Bronchial Ashthma

8/7/2019 Bronchial Ashthma

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MARIANO MARCOS STATE UNIVERSITY

College of Health Sciences

Batac, Ilocos Norte

A CASE ANALYSIS:

BRONCHIAL ASTHMA

IN ACUTE EXACERBATION

Submitted to:

MRS. MAXIMA JOHANNA L. RAFOLS

MRS. RUTH T. LAYAOENClinical Instructors

Submitted by:

MARY ANN C. ALLAUIGAN

JENNIFER B. AQUE

HAYDEN MAY S. BALTAZAR

CARISSA B. DAYOAN

RICHILDA S. ERLANDEZ

DANNI RICA S. GAZMEN

MADELYN C. MACADANGDANG

GERALDINE C. RAMOS

CHRISTINE V. REYES

CHATY P. SIBUCAO

ARISTOTLE S. TABIOSRICHELLE Q. VALITE

CELSO C. VILLANUEVA

MARIA ALELI A. YANOSBSN IVC, GROUP III

January 27, 2005

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TABLE OF CONTENTS

Title Page - - - - - - - - - - -1

Table of Contents- - - - - - - - - -2

I. ANATOMY AND PHYSIOLOGY - - - - - -3

Respiratory System - - - - - - - -3

II. PATHOPHYSIOLOGY - - - - - - - -8

Readings- - - - - - -- - - -8

Paradigm - - - - - - - - -12

III. PERSONAL DATA- - - - - - - - -13

IV. FAMILY BACKGROUND - - - - - - - -14

V. HEALTH HISTORY- - - - - - - - -15

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Family Health History- - - - - - - -15

Past Health History - - - - - - - -16

Present Health History- - - - - - - -17

VI. DEVELOPMENTAL DATA- - - - - - - -17

VII. PATTERNS OF FUNCTIONING- - - - - - -19

VIII. LEVEL OF COMPETENCIES- - - - - - -21

IX. PHYSICAL ASSESSMENT- - - - - - - -25

X. ON GOING APPRAISAL - - - - - - - -26

XI. LABORATORY AND DIAGNOSTIC PROCEDURES- - - -29

XII. MEDICAL MANAGEMENT- - - - - - - -36

XIII. DRUG STUDY- - - - - - - - - -38

XIV. NURSING CAREPLAN- - - - - - - -43

XV. GENERAL EVALUATION - - - - - - -49

XVI. IMPLICATION OF THE STUDY - - - - - -50

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I. ANATOMY AND PHYSIOLOGY OF RESPIRATORY SYSTEM

The respiratory system contains the structures through with oxygen comes into the body to reach

the bloodstream, and through which carbon dioxide and water vapor leaves. These structures include the

lungs and the airways or air passages connected with them.

Gas exchange is the primary function of the respiratory system. The respiratory system takes

oxygen from the atmosphere, transport oxygen into the lungs, exchanges oxygen for carbon dioxide in the

alveoli, and returns carbon dioxide in the air.

Besides its major function, exchanging carbon dioxide and oxygen, the respiratory system also

supports all vital functions. The respiratory system helps maintain the bodys acid base balance to ensure

as table hydrogen ion concentration. Moreover, the system warms inhaled air, filters air thru the nasal

hairs, and distributes air through the vocal cords to allow speech.

STRUCTURES OF THE RESPIRATORY SYSTEM

UPPER AIRWAY

The upper airway consist the nose the nasal cavity, pharynx and larynx. Major functions of the

upper airway are (1) air conduction to the lower airway to the gas exchange; (2) protection to the lower

airway from foreign matters; and (3) warming filtration and humidification of inspired air.

Nose and Nasal Cavity

The term nose usually refers to the visible structure that forms a prominent feature of the face and

also can refer to the internal nasal cavity. The bridge of the nose consists of the nasal bones and

extensions of the frontal and maxillary bones, but most of the nose is composed of cartilage. The rigid

bone and cartilage are covered with connective tissue and skin.

The nasal cavity extends from the external openings in the nose to the pharynx, and it is divided

by the nasal septum into the right and left sides. The external openings to the nasal cavity are the external

nares and nostrils, and the internal openings from the nasal cavity into the pharynx are the internal nares.

The external nares lead to a cavity called vestibule. The vestibule is lined interiorly with skin and

hair (called vibrissae). The vibrissae filters foreign object and prevent them from being inhaled. The

posteriors vestibule is lined with mucus membrane. This membrane is composed of columnar epithelial

cells, which secretes mucus. Along the side of the vestibule are turbinate. The turbinate are mucus

membrane covered projections. They contain a very rich blood supply from the external and internal

carotid arteries, and they warm and humidify inspired air.

Paranasal sinuses are open areas within the skull. They are anmed from the bones in which they

lie frontal, ethmoid, sphenoid, and maxillary. Passageways from the paranasal sinuses drain into the

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nasal cavities. The nasolaryngeal ducts, which drain tears from the surface of the eyes, also drain into the

nasal cavity.

Pharynx

The pharynx is a funnel-shaped tube that extends from the nasal cavities to the larynx, where it

becomes continuous with the esophagus. The pharynx is the common passageway of both the digestive

and respiratory system. It receives air from the nasal cavity and air, food, and water from the mouth.

Inferiorly, the pharynx leads to the opening of the respiratory system (opening into the larynx) and the

digestive system (the esophagus). The pharynx can be divided into three regions, the nasopharynx, and

the laryngopharynx.

The nasopharynx is the superior portion of the pharynx and extends from the internal nasal cavity

to the level of the uvula, a soft process that extends from the posterior edge of the soft palate. The soft

palate forms the floor of the nasopharynx. The nasopharynx is lined with a mucus membrane similar to

that of the nasal cavity. The auditory tubes open into the nasopharynx, and the posterior portion of the

nasopharynx contains the pharyngeal tonsils, which aid in defending the body against infection. The soft

palate and uvula are elevated during swallowing, and this movement results in the closure of the

nasopharynx, which prevents food from passing from the oral cavity into the nasopharynx.

On the other hand, oropharynx extends from the uvula to the epiglottis. The oral cavity opens into

the oropharynx. Thus food, drink, and air all pass through the oropharynx. The oropharynx is lined with

stratified squamous epithelium, which protects against abrasion.

The laryngopharynx extends from the epiglottis to the lower margin of the larynx. The

laryngopharynx, like the oropharynx, is lined with stratified squamous epithelium.

Larynx

The larynx or the voice box is that part of the respiratory tract between the pharynx and the

trachea, containing the vocal cords. It consists of an outer casing of nine cartilages that connected to each

other by muscles and ligaments. Six of the nine cartilages form three pairs of cartillages, and three

cartillages are upaired.

One unpaired cartilage is the epiglottis, which consists of elastic cartilage rather than hyaline

cartilage. Its inferior margin is attached to the thyroid cartilage anteriorly, and the superior part of the

epiglottis projects as a free flap forward the tongue. During swallowing, the epiglottis covers the opening

of the larynx and prevents materials from entering it. The thyroid cartilage is another unpaired cartilage.

The thyroid cartilage (or Adams apple) is known to be the largest cartilages composing the larynx. The

unpaired cricoid cartilage is the most inferior cartilage of the larynx. It forms the base of the larynx where

the other cartilages rest.

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The six paired cartilages are stacked in two pillars, each consisting of three cartilages, between

the cricoid and thyroid cartilages on the posterior portion of the larynx.

Two pairs of ligaments extend from the posterior surface of the thyroid cartilage to the paired

cartilages. The superior pair forms the vestibular folds, or false vocal cords, and the inferior pair

composes the vocal folds, or true vocal cords. The true vocal cords are involved in voice production. Air

moving past the true vocal cords causes them to vibrate, producing sound. The force of air moving past

the true vocal cords controls the loudness and the tension of the true vocal cords controls the pitch of the

voice.

LOWER AIRWAY

The lower airway (tracheobronchial tree) is composed of the trachea, right anf left main stem

bronchi, segmental bronchi, sub segmental bronchi, and terminal bronchioles. The major functions of the

lower airway include (1) conduction of air through the many branches of airways to the alveolar level; (2)mucociliary clearance; and (3) production of pulmonary surfactant.

Trachea

The trachea (windpipe) ia a thin-walled tube of cartilaginous and membranous tissue descending

from the larynx to the bronchi and carrying air to the lungs. It is about 1 inch wide and 4-5 inches long,

reinforced with 15-20 C-shape pieces of cartilage.

The C-shape cartilages form the anterior and lateral sides of the trachea, and they protect the

trachea and maintain an open passageway of air. The posterior wall of the trachea has no cartilage and

consists of a ligamentous membrane and smooth muscle.

The trachea is lined pseudostratified columnar epithelium that contains numerous cilia and goblet

cells. The cilia propel mucus produced by the goblet cells and foreign particles toward the larynx, where

they enter the esophagus and are swallowed.

