CENTRAL LUZON DOCTORS HOSPITAL - EDUCATIONAL INSTITUTION San Pablo, Tarlac City

In partial fulfillment of requirement in NCM 106 Community

ASTHMA
Submitted by:
Beltran, Mariya Ciemicah David, Kathrina Dino, Shiela May Galang, Paul Danielle Iglesia, Marinel Larona, Jerry Magday, Cherry Pamintuan, Fatima Shayne Sarmiento, Mark Joseph Tomas, Cheska Marie BSN IV-A/ Group 4

Submitted to: Mrs.Ma. Jesusa Bermudez, RN, MSN Clinical Instructor

I. INTRODUCTION

For the purpose of confidentiality the real name of the patient in this case study is withheld and we used the pen name Baby breath. Baby breath was a 1 year old, male and currently residing at Sitio Apalang, Tarlac City. Baby Breath was brought to OPD of Tarlac Provincial Hospital last May 2011 with a chief complaint of difficulty of breathing and was diagnosed having asthma.

Asthma is a common chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm. It may be classified as atopic (extrinsic) or non-atopic (intrinsic) depending on the triggering factors. Known causes are either genetic, environmental or both. These include presence of allergies, family history of asthma, frequent respiratory infections, low birth rate, exposure to tobacco smoke before and/or after birth, being male and being raised in a low-income environment.

Asthma is the leading cause of chronic illness in children. It affects as many as 10%12% of children in the U.S. and, for unknown reason it is steadily increasing. It can begin at any age, but most children have their first symptoms by age 5. Treatment of acute symptoms is usually with an inhaled short-acting beta-2 agonist (such as salbutamol).Symptoms can be prevented by avoiding triggers, such as allergens and irritants, and by inhaling corticosteroids. Leukotriene antagonists are less effective than corticosteroids and thus less preferred.

II. OBJECTIVES:

To establish rapport or therapeutic relationship with the patient and with his family. To utilize and improve assessment skills to have proper and accurate data. To render proper nursing interventions to meet the demands and body needs of the patient. To familiarize ourselves with the role of a nurse in caring for our patient. To work harmoniously with the other health care providers in giving continuous care to the patient.

III. NURSING PROCESS A. DATA BASE a. NURSING HEALTH HISTORY A Demographic Data Patient: Baby breath Address: Apalang, Tarlac Age: 1yr 8 mos. Sex :Male Place of Birth: Apalang, Tarlac Nationality: Filipino Examiner: Group 4 Informant: Mother Date of birth: October 30, 2009 Religion: Roman Catholic

I. CHIEF COMPLAINT -----------------II. HISTORY OF PRESENT ILLNESS This last May 2011, patient suddenly experienced difficulty of breathing and was immediately brought to OPD of Tarlac Provincial Hospital. III. PAST MEDICAL HISTORY A. Pediatric and Adult Illnesses

Mumps Measles Rubella

_____ _____ _____

Pertusis Rheumatic Pneumonia

______ ______ ______

HPN Hepatitis

______ ______

Heart Disease ______ Others: Asthma

Chicken Pox _____

Tuberculosis ______

B. Immunization/Tests BCG ____ DPT __x__ OPV __x__ C. Hospitalizations None D. Injuries None E. Transfusions None F. Medications Baby Breath takes Ventolin and Prednisone. When the client have fever her mother give her paracetamol. G. Allergies The patient has an allergy to poultry products such as eggs. HEP B Measles ___x___ ___x___ Pneumonia: _____ Others: _____

Tuberculosis: ______

IV. FAMILY HISTORY AGE L D 56 y/o 34 y/o 36 y/o List: Parents, Spouse, Children Grandmother breath (father side) Grandfather breath (father side) Grandmother breath (mother side) Father breath Mother breath Brother breath (1) Brother breath (2) Sister breath (3) Sister breath (4) Brother breath (5) DM = Diabetes mellitus MI = Mental Illness HP = Hypertension CA = Cancer KD = Kidney Disease Healthy Healthy Healthy Asthma Healthy Healthy O = Obesity HT= Hyperthyroidism O = Other J- Jaundice Health Status or Cause of Death Heart Attack Rupture of appendix Breast cancer HPN Diseases Present in the Family

