Case Presentation Geriatric

7/23/2019 Case Presentation Geriatric

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Special issues:geriatricHis 2038

‘asthma’

Name: nurdina afni binti izamudin

(031390)



IntroductionDefnition:

Clinical syndrome characterized by attacks oheezin! and breathlessness due to narroin! o

the intra"ulmonary airays# $emission may bes"ontaneous or as a result o treatment# Durin! anasthma attack% the muscles surroundin! the airaysti!hten# &he linin! o the air "assa!es sells# 'essair is able to "ass throu!h as a result#



Durin! an asthma attack smoothmuscles located in thebronchioles o the lun! constrictand decrease the o o air in theairays# &he amount o air ocan urther be decreased byinammation or ecess mucus

secretion#





Types of asthma*+&$,N-,C (ato"ic) ,N&$,N-,C (non.atro"ic)

• occur in youn!er a!e !rou"s #• readily orm antibodies toaller!ens#• sensiti/e to dierent actors(e!: "ollen% eathers% ood% ur%

and occasionally ood or dru!)#• amily history o similarsensiti/ities#• e"osure to the "erci"itatin!actor causes a mucosal

inammatory aller!ic reaction#• tends to be e"isodic#

• tends to occur in the older "t#as a chronic condition#• no a""arent aller!ic cause oramily history#• "reci"itated by% or associated

ith bronchial inections %chronic bronchitis% strenouseercise% stress or aniety#



ATI!"!#$

&he underlyin! causes o childhood asthma arentully understood# De/elo"in! an o/erly sensiti/eimmune system !enerally "lays a role# -ome actorsthou!ht to be in/ol/ed include:•,nherited traits•-ome ty"es o airay inections at a /ery youn! a!e•*"osure to en/ironmental actors% such as ci!arettesmoke or other air "ollution



,ncreased immune system sensiti/ity causes thelun!s and airays to sell and "roduce mucushen e"osed to certain tri!!ers# $eaction to a

tri!!er may be delayed% makin! it more di2cult toidentiy the tri!!er# &hese tri!!ers /ary rom childto child and can include:

•

iral inections such as the common cold•*"osure to air "ollutants% such as tobacco smoke•4ller!ies to dust mites% "et dander% "ollen or mold•5hysical acti/ity•6eather chan!es or cold air

-ometimes% asthma sym"toms occur ith noa""arent tri!!ers#



the wall

pathology7ain "atholo!ical chan!es occur durin! an asthmatic attack

are:• -"asm o the smooth muscle in the alls o the bronchi andbronchioles#•8edema o the mucous membrane o the bronchi andbronchioles#•

*cessi/e mucus "roduction#

&hese chan!es result in airays obstruction#ronchial alls become infltrated ith eosino"hilsthickenin! o the e"ithelial basement membrane#

4t the end o an attack these chan!es are totally re/ersible &i the attacks occur re;uently lon!.standin! chan!es ill occursuch as:•<y"ertro"hy o the smooth bronchial muscle% the eect obronchial s"asm durin! and attack #•5ermanent thickenin! o the mucous membrane ith an theno# o !oblet cell and mucous !land#•



6here the "redominant actor "reci"itatin! asthma is analler!ic reaction# &here is anti!en mediated bronchoconstriction# &his means that the anti!en binds to to ,!* molecules(immuno!lobulin antibodies) on the membrane o mast cells"resent in bronchial linin!#$elease mediators hich act on rece"tor sites on smoothmuscle cell chan!es in intracellular cyclic 475 le/els

hich muscular contraction# &he mediators histamine% neutro"hil chemotactic actor(NC=.4)% "latelet acti/atin! actor(54=)% and eosino"hilchemotactic actor (*C=.4) are stored in !ranules ithin mastcells as "erormed mediators#

&his anti!en.antibody reaction is a "art o the body >simmune res"onse% and "re/ious e"osure to the anti!enresults in bronchoconstriction#



%linical featurs6heezin!: 4 musical% hi!h."itched histlin! sound

"roduced by airo turbulence is one o the most commonsym"toms o asthma# &he heezin! is usually durin!ehalation#Cou!h: sually% the cou!h is non"roducti/e andnon"aroysmal? cou!hin! may be "resent ith heezin!