Mainstem Bronchi

The main stem bronchi are also called primary or main brochi. They are subdivisions of the

trachea branching off from the tracheal bifurcation. One main stem bronchus enters each lung. These

tubular passages conduct air between the trachea and the pulmonary bronchi. Like the trachea, the walls

of the bronchi contain cartilaginous rings and are covered with ciliated mucous lining.

Because of the location of the heart in the thoracic cavity, the left primary bronchus is more

horizontal than the right primary bronchus. The right primary bronchus is also shorter and wider so

foreign objects that enter the trachea usually lodge in the right primary bronchus.

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Segmental and Subsegmental Bronchi

Segmental and subsegmental bronchi are also referred to as secondary bronchi or bronchial tubes.

They are subdivisions of main bronchi and spread in an inverted treelike formation, branching through

each lung. These tubular passages convey air within the lung between the main stem bronchi and the

bronchioles.

Terminal Bronchioles

Terminal bronchioles are the last airways of the conducting system and also the smallest

subdivisions of bronchi. Segmented bronchi divide into smaller bronchioles within the broncho-

pulmonary segments. The final branches of bronchioles, i.e., respiratory bronchioles, communicate

directly within clusters of alveoli. The smooth muscles of the bronchioles are supplied by both divisions

of the autonomic nervous system, the sympathetic (promoting relaxation) and the parasympathetic

(promoting contraction).

LUNG PARENCHYMA

The lung is metabolically very active and accounts for approximately 10 percent of oxygen

consumption. The lung parenchyma is the working area of lung tissue, consisting of millions of alveolar

units. Alveoli, small air sacs at the end of the respiratory bronchioles, permit exchange of oxygen and

carbon dioxide. The entire alveolar is made up of respiratory bronchioles, alveolar ducts, and alveolar

sacs. Gas exchange actually begins in the respiratory bronchioles.

It is estimated there are 24 million alveoli at birth. By the time the person is 8 years old, the

number of alveoli has increased to the adult number of 300 million. The total working alveolar surface

area is approximately 70-80 sq.m. The large number of alveoli and the large surface area are necessary to

meet both resting and exercise oxygen requirements. Each alveolar unit is supplied with 9-11

prepulmonary and pulmonary capillaries. The blood supply for these capillaries comes from the right

ventricle of the heart. The major function of the lung parenchyma is the passage and exchange of

molecular oxygen and carbon dioxide from the pulmonary capillaries and alveoli.

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LUNGS

The lungs lie within the thoracic cavity on either side of the heart. They are light, spongy, porous,

elastic, and cone-shaped. The lungs inflate with expiration and deflate (but do not completely collapse)

with expiration. They extend from the diaphragm to just above the clavicles. The base of the lungs rests

on the diaphragm, while the apex (top) extend above the first rib. The hilus or the hilum (root of the

lung) is a notch or depression in the medial surface of the lung where the main stem bronchus,

pulmonary blood vessels, and nerves enter the lung. The lungs lie free within the thorax and are attached

only at the hilus.

The two

lungs are separated

by a space

the

mediastenum. Each

lung is divided

into superior and

inferior lobes by an

oblique fissure.

The right lung is further

divided by a

horizontal fissure, which bound as middle lobe. The right lung, therefore, lies three lobes, whereas the

left lobe has only two. In addition to these five lobes that are externally visible, each lung can be

subdivided into about ten smaller units called broncho-pulmonary segments. Each broncho-pulmonary

segment represents the portion of the lung that is supplied by a specific tertiary bronchus.

Lungs are made of elastic tissue with a tendency to recoil. They are capable of stretching if a

pulling force is exerted on them from outside or if they are blown up (inflated) from within. Normally

the elastic fibers of the lung are partially stretched all the time, thus, filling the lung chamber. Lung

parenchyma (essential functional parts) is a network of air tubes and blood vessels, honeycombed with

air-filled sacs (alveoli).

PLEURAE

The pleurae are membranes protectively covering each lung and lining the thoracic cavity. The

two pleural layers are (1) the parietal pleural, lining the inner surface of the chest wall and covering the

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coastal, diaphragmatic, and mediastinal surfaces of the thorax, and (2) the visceral pleura, hugging the

contours of the lung tissue, including the fissures between the lobes of the lungs.

The pleura are continuous with one another and form a closed sac. Normally, there is no space

between them. A potential space exists called the pleural space (pleural cavity). A thin film (only a few

ml) of serous fluid (pleural fluid) is present in the pleural space acting as a lubricant. It also causes the

moist pleural membrane to adhere somewhat, the cohesion producing a tensile strength or pulling force

that helps hold the lungs in an expanded position. It is through (a) muscular energy exerted on the thorax,

and (b) changes between the relationship of intrathoracic and atmospheric pressures that gasses are able to

move in and out of the lungs.

The pressure within the lungs and thorax must be less than atmospheric pressure for inspiration to

occur. Gas flows from an area of higher pressure to one of a lower pressure. As the diaphragm and inter-

coastal muscles work to enlarge the size of the thorax, intrathoracic pressure decreases below atmospheric

pressure and air moves into the lungs. During the exhalation, inspiratory muscles relax and the elastic

recoil of the lung tissue, along with a rise in the intrathoracic pressure, causes air to move out of the lung.

The viseral pleura (which lines the lungs) adhere to the parietal pleura. As the chest wall moves,

the parietal pleura (attach to the arterial wall of the thorax) carry the visceral pleura along with it. This

mechanism simultaneously pulls the lung downward as the diaphragm descends. This counteracts the

elastic recoil of the lung tissue.

II. PATHOPHYSIOLOGY

A. Readings

A pulmonary disease characterized by reversible airway obstruction, airway inflammation, and

increased airway responsiveness to a variety of stimuli.

Airway obstruction in asthma is due to a combination of factors that include spasm of airway

smooth muscle, edema of airway mucosa, increased mucus secretion, cellular (especially eosinophilic and

lymphocytic) infiltration of the airway walls, and injury and desquamation of the airway epithelium.

Bronchospasm due to smooth muscle contraction used to be considered the major contributor tothe airway obstruction. But now, inflammatory disease of the airways is known to play a critical role,

particularly in chronic asthma. Even in mild asthma, there is an inflammatory response involving

infiltration, particularly with activated eosinophils and lymphocytes but also with neutrophils and mast

cells; epithelial cell desquamation also occurs. Mast cells seem important in the acute response to inhaled

allergens and perhaps to exercise but are less important than other cells in the pathogenesis of chronic

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inflammation. The number of eosinophils in peripheral blood and airway secretions correlates closely

with the degree of bronchial hyperresponsiveness.

Typically, all asthmatics with active disease have hyperresponsive (hyperreactive) airways,

manifest as an exaggerated bronchoconstrictor response to many different stimuli. The degree of

hyperresponsiveness is closely linked to the extent of inflammation, and both correlate closely with the

severity of the disease and the need for drugs. However, the cause of hyperresponsive airways is not

known. Structural changes in the airways may contribute to it. For example, desquamation of epithelium

(due to eosinophil major basic protein) results in a loss of epithelium-derived relaxing factor and of

prostaglandin E2, both of which reduce contractile responses to bronchoconstricting mediators. Neutral

endopeptidases responsible for metabolizing bronchoconstricting mediators (eg, substance P) are

produced by epithelial cells and are also lost when the epithelium is damaged. Another possible cause of

airway hyperresponsiveness is airway remodeling resulting in a small increase in airway thickness.

Many inflammatory mediators in the airway secretions of patients with asthma contribute to

bronchoconstriction, mucus secretion, and microvascular leakage. Leakage, a constant component of

inflammatory reactions, leads to submucosal edema, increases airway resistance, and contributes to

bronchial hyperresponsiveness. Inflammatory mediators are either released or formed as a consequence of

allergic reactions in the lungs; they include histamine and products of arachidonic acid metabolism

(leukotrienes and thromboxane, both of which can transiently increase airway hyperresponsiveness). The

cysteinyl leukotrienes, LTC4 and LTD4, are the most potent bronchoconstrictors yet studied in humans.

Platelet activating factor is no longer thought to be an important mediator of asthma.

T-cell activation of the allergic response is a key event in the inflammation that characterizes

asthma. T cells and their secretory products (cytokines) perpetuate airway inflammation. Cytokines

produced by one particular lineage of lymphocytes, the CD4Th2 (helper) T cells, promote growth and

differentiation of inflammatory cells, activate them, induce their migration into the airways, and prolong

their survival there. The principal cytokines involved include interleukin (IL)-4, which is necessary for

IgE production; IL-5, which is a chemoattractant for eosinophils; and granulocyte-macrophage colony-

stimulating factor, which is similar to IL-5 in its effects on eosinophils but less potent.

