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BYSarah alatwiRanay khalfJamelaGaoaherezdeharBronchial asthma

Outlines IntroducationStatisticCase presentationDEMOGRAPHIC DETAILSYSTEMIC REVIEWPRESENTING COMPLAINhisteryPHYSICAL EXAMINATIONDISCUSSION OF ASTHMAMangementDrug studyNursing care plan

Interducation:Asthma is a chronic respiratory disorder in which there is primarily swelling ofairways in the lungs. The airways are therefore narrowed making it difficult to breathe Normal Inflamed (untreated) Regular Inhaled Steroid Partly Treated.

Why focus only in asthma?As per WHO, saoudi has 15 million asthmatics which is 10% of the global asthmatic populationThe prevalence of asthma is higher in children. Today, up to 1 out of 10 children in saoudi has asthma.Asthma is the most common chronic condition in children.As per a study, Asthma in children has doubled over the past 5 years and is rapidly increasing.There will be an additional 100million asthmatics worldwide by 2025. I.Case presentation6DEMOGRAPHIC DETAILInitials : MHAge: 6 years and 8 months oldEthnicity: saoudiGender: MaleDOA:8/5/1436DOD: 10/5/1436Informant: Grandmother7PRESENTING COMPLAINMH, a 6 years and 8 months old saoudi boy, a known case of G6PD and asthma was admitted to MCH due to fever, cough and 1 episode of vomiting since one day prior to admission and S.O.B and rapid breathing 4 hours prior to admission.8SYSTEMIC REVIEWCVS: No excessive night sweating, no orthopnea.CNS: No headache/dizziness, no episode of fainting or fit attack.GIT: No constipation, no diarrhea, normal bowel habit.MSK: No muscle pain or join pain.Urinary System: No dysuria or hematuria.Skin: No rashes or itchiness.ENT: No sore throat, no runny nose.

9PAST MEDICAL/SURGICAL HxHe has been diagnosed to have asthma since he was 4 years old.The pattern of the attack is once in 2 monthsIt occur mostly when px took cold drinks, cold weather or do vigorous exerciseHe also has the intervals symptoms of cough and wheezing.The last attack was on six month agoTook nebulizer when attack occur but no hospitalization required.No hx of eczema.

10DRUGS HxHe is not on any medicationDoctor advice him to take MDI but mother insist as she claimed that px did not know how to handle the medication.ALLERGIESNo known allergies 11BIRTH HxBorn at King Khlid Hospital FTSVDWeight : 2.5kgAntenatal, intrapartum and postpartum hx was uneventfulAdmitted to NICU for 15 days due to neonatal jaundice diagnosed to have G6PD12FEEDING HxGrandmother did not recall how long he had exclusive breastfeedingCurrently he is on family diet with balance and adequate amount of fish, meat and riceIMMUNISATION HxUp to his ageDidnt have any complications after taking the injections

13DEVELOPMENTAL HxUp to his chronological age. He is currently at preschool and his performance is good.Gross motor: Can walks heel to toe, Can kick, climbs and throwing, can ride tricycle.Fine motor: Can imitate or copies pictures like steps with 10 cubes , can write his nameSpeech and language: Can speak fluently, knows age, knows ABC and numbers.Social:Can dresses and undresses alone.14FAMILY Hx2nd child out of 3 siblingsBoth father and mother have asthma and currently on medication.Grandmother in paternal side also have asthma.Elder sister is 3 years old and younger sister is 13 months old. Both of them are wellNo history of consanguinity

15PHYSICAL EXAMINATIONMH was sitting on the bed comfortably. His grandmother was sitting next to him. He was conscious and cooperative and orientated to time and place. He is not in pain. He was in respiratory distress as there was suprasternal and subcostal recession. His hydration and nutritional status were good. There was a brannula attached to the dorsum of his left hand. No gross deformities and abnormal movement seen.

