increased. Typically, the individual usually breathes relatively normally, and will have periodic attacks of wheezing. Asthma attacks can last minutes to days, and can become dangerous if the airflow becomes severely restricted. Asthma affects 1 in 20 of the overall population, but the incidence is 1 in 10 in children. Asthma can develop at any age, but some children seem to outgrow the illness. Risk factors include self or family history of eczema, allergies or family history of asthma. Bronchial asthma causes cough, shortness of breath, and wheezing. Bronchial asthma is an allergic condition, in which the airways (bronchi) are hyper-reactive and constrict abnormally when exposed to allergens, cold or exercise. Treatment is aimed at avoiding known allergens and controlling symptoms through medication. A variety of medications for treatment of asthma are available. People with mild asthma (infrequent attacks) may use inhalers on an as-needed basis. Persons with significant asthma (symptoms occur at least every week) should be treated with anti-inflammatory medications, preferably inhaled corticosteroids, and then with bronchodilators such as inhaled Alupent or Vanceril. Acute severe asthma may require hospitalization, oxygen, and intravenous medications.

Decrease or control exposure to known allergens by staying away from cigarette smoke, removing animals from bedrooms or entire houses, and avoiding foods that cause symptoms. Allergy desensitization is rarely successful in reducing symptoms.

Asthma affects 7% of the population, and 300 million worldwide.

II. OBJECTIVES General Objective After our clinical exposure, we should be able to assess and diagnose patients current status and to plan, implement, and evaluate our nursing procedures towards phases. Also to be able to materialized specific objectives on cognitive, psychomotor, and affective domains, and to be able to carry out and practice all these things with Vincentian values. Specific Objectives KNOWLEDGE 1 2 3 To be able to comprehend the pathophysiology of Bronchial Asthma in Acute Exacerbation. To be able to determine the purposes of all the medications being administered to the patient and its actions and mechanism of action. To be able to gather factual information through interview and medical chart. 4 5 To be able to correlate learned knowledge from the classroom to the clinical area. To be able to determine the implications of laboratory and diagnostic results. SKILLS 1. 2. 3. 4. 5. To be able to perform planned nursing interventions. To be able to set priorities and goals in collaborative with the To be able to obtain a nursing health history, conduct physical To be able to formulate nursing diagnoses and collaborative To be able to select nursing strategies and interventions.

patient. assessment, review records, organize and validate data. nursing statements.

6.

To be able to perform physical assessment in a head-to-toe

approach. ATTITUDE 1 2 3 4 To be able to establish rapport with the patient and folks. To be able to empathize with the patient and folks. To be able to know the patient better and encourage verbalization of fear and anxiety. To be able to understand the feelings of the mother towards her daughters condition.

III. VITAL INFORMATION:

Name: R.M.M Age: 3 years 10/12 months Sex: Female Nationality: Filipino Civil Status: Single Date of birth: March 27, 2010 Address: Li-ong, Roxas City Religion: Roman Catholic Date and Time Admitted: January 20, 2011 at 1:40 p.m Ward: Nio de Praga Ward (Broncho Ward) Chief Complaint: Difficulty of breathing Admitting Diagnosis: Community Acquired Pneumonia, Bronchial Asthma in

Acute Exacerbation
Final Diagnosis: Pneumonia, Bronchial Asthma in Acute Exacerbation Attending Physician(s): Dra. Samillano

IV. CLINICAL ASSESSMENT

A. Nursing History

1. History of Present Illness: 3 days prior to admission, patient had experienced difficulty of breathing so her grandmother decided to put lampunaya to her head. 2 days prior to admission, patients mother decided to seek for consulation at Dra. Samillanos clinic. On the day of admission, symptoms persisted. Patients mother decided to bring her to Saint Anthony College Hospital and prompted admission at Nio de Praga ward for further care under the service of Dra. Samillano.

2. Past HealthHistory: 2007 patient was admitted at Saint Anthony College Hospital with the chief complaint of burns.

3. Family Health History:

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B. Clinical Inspection:

1. Vital Signs:

Upon admission

During my Shift

Temperature: Respiration: Apical Rate:

36.8 C 62 bpm 162 bpm

36.3 C 38 bpm 107 bpm

2. Height: 90.17 cm
Weight: 11.3 kgs BMI: 13.9 (Underweight)

3. Physical Assessment

General Appearance: Patient shows no signs of distress, mobile and calm conscious and oriented

Skin, Hair and Nails: Skin: Brown complexion, normal turgor, dry and warm to touch. Hair: Equally distributed, no lice, no flakes. Nails: Clean and well trimmed, its capillary refill is normal.

Head, Eyes, Ears, Nose, Mouth, Throat and Lymphatics: Head: Symmetrical and freely movable, scalp is smooth and hairs are thick in quantity. Normocephalic, posterior and anterior fonatanelles are closed. Eyes: Equally round, pupils constrict 2mm and reactive to light and accomodation. Ears: Symmetrical, similar in color to face with good hearing capacity. No presence of lesions and discharges. Levels at the outer cantus of the eye. Nose: Nasal mucosa pink, no polyps nor discharges. Septum is found in midline. Mouth: Gums and buccal mucosa are pink, smooth and moist. No presence of lesion found. Tongue moves freely. Tonsils are not inflamed. Throat: No mass palpated. Lymphatics: Normal in size and palpable. No significant finding.

Neck Symmetrical; proportional to head and shoulders. Carotid pulses are strongly palpable, trachea at the midline.

Respiratory System: Respiration rate ranging from 34-40 breaths per minute.

