I. Introduction

a.) Description of Health Condition

Status asthmaticus It is a medical emergency in which asthma symptoms are refractory to initial

bronchodilator therapy in the emergency department. Patients report chest tightness, rapidly progressive shortness of breath, dry cough, and wheezing. Typically, patients present a few days after the onset of a viral respiratory illness, following exposure to a potent allergen or irritant, or after exercise in a cold environment. Frequently, patients have underused or have been under prescribed anti-inflammatory therapy. Illicit drug use may play a role in poor adherence to anti-inflammatory therapy. Patients may have increased their beta-agonist intake (either inhaled or nebulized) to as often as every few minutes. 

An acute, severe asthma attack that doesn't respond to usual use of inhaled bronchodilators and is associated with symptoms of potential respiratory failure is labelled status asthmaticus. This is life-threatening and requires immediate medical attention. It is important to be aware of these severe asthma attacks and prevent it with early intervention.

b.)Statistical data: Global and National

I. Burden of Illness in the Philippines

II. Burden of Illness globally

c.) Scope and Limitation

The study was a patient base, and it focuses on the nursing assessment, pathophysiology, diagnostic and laboratory results, medical and nursing management. The study involves patient and relative interview and home visit. This aims to provide information to all nursing students and others who are interested with this case analysis. The study we conducted for a month does not offer a treatment for a problem but may help people understand what status asthmaticus is.

This study is not limited to the Status Asthmaticus patients only, but it is for all people who are interested. We are more focused on primary prevention through health education because primary prevention is the true prevention.

In the case study that we conducted we encountered a lot of problems especially in choosing the best case so we can come up with a good output. One of the problems we face was the assessment because from the time that we decided to study status asthmaticus the patient was discharged so the baseline data that was when one of the group members handled him in RLE duty. The patient was not assessed properly because he was irritable and restless but his mother was cooperative she helped us in interview. The laboratory test was also not completed especially the Arterial Blood Gas or ABG.

d.) Background of the Study

Status asthmaticus occur in the patient because he was an active smoker for 1 ½ months, 2-3 times a week and a family history of lung disease like Pulmonary Tuberculosis. The patient hobbies were playing basketball and billiards four days a week. He also has previous history of bronchial asthma which is extrinsic because of exposure to allergens such as dust, powder used in billiards and extreme hot and cold weather and intrinsic factors like cough and colds which present in our client 2 days before the progression of his disease.

II. Patient Profile Case No: 67428

Ward: Pedia ward

Patient Name: R.C

Address: Purok 3 San. Antonio Bay, Laguna

Birthday: December 28, 1998

Age: 12 yrs old

Birthplace: San. Antonio Bay, Laguna

Nationality: Filipino

Religion: Roman Catholic

Father’s Name: Amiel Arbolida

Mother’s Name: Evelyn Arbolida

Address: San. Antonio Bay, Laguna

Admission date/time: September 06, 2010 @ 4:48pm

Diagnosis: Status Asthmaticus

Admitting Physician: Dr.Manuel

Data furnished by: Evelyn Arbolida

Relation of the Patient: Mother

Chief Complaint: DOB, Productive cough

III. Patient history

a.) Present History

One day prior to admission the patient experienced productive cough slight Difficulty of breathing and fever thus consulted to the Barangay health center, the doctor prescribed Ambroxol tablet and Paracetamol tablet. The medications are taken only twice.

Two hours prior to admission the patient experienced severe DOB, Cyanosis, loss of consciousness, intermittent apnea thus the patient was immediate brought to the hospital.

b.) Past History

Two months ago, the patient experienced difficulty of breathing associated with cough which was relief by taking of herbal medication such as oregano.

c.) Family History

The patient has a family history of pulmonary tuberculosis on his father’s side and Hypertension on his mother’s side.

d.) Developmental History

Erick EricksonIdentity vs Role confusion

The patient interested in joining group of male teenagers and playing billiards and basketball with them. He was also influenced to use cigarette by one of his friends who smoke.

Jean Piaget Formal Operation (11 years-adulthood)

The patient did not want to go in school. There are times he wanted to go in school but most of the times do some way just not to go in school.