Cholinergic reflex bronchoconstriction probably occurs in the acute response to inhalation of

irritant substances; however, neuropeptides released from sensory nerves in an axon reflex pathway may

be more important. These peptides, which include substance P, neurokinin A, and calcitonin gene-related

peptide, cause vascular permeability, mucus secretion, bronchoconstriction, and bronchial vasodilation.

The pathophysiologic changes described above lead to varying degrees of airway obstruction and

to ventilation that is typically nonuniform. Continued blood flow to some hypoventilated areas causes

ventilation/perfusion imbalance, resulting in arterial hypoxemia. Early in an attack, a patient typically

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compensates by hyperventilating the unobstructed areas of the lung, resulting in a decrease in PaCO 2. As

the attack progresses, the capacity for hyperventilation is impaired by more extensive airway narrowing

and muscular fatigue. Hypoxemia worsens, and PaCO2 begins to rise, leading to respiratory acidosis. At

this point, the patient is in respiratory failure.

Symptoms and Signs

The frequency and severity of symptoms vary greatly from person to person and from time to

time in the same person. Some asthmatics have occasional episodes that are mild and brief. Others have

mild coughing and wheezing much of the time, punctuated by severe exacerbations after exposure to

known allergens, viral infections, exercise, or nonspecific irritants. Psychologic factors, particularly those

associated with crying, screaming, or hard laughing, may precipitate symptoms.

Usually, an attack begins acutely with paroxysms of wheezing, coughing, and shortness of breath

or insidiously with slowly increasing manifestations of respiratory distress. However, especially in

children, an itch over the anterior neck or upper chest may be an early prodromal symptom, and dry

cough, particularly at night and during exercise, may be the sole presenting symptom. An asthmatic

usually first notices dyspnea, cough, shortness of breath, and tightness or pressure in the chest and may

hear wheezes. The cough during an acute attack sounds tight and generally does not produce mucus.

Except in young children, who rarely expectorate, tenacious mucoid sputum is produced as the attack

subsides.

Physical examination: During an acute attack, the patient shows varying degrees of respiratory

distress, depending on the severity and duration of the episode. Tachypnea and tachycardia are present.

The patient prefers to sit upright or even leans forward, uses accessory respiratory muscles, is anxious,

and may appear to struggle for air. Chest examination shows a prolonged expiratory phase with relatively

high-pitched wheezes throughout inspiration and most of expiration. The chest may appear hyperinflated

due to air trapping. Coarse rhonchi may accompany the wheezes, but fine crackles are not heard unless

pneumonia, atelectasis, or cardiac decompensation is also present.

During more severe episodes, the patient may be unable to speak more than a few words without

stopping for breath. Fatigue and severe distress are evidenced by rapid, shallow, ineffectual respiratory

movements. Cyanosis becomes apparent as the attack worsens. Confusion and lethargy may indicate the

onset of progressive respiratory failure with CO2 narcosis. In such patients, less wheezing may be heard

on auscultation, because extensive mucous plugging and patient fatigue result in marked reduction of

airflow and gas exchange. A quiet-sounding chest in a patient having an asthma attack is an alarm that the

patient may have a severe respiratory problem that can quickly become life threatening.

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The most reliable signs of a severe attack are dyspnea at rest, the inability to speak, cyanosis,

pulsus paradoxus (> 20 to 30 mm Hg), and use of accessory respiratory muscles. Severity is most

precisely assessed by measuring arterial blood gases.

Between acute attacks, breath sounds may be normal during quiet respiration. However, fine

wheezes may be audible during forced expiration or after exercise. Low- to moderate-grade wheezing

may be heard at any time in some patients, even when they feel asymptomatic. With long-standing severe

asthma, especially if dating from childhood, chronic hyperinflation may affect the chest wall, eg,

producing a squared off thorax, anterior bowing of the sternum, or a depressed diaphragm.

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13B. Paradigm

EMOTIONALSTRESS

EXERCISE RESPIRATORYTRACT INFECTION

ALLERGENS,

IRRITANTS, FOODS,DRUGS,

OCCUPATION

Modification of vagal

efferent activity and

activation of brainendorphines

Hyperemia

Increase minuteventilation

Microvasculatureengorgement

Epithelial damage

Stimulation of IgE

Activation of mastcells

Release of chemicalmediators

Leukotrienes

Hypersecretion ofmucus

Histamine, bradykinin,prostaglandin

Attracts WBC (neutrophils,

eosinophils and lymphocytes andincrease cellular permeability

Edema on mucus membrane

BRONCHOSPASM

BRONCHOCONSTRICTION

Increase work of breathing

RestlessnessTachypnea and dyspnea

TachycardiaFalring of alae nasi

DiaphoresisCold clammy skin

WheezingRetractions

Pallor to cyanosis

Use of Accessorymuscles

Exhaustion

Slow, shallow respiration

Retention of CO2Hypoxia, Hypoxemia

Respiratory acidosiss/s: headache, dyspnea, fine tremors, HPN,

tachycardia, vasodilation


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III. PERSONAL DATA

Name:Ang Khit

Age: 58 years old

Date of Birth:September 28, 1946

Place of Birth:Dingras, Ilocos Norte

Sex: Female

Civil Status: Widow

Religion:Bathle Community Church

Nationality: Filipino

Address: #4 Laoag City

Educational Attainment:High School Level

Occupation:Housekeeper

Chief Complaint: Difficulty of Breathing

Diagnosis:

Admitting: Bronchial Asthma with Acute Exacerbation

Final: Bronchial Asthma with Acute Exacerbation

Inductive period of Hospitalization:

Date of Admission:January 1, 2005

Admitting Physician:Dr. Magcalas / Dr. Catcatan

Ward & Room:Medicine 4F, Room 409 Alley

Category:Service

Hospital Number: 754953

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IV. FAMILY BACKGROUND

Members Position Relationship

with the

Head

Age Sex Civil

Status

Residence Occupation Religion Educationa

Attainmen

Hi-ngal Eldest

child

Daughter 37 F M Hong

Kong

Domestic

Helper

Bathle

Community

Church

College

Graduate

(Commerce

Rharek Second

child

Daughter 35 F M Hong

Kong

Domestic

Helper

Bathle

Community

Church

High Schoo

Graduate

Ah-nangsab

Thirdchild

Daughter 32 F S HongKong

DomesticHelper

BathleCommunity

Church

CollegeGraduate

(BSIT)

Uh-yhek Fourthchild

Son 30 M M Laoag City Tricycledriver

BathleCommunity

Church

VocationalGraduate

Sa-whaw Fifth

child

Son 21 M M Laoag City Tricycle

driver

Bathle

Community

Church

High Schoo

Graduate

Phle-mas Sixth

child

Daughter 15 F S Laoag City Student Bathle

Community

Church

High Schoo

Level

Approximate Income: P 10, 000.00

Main source of income: Foreign Aid (from the daughters in Hong Kong)

Ang Khits family is an extended type since her all her four children who are married are staying

in their family house, sharing all the resources available.

The main source of living of her family comes from her 3 children in Hong Kong working as

domestic helpers. Her married children holds their own money however, they also contributes on the

different need s in their house.

According to Ang Khit, shes the one who budgets the money given by her children and in-laws

for all the things needed in their house including the food, groceries, electric bills, water bills,

transportation and other miscellaneous.

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In terms of decision making, shes usually the one who makes decision when it comes with their

properties. However, it its already in terms of financial and health, its already her children with their

husbands.

V. HEALTH HISTORY

A. Family Health History

According to Ang Khit, there are only two hereditary diseases present in their family that

includes diabetes mellitus and asthma. Her husband died because of his diabetes. Her parents and

grandparents did not die of any kind of disease but due to old age as claimed by her.

Ang Khit also revealed that they had experienced having cough, colds, fever during extreme

temperatures (hot and cold weathers), headache, stomachache, toothache and body ache. They usually

manage them with over the counter drugs such as Decolgen for cough, Neozep for colds, Paracetamol

for fever, Alaxan for headache, body ache and toothache, and Kremil-S for stomachache. They also had

experienced some infectious and communicable diseases such as chicken pox, measles, mumps and

sore eyes. They manage chicken pox by applying singkamas on the vesicles to relieve irritation; for

measles, they let her wear black color clothes for they believe that this will lessen the irritation; and for

mumps, they applying akot-akot on the affected area. For other managements for these diseases, she

identified bedrest, enough sleep and adequate nutrition as their practices.

They also utilize herbal medicines such as oregano decoction and lagundi decoction for cough,

boiled guava leaves for cleaning wounds, ampalaya leaves for an-an and kutsay leaves for boils.