Cardiovascular System: Palpable pulsation, heart rate ranges 104-110 beats per minute with a regular rhythm.

Gastrointestinal System: Able to urinate adequate amount of urine. No complaints of pain noted. Abdomen: The bowel sounds are heard. No abdominal tenderness noted.

Genito-urinary System: No catheter attached. Urine output is adequate every hour.

Musculoskeletal System: On complete bed rest with bathroom privileges, can move freely on bed, able to stand with two feet. Can walk without any support.

V. CASE DISCUSSION Definition A condition of the lungs characterized by widespread narrowing of the airways due to spasm of the smooth muscle, edema of the mucosa, and the presence of mucus in the lumen of the bronchi and bronchioles. Bronchial asthma is a chronic relapsing inflammatory disorder with increased responsiveness of tracheobroncheal tree to various stimuli, resulting in paroxysmal contraction of bronchial airways which changes in severity over short periods of time, either spontaneously or under treatment. Causes Allergy is the strongest predisposing factor for asthma. Chronic exposure to airway irritants or

allergens can be seasonal such as grass, tree and weed pollens or perennial under this are the molds, dust and roaches. Common triggers of asthma symptoms and exacerbations include air way irritants like air pollutant, cold, heat, weather changes, strong odors and perfumes. Other contributing factor would include exercise, stress or emotional upset, sinusitis with post nasal drip , medications and viral respiratory tract infections. Most people who have asthma are sensitive to a variety of triggers. A persons asthma changes depending on the environment activities, management practices and other factor. Clinical Manifestation The three most common symptoms of asthma are cough, dyspnea, and wheezing. In some instances cough may be the only symptoms. An asthma attack often occurs at night or early in the morning, possibly because circadian variations that influence airway receptors thresholds. An asthma exacerbation may begin abruptly but most frequently is preceded by increasing symptoms over the previous few days. There is cough, with or without mucus production. At times the mucus is so tightly wedged in the narrow airway that the patient cannot cough it up. Prevention Patient with recurrent asthma should undergo test to identify the substance that participate the symptoms. Patients are instructed to avoid the causative agents whenever possible. Knowledge is the key to quality asthma care. Medical Management There are two general process of asthma medication: quick relief medication for immediate treatment of asthma symptoms and exacerbations and long acting medication to achieve and maintain control and persistent asthma. Because of underlying pathology of asthma is inflammation, control of persistent asthma is accomplish primarily with the regular use of anti inflammatory medications. Long-acting control Medication Corticosteroid are the most potent and effective anti inflammatory currently available. They are broadly effective in alleviating symptoms, improving air way functions, and decreasing peak flow variability. Cromolyn sodium and nedocromil are mild to be moderate anti-inflammatory agents that are use more commonly in children. They also are effective on a prophylactic basis to prevent exerciseinduced asthma or unavoidable exposure to known triggers. These medications are contraindicated in acute asthma exacerbation. Long acting beta-adrenergic agonist is use with anti-inflammatory medications to control asthma symptoms, particularly those that occur during the night these agents are also effective in the prevention of exercise-induced asthma.

 Quick relief medication Short acting beta adrenergic agonists are the medications of choice for relief of acute symptoms and prevention of exercise-induced asthma. They have the rapid onset of action. Anti-cholinergic may have an added benefit in severe exacerbations of asthma but they are use more frequently in COPD. Nursing Management The main focus of nursing management is to actively assess the air way and the patient response to treatment. The immediate nursing care of patient with asthma depends on the severity of the symptoms. A calm approach is an important aspect of care especially for anxious client and ones family. This requires a partnership between the patient and the health care providers to determine the desire outcome and to formulate a plan which include; The purpose and action of each medication Trigger to avoid and how to do so When to seek assistance The nature of asthma as chronic inflammatory disease

VI.ANATOMY AND PHYSIOLOGY

The upper respiratory tract consists of the nose, sinuses, pharynx, larynx, trachea, and epiglottis. The lower respiratory tract consist of the bronchi, bronchioles and the lungs. The major function of the respiratory system is to deliver oxygen to arterial blood and remove carbon dioxide from venous blood, a process known as gas exchange. The normal gas exchange depends on three process: Ventilation is movement of gases from the atmosphere into and out of the lungs. This is accomplished through the mechanical acts of inspiration and expiration. Diffusion is a movement of inhaled gases in the alveoli and across the alveolar capillary membrane Perfusion is movement of oxygenated blood from the lungs to the tissues.

Control of gas exchange involves neural and chemical process The neural system, composed of three parts located in the pons, medulla and spinal cord, coordinates respiratory rhythm and regulates the depth of respirations The chemical processes perform several vital functions such as: regulating alveolar ventilation by maintaining normal blood gas tension guarding against hypercapnia (excessive CO2 in the blood) as well as hypoxia (reduced tissue oxygenation caused by decreased arterial oxygen [PaO2]. An increase in arterial CO2 (PaCO2) stimulates ventilation; conversely, a decrease in PaCO2 inhibits ventilation. helping to maintain respirations (through peripheral chemoreceptors) when hypoxia occurs.

The normal functions of respiration O2 and CO2 tension and chemoreceptors are similar in children and adults. however, children respond differently than adults to respiratory disturbances; major areas of difference include: Poor tolerance of nasal congestion, especially in infants who are obligatory nose breathers up to 4 months of age

Increased susceptibility to ear infection due to shorter, broader, and more horizontally positioned eustachian tubes. Increased severity or respiratory symptoms due to smaller airway diameters A total body response to respiratory infection, with such symptoms as fever, vomiting and diarrhea.