35y/ o 36y/ o
12y/o

9y/o 8 y/o 6y/o 3y/o L = Living D = Dead H = Heart D = Disease TB = Tuberculosis

V. SOCIAL AND PERSONAL HISTORY Birthplace: Apalang, Tarlac Birthday: October 30, 2009 Ethnic Background: Kapampangan Clients Position in the Family: Youngest son

Occupation: N/A

Financial Support System: Baby breath and his family get financial support from his father who currently works at Tarlac City as a Tocino maker.

Habits (tobacco/alcohol use, others): None Diet (meal distribution, others): He eats 3 times a day and breastfed by her mother before he goes to sleep. Physical Activity/Exercise, if any: Play sessions with his older brother serves as his daily exercise. Brief Description of Average Day: According to his mother, a typical day of her son is described as sequence of, eatplay-eat-nap-eat-sleep.

b. NURSING HEALTH HISTORY B

General Description of the Client Our patient is a 1 y/o, male. He is residing at Sitio Apalang, Armenia Tarlac and he was born on October 30, 2009. He has unkempt hair, untidy fingernails and clothing which show poor hygienic practices.

Health Perception-Health Management Pattern As verbalized by the patients mother, they seek medical attention at their clinic or at the provincial hospital whenever Baby Breath experiences unusual symptoms like difficulty of breathing. The mother also stated that she uses lagundi when the client has cough.

Nutritional Metabolic Pattern The patient eats 3 times a day and drinks breast milk before every nap or sleep. Moreover, he preferred vegetables and fish much better than meat.

Elimination Pattern The patient defecates twice a day and a urine elimination of 5-7x a day.

Activity-Exercise Patterns His usual activity pattern is playing with his playmates.

Sleep-Rest Pattern The patient sleeps approximately 9 hours every regular sleep plus 2 hours for his daily afternoon nap.

Cognitive-Perceptual Pattern According to his mother, Baby Breath makes no unusual behavior. He expresses his self through crying, pointing and mumbling which is typical to a one year old.

Self-Perception-Self-Concept Pattern N/A

Value-Belief Pattern N/A

VI. REVIEW OF SYSTEM

General Description: Weight Loss [ ] Night sweats [ ] Skin: Itch [ ] Lesions [* ] Eyes: Pain [ ] Blurring [ ] Ears: Earaches [ ] Nose: Obstruction [ ] Discharges [* ] Epistaxis[ ] Tinnitus [ ] Hearing loss [ ] Discharges [* ] Itch [ ] Vision Loss [ ] Diplopia[ ] Excessive Tearing [ ] Glasses/Contact lenses [ ] Rash [ ] Bleeding [ ] Bruises [ Color changes [ ] ] Fatigue [ ] Weakness [ ] Anorexia [ ]

Throat and Mouth: Sore throat [ ] Toothache [ ] Bleeding Gums [ ] Decay [*]

Neck: Dyspahagia [ ] Chest: Cough [* ] Sputum [ ] CVS: Chest pain [ ] Palpitation [ ] GIT Food tolerance [ ] Vomiting [ ] Excessive gas [ ] GU: Dysuria [ ] Polyuria [ ] Extremeties: Joint pain [ ] Edema [ ] Neuro: Headache [ ] Memory loss [ ] Mental health: Anxiety [ ] Depression [ ] Insomnia [ ] Fears [ ] Dizziness [ ] Paralysis [ ] Fainting [ ] Paresis [ ] Numbness [ ] Varicose Vein [ ] Claudication [ ] Tremors [ ] Stiffness [ ] Nocturia [ ] Hematuria [ ] Retention [ ] Dribbling [ ] Flank pain [ ] Heartburn [ ] Jaundice [ ] Change in BM [ ] Nausea [ ] Constipation [ ] Melena [ ] Pain [ ] Bloating [ ] Dyspnea on exertion [ ] Orthopnea [ ] Others [ ] Dyspnea [ ] Hemoptysis [ ] Apnea [ ] Wheeze [* ] Pain on respiration [ ] Swelling [ ] Hoarseness [ ]

PHYSICAL ASSESSMENT June 23, 2011 Skin The color of the skin is brown. There is no jaundice observed. The texture is smooth. Temperature is warm. With good skin turgor (2-3 seconds). Head/Skull (Inspection, Palpation) Head is symmetrical and round. Facial structures are symmetrical. Some scars are present.