Ang Khit pointed out that they directly go to private clinics or to the nearest hospital for severe

cases. She stressed out that they doesnt believe in ghost, bad spirits, witchcraft, herbolaryos, and

arbolaryos. But she stated that she often consults a hilot whenever there are sprains and dislocated

bones, and claimed to be effective.

For the immunization of the family members, Ang Khit cannot really tell if her husband had

received one. She cannot also remember if they have a complete immunization but she was very much

sure that they had received one, she just cant remember what kind of immunization it was.

Ang Khit disclose that her in-laws are smoker consuming one pack of cigarette (hope) per day.

Ang Khit stated that they had tried to talk to them and encourage them to stop smoking but they were

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not listening to the them. Every night, they are also drinking one cuatro cantos of Ginebra San Miguel

but she claimed that there were no troubles that usually happens between them.

The family prefers to eat vegetables and fish, however they also buy meat when they have extra

money. The family drinks water from their well. They also drink coffee every morning sometimes

softdrinks when theres an occasion. There were no allergies identified in the family.

B. Past Health History

According to Ang Khit, she experienced having common illnesses during her childhood days

such as fever, colds, cough, stomachache, headache, and flu. These illnesses were managed by taking

in over the counter drugs such as Paracetamol for fever, Neozep for colds, Decolgen for cough, Kremil-

S for stomachache, and Alaxan for headache. She also uses herbal plants such as oregano decoction

plus breast milk for cough, and kutsay for minor wounds.

Ang-Khit also had experienced having chicken pox, measles, and mumps. They manage her

chicken pox by applying singkamas on the vesicles to relieve irritation; for measles, they let her wear

black color clothes for they believe that this will lessen the irritation; and for mumps, they applying

akot-akot on the affected area.

Ang Khit doesnt know if she had received any immunizations. She also claimed that she doesnt

have any allergies to foods and drugs except for the dust and other allergens ands irritants present in the

environment because this triggers her asthma. Ang Khit is fond of drinking coffee with at least three

cups of day Shes also fond of drinking juice and softdrinks. Ang Khit is also fond of eating raw fishes,

salty and fatty foods, and vegetables but dislikes beef very much.

According to her, this is her second hospitalization next to her hospitalization in 1980 also in

MMMH and MC with a diagnosis of Bronchial Asthma. She was then stayed at the hospital for one

week, given due medication and was relieved. In this time, she was give Theophyllin 200 mg twice a

day as her maintenance medication and nebulization as needed.

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C. Present Health History

Ang Khit is a diagnosed case of Bronchial Asthma (since 1980) with an intake of theophylline

200 mg BID and PRN nebulization.

According to Ang Khit, her asthma usually occurs once a month depending on the situation. She

pointed out that shes usually having asthmatic attack when exposed to dust, fumes, smoke, pollens, and

other environmental irritants and allergens. No hospitalizations or consultations to private were usually

done during these times because according to her, her maintenance medication usually relieves her

discomfort.

Three weeks prior to admission, the client started coughing accompanied by colds and difficulty

of breathing . Ang Khit self medicated with theophylline and nebulization which afforded relief.

One day prior to admission, she developed severe difficulty of breathing. She again nebulized

three times at home and afforded slight relief. However, few minutes prior to admission, difficulty of

breathing worsens prompting her for consultation, hence admission.

According to her, the attack of her asthma was caused by the smoke of the firecrackers during the

celebration of the New Years Eve.

VI. DEVELOPMENTAL DATA

ERIK ERICKSON

Just as physical growth patterns can be predicted, certain psychosocial tasks must be mastered in

each developmental stage. According to Erickson's theory of psychosocial development, the middle age

or adulthood stage (25-65 years old) is the stage in which our patient has to accomplish a certain task,

which isgenerativity, the tendency to produce orstagnation, the tendency to stand still.

Ang Khit, having the age of 58 belongs to middle adulthood. Her developmental task is

generativity where in she is expected to develop an attitude of creativity and productivity in all aspect.

Stagnation on the other hand, suggests a lack of psychosocial movement or growth. When generativity

also is not achieved, the individual may turn into self- indulgence, self-concern and lack of interest and

commitment and eventually, crisis would exist.

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In addition, at this stage, she is expected to develop attitude-establishing priority of needs,

concern for others through transmitting good values to the next generation.

Relating this to our client's life in terms of creativity and concern for others, Ang Khit claimedthat she is very concerned to her family and to other people. Her secret according to her in establishing

good interpersonal relationship with other people is to be honest, trustworthy, and be good always. She

considers her family as her source of inspiration that's why she wants them to have a very good future.

She also stressed out that her source of happiness is her family, she is very supportive and caring

to her children and grandchildren Though sometimes she becomes lonely when she remember her

husband who died at the age of 52, however she said that maybe it is the will of GOD.

Ang Khit achieved certain task under generativity in the sense that she stated that she is happy

and contented with her life and willing to abreast the best that she can be for the good of his family.

ROBERT HAVIGHURST

In Havighurst theory of developmental task, biologic changes become apparent during middle

age. There is an important milestone in which both physiological and psychological adjustment must be

made for successful personal development. The following are the tasks he must achieved:

1. Achieving adult civic and social responsibility

2. Establishing and maintaining an economic standard of living

3. Assisting teenage children to become responsible and happy adults

4. Developing adult leisure-time activities

5. Relating oneself to ones spouse as a person

6. Accepting and adjusting to the physiologic changes of middle age

7. Adjusting to aging parents

Basing from these criteria, Ang Khit is performing her tasks. In fact, as what have stated they

have good relationship with her husband when he was still living. She is responsible enough looking for

the welfare of her family that even shes already old, she still finds a way to help her children in their

daily living.

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Aside from being a good mother of six she is also a good provider and mentor to her children.

She wanted them to be trained well and to become better individuals wherein as claimed by Phle-mas,

her mother achieved this goal.

When there are civic activities in the barangay such as Oplan Dalus, meeting of the WomensOrganization, Bingo social, etc. she finds time to support the said activity She utilizes her leisure time

listening to AM radio specially on news and drama.

Ang Khit admitted that she is getting older, and she finds her becoming more matured and more

knowledgeable for as she believes that experience is the best teacher.

ANALYSIS:

Based on the information we gathered, we believed that Ang Khit is normally developinganalogous to Erickson and Havighurst's theories. She is doing well with the tasks he is expected to

possess and to perform.

Moreover, if he continuously carries out these tasks, most definitely, he would be able to move to

the next stage and could perform the succeeding task. Though her condition sometime gives her

problem and makes her worried, it did not serve as a hindrance to attain the different tasks expected of

her.

VII. PATTERNS OF FUNCTIONING

Patterns Before Illness During Illness During

Hospitalization

Analysis

1. Eating Breakfast

Time: 5-7 am

Food content &

amount:

3-4 pcs. Pandesal

1 fried & 1 cup

rice 1 cup rice & 2

pcs. longganisa

Breakfast

Time: 6-7 am

Food content &

amount:

3-4 pcs.

pandesal

1 fried egg & 1cup rice

1 cup rice & 2

pcs.

longganisa

Breakfast

Time: 8 am

Diet:

Food content &

amount:

2 slices bread & 1

banana

There is a change of

the clients food

intake during

hospitalization

because of he

asthma wherein

there is a

bronchospasm tha

lead to different

problems such as for

activity intolerance,

ineffective breathing

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pattern, etc., tha

decreases her

appetite to eat. And

in addition, it is very

much hard to eat for

the client since shes

having difficulty of breathing and was

striving for oxygen.

Lunch

Time: 12:00 pm

Food content &

amount:

1 cup rice, serving

vegetable ( in any

type) or I cup rice& 3-4 [pcs. Meat

9matachbox

size)/ I cup rice

and 2 pcs. Fish

(medium size)

1 banana

Lunch

Time: 12:00 pm

Food content &

amount:

1 cup rice, serving

vegetable ( in any

type) or I cup rice& 3-4 [pcs. Meat

9matachbox

size)/ I cup rice

and 2 pcs. Fish

(medium size)

1 banana

Lunch

Time: 12:00-1:00 pm

Food content &

amount:

1 cup rice, I serving

squash (ginisa), I

pc. Fish (mediumsize)/ 2 pcs. Meat

(matchbox size)

Dinner

Time: 6:00 pm

Food content &amount:>1 cup rice, serving

vegetable (in any

type), 3-4 pcs. Meat

(matchbox size) 2pcs. Fish (medium

size)

Dinner

Time: 6:00 pm

Food content &amount:>1 cup rice, serving

vegetable (in any

type), 1 pcs, fish

(medium size)

Dinner

Time: 5:00-6:00 pm

Food content &amount:>1 cup rice, I serving

vegetable (in any

type), 2 pcs. Meat

(matchbox size)

Snack

Time: 9 10 AM /

3 4 PM

Food content &amount:

> any home made

delicacies

Snack

Time: 9 10 AM /

3 4 PM

Food content &amount:

>2-3 pcs, bread

Snack

Time: 10 AM

Food content &

amount:>1 pack sky flakes

2. Drinking Content: water, coke ,

orange juice, coffe

>5-7 glass of water

>1 cup of coffe

>1 glass juice

Amount:

approximately 1200-

1600ml/day

Content: water, coke ,

orange juice, coffe

>5-7 glass of water

>1 cup of coffe

>1 Amount:

approximately 1200-

1600ml/day glass

juice

Content: water

milk/coffe

>5-7 glass of water

>1 cup of milk/coffe

Amount approximately

1000-1200ml/day

In drinking pattern

there is slight

decrease during

hospitalization

because of the

presence of ashma,

due to easy

fatigability

3. Bladder Frequency: 7times a

day( 6times atdaytime & once at

night)

Color : pale yellow

Characteristic: clear

Frequency 7times a

day( 6times atdaytime & once at

night)

Color : pale yellow


Frequency: 5-6 times a

day( 5times at daytime& once at night)

Color : pale yellow


Amount

There is a

significant change inthe bladder

elimination of the

client. There is a

decrease in urine

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Amount

approximately: 1200-

1400ml/day

Amount


1400ml/day


1300ml/day

output as observe in

the during

hospitalization. This

is brought by the

decrease fluid intake

by the client.

4. Bowel Frequency: once a

day (every morning)Color: Brownish

Consistency: semi

formed

Amount :normal

Frequency: once a

day (every morning)Color: Brownish

Consistency: semi

formed

Amount :normal

Frequency: She only

defecated once onJanuary 3, 2005.

There is significant

change on the bowelelimination because

there is a lesser fluid

intake and lesser

mobility.

5. Bathing/

Grooming

Frequency:

> complete bath in

the morning

> sponge bath before

going to bed

Frequency:

> complete bath in

the morning

> sponge bath before

going to bed

Frequency:

> sponge bath every

morning

There is a

significant change in

bathing pattern

during

hospitalization

because patient is

not able to take a

bath by herself due

to easy fatigability.

She have her sponge

bath every morning

with the aid of her

daughter.

6. Sleeping Duration: 9 hours

Time of sleepingand awaking

>9 pm to 6 am

Characteristic:

> continuous

Nape time: 1-2 hours

Duration: 9 hours

Time of sleeping andawaking

>9 pm to 6 am

Characteristic:

> continuous


Duration: 10 hours

Time of sleeping andawaking

>9 pm to 7 am

Characteristic:

> with interruptions


There is no change

in sleeping patternexcept for thecharacteristic during

hospitalization that

there is a

interruptions for

medical purposes.

But there is also a

longer sleeping and

nape time.

VIII. LEVELS OF COMPETENCIES

Patterns Before Illness During Illness During

Hospitalization

Analysis

Physical Ang Khit then can

meet her physical

needs and active in

At home, her

activities of daily

living have been

In the hospital, she

usually stayed on bed

during her

There is a decrease in

the physical

competency of our

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performing her

activities of daily

living. At home, she

was able to do any

household chore such

as cleaning the house,

dishwashing, andothers. After doing

the entire household

chore, she goes to

their store andmanages it. She also

sees to it that she was

properly groomed

whenever she goes

out of their house and

before going to their

store.

limited such as

cleaning the house,

dishwashing, and

others. She could

still do these kind of

household chores

but then she musthave to stop and

take a rest at the

middle of her

activity since sheexperiences

difficulty of

breathing. She could

no longer also go to

their store because

she claimed to us

that her condition

worsens everytimeshe was exposed to

smokes. Since their

store is not nearby

their house, she has

to travel then to go

to there but because

of her condition she

could no longer

manage their store.

She was also afraidthat those smokes

that she inhalesmight have

triggered her

condition. Still she

made mention to us

that she was able to

maintain her proper

grooming.

hospitalization. She

claimed to us that

sometimes she able

also to go for a walk

along the ward. She

could still do proper

grooming but asks herdaughter to assist her

because she feels

weaker when she was

already confined inthe hospital. She also

told us that she

sometimes gets tired

especially when is

coughing

continuously.

client due to her

present condition

(asthma) that causes

different problems

such as difficulty of

breathing, body

weakness, and easyfatigability which

disables her to do her

usual routines.

Emotional Ang Khit is an

expressive type of

person andemotionally stable.

She laughs and smile

at things that are of

interest to her . She is

happy and satisfied

with her life because

her family is very

supportive to her and

At home, she is still

emotionally stable

and she is notirritable and

sensitive. She could

still hold her temper

during the presence

of her illness. Even if

she gets tired and

feels weak for some

time, she dont still

During her stay in the

hospital, she told us

that she gets irritatedfor quite some time

especially when some

of the

watchers/visitors in

the hospital are noisy.

This usually causes

her sleeping time to

be disrupted. And as

A deviation of

emotion was noted to

our client particularlywhen she was already

confined in the

hospital. Her

irritability was

mainly brought about

by her condition

(frequent coughing)

and by the noise in

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she is also very open

to her family and

friends. She is a type

of person who can

hold her temper

whenever she got

angry or irritated.According to her,

whenever she had

any misunderstanding

to anybody or toanyone on their

family, shed rather

go out to calm her

self and at the same

time to avoid their

problem to become

more complicated.

gets easily irritated.

However, our client

claimed that she

believes that all the

members of her

family will

understand her unexpected behavior

if even there might

come a time that

theyll be havingsome conflict during

her illness.

she has not slept well

during the night, she

awakes to be irritated

during the day. She

also stated that her

condition also

contributes to her being irritable one

since everytime she

was on the middle of

rest periods, she wasalso easily disrupted

by her frequent

coughing.

her environment.

Social According to ourclient, she has a lot of

friends in their place.

She also claimed that

she is fond of

attending social

gatherings and loves

to interact and make

friends to the people

whom she come

across with. She alsotold us that there

were times when she

was already in their

house, some of theirneighbors needs her

help, she always offer

a help for as long as

shes able to give. In

addition, she also

participates in

barangay programs

such as clean andgreen and meetings.

During the course ofher illness at home,

she was still able to

interact and make

friends especially

with their

neighbors.

However, she

claimed to us that

she seldom go out

already since herillness was triggered

by some

environmental

factors particularlysmokes. She still

makes sure that

whenever their

neighbors needs her

help for as long as

shes able to give.

Lastly, she also told

us that she seldom participates to

barangay programs

such as clean and

green and

meetings.

In the hospital, shestill do her best to

socialize with other

people particularly to

us and her fellow

patients but not that

much anymore since

she feels weak for

quite some time.

However, during our

interaction with her,she frequently

experiences cough

and she believes that

this contributes to theway she feels that

sometimes she gets

tired upon long time

of talking to us.

There is nosignificant change on

the social life of Ang

Khit except to the

fact that she can no

longer went house to

house for

socialization. In the

hospital, though shes

confined on bed, she

still sees to it that shemakes friends with

the other clients and

watchers, and also to

student nurse whousually interacts with

her.

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Mental Ang Khit is a person

who easily

understands /

comprehend of what

is being explained/

instructed to her. Sheis well oriented about

events, time, place,

person, and what is

happening aroundher. However, even if

she was already

aware that those

smokes triggered her

condition she inhales.

Sometimes she still

goes to their store and

manages it eventhough she knows the

fact that her condition

worsens everytime

she goes out and

inhales smoke

pollutants.

At home she

already avoided

those things which

she was already

aware that

contributes to theworsening of her

condition. She

started to avoid these

risk factorstriggering her

condition when she

had already

submitted her self for

consultation at

Dingras District

Hospital.

In the hospital, due to

the fact that she has

already been aware/

she had already

realized the effects of

inhaled smokes, she just follow what the

doctor ordered for the

betterment of her

health. She is still ableto recall the past

events that happened

in her life before and

during the course of

her disease. However,

during the assessment,

the client was restless,

lethargic and slightlyconfused.

The mental status of

our client has

changed. Before and

during her illness, she

was oriented of what

is happening. Herknowledge about her

disease causation has

increased as a result

of health educationdone by the members

of the health team.

She was able to

answer the questions

and share relevant

information therefore,

she is still mentally

stable, no alterationin the patients

mental competency.

The restlessness,

lethargy and

confusion of the

client during the

assessment are just

some of the

manifestations of

asthma.

Spiritual Our client strongly

believes in God and

has a very strong

faith in her. She alsoattends church

services every

Sunday. She also

claimed that within

their family, they

pray to God before

their meals as a way

of thanking Him forthe food and

blessings He had

given.

She still have faith in

God and she didnt

blame God for the

things that arehappening to her,

instead she accepted

it wholeheartedly

and pray to God to

help her and guide

her everyday. She

believed that God is

always at her side.