1. GENERAL CONDITIONTemperature: 38.50CBlood pressure: 115/66 mmHg, regular rhythm and normal volumePulse rate: 110 beat per minuteRespiratory rate: 32 breaths per minute

Impression: His vital signs are normal. 2. VITAL SIGNSHeight: 110cm. Weight: 17kg. BMI: 14.05kg/m2.

Impression:His growth is within normal.

3.Anthropometric measurements

SYSTEMIC EXAMINATION1.RESPIRATORY SYSTEMMH was having respiratory disorders evidenced by suprasternal and subcostal recession and presence of added breath sound, ronchi during expiration on the upper zone of his chest.

2. Cardiovascular Examination There were no abnormal findings during Inspection ,Palpation , Auscultation.3. Abdominal examinationNo abnormal findings.

4. Lymphatic SystemCervical / Supraclavicular Nodes Right submandibular lymph node enlargement

Axillary Node- not palpable

Inguinal Nodes not palpable

Other groups of Lymphnodes (specify) not palpable

Impression: Infection causing enlarged lymph node.

III.DISCUSSION OF ASTHMA Chronic inflammatory disorder of airways that causes recurrent episodes of wheezing, breathlessness, chest tightness and coughing.DEFINITION:

RISK FACTORS

Host Factors

Genetic predispositionAtopyAirway hyper- responsivenessGenderRace/Ethnicity

Environmental Factors Indoor /allergensSocioeconomic factors Family size weather changes Obesity

TRIGGERS FACTORSAllergensSmoke (passive smoker)Respiratory infectionsExercise and hyperventilationEmotional upset or excitementFood, additives, drugs

Pathogenesis of asthmaEnviromental factorsGenetic factorsBronchial inflamationBronchial hyperactivity + trigger factorsOedema , bronchononstriction, & increase mucous productionAirways narrowingSymptoms:-cough-wheezing-breathlessness-chest tightnessCLINICAL FEATURESCoughChest tightnessWheezing sound of breathEpisodic shortness of breathWorsen during night

Various severities of asthmaClassification of asthma severity-Mild intermittent -Mild persistent -Moderate persistent -Severe persistent

*In this patient, it is mild intermittent.*Patient only developed asthma once in two month.

DIAGNOSISHistory and patterns of symptomsPhysical examinationMeasurements of lung functionMeasurements of allergic status to identify risk factors

INVESTIGATION

1)LUNG FUNCTION TEST

This can be done by using Peak Expiratory Flow Rate(PEFR). 2)Blood and sputum test.

3)Chest X-ray.

Asthmatic patient may have increase number of neutrophils in pheripheral bloodHelpful in excluding a pneumothorax / pneumonia.Criteria for admission failure to respond to standard home treatmentFailure of those with mild or moderate acute asthma to respond to nebulised B2-agonist.Relapse within 4 hours of nebulised B2-agonist.Severe acute asthma* This patient was admitted to ward because failed respond towards the nebuliser salbutamol given in the ED.Common management for AEBAGives neb oxygen+ neb salbutamol+ neb ipratopium bromide+ IV hydrocortisone+ hydration IV normal salineIf symptoms not subside, gives IV salbutamolIf symptoms still not subside, do endotracheal intubation and gives mechanical ventilation.

MANAGEMENTGive drug treatment to the patient by following the severity of the asthma.Hydration-give maintenance fluidMonitor pulse, colour, PEFR, VBG and SPO2. (4 hrly)Antibiotic indicated only if bacterial infection suspectedAvoids sedatives and mucolyticsHealth education involving the parents and their asthmatic child.-how to recognized & treat worsening asthma-when to seek for medical attention-how to used MDI correctly

Impact of asthmaNight cough, disturbed sleepRestriction in activity / exerciseIncreased school absences (not able to pay attention in the class, academic performance will drop)Ongoing symptoms may have a detrimental effect on physical, psychological and social well-being

* Patient only had continuous night cough and sleeping disturbance during the attack.Acute severe asthmaInability to complete a sentence in one breath.Respiratory rate >50/minTachycardia >140/minPEFR