Name: Age:

Mr. XXER 18 years old

Gender: Status: Religion:

Male Single Roman Catholic

Adress:

Brgy.Ibabang Dupay Lucena City

Occupation:

None

Significant others: Admission Date: Admission Time:

Mr.YYER January 11, 2012 10:46 AM

Chief Complaint:

Difficulty of breathing

Physician:

Dra. De Luna

The patient XXER is brought to the emergency area of Quezon Medical Center, with a chief complaint of DOB. His Respiratory rate is 43 breaths per minute. As an initial action the chart is accomplish and vital sign is taken. Oxygen cannula is prescribed to the patient SO. The staff and we the student nurse waits for the cannula. Then the oxygen is administered and the patient started to calm, but with noted respiratory depression and use of accessory muscle also. According to the patient SO the DOB of patient started at 9:00 am while he is taking a stick of cigarette. From that the DOB of patient continue until he is brought by his brother at the hospital. The patient DOB can be considered severe as assessing his RR, its pattern is rapid inspiration and expiration.

The patient has not been hospitalized before according to his brother, the patient SO also told that the patient DOB is his only problem in terms of health. His brother also mentioned that the only illness that his brother acquired for the past weeks or months is only simple cough, colds and mild fever which he treated with over the counter drugs only.

Patient Mother

Patient Brother

Patient Father

Patient

With ASTHMA

The patient lives in lucena city, their house is compose of concrete and wood as his brother describe, although the conversation is short because of dilemma of his brother because of his death. We can still concur that the patient surrounding may further trigger the patient illness because of the dust coming from construction mill near on their house as his brother describe. His brother able to describe his lifestyle to the physician upon hearing it we can also analyze that the patient habit of escaping meal and taking a pack of cigarette instead may further trigger the situation of the illness itself.

General:      Mildly Conscious Irritated Restless Respiratory distress The patient is fatigued, weak, shortness of breath noted

Vital signs:       Temperature: 36.8 C axillary Pulse: 71 beat per minute Blood pressure: 150/90 mmHg Respiratory rate: 42 breathe per minute Height: Wight: estimated 50 kg

Skin: Head: Eyes:

   

Dry Cold and clammy Pale and bluish in color No rashes or lesion noted

 Without masses noted  With palpable bruise on occiput area  With pale conjunctivae  With whitish sclera  With good vision acuity          With good hearing With minimal dry discharge Upper pinna in line with eye cantus With firm cartilage With good pinna recoil With nasal congestion With whitish discharge Without septal deviation With nasal flaring seen

Ears:

Nose:

Mouth: Neck:

 Dry lips, pale in color  Lips id cracked  With thick mucus discharge  Without inflamed lymph node

Chest/breast:

   

With labored breathing Dyspnea noted With abnormal rise and fall of chest With wheeze sound heard upon auscultation  With noted use of accessory muscle on breathing

Abdomen: Genital:

 With normal bowel sound  Without rashes seen on abdomen  With normal elimination pattern  With normal defecation pattern

The upper respiratory tract consists of the nose, sinuses, pharynx, larynx, trachea, and epiglottis. The lower respiratory tract consists of the bronchi, bronchioles and the lungs. The major function of the respiratory system is to deliver oxygen to arterial blood and remove carbon dioxide from venous blood, a process known as gas exchange. The normal gas exchange depends on three processes:
y y y

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:
y y

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:
y y y y

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.

BRONCHIIAL ASTHMA BRONCH AL ASTHMA

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 trachea broncheal 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.

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 exercise-induced 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. y 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. y y y y y 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

Assessment Subjective:

Nursing Diagnosis P: Ineffective

Planning After 4-5 hours of nursing intervention Patient will manifest signs of decreased respiratory effort

Interventions  Assess pt. s general condition  Auscultate breath sounds and assess airway pattern  Elevate head of the bed and change position of the pt. every 2 hours.  Encourage deep breathing and coughing exercises.  Demonstrate diaphragmatic and pursed-lip breathing to the patient.  Encourage increase in fluid intake  Encourage opportunities for rest and limit physical activities.  Reinforce low salt, low fat diet as ordered.

Rationale
 To obtain

Evaluation
 Goal not met patient remained respiratory distress, respiratory effort increase every hour in

baseline data
 to check for the

Nahihirapan akong breathing pattern huminga as

verbalized by the E: r/t presence of patient secretions of productive cough Objective: y and dyspnea

presence of adventitious breath sounds  To minimize difficulty in breathing

wheezing upon secondary to acute inspiration and attack of bronchial expiration asthma in acute exacerbation

 To maximize effort for expectoration.  To decrease air trapping and for efficient breathing.  To prevent fatigue.  To prevent situations that will aggravate the condition  To mobilize secretions.

until the limit reach and the patient expired

y y y y

dyspnea tachycardia chest tightness suprasternal retraction

S: as manifested by dyspneic movement and RR of 42bpm

y y

restlessness irritated

Assessment Subjective: Nahihirapan akong huminga as verbalized by the patient Objective: y wheezing upon inspiration and expiration dyspnea tachycardia chest tightness suprasternal retraction productive cough restlessness irritated

Nursing Diagnosis P: Ineffective airway clearance E: Related To broncho constriction, increased mucus production on the bronchiole area and tracheal area S: as manifested by wheezing upon auscultation, dyspnea, and cough