During her

hospitalization, she

wasnt able to attend

their church servicesalready but still didnt

forget to pray. She

also claimed that her

faith in God has

always been strong

and kept on praying

for faster recovery

from her illness, blessings for her and

her family and for

them ( her family) to

have more patience

and strength in taking

good care of her.

Her spiritual life has

not changed even

though she doesnt

attend their churchservices already due

to her condition. She

still has strong faith

in God. She always

pray to Him. This is

due to the fact that

since she was a child,

her parents moldedher to be a good

Christian which she

carried until now that

she already old.

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IX. PHYSICAL ASSESSMENT

Date of Assessment: January 01, 2005 @ 2 PM

General Appearance:

Position on Bed: Sitting on bed leaning forward

Intravenous Fluid: D5NSS 1L at 700 cc level regulated to 32 gtts/min

Gadgets: with Oxygen inhalation via nasal cannula regulated 4 5 LPM

Appearance: with difficulty of breathing, anxious and restless

Height: 53 Weight: 59 kg

Body temp. 37.4o

C PR: 98 bpm

RR: 30 bpm BP: 130/80 mmHg

Head to Toe Assessment:

Skin: with light brown complexion; with cold clammy skin; on diaphoresis; with fine skin turgor

(due to aging process); with minimal scars noted on upper and lower extremitites; no

open wounds noted, no edema noted.

Hair: withwhite and gray hairs; fine, smooth and silky; proportionally distributed; no baldness, lice

and dandruff noted.Nails: with short and dirty nails; with pale nailbeds on both extremities; with fine capillary on both

extremities; no clubbing noted.

Head: normoephalic; round in shape; no lesion and masses noted, no scars noted.

Face: symmetrical; with few moles irregularly distributed; no masses, lesions nor irregularity noted.

Eyes: with pinkish palpebral conjunctiva; with whitish to reddish sclera, pupils normally constrict

when exposed with increasing light and accommodation; with poor visual acuity (cannot

read without corrective glasses); extraocular muscles are intact, symmetrical.

Ears: with moderately clean external canal; with good hearing acuity (can understand statementsclearly); no lesions, masses nor discharges noted.

neither blisters noted.

Nose: symmetrical, with flaring of nares noted; no lesions, masses nor discharges noted.

Lips: with pinkish lips; moist, smooth, symmetrical in contour and shape; no lesions, dryness, cracks

Oral cavity: with pinkish gums and tongue; with only 2 remaining teeth (incisors).

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Neck: with symmetrical movement; no palpable lymph nodes noted; no masses nor lesions noted.

Chest and Lungs: with symmetrical movement; with difficulty of breathing; with chest retraction;

with wheezing breath sound and rales upon auscultation (upper lobes), increase in

respiratory rate (30bpm); with use of accessory muscles.

Heart: with regular rhythm; no bigeminal heart beat noted during auscultation; increase in cardiac

rate (99).

Abdomen: with slightly convex abdomen; with normal bowel sound; no tenderness noted; no lesions

nor masses noted.

Extremities

Upper extremities: with symmetrical movement; with good muscle tone; with good fine and

gross motor; able to flex and extend, circumduct arms.

Lower extremities: with symmetrical movement; able to flex and extend legs.

CNS: Restless, lethargic and slightly confused

X. ON GOING APPRAISAL

The on going appraisal was started the day when Ang Khit was admitted at MMMH & MC

until she was discharged.

January 1, 2005

At 6:30 in the morning, the client was admitted to ER with a chief complain of difficulty of

breathing. She was seen and examined by Dr. Catcatan. After history taking and thorough

examination, she was then admitted to MMMH and MC at 7:00 in the morning.

Dr. Catcatan ordered as follows: TPR every shift and record pls; DAT; CBC typing;; chest X-

ray; 12 lead ECG; stat serum Na, K, Cl, stat BUN and creatinine. She was also for vital signs

monitoring every 2 hours and record. Also she was for oxygen inhalation at 4-5 liters per minute.

At 7:15 AM, she was admitted to fourth floor room 409-Alley in medicine department. She

was placed comfortably on bed and immediately given oxygen inhalation. Nebulization was done

twice and at 7:30, an IVF of D5NSS 1L at full level was inserted as venoclysis regulated to 16

gtts/min.

At 10:00 AM, she was seen and examined by Dr. Magcalas, however, there were no new

orders made.

All throughout the day, she complained of difficulty of breathing and was given attention

with.

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All her recorded BP and boy temperature were within the normal range except for the

respiratory rate and pulse rate which are above normal.

VS 8 AM 10 AM 12 PM 2 PM 4 PM 6 PM 8 PM 10 PM

Btemp. 37.4 37.2 36.9 37.4 36.8 37.2 37.1 37

CR 101 105 103 99 95 92 91 80

RR 35 33 30 30 29 27 30 37.1

BP 130/80 120/70 120/80 110/80 120/90 110/80 110/70 120

Urine: 6 Stool: 0

January 2, 2005

She spent most of the time lying on bed in semi-fowlers position, awake. With an IVF of

D5NSS I L at 70 cc level regulated to 16gtts/min, infusing well. After few minutes, at 7 AM, previous

IVF was consumed and was replaced with the same IVF and regulation With no difficulty of

breathing noted.

The client was seen and examined by Dr. Catcatan during the rounds with new orders made

and carried out such as to continue medication and new medications were prescribed such as

Bambuterol 16mg/tab OD.

She was also able to eat all her meals served for breakfast, lunch and dinner.

All her vital signs are already within normal.

VS 8 AM 12 PM 4 PM 8 PM 12 AM

Btemp. 36 36.6 37 37 36.3

CR 82 88 68 76 75

RR 23 22 22 21 22

BP 130/80 120/70 120/80 110/80 120/90

Urine: 6 Stool: 0

January 3, 2005

She spent most of the time lying on bed in semi-fowlers position, awake. With an IVF of

D5NSS I L at 500 cc level regulated to 16gtts/min, infusing well. With no reported complaint of

difficulty of breathing.

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She was seen and examined by Dr. Torralba with new orders made and carried out such as

continue medications. And also the X-ray result was referred to the doctor.

She was also able to eat all her meals served for breakfast, lunch and dinner.

All her vital signs are within normal.

January 4, 2005

The client spent lying on bed most of the time. No complaint of difficulty of breathing and other

complains.

At 9:00 in the morning, the client was seen and examined by Dr. Magcalas and ordered MGH

with home medications.

At 1:00 in the afternoon, the client went home per stretcher accompanied by relatives.


BTemp. 36.6 36.8 36.9 36.6 36.7

CR 72 76 74 79 78

RR 21 20 21 19 22

BP 120/70 120/70 120/70 110/60 80/60

Urine: 3 Stool: 0


Btemp. 36.2 36.8 36.7 36.6 37.1

CR 88 88 72 82 68

RR 21 21 22 21 21

BP 120/80 120/80 130/80 120/80 130/80

Urine: 5 Stool: 1

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XI. LABORATORY AND

DIAGNOSTIC PROCEDURES

1.X-ray

Indications: As part of routine screening procedure; when pulmonary disease is suspected; tomonitor the status of respiratory disorder and abnormalities; to confirm

endotracheal or tracheostomy tube placement; after traumatic chest injury; in any

other situation in which radiographic information helps in the management of a

respiratory problem.

Result:

Chest X-ray is a procedure done to determine if there are any abnormalities of the lungs

including the heart. It provides information about the chest that may not be available through other

assessment means. Also, they often graphically illustrate the cause of respiratory dysfunction. Chest

films may reveal abnormalities when there are no physical manifestations of pulmonary disease. In

posteanterior (PA) position, the x-ray beam penetrates from posterior.

Nursing Responsibilities:

1. Make a laboratory request and forward it to the x-ray room.

2. Explain the procedure and its importance to the patient and significant others in order to

get their cooperation.

3. Instruct the patient to remove any radiopaque objects such as jewelry or metal buttons

above the waist. Metals appear in the x-ray results and would tend to give a false result.

4. Accompany the patient to have someone that assists him.

5. Instruct the to hold his breath and to remain still when performing the procedure.

6. Follow-up result and refer to the physician to evaluate the condition of the patient.

2. Electrocardiogram

Date taken: January 1, 2005

Examination desired: CXR-PA

Requesting Physician: Dr. Catcatan

Result: Pneumonitis bases more on the right

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Date Performed: January 1, 2005

Result: Available but no remarks

This electrophysiologic test is used primarily to screen for and diagnose a variety of cardiac

conditions as well as to monitor the hearts response to therapy. The electrocardiogram (ECG) isfrequently used to diagnose abnormal heart rhythms, conduction disturbances, hyperthropy of

cardiac chambers, myocardial infarction and ishemia, and pericarditis. An ECG measures

electrical flow through the heart by using electrodes applied painlessly to the chest wall and

limbs.