Eye/Vision (Inspection) The sclera is white and pupil is equally round and reactive to light accommodation. Both irises are brown. Both eyes move coordinated manner in all direction. Conjunctiva is pink in color.

Ears/Hearing (Inspection, Palpation) The ears are symmetrical in size and the top of the pinna is positioned at level of eyebrows bilaterally and free from masses. Ears are similar in appearance, texture is smooth and elastic and pinna recoils when fold. There is a presence of yellowish discharges.

Nose (Inspection) The color of the nose is same as face, smooth to touch, with whitish discharge noted. with nasal flaring and use of accessory muscle when breathing. No nodules or masses reported or palpated. Nose is non-tender.

Mouth/Tongue/Teeth (Inspection) Lips and surrounding tissue relatively symmetrical with no lesions, swelling. Lips is cyanotic in color and dry mucus membrane. Teeth are yellowish in color, presence of dental caries no presence of tongue lesions noted. Hard palate is pale in appearance while soft palate is pinkish in color.

Throat/Neck (Inspection, Palpation) Neck is with smooth controlled movements, lymph nodes are palpated. Trachea is in the midline and no lymph nodes palpated.

Circulatory/Cardiovascular (Auscultation, Palpation) Patient has heart rate of 92 bpm, and respiratory rate was 29.

Gastrointestinal (Palpation, Auscultation) Abdomen rounded in contour and symmetrical and has lighter color than those of the extremities. No rashes and lesions noted. Umbilicus is centrally located with pinkish color. The color of stool is brown. Bowel sounds auscultated 24 times per minutes in all four quadrants. Musculoskeletal Weight evenly distributed, able to stand at erect posture and arms swinging of position and symmetrical structure and development of muscles. Genitalia (inspection) With no discharges. No masses palpated and no presence of lesions.

ANATOMY AND PHYSIOLOGY:

The respiratory system's function is to take oxygen into the lungs and output carbon dioxide and a small amount of oxygen. The space between the alveoli and the capillaries, the anatomy or structure of the exchange system, and the precise physiological uses of the exchanged gases vary depending on organism. In humans and other mammals, for example, the anatomical features of the respiratory system include airways, lungs, and the respiratory muscles. Molecules of oxygen and carbon dioxide are passively exchanged, by diffusion, between the gaseous external environment and the blood. This exchange process occurs in the alveolar region of the lungs. Ventilation Ventilation of the lungs is carried out by the muscles of respiration. Control Ventilation occurs under the control of the autonomic nervous system from parts of the brain stem, the medulla oblongata and the pons. This area of the brain forms the respiration regulatory center, a series of interconnected brain cells within the lower and middle brain stem which coordinate respiratory movements. The sections are the pneumotaxic center, the apneaustic center, and the dorsal and ventral respiratory groups. This section is especially