Planning  After 5-6 hours of  nursing intervention the Patient will maintain/improve airway clearance  and there will be a absence of signs of respiratory distress

y y y y y y y

y y y

y y

Interventions Adequately hydrate the pt. Teach and encourage the use of diaphragmatic breathing and coughing exercises. Instruct pt to avoid bronchial irritants such as cigarette smoke, aerosols, extremes of temperature, and fumes. Teach early signs of infection immediately. Increases sputum production Change in color of sputum Increased thickness of sputum Increased SOB, tightness of chest, or fatigue Increased coughing Fever or chills

Rationale Evaluation  Goal not met Systemic hydration keeps patient secretion moist remained in and easier to expectorate. respiratory These distress, techniques help respiratory to improve ventilation and effort increase mobilize every hour secretions until the limit without causing breathlessness reach and the and fatigue. patient expired Bronchial irritants cause broncho constriction and increased mucus production, which then interfere with airway clearance. Minor respiratory infections that are of no consequence to

 As ordered perform postural drainage with percussion and vibration in the morning and at night as prescribed.

the person with normal lungs can produce fatal disturbances in the lungs of an asthmatic person. Early recognition is crucial.

Assessment Subjective: Hirap na hirap na talaga ako huminga as verbalized by the patient Objective: y y y y Weakness Agitated Restless irritated

Nursing Diagnosis P: Risk for Activity Intolerance E: r/t decrease oxygen supply on the tissue and muscle in the body S: as manifested by distress RR of 42 bpm, increasing gasping for air as seen on patient

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

Interventions  Assess motor function.  Note contributing factors to fatigue.  Evaluate degree of deficit.  Ascertain ability to stand and move about.  Assess emotional or psychological factors  Plan care with rest periods between activities  Increase activity/exercise gradually such as assisting the patient in doing PROM to active or full range of motions.  Provide adequate rest periods.

Rationale  To identify causative factors.  To identify precipitating factors.  To identify severity.  To identify necessity of assistive devices.  Stress and/or depression may increase the effects of illness.  To reduce fatigue  Minimizes muscle atrophy, promotes circulation, helps to prevent contractures

Evaluation
Goal not met patient activity continue to lessen due to weakness, patient became unconscious, patient is try to revive, patient severe distress lead him to his expiration

 To replenish energy.

 Assist client in doing self care needs  Elevate arm and hand  Place knees and hips in extended position

 To promote independence and increase activity tolerance  Promotes venous  Maintains functional position

Name of drug
Epinephrine

Classification

Indication

Mechanism of action
Lidocaine is a local anesthetic which decreases permeability of sodium ions, blocking induction and conduction of nerve impulses. Combination with epinephrine restricts systemic spread of lidocaine, vascular absorption and its duration of local anesthetic effect.

Contraindication
Tachycardia, hypertension, cerebral arteriosclerosis, ischemic heart disease, IV admin, anaesthetizes digits or appendages, myasthenia gravis.

Adverse Reaction
Severity of adverse effects in CNS and CVS are directly related to blood levels of lidocaine; the effects are more likely to occur after systemic administration rather than infiltration; dizziness; muscle twitching; local anesthetic of mouth/throat impairs swallowing and increases the risk of aspiration (patients cautioned against eating or drinking for 3-4 hr system of neonate; erythema; pigmentation;

Nursing responsibility
Regular-release: May be taken with or without food. (Avoid grapefruit juice 1 hr before or 2 hr after a dose.) Extendedrelease: Should be taken with food. (Avoid grapefruit juice 1 hr before or 2 hr after a dose. Avoid taking w/ high fat meals. Swallow whole, do not crush/chew.)

Anesthetic local Adult: Per ml prep and general contains lidocaine HCl 20 mg and epinephrine 5 mcg. Dosage depends on several factors such as route, type and extent of surgical procedure, duration of anesthesia and patient's condition and age. Max dose of lidocaine given with epinephrine: 7 mg/kg and not >500 mg. Child: 3 mth-12 yr: Per ml prep contains lidocaine HCl 20 mg and epinephrine 5 mcg. Dosage depends on several factors such as route,

Hydrocortisone

Corticosteroid hormone

Parenteral therapy of acute adrenal cortical insufficiency, acute hypersensitivity reactions like status asthmaticus or anaphylactic drug allergy in combination with epinephrine, as adjunct to severe acute traumatic shock; for initial IV treatment of generalized, recurrent lupus eyrthematodes.

Producing relation effect on smooth muscle

Hypersensitivity to corticosteroids, keratitis, herpetica, acute psychoses and latent, cured or manifest tuberculosis, gastrointestinal ulcer, hypertension, osteoporosis, myasthenia gravis and renal insufficiency.

Corticosteroids, like hydrocortisone, might impair balance between water and electrolytes leading to fluid retention and hypertension, hypokalemia and congestive heart failure. Muscular atrophy and osteoporosis may occur. Gastrointestinal ulcers associated with hemorrhage have often been reported. There is a negative nitrogen balance due to protein catabolism and healing wounds is impaired. Psychic disturbances and convulsions

Before treatment initiation, it is recommended to perform an ECG, usTSH assay and serum potassium measurement. Undesirable effects (see Adverse Reactions) are usually dose related; therefore, careful attention should be paid to determine the minimum effective maintenance dose in order to avoid or minimize undesirable effects. Patients should be instructed to avoid exposure to sun or to use protective measures during therapy.