Santiago City, Philippines

College of Nursing

A Case Study of

Bronchial Asthma In Acute Exacerbation

(BAIAE)

Submitted by:

Orlando Dexter T. Rodriguez

SN-NC 3rd Year Block A

Submitted to:

Clinical Instructor

A. Significance of the study

Lower airway problems directly affect gas exchange and have serious consequences.

Many of these problems are chronic and progressive, requiring major changes in person’s

lifestyles. Such airway problem includes Bronchial Asthma which is a serious problem and could

probably lead to death if proper precautions are not observed. This study is made so that every

reader or listener of the case study and research will gain enough knowledge and understand

Bronchial asthma, its cause, manifestations, treatment, and preventions. This study points and

focuses on the significance of reaching out to the awareness of every individual who may have

this kind of disease and to the member of the health care team and share to them the proper ways

on how to effectively care to patients suffering from this problem.

B. Objectives of the Study

At the end of the case-presentation the student will be able to:

1. To identify what Bronchial Asthma is all about.

2. Apply the knowledge that they have learned in the floor.

11Gordon’s Functional Health Pattern

1. Health Perception-Health Management

She is a very active and playful child. She doesn’t have any allergies on any

foods.

2. Nutritional-Metabolic

She doesn’t have any special diet but she is taking Celeen for her vitamin. At

home, as verbalized by the mother, she can eat all of the food served. She didn’t

have difficulty of swallowing, and started solid food as the main composition of

the food of the patient.

3. Elimination Pattern

She did not experience any decrease in defecating or difficulty of urinating. Her

bowel elimination pattern is once a day even during her stays at the hospital. Her

way of breathing is better than she is at home, and she could go to comfort room

with assistance of mother (with IV), read books, and eat all food served.

4. Activity-Exercise Pattern

Our patient loves to play bahay - bahayan and running. She independently wears

her dress but with assistance from her mother. She can go to the bathroom,

whenever she wants to urinate and defecate but her mother still washes her anus

after defecating. She goes schooling in prep-school and playing or socializing,

talking, mingling with her classmates.

5. Sleep-Rest Pattern

She experience difficulty of sleeping while admitted in the hospital. Before her

admission, she sleeps as early as 10 in the evening and wakes at 8 in the morning.

During her hospitalization, she sleeps at 10 and wakes at 8 in the morning. She

also sleeps one hour in the afternoon. During night when her asthma attacks, she

can’t breathe normally usually having a hard time of breathing so her sleep during

night is disturbed during her hospitalization period.

6. Sexuality-Reproductive Pattern

She is a girl

7. Cognitive-Perceptual

She neither has hearing difficulties nor eye problems. She has a good memory for

learning activities in school like problem solving and her mother makes decisions

for her during medications, treatments, etc. and she also learns easily.

8. Self Perception – Self Concept

She’s feeling better every time she is asked how she feels. Her illness makes her

feel worthless because she cannot do anything. She is very anxious every time her

asthma attacks.

9. Role relationship

She lives with her family and depends on her parents for her needs. She misses

her siblings and likes to talk about them. In their house she can easily express

what she wants or needs but during her hospitalization time her parents didn’t

knew what are the needs that she wanted or needed because of her condition.

10. Coping – Stress Tolerance

She always wants her mother to be beside her because she provides all that she

needs and she cries whenever she can’t get something that she wants. She always

wanted to go home right away but because of the doctors order they can’t go

home right away, so the only thing she can do is to cry.

11. Value and Beliefs

They are Roman Catholic. She verbalized that she knows God loves her and He

will wash her illness away so that she can go home. The parents react patiently to

their daughters needs, and they supported all what their child needs.

DefinitionDefinition

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.

CausesCauses

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 person’s asthma changes depending on the environment activities, management practices and other factor.

Clinical ManifestationClinical 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.

PreventionPrevention

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 ManagementMedical 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.

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 acton. Anti-cholinergic may have an added benefit in severe exacerbations of asthma but they are use more frequently in COPD.