sensitive during infancy, and the neurons can be destroyeda if the infant is dropped and/or shaken violently. The result can be death due to "shaken baby syndrome". Inhalation Inhalation is initiated by the diaphragm and supported by the external intercostal muscles. Normal resting respirations are 10 to 18 breaths per minute, with a time period of 2 seconds. During vigorous inhalation (at rates exceeding 35 breaths per minute), or in approaching respiratory failure, accessory muscles of respiration are recruited for support. These consist of sternocleidomastoid, platysma, and thescalene muscles of the neck. Pectoral muscles and latisimus dorsi are also accessory muscles. Under normal conditions, the diaphragm is the primary driver of inhalation. When the diaphragm contracts, the ribcage expands and the contents of the abdomen are moved downward. This results in a larger thoracic volume and negative (suction) pressure (with respect to atmospheric pressure) inside the thorax. As the pressure in the chest falls, air moves into the conducting zone. Here, the air is filtered, warmed, and humidified as it flows to the lungs. During forced inhalation, as when taking a deep breath, the external intercostal muscles and accessory muscles aid in further expanding the thoracic cavity. Exhalation Exhalation is generally a passive process; however, active or forced exhalation is achieved by the abdominal and the internal intercostal muscles. During this process air is forced or exhaled out. The lungs have a natural elasticity: as they recoil from the stretch of inhalation, air flows back out until the pressures in the chest and the atmosphere reach equilibrium. During forced exhalation, as when blowing out a candle, expiratory muscles including the abdominal muscles and internal intercostal muscles generate abdominal and thoracic pressure, which forces air out of the lungs. Gas exchange The major function of the respiratory system is gas exchange between the external environment and an organism's circulatory system. In humans and mammals, this exchange facilitates oxygenation of the blood with a concomitant removal of carbon dioxide and other gaseous metabolic wastes from the circulation. As gas exchange occurs, the acid-base balance of the body is maintained as part of homeostasis. If proper ventilation is not maintained, two opposing conditions could occur: respiratory acidosis, a life threatening condition, and respiratory alkalosis. Upon inhalation, gas exchange occurs at the alveoli, the tiny sacs which are the basic functional component of the lungs. The alveolar walls are extremely thin (approx. 0.2 micrometres). These walls are composed of a single layer of epithelial cells (type I and type II

epithelial cells) in close proximity to the pulmonary capillaries which are composed of a single layer of endothelial cells. The close proximity of these two cell types allows permeability to gases and, hence, gas exchange. This whole mechanism of gas exchange is carried by the simple phenomenon of pressure difference. When the atmospheric pressure is low outside, the air from lungs flow out. When the air pressure is low inside, then the vice versa.

PATHOPHYSIOLOGY Modifiable Factors

y y y y Allergens Change in weather Too much exposure to cold weather foods

Non-Modifiable Factors
Hereditary

Exposure

Production of: y Most cells y Neutrophils y Eosinophils y lymphocytes

Activation of: y y y y Histamines Bradykinins Prostaglandin Leukotrienes

Increase blood flow

Inflammation

hyperresponsiveness

Broncho constriction

Mucus production

Dyspnea and DOB Wheezing

Coughing

NURSING CARE PLAN:

CUES

NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION The client

PLANNING

INTERVENTION

RATIONALE

EVALUATION

S> O> irritable >use of accessory muscle >with non productive cough >with wheezing sound upon auscultation >RR : 29bpm

Ineffective

has After 4 hours of nursing airway problem is interventions clearance r/t respiration due to the client will demonstrate retained inflammatory improvement in secretions s/t reaction of the breathing pattern inflammatory body to foreign reaction microorganisms. As the body

>position the client on a folwers position >minimize allergens as possible >perform chest physiotherapy >let the patient breathe on a paper bag > Instruct the SO to provide an increased fluid intake.

>to promote lung expansion and facilitates easier breathing >prevent worsening of condition >to help expel secretions >to promote proper exchange of gases > To help liquefy the secretions

After 4 hours of nursing interventions goal met as evidence by improvement of breathing pattern of the client.

reacts, it causes constriction of the airway patency.

Assessment S>

Nursing Diagnosis

Scientific Explanation

Planning

Nursing Interventions

Rationale >To promote heat loss by evaporation and conduction. >to release the heat of the body and to prevent possible dehydration. >for comfort

EVALUATION Goal partially met as evidence by the clients temperature decreased from 37.8 to 36.7 C

Hyperthermia r/t The body reacts to After 3 hours of >Perform tepid inflammatory the foreign body nursing sponge bath O>Skin is warm to reaction s/t asthma by compensating interventions touch. to the situation. It the pts causes elevation of temperature will >>Increase body >Instruct SO to temperature. be decrease to temp. at 37.8C provide an from 37.8 to increase fluid 36.5 C >RR: 29bpm intake

>provide loose clothing

Drug study Drug VENT OLIN Classifi Dosage cation Bronch odilator , anti asthmat ic. Action Indication - To prevent and relieve bronchospasm in patients with reversible obstructive airway disease. Contraindicatio n Hypersensitivity to drug or its components Side effects dizziness, headache, hyperactivity, insomnia tachycardia, chest pain nausea, vomiting, dry mouth cough, wheezing, paradoximal bronchospasm pallor, flusing, sweating, rash tooth discoloration, increase appetite, Nursing responsibilities >Teach SO that drug may lowers resistance to infection. > Advise to immediately report fever, cough, breathing problems and other signs or symptoms of infection. > Instruct SO to give the medication after meals >Instruct SO to notify prescriber immediately if prescribed dosage fails to provide usual relief because this may indicate seriously worsening asthma.

1 TBSP Relaxes smooth muscle by stimulatin g beta z receptors, thereby causing bronchodil ation and vasodilatat ion.

Drug PARA CETA MOL

Classifi Dosage cation Antipyr etic , Analge asic 5ml or 1tsp PRN

Action Pain relief may result from inhibition of prostaglandi n synthesis in CNS, with subsequent blockage of pain impulses.

Indication -Mild to moderate pain. -Fever

Contraindicatio n Hypersensitivity to drug

Side effects Rash, GI upset, Diaphoresis

Nursing responsibilities > Take drug with meals

> Kept back dry

>Advise patient or SO to contact prescriber if fever or other symptoms persist despite taking recommended amount of drug.

>As appropriate, review all other significant and life threatening adverse reactions, especially those related to the drugs, tests, and behaviors mentioned above.

Drug Predni sone

Classifica tion Antiinflammat ory, immunosu pressnt

Dosa ge

Action
Decreases inflammation

Indication Severe inflammation;

Contraindication -Hypersensivity to drug, other drugs, other corticosteroids. -Systemic fungal infection. -Active untreated infections (except in selected meningitis patients)

Side effects -headache, depression, personality changes, paresthesia, insomnia, restlessness

Nursing responsibilities -Check for signs and symptoms of depression and psychosis. -Monitor patients for signs and symptoms of infection, which drug may mask or exacerbate. -Assess for early indications of adrenal insufficiency (fatigue,

by reversing immunosupresincreased cell

sion.

capillary permeability and inhibiting migration of polymorpho nuclear leukocytes. Suppresses immune system reducing lymphatic activity. by

-nasal irritation weakness, joint pain, and fever, and congestion, sneezing, throat irritation. -cough, wheezing, decreased or increased appetite, hypersensivity reaction and appetite loss, shortness of breath, dizziness and syncope). -Tell patient to take with food or milk to reduce GI upset. -Inform significant other that drug increases his risk of infection. Instruct SO to contact prescriber at first sign of infection. -Caution patient not to stop drug suddenly.

EVALUATION

Handling patient in the community has a big difference in handling patient in the hospital. Where in imposing self-reliant to the people in community is not just simple and will be base on their lifestyle and resources. We were able to define asthma, the manifestation and possible complication of it. Through that all, we give health teachings appropriate on the underlying disease on how manage asthma attack and how to prevent it. Understanding of the disease process the and manifestation including the complication, where we come out the nursing management appropriate to deliver based on the assessment findings, patient needs and available resources in the community and formulation of proper and accurate nursing diagnosis. Where we able to formulate appropriate nursing care plan by identifying, analyzing the sign and symptoms of the disease.

RECOMMENDATION

We recommend this case study to: To our fellow nursing students for them to develop their skills, widen knowledge and critical thinking and to better understand the disease process and work through the use of nursing process and to apply proper nursing intervention regarding asthma. To community and family with cases like Asthma to help them to prevent or aggravate the disease entity and prevents its complication. And to educate them what is Asthma, the signs and symptoms, the possible complication and to prevent the disease on their family.