1.Explain the procedure to gain cooperation.

2.Assure that there is no pain with this test.

3.Remove any metal and jewelries on the clients body.4.Instruct the patient to lie still on his back while ECG machine is recording the hearts

activity.

5.Explain that the chest will need to be exposed during the electrode placement. Drape

female client as much as possible during placement.

6.After the procedure, wipe off electrode paste or jelly.

7.Educate the patient and family a heart healthy diet.

3. Hematology or Complete Blood Count (CBC)

Date performed: January 1, 2005

Normal Value Found Value Analysis

Hemoglobin 110-160 127 Normal

Hematocrit 0.38-0.54 .0.40 Normal

RBC 4.5-5.5 4.2 Normal

MCV 80-100 89 Normal

MCH 27-32 30 Normal

MCHC 31-35 34 Normal

WBC 5-10 10.5 Normal

Neutrophils .50-.70 0.75 Increased

Lymphocytes .20-.40 0.23 Normal

Eosinophils 0.01 0.04 0.02 Normal

Platelet coutns 150 - 400 226 Normal

A complete blood count is one of the most routinely preferred test in clinical laboratory

and one of the most valuable screening and diagnostic technique. It identifies the total number of

blood cells (WBC,RBC, and platelets) as well as the hemoglobin, hematocrit (percentage of

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blood consisting of RBCs) and RBC indices. The CBC may reveal considerable data about the

patient including diagnosis, prognosis, treatment response and recovery.

Purpose: CBC was done as a part of hospital routine to evaluate other abnormal conditions.

Procedure:

1. Perform a venipuncture and collect a blood sample in a 7 ml lavender top-tube.

2. Fill the collection tube completely and invert it gently several time to adequately

mix the sample with the anti-coagulants.

a. Hemoglobin

Hemoglobin is the main component of RBC which contains iron and which makes up

95% of the cell mass. It delivers oxygen through circulation to body tissues and returns

carbon dioxide from tissues to lungs.

A decreased in the normal value of hemoglobin indicates a decrease oxygen carrying

capacity of the blood that affects the transport of oxygen between lungs and tissues and

eventually affects cellular activities.

Indication: This test is done to determine anemia and other disease related abnormal

Hemoglobin concentrated in the blood and oxygen carrying capacity.

Analysis:Normal

b. Hematocrit:

Hematocrit is a measure of the packed cell volume of red cells, expressed as a percentage

of the total blood volume. It indicates relative proportions of plasma and RBCs (volume of

RBCs/L whole blood).

Indication: It is done to determine the space occupied by pack RBC. It is expressed as the

percentage of red cells in a volume of per blood and also to determine the

hydration of patient.

Analysis:Normal

c. Red Blood Cells (RBC)

RBC (Red blood cell) count is a count of the erythrocytes in a specimen of whole blood.

Erythrocyte is the major cellular element of the circulating blood. It is a reddish biconcave

disk that contains hemoglobin confined within a lipoid membrane. Its principal function is to

carry hemoglobin to provide oxygen to tissues.

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Indication: This test determines the total number of RBC found in a cubic millimeter of

blood. It is an important measurement in the determination of anemia.

Analysis:Normal

d. Mean Corpuscular Volume (MCV)This is an evaluation of the average volume of each red cell derived from the ratio of

volume of the packed red cells to the total number if RBC. It also describes the individual red

cell size. It is expressed in cubic microns.

Indication: These test determines if there is a deviation of the RBC production and important

in the determination of anemia.

Analysis:Normal

e. Mean Corpuscular Hemoglobin (MCH)This is an estimate of the amount of Hemoglobin in an average erythrocytes, derived

from the ratio between the amount and Hemoglobin and in the number of erythrocytes

present. It is related to MCV because weight of a red blood cell increases when the amount of

hemoglobin increases and therefore its size increases.

Indication: To determine the ratio of amount of Hemoglobin and the number of erythrocytes

present.

Analysis:Normal

f. Mean Corpuscular Hemoglobin Concentration (MCHC)

This is an estimation of the concentration of hemoglobin in grams per 100 ml of packed

red blood cells, derived from the ratio of the hemoglobin to the hematocrit. This is an average

concentration of hemoglobin in RBCs. It measures the portion of hemoglobin in an average

cell. It is the ratio of the weight of hemoglobin to the volume of the red blood cells.

Indication: To determine the concentration of Hgb

Analysis: Normal

g. White Blood Cells (WBC)

This is one of the formed elements of the circulating blood system. WBC is needed to

depend against invading microorganisms through phagocytosis to produce or transport and

distribute Anti bodies to help maintain immunity. WBC count is a test that counts the total

number of WBCs in 1cubic mm of peripheral venous blood.

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Indication: This test is done to determine the presence of infection, inflammation and also

serves as a useful guide to the severity of the disease process.

Analysis:Normal

h. Neutrophils

Neutrophils are the circulating white blood cells they are the first one to launch at the site

of injured tissue. They are also essential for phagocytosis and proteolysis by which bacteria,

cellular debris, and solid particles are removed and destroyed. It is essential in preventing or

limiting bacterial infection via phagocytosis. The protective function of neutrophils include

phagocytosis where foreign particles were degraded pyrogen are released that causes fever by

acting on the hypothalamus to set the bodies thermostat at the higher level.

Indication: This test determines the presence of infection and inflammation.

Analysis: Increased because in asthma, there will be an release of chemical mediators that

attracts the neutrophils and activation of its production.

i. Lymphocytes

These are small agranulocytic leukocytes originating from fetal stem cells and developing

in the bone marrow. Lymphocytes normally comprise 25% of the total WBC count but

increase in number in response to infection. It is the integral component of immune system

and helps in the antibody production. These cells are the source of serum immunoglobulins

and of cellular immune response and play an important role in immunologic reactions.

Indication: It determines the presence of infection and inflammation.

Analysis: Normal

j. Eosinophils

A granulytic bilobed leukocyte somewhat larger than a neutrophil. It is characterized by

large numbers of coarse refractile cytoplasmic granules that stain with the acid dye eosin.

Indication: This test determines the presence of infection and inflammation.

Analysis:Normal

k. Platelet Count

It is the total number of platelets in circulation. Platelet is the smallest of the cells in the

blood. These are disk-shaped and contain no hemoglobin. They are essential for the

coagulation of blood.

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Indication: This test measures the total number of platelets in circulation.

Analysis: Normal


1. Fill up laboratory request and send to laboratory to inform the medical technologist2. Inform patient about the type of the procedure and its purpose to gain her cooperation and

also to increase his awareness regarding the procedures that will be done to her.

3. Follow up results, attached to the chart of the patient and refer it to the Physician to

inform the abnormality of the found value and to evaluate the condition of the patient.

4. Blood Chemistry

Date Performed: January 1, 2005

Result Normal Value Analysis

Creatinine 58.9 44.2-150.3 mmol/L Normal

Urea Nitrogen 6.4 1.7 8.3 mmol/L Normal

Sodium 138.4 133 150 mmol/L Normal

Potassium 3.40 3.4 5.3 mmol/L Normal

Chloride 100.0 96 106 mmol/L Normal

a. Creatinine

This is a substance formed from the metabolism of creatine (nitrogenous compound

produced by metabolic processes in the body) commonly found in blood, urine, and muscle

tissues. Therefore, its formation and release are relatively constant and proportional to the

amount of muscle mass present. Because creatinine is filtered in the glomeruli but not

secreted into the tubules from the blood or reabsorb from the tubules into the blood, its blood

values depend closely on the GFR (glomerular filtration rate). Creatinine is the end product

of muscle energy metabolism. In normal function, level of creatinine, which is regulated and

excreted by the kidneys, remains fairly constant in the body. Serum creatinine levels reflect

the glomerular filtration rate (GFR). Serum creatinine is often used as a screening measure to

evaluate kidney/renal function.

Indication: This test measures the effectiveness of renal function. It is used to diagnose

impaired renal function.

Analysis:Normal

b. Urea Nitrogen

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Urea, the end product of protein and amino acid metabolism in the liver, enters the blood

and passes to the kidneys for excretion. The blood urea nitrogen is, therefore, an indicator of

both the metabolic function of the liver and the excretory function of the kidney.

Indication: Blood urea nitrogen measures renal function and hydration.

Analysis:Normal

c. Sodium

This is one of the most abundant elements in the ECF. Consequently, sodium is the

primary determinant of ECF osmolality. Sodium ions are involved in acid-base balance,

water balance, the transmission of nerve impulses, and the contraction of muscles. Sodium is

the chief electrolyte in interstitial fluid, and its interaction with potassium as the main

intracellular electrolyte is critical to survival.

Indication: This test measures the ability of the kidneys to maintain fluid-electrolyte balance.