Cou!h at ni!ht or ith eercise: Cou!hin! may be the onlysym"tom o asthma% es"ecially in cases o eercise.inducedor nocturnal asthma? children ith nocturnal asthma tend tocou!h ater midni!ht% durin! the early hours o mornin!-hortness o breath

Chest ti!htness: 4 history o ti!htness or "ain in the chestmay be "resent ith or ithout other sym"toms o asthma%es"ecially in eercise.induced or nocturnal asthma



-"utum "roduction,n an acute e"isode o asthma% sym"toms /ary accordin! to thee"isode@s se/erity# ,nants and youn! children suerin! a se/ere

e"isode dis"lay the olloin! characteristics:reathless durin! restNot interested in eedin!-it u"ri!ht to assist the accessory muscles o res"iration# &hechest is held in ins"iration# &alk in ords (not sentences)sually a!itated6ith imminent res"iratory arrest% the child dis"lays theaorementioned sym"toms and is also drosy and conused#<oe/er% adolescents may not ha/e these sym"toms until theyare in rank res"iratory ailure#

Cyanosis may occur centrally but not usually until the latersta!es o the disease#



&r'

management(hysical e)amination:

=indin!s durin! a se/ere e"isode include the olloin!:$es"iratory rate is oten !reater than 30 breaths "er minute4ccessory muscles o res"iration are usually used-u"rasternal retractions are commonly "resent &he heart rate is !reater than 1A0 beats "er minute'oud bi"hasic (e"iratory and ins"iratory) heezin! can be

heard5ulsus "aradous is oten "resent (A0.B0 mm <!)8yhemo!lobin saturation ith room air is less than 91



6heezin! may be absent (in "atients ith the most se/ere airay

obstruction)-e/ere hy"oemia may maniest as bradycardia5ulsus "aradous may disa""ear: &his fndin! su!!ests res"iratorymuscle ati!ue

=indin!s in status asthmaticus ith imminent res"iratory arrestinclude the olloin!:5aradoical thoracoabdominal mo/ement occurs



&iagnosis &ests used in the dia!nosis o asthma include the olloin!:5ulmonary unction tests: -"irometry and "lethysmo!ra"hy*ercise challen!e: ,n/ol/es baseline s"irometry olloed by

eercise on a treadmill or bicycle to a heart rate !reater than0 o the "redicted maimum% ith monitorin! o theelectrocardio!ram and oyhemo!lobin saturation=raction o ehaled nitric oide (=eN8) testin!: Nonin/asi/emarker o airay inammation

$adio!ra"hy: $e/eals hy"erination and increased bronchialmarkin!s? radio!ra"hy may also sho e/idence o "arenchymaldisease% atelectasis% "neumonia% con!enital anomaly% or aorei!n body4ller!y testin!: Can identiy aller!ic actors that maysi!nifcantly contribute to asthma<istolo!ic e/aluation o the airays: &y"ically re/ealinfltration ith inammatory cells% narroin! o airay lumina%bronchial and bronchiolar e"ithelial denudation% and mucus"lu!s



ASTH*A *&I%I+S &here are to basic kinds o medicine used to treat asthma#'on!.term control dru!s are taken e/ery day to "re/ent asthma

sym"toms# 5t# should take these medicines e/en i no sym"tomsare "resent# -ome children may need more than one lon!.termcontrol medicine# &y"es o lon!.term control medicines include:•,nhaled steroids (these are usually the frst choice o treatment)

•'on!.actin! bronchodilators (these are almost alays used ithinhaled steroids)•'eukotriene inhibitors•Cromolyn sodium



Fuick relie or rescue asthma dru!s ork ast to control asthmasym"toms#Children take them hen they are cou!hin!% heezin!% ha/in!trouble breathin!% or ha/in! an asthma attack#*am"les o ;uick relie medicines include 5ro/entil% entolin%and +o"ene#-ome o childs asthma medicines can be taken usin!an inhaler#Children ho use an inhaler should use a Gs"acerG de/ice# &his

hel"s them to !et the medicine into the lun!s "ro"erly#, the child uses the inhaler ron! ay% less medicine !ets intothe lun!s# Houn!er children can use a nebulizer instead o an inhaler to taketheir medicine# 4 nebulizer turns asthma medicine into a mist#



pt'management

Aims of t)'Assist in the remo,al of secretions'#ain rela)ation of the nec-. shoulder girdle. andupper chest muscles'Teach the pt' /reathing control*aintain mo/ility of the nec-. shoulder girdle.

thoracic spine and thora)'ducate postural aareness'*aintain or impro,e e)ercise tolerance'ncourage a full. acti,e lifestyle'



1emo,al of secretions5ostural draina!eibrations

*ecti/e cou!hin!=*& ithout increasin! bronchos"asm#-uction

1ela)ation and /reathing control





lessness

*o/ility e)ercises and postural aareness &o ensure /entilation o the basal al/eoli the "t beencoura!ed to ado"t a balance relaed "osture# &horacic% neck% and shoulder mobility eercises shhould be

"erormed daily to!ether ith stren!thenin! eercises oreak muscle(e#!#shoulder !irdle retractor% abdominals andthoracic s"ine etensors)#