Sigmund Freud Puberty onwards- Genital

The patient shows sign of being shy when his grandmother stated that “ Nagkakacrush na nga yan eh un kaibigan niyang dalaga, ayaw naman magpakatino”. “ Hindi ko naman crush yon, high school na un eh” the patient

stated. He seems to be attracted to opposite sex yet ashamed because he was only a grade II student.

e.) Socioeconomics

His mother and auntie are Fishnet Maker and earned 1,000 pesos per week. His grandfather is a Fisherman and earned 900 pesos per week. The family has no other source of income and has been exhausted due to crisis. Relatives and friends support as well as LGU is also extending help to the family but still very insufficient.

f.) Psychological

During hospitalization the patient can’t interact with other people because of his condition there are certain times that he feels anxious. The patient is irritable and shows unwillingness to the recommended treatment.

g.) Sociocultural

The family of our patient still believes in “Albolaryo” but knows the importance of seeking medical advice inspite of having inadequate resources to comply in the medical regimen. They also use some herbal medicines like oregano in treating or helping the client recover in illnesses such as cough and colds.

h.) Spiritual1 year ago, the patient was encouraged by her grandmother to be a

sacristan but he feels not interested and do not even come to the church together with his family.

i.) Nutrition

Before hospitalization During hospitalization

The patient usually eats fish and he doesn’t like to eat ampalaya, okra and kalabasa.

The patient was NPO during hospitalization.

j.) Elimination

Before hospitalization During hospitalization

He usually defecates once a day and urinates 3-4 times a day.

Since he is NPO his elimination pattern was slightly altered and his bowel movement has decreased and he defecates after 2 days.He urinates 5-6 times a day.

k.) Exercise

Before hospitalization During hospitalizationPatient usually spends his times in playing billiard and walks around together with his friends.

The patient cannot perform his daily activities without the assistance.

l.) HygieneBefore hospitalization During hospitalization

The patient usually takes a bath everyday and performed all self-care activities with his own self.

During hospitalization, the patient doesn’t perform his daily activities and usually done some of it with the assistance of her mother and grandmother. He did not take a bath due to his condition.

m). Rest and Sleep

Before hospitalization During hospitalization

Before the patient was admitted to the hospital he usually sleeps at 11pm and wake up at 6-7am.

When the patient was hospitalized his sleep pattern was altered as evidenced by 1-2 hours time of sleep because of his condition.

IV. Physical Assessment

Area Method Findings Interpretation

Integument:Skin

Inspection and palpation

With fair complexion. The palms are slightly pallor. Indicates slight hypoxia

or insufficient oxygen supply in the peripheries.

Nail Inspection The nails are inspected spoon-like or clubbed

Inadequate oxygen supply to the distal part of the body.

Hair Inspection and palpation The hair is thin and is

evenly distributed throughout the upper part of theskull

Hair is black and is slightly greasy in texture whentouched

Normal

Head

Skull & faceInspection and Palpation No scars noted.

Free from lice, nits and dandruff.No lesions, no tenderness and masses noted during palpation.

Normal

Eyes & vision Inspection

Pupils are black and equally round and reactive to light and accommodation

Sclera is anicteric

Has pale pink palpebral conjunctiva

Able to close and open the left upper eyelids

Normal

Due to decrease oxygen supply needed by the body.

Normal

Ears &hearing Hearing acuity test

Exhibits a good sense of hearing as observed, he responds whenever his name is called.

Has auricles that has the same color as his facial skin, symmetricallyaligned with the outer canthus of the eye

There is minimal accumulation of brownish waxy cerumen on both ears

Normal

Nose & sinuses Inspection Nose is uniform in color with nasal flaring.

There is lack of oxygen supply so that the patient is compensating in order to have adequate oxygen needed by the body.

Mouth and oropharynx

Inspection Lips is cyanotic and there is excessive salivation;

Have the ability to do purse lips breathing.

The lips are cyanotic due to lack of oxygen supply.

Thorax and Lungs:

InspectionDifficulty of breathing (used of accessory muscle)Chronic productive coughPresence of purulent sputum

Due to retained mucus secretions and severe bronchospasm which lead to the infectivity of the airway resulting to difficulty of breathing.