Analysis: Normal

d. Potassium

Potassium in the body constitutes the predominant intracellular cation, with only 2%

found in the extracellular space, helping to regulate neuromuscular excitability and muscle

contraction. It also functions in maintaining normal acid-base balance.

Indication: This test measures the effectiveness of renal function. Because the renal system

must function to maintain K balance, because 80% of the K is excreted daily from the body

by way of the kidneys; the other 20% is lost through the bowel and sweat glands. The kidneys

are the primary regulators of K balance and accomplish this by adjusting the amount of K that

is excreted in the urine.

Analysis: Normal

e. Chloride

Chloride is the major anion of the ECF. It is found more in interstitial and lymph fluid

compartments than in blood. Chloride is also contained in gastric and pancreatic juices as

well as in sweat. Na and Cl in water make up the composition of the ECF and assist in

determining osmotic pressure. The serum level of chloride reflects a change in dilution or

concentration of the ECF and does so in direct proportion to Na.

Indication: This test measures the effectiveness of renal function.

Analysis: Normal

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1. Fill up laboratory request and send to laboratory to inform the medical

technologist.

2. Inform client about the type of the procedure and its purpose to gain her cooperation and also to increase her awareness regarding the procedures that will be done to

her.

3. Reemphasize NPO (since the client is already in NPO).

4. Follow up results, a ttached to the chart of the patient and refer i t to the

Physician to inform the abnormality of the found value and to evaluate the condition of the

patient.

XII. MEDICAL MANAGEMENT

A. Intravenous Therapy

IVF therapy was given to the patient because it is an efficient method of supplying fluids

and electrolytes directed to the extracellular components especially the venous system. IVF was

also used to supply or provide nutrients and also a way of drug administration.

Purpose: The choice if IV solution depends on the purpose of the administration. Generally

fluids are administered to achieve one or more of the following goals:

To provide water, electrolytes and nutrients to meet daily requirements

To replace water and correct electrolyte imbalance

To administer medications and blood products

IV solutions contain dextrose or electrolyte mixed in various proportion with water. Pure-

electrolyte-free water never administered IV because it rapidly enters the Red Blood Cells and

causes them to rupture.

Indication: IV is used as an avenue for IV drug administrationand to supply or provide nutrients

to our patient.


1. Verify doctors order

2. Inform the patient about the procedure to gain cooperation

3. Know the type, amount, and indication of IV therapy

4. Always use aseptic technique when handling IV solutions to prevent further

infection

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5. Check for IVsolutions and needles for potency

6. Regulate IV flow properly to maintain proper hydration

7. Asses for infiltration on the IV site such as swelling, heat and pain around vein at

the infusion site or proximal to it may indicate thrombophlebitis

8. Change the solution container to prepare it empties to prevent embolism

9. Place the pad in proper slot to prevent needle displacement or removal during

movement

B. Diet Therapy

DAT (Diet as Tolerated)

Indication:

it was ordered to our client to supplement necessary nutritional needs or to meet optimum

nutrition for him to function well and increase resistance

Nursing Responsibilities

1. Check the doctors order

2. Transcribe the order in the diet list of the patient and inform the dietician

3. Inform the patient of what is to be included in the patients meal, which is all

foods except those for dark colored foods and beverages

4. Encourage patient to eat foods which are not spicy to avoid gastric irritation

C. OXYGEN THERAPY

Administration of oxygen above 21% which is prescribed by the physician who specifies

the specific concentration, method, and liter flow per minute.

Oxygen colorless, odorless, tasteless, and dry gas that support the combustion

Indications:

1. To deliver oxygen, adequate to meet the body cells needs

2. To provide high humidity

3. To allow uninterrupted delivery of oxygen while patients ingest foods/fluids.

4. It was given to client with difficulty of breathing, this will help client by supplying enough

oxygen needed by the body to facilitate efficient breathing.

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Oxygen Inhalation via Nasal Cannula

- Is a method of administering oxygen

- simple device that can be inserted into the nares for delivery of oxygen and that allows

the client to breath through her mouth or nose.

- it does not interfere with the clients ability to eat or talk.


1. Verify the order of the doctor to prevent error

2. Position the patient in moderate high back rest to allow the full expansion of the lungs and to

establish a better flow of air movement

3. Before administering the O2 equipment wash your hands- to reduce transmission of

microorganism.

4. Open source of O2 before insertion of O2 device to check if the device is functioning

5. Lubricate nares with water soluble lubricant to soothe the mucus membrane

6. Place No Smoking Sign at the bedside to avoid possible danger like fire.

7. Provide good oro-nasal hygiene to prevent infection and promote relaxation

D. Vital Signs Taking

- Vital Signs Taking every four hours

- Frequent assessment of the vital signs provides information about the development or

progress of deterioration of patients condition.


1. Explain the purpose to gain cooperation.

2. Monitor vital signs including blood pressure, cardiac rate and respiratory rate for a full

minute and body temperature.

3. Record vital signs and refer for abnormalities especially if higher and lower than normal.

XIII. DRUG STUDY

A. Generic Name: Albuterol (Salbutamol)

Brand Name: Ventolin

Classification: Bronchodilator

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Dosage, Route and Frequency: 2.5 cc + NSS 1.5cc every 4 hours

Mechanism of Action:

Relaxes bronchial and vascular smooth muscle by stimulating beta - 2 receptors.

Desired Effect:

Albuterol is a short-acting, beta-adrenergic bronchodilator drug used for relief andprevention of bronchospasm. It is also used to prevent exercise-induced bronchospasm.

Side Effect / Adverse Reaction:

CNS: tremor, nervousness, dizziness, insomnia, headache, hyperactivity, weakness, CNS

stimulation, malaise.

CV: tachycardia, palpitations, hypertension.

EENT: dry and irritated nose and throat (with inhaled form), nasal congestion, epistaxis,

hoarseness.

GI: heartburn, nausea, vomiting, anorexia, bad taste in mouth, increased appetite.

Metabolic: hypokalemia.

Musculoskeletal: muscle cramps.

Respiratory: bronchospasm, cough, wheezing, dyspnea, bronchitis, increased sputum.Other: hypersensitivity reactions.


1. Check Doctors order.

2. Observe the 10 Rs.

3. Teach patient to perform oral inhalation correctly.

Clear nasal passages and throat.

Breathe out, expelling as much air from lungs as possible.

Place mouthpiece well into mouth as dose from inhaler is released, and inhales

deeply. Hold breath for several seconds, and exhale slowly.

4. Tell patient to wash inhaler every after used.

5. Do bronchial clapping after nebulization.

6. Instruct patient to do deep breathing and coughing exercise.

7. Warn patient about possibility of paradoxical bronchospasm. Tell him to stop drug

immediately if it occurs.

B. Generic Name: Bambuterol

Brand Name: Bambec

Classification: Sympathomimetics bronchodilator

Dosage, Route & Frequency: 10 mg 1 tab od & hs


Closely resembles the response to stimulation of adrenergic nerves, it exert a peripheral

inhibitory action on smooth muscle thus decreasing bronchial constriction.

Indication:

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Bronchial asthma, chronic bronchitis, emphysema, and other lung diseases, where

bronchospasm is complicating factor.

Desired Effect:

This drug is given to our client because it decreases bronchial constriction; dilate the

bronchioles thereby allowing airway clearance.

Side Effects:

headache

tonic muscle cramps

palpitations


1. Take with food or after meal to decrease gastric irritation

2. Check for adverse reactions. Discontinue drug and notify physician.

3. Decrease irritants and increase hydration.

4. Teach the following:

a. breathing techniques

b. coughing techniques

c. nebulization

d. if it is given over a long period of time, cumulative effect

takes place takes place thus medication becomes ineffective.

C. Generic Name: Ambroxol

Brand Name:

Classification: Mucolytic

Dosage, Route and Frequency: 75 mg cap OD


Ambroxol is a metabolite of bromhexine, which liquefies and changes the structure of

bronchial secretions, reduce viscosity of sputum and promotes the expectoration of blocked-up

secretions and also eases cough.

Desired Effect:

This drug is given to the patient to relieve cough and loosens the phlegm.Side Effect/Adverse Reaction:

- stomatitis

- nausea

- rhinorrhea

- bronchospasm

- bronchial/tracheal irritation

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- drowsiness


1. Check doctors order.

2. Observe the 10 Rs.

3. Patient must be taught on how to cough out effectively.

4. Check proper disposal of secretions.

5. Encourage increase in fluid intake.

6. Cough should not be suppressed if productive.

7. Observe for bronchial spasm, wheezing and increased congestion.

8. drug must always be found at hand in case of bronchospasm.

D. Generic Name: Theophylline

Brand Name:Classification: Bronchodilator

Documents

Bronchial Ashthma