)ercise tolerance

&o !ain breathin! control durin! all daily acti/ities# &o increase the "t# ability to "erorm eercises hich"roduce breathlessness ithout brin!in! on an asthmaticattack# &he breathlessness is o/ercome by the breathin! control#



ull acti,e lifestyleIee" encoura!ed to kee" ft#4/oid ith smokin! "erson*at sensibly'i/e a normal lie in relation to school% hobbies and socialacti/ities#-immin! hel"s to !ain relaation amd im"ro/e breathin!control#=or children ho suer mild attacks and eercise "ro!ramme

should be de/elo"ed and they should be encoura!ed to attendkee" ft classes# Children may attend !rou" class#Children ith chronic asthma may beneft rom residentialcourses oerin! acti/ities such as ei!ht trainin!% ski""in!%ootball% static bicycle% simmin! and ater "olo#

ery youn! children like made u" !ames such as mimickin!dierent zoo animals to include relaation% ho""in!% bloin! outand a/in! arms#



references•'mayoclinic'org•

'nlm'nih'go,



C4-*

-&DH

Jeriatric

aeba



Name: Mrs. T

Age: 65y/o

Gender: femaleRace: Malay

R/N: 12234

Date of Admtted: 5 / ! / 2"14

Date of Assessment: #/ ! / 2"14Dr. Dagnoss:

A$%A

Dr m&:

'onser(at(e m&. and refer )*yso



+,%-$'T$+ A++$++M$NT

0rolems:

0t. c/o +% and cog*.0t. c/o nale to s)t ot )*legm.

'rrent *&:*/o +% on 5/!/2"14. +ee for medcal t&.T*en

admtted to ard on t*e same day.Dr. refer *er to)*yso for frt*er m&.

0ast *&:N



0ast medcal *&:

7 80T snce 1 years ago and on medcaton

7 A$%A snce 1 years ago and on n*aler

9amly *&:NDrg / medcaton:

80T medcne snce 1 years ago

n*aler snce 1 years ago

+ocal *&: cc: *osefe

+tay t* *sand n a sngle7storey *ose

Martal stats: Marred t* 3 c*ldren

Not smong or alco*ol ntae Recreaton: Gardenng



n(estgaton:

a (ales: N

't7scan: N

MR : N

'*est &7ray:N



General ser(aton: An endomor)*c ody se ofmalay female; sttng on ed. 'onscos; alert; oeycommand and ale to tal fll sentences.

ocal oser(aton:

8ands: no clng; no cyanoss; no )ale; ( dr) on Rt*and

'*est: no te nserted $&amnaton on c*est: no deformty

%reat*ng )attern : $)nea

%reat*ng le(el: A)cal reat*ng

'og*: dry cog*< )rodct(e and not effect(e



0al)aton:

'*est e&)anson:e(el +ymmetrcal/assymetrcal

Manorosternal =ncton +ymmetrcal

>)*sternal =ncton +ymmetrcal

1"t* r +ymmetrcal



Ascltaton:

nter)retaton: ot* a)cal loe )resents of cre)ts d/tsecreton retenton and ot* loer loe redce reat*sond d/t ncorrect reat*ng )attern.

e(el Rg*t eft

A)cal Normal and cre)ts Normal and cre)ts

Medal Normal Normal

oer Redce reat* sond Redce reat* sond



9nctonal act(ty:

%ed molty7ell

ANA?++:

0T m)resson:+% d/t ncorrect reat*ng )attern

'og* d/t secreton retentonRedce reat* sond d/t ncorrect reat*ng

)attern



+*ort Term Goal:To redce +% t*n 2 days

To redce secreton retenton t*n 3 daysTo m)ro(e reat* sond o(er lateral loer loe

t*n 4 days

ong Term GoalTo m)ro(e @To o)tme res)ratory fncton

To )re(ent secondary com)lcaton sc* as lngcolla)se.



0AN 9 TR$ATM$NT:0%Rela&aton )ostonManal tec*nes7(raton;)ercsson;s*ang%reat*ng e&sA'%TTM$'rclatory e&s0t. ed.8$0



NT$R$NTN+0t. n *g* stt. on edge of ed; teac* 0% B5& 2set0t. n *g* stt. on edge of ed; reat*ng e&s B

da)*ragmatc reat*ng7 3& 2set0t. n *g* stt. on edge of ed; c*est (raton0t. n *g* stt. on edge of ed; A'%T 2& 2 set.0t. n *g* stt. on edge of ed; TM$; 3& 2 set.

'rclatory e&s7anle )m)ng 1"&Rela&aton )oston ; )t. n forard lean sttng.0t edcaton: contne reat*ng e&s; 0% s ad(ce

*en +%< )ostonng7 c*ange e(ery 2 *ors<

8$0: Ad(se to do all e&s. reglarly at *ome.



$A,ATN:

0t can tolerate all t& g(en

0t feel tred after t&

0t. ale to cog* affect(ely and )rodct(ely.

+)tm analyss: ?ellos*; t*c; small amont.

R$A++$++M$NT:

'ontne same t& as ao(e

9ocs more to reat*ng e&s

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Case Presentation Geriatric