Chest shape and size

Breath sounds

Inspection

Auscultation

Has an anteroposterior to transverse diameter ratio of 1:2, elliptical in shape and symmetrical chest.

Has wheezing sound on both lung field during auscultation.

Normal

Abnormal, indicates spasm of the bronchioles in the passage of the airway.

Cardiovascular

Heart sounds

Auscultation The heart rate is normal with no missed beats.S1, the LUB is the loudestS2, the DUB is the loudest

Absence of murmurs

Normal

Breast and Axillae Inspection and Palpation

No lumps or masses are palpable.

No tenderness upon palpation.

No discharges from the nipples.

Normal

Abdomen

Abdominal contour, symmetry

Inspection and palpation

Has a flat abdomen.Has a symmetrical abdominal contour

Normal

Bowel sound Auscultation Borborygmy

With 15 bowel sounds per minute

Normal

Musculoskeletal system

Muscle

Joints

Bones

Inspection

Both extremities are equal in size.

Have the same contour with prominences of joints.No involuntary movements.

Can perform complete range of motion.

Normal

Neurologic:

Mental status

Level of consciousness

Motor function

Sensory function

InspectionHe is not able to respond in all the questions given Irritable at times.

Disoriented.

Hand grip:L- presentR-presentLeg Movement:L- presentR- present

Ability to feel sensations of touch, detect any information from sense of

Due to difficulty of breathing experienced by the patient and associated with fatigue related to his condition.

sight, smell, hearing and taste.

V. Anatomy and Physiology

The respiratory system consists of all the organs involved in breathing. These include:

the nose pharynx larynx trachea Bronchi and lungs.

The respiratory system does two very important things:

It brings oxygen into our bodies, which we need for our cells to live and function properly;

It helps us get rid of carbon dioxide, which is a waste product of cellular function. The nose, pharynx, larynx, trachea and bronchi all work like a system of pipes through which the air is funneled down into our lungs. There, in very small air sacs called alveoli, oxygen is brought into the bloodstream and carbon dioxide is pushed from the blood out into the air.

How they work

Air enters your lungs through a system of pipes called the bronchi.

These pipes start from the bottom of the trachea as the left and right bronchi and branch many times throughout the lungs, until they eventually form little thin-walled air sacs or bubbles, known as the alveoli.

The alveoli are where the important work of gas exchange takes place between the air and your blood. Covering each alveolus is a whole network of little blood vessel called capillaries, which are very small branches of the pulmonary arteries.

It is important that the air in the alveoli and the blood in the capillaries are very close together, so that oxygen and carbon dioxide can move (or diffuse) between them.

Physiology of Gas Exchange

Each branch of the bronchial tree eventually sub-divides to form very narrow terminal bronchioles, which terminate in the alveoli. There are many millions of alveoli in each lung, and these are the areas responsible for gaseous exchange, presenting a massive surface area for exchange to occur over.

Each alveolus is very closely associated with a network of capillaries containing deoxygenated blood from the pulmonary artery. The capillary and alveolar walls are very thin, allowing rapid exchange of gases by passive diffusion along concentration gradients. CO2 moves into the alveolus as the concentration is much lower in the alveolus than in the blood, and O2

moves out of the alveolus as the continuous flow of blood through the capillaries prevents saturation of the blood with O2 and allows maximal transfer across the membrane.

VII. Laboratory Result

Complete Blood Count Date: September 7, 2010

Test Result Normal Value InterpretationHgb 142 g/L 130-180 g/L >a good measure of

the blood's ability to carry oxygen throughout the body.

Hct 0.445 g/L 0.42-0.54 g/L >45% of blood made up of RBC

RBC 4.9 x 10^12/L 4.5-6.2 x 10^12/L  >the body gets the oxygen it needs

WBC 23.7 x 10^9/L 5-10 x 10^9/L due to the inflammation of the bronchi

Lymphocyte 4.7 % 20-40 % viral infection is usually associated with an increase in lymphocytes,

Monocyte 4.9% 2-6 % parasitic infection, viral infection

Blood Chemistry Date: September 7, 2010

Test Result Normal Value InterpretationSodium (Na) 126.50 135-145 mmol/L In patients with

acute asthma decreased filling of theleft atrium occurs owing to increased resistance toblood flow through the pulmonary vascular bed.This in turn acts as a potent stimulus to the releaseof antidiuretic hormone.

Potassium (K) 4.38 3.5-5.3 mmol/L >normal

Chest X-ray Date: September 7, 2010

Result>consider intrathoracic mass is consolidated left lung, CT scan correlation is suggested

CT scan Date: September 13, 2010

ResultPartial consolidation is seen in lateral segment of the right middle lobe and superior segment of the left lower lobe with thickening of the adjacent left interlobal fissure

There are interstitial infiltrates in the right middle lobe Linear densities are noted in the right middle lobe, right medial basal segment, left lingular segment

Impression: Pneumonia with partial consolidation in the superior segment of the left lower

lobe and lateral segment of the right middle lobe.

Linear fibrotic densities or subsegmental atelectasis, both basal areas

Chest X-ray Date: September 16, 2010

ResultHomogenous air-space consolidation in the left hemithoraxCoarsened bronchopulmonary vascularity noted

Impression:

Healed consolidation Pneumonia, left hemithorax Acute bronchitis is considered

VIII. Medical Management

Pharmacological management Co-Amoxiclav 1.2g q8 ANST (-)

Paracetamol 1 amp 300mg TIV q4 Epinephrine subq Hydrocortisone 250mg Dexamethasone ½ amp HNBB 10mg TIV Duavent 1cc + neb q30 x 3 doses Salbutamol + ipratropium ½ neb + 1cc NSS q4 Salbutamol + guaifenissin 5ml syrup TID x 7 days

Contraption:With oxygen inhalation at the rate of 4 lpm.

Intravenous FluidD5NM 1L KVO Side drip: Aminophylline drip (30 ugtts/ min)

Diet There’s no special asthma diet. We don’t know of any foods that reduce the

airway inflammation of asthma. Beverages that contain caffeine provide a slight amount of bronchodilation for an hour or two, but taking a rescue inhaler is much more effective for the temporary relief of asthma symptoms.

IX. NURSING MANAGEMENT

The main focus of nursing management is to actively assess the airway and the patient’s response to treatment.

The nurse constantly monitors the patient for the first 12 to 24 hours, or until status asthmaticus is under control.

The nurse also assesses the patient’s skin turgor for signs of dehydration. Fluid intake is essential to combat dehydration, to loosen secretions, and to

facilitate expectoration. Blood pressure and cardiac rhythm should be monitored continuously during the

acute phase and until the patient stabilizes and respond to therapy. The patient’s energy needs to be conserved, and his room should be quiet and

free of respiratory irritants, including flowers, tobacco smoke, perfumes or odors of cleaning agents. No allergic pillows should be used.

PREVENTIONAvoid smoke of all kinds. Stop smoking and avoid second-hand smoke. Eat, work, travel, and relax in smoke-free areas. Stay away from wood burning stoves.

Avoid air pollution. Stay indoors when the air pollutions is high. Avoid strong odors, fumes, and perfumes. Avoid breathing cold air. In cold weather, breathe through your nose and cover

your nose and mouth with a scarf or cold weather mask. Avoid indoors pets with fur or feathers. Outdoors pets or pets such as fish or

turtles may cause less trouble. Reduce your risk of colds and flu by washing your hand often and getting a flu

shot each year.

Build up the strength of your lungs and airways: Get regular exercise. Swimming or water aerobics may be good choices because

the moist air is less likely to trigger a flare-ups. If vigorous exercise triggers asthma flare-ups, talk with your doctor. Adjusting your medication and your exercise routine may help.

X. Recommendation

We shall recommend to the patient to avoid smoking and strenuous activities and emphasized use of wet sponge in cleaning the house to prevent spread of dust thus preventing the recurrence of asthma attack.

XI. Summary of dischargeM- E-

T-H-O- D-

XIII. Bibliography

Brunner and Suddarth’s Medical Surgical Nursing Twelfth Edition Suzanne C. Smeltzer Brenda G. Bare Janice L. Hinkle Kerry H. Cheever

Pages 630-631

Nursing Care Plans (Nursing Diagnosis and Intervention) 6thEdition Gulanick/ Myers

Nursing 2008 Drug Handbook Wolters Kluter Lippincott Williams & Wilkins