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CASE PRESENTATION: BRONCHIAL

ASTHMA

INTRODUCTION

A. BACKGROUND OF THE STUDY


Asthma is a chronic disease of the airways that causes airway
hyperresponsiveness, mucosal edema and mucus production. This
inflammation, ultimately leads to recurrent episodes of asthma
symptoms: cough, chest tightness, wheezing and dyspnea.
(Medical-Surgical Health Nursing Volume 1 by Smeltzer and Bare
page 587). It is a multifactorial disease process associated with
genetic, allergic, environmental, infectious, emotional, and
nutritional components. Because of their symptomatology the
majority of individuals with asthma experience a significant
number of missed work or school days. This can create a severe
disruption in quality of life, often leading to depressive episodes.
It also disrupts the lives of caregivers and family members of the
affected individual. Asthma patients who have increased
symptomatology at night (a significant portion) also tend to have
disturbed sleep patterns and impaired daytime attention,
concentration, and memory.

B. RATIONALE FOR CHOOSING THE CASE


Most of our patient assignments have bronchial asthma. We
choose the case of bronchial asthma because it would help us to
have a focus study regarding this case—more nursing care would
be given. Added to that, we choose the client because of the fact
that she is cooperative in the sense that she always try to answer
the questions asked in her full knowledge and try to verbalize
anything that she wants to say. Moreover, other patients without
asthma were may go home (MGH) and was given discharge
teaching by student nurses according to their respective cases

C. LEARNING OBJECTIVES
(1) To explore patient’s past health history prior to bronchial
asthma
(2) To review the body system involve in bronchial asthma
(anatomy and physiology)
(3) To review the disordered function of the body related to
bronchial asthma (pathophysiology)
(4) To review the laboratory results and compare it to normal
and the implication of the abnormal
(5) To make a list of nursing problems
(6) To prioritize listed nursing problems
(7) To make Nursing Care Plan for prioritized problem
(8) To make a health teaching to the client and other potential
candidates regarding about bronchial asthma

I. CLINICAL SUMMARY

A. GENERAL DATA
Name: B.V. y B
Age: 56 years old
Birth date: May 9, 1950
Birth place: Samar, Leyte
Sex: Female
Religion: Roman Catholic
Civil Status: Married
Address: K.V. D.D
Occupation: vendor
Room & bed #: Female Medical Ward 364B
Date Admitted: November 15, 2006
Time Admitted: 11:15 pm

B. CHIEF COMPLAINT
The chief complaint of the patient is difficulty of breathing
HISTORY OF PRESENT ILLNESS
A few days prior to admission, the client has on and off
difficulty of breathing (DOB). She added, “Bago ako isugod dito
sa ospital, nakalanghap ako noon ng pamatay ng ipis tapos sa
bahay nag-insenso sila kaya inatake ako ng asthma ko. Nanikip
na ang dibdib ko tapos ayun na, sinugod na nila ako dito”
When asked about her medication whenever she has an
asthma attack, she verbalized, “Kapag inaatake ako ng asthma,
salbutamol lang ang iniinom ko tapos nawawala naman
pagkatapos.”
The client was admitted at President Diosdado Macapagal
Memorial Medical Center last November 15, 2006 around 11: 15
in the evening
According to the client’s medical history, asides from
bronchial asthma, she also has hypertension

C. PAST MEDICAL HISTORY

1. Childhood Illnesses
--The client verbalized that she had experienced having
measles, small pox, diphtheria and asthma during his childhood
days

2. Immunizations
--According to the client, she had completed her childhood
immunizations.

3. Allergies
--The client stated that whenever she smells and inhales
pollutants and fume of insecticides, her asthma is triggered.
She added that when she inhales these allergens, she has chest
tightness at dyspnea.

4. Accidents
--According to the client she doesn’t have any accidents
encountered

5. Hospitalization
--According to the client, she never been hospitalized but
she consulted health center when her asthma attacked.

6. Medicines
--Her medicine is salbutamol

7. Foreign Travel
--According to the client she doesn’t have travels outside the
country.

8. General Health Status


> Adolescent
--The client verbalized “Bata pa lang ako may asthma na
ako. Ginagamot naman ng salbutamol kaya kahit papano ayos
ayos na. Tapos nawala rin siya.”
> Adulthood
-