Nursing ManagementNursing 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 one’s 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

Assessment Nursing Diagnosis

Planning Interventions Rationale Evaluation

Subjective: (none)

Objective: Immobility Weakness

Risk for Activity Intolerance r/t decrease oxygenation

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

1. Monitor VS.

2. Assess motor function. 3. Note contributing

factors to fatigue.4. Evaluate degree of

deficit.5. Ascertain ability to

stand and move about.6. Assess emotional or

psychological factors 7. Plan care with rest

periods between activities

8. Increase activity/exercise gradually such as assisting the patient in doing PROM to active or full range of motions.

9. Provide adequate rest periods.

10. Assist client in doing self care needs

11. Elevate arm and hand12. Place knees and hips in

extended position

1. For baseline data.2. To identify causative

factors. 3. To identify precipitating

factors.4. To identify severity.

5. To identify necessity of assistive devices.

6. Stress and/or depression may increase the effects of illness.

7. To reduce fatigue

8. Minimizes muscle atrophy, promotes circulation, helps to prevent contractures

9. To replenish energy.

10. To promote independence and increase activity tolerance

11. Promotes venous12. Maintains functional

position

Goal met

Patient participated willingly in necessary/ desired activities such as deep breathing exercises.

Assessment Nursing Diagnosis

Planning Interventions Rationale Evaluation

Subjective:“Nahihirapan akong huminga” as verbalized by the patient

Objective: wheezing

upon inspiration and expiration

dyspnea tachycardia chest

tightness suprasternal

retraction restlessness

Ineffective breathing pattern r/t presence of secretions AEB productive cough and dyspnea

After 4-5 hours of nursing interventionPatient will manifest signs of decreased respiratory effort AEB absence of dyspnea

1. Establish rapport.2. assess pt.’s condition3. VS monitor and

record4. Auscultate breath

sounds and assess airway pattern

5. Elevate head of the bed and change position of the pt. every 2 hours.

6. Encourage deep breathing and coughing exercises.

7. Demonstrate diaphragmatic and pursed-lip breathing.

8. Encourage increase in fluid intake

9. Encourage opportunities for rest and limit physical activities.

10. Reinforce low salt, low fat diet as ordered.

1. To gain pt.’s trust.2. To obtain baseline data3. Serve to track important

changes4. to check for the presence

of adventitious breath sounds

5. To minimize difficulty in breathing

6. To maximize effort for expectoration.

7. To decrease air trapping and for efficient breathing.

8. To prevent fatigue.

9. To prevent situations that will aggravate the condition

10. To mobilize secretions.

Goal metPatient demonstrated pursed-lip breathing and diaphragmatic breathing.

Assessment Nursing Diagnosis

Planning Interventions Rationale Evaluation

Subjective: “Nahihirapan akong huminga” as verbalized by the patient

Objective: wheezing

upon inspiration and expiration

dyspnea tachycardia chest

tightness suprasternal

retraction productive

cough

Ineffective airway clearance RT bronchoconstriction, increased mucus production, and respiratory infection AEB wheezing, dyspnea, and cough

After 5-6 hours of nursing intervention thePatient will maintain/improve airway clearance AEB absence of signs of respiratory distress

1. Adequately hydrate the pt.

2. Teach and encourage the use of diaphragmatic breathing and coughing exercises.

3. Instruct pt to avoid bronchial irritants such as cigarette smoke, aerosols, extremes of temperature, and fumes.

4. Teach early signs of infection that are to be reported to the clinician 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

5. If indicated, perform postural drainage with percussion and vibration in the morning and at night as prescribed.

1. Systemic hydration keeps secretion moist and easier to expectorate.

2. These techniques help to improve ventilation and mobilize secretions without causing breathlessness and fatigue.

3. Bronchial irritants cause bronchoconstriction and increased mucus production, which then interfere with airway clearance.

4. Minor respiratory infections that are of no consequence to the person with normal lungs can produce fatal disturbances in the lungs of an asthmatic person. Early recognition is crucial.

Goal metBy verbalization of the patient of “Ok na po ang aking paghinga, hindi na ako nahihirapan”

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.

Patient’s Profile

Name:

Age:

Sex:

Location:

Admitting diagnosis:

Chief complaint:

Date of admission:

Attending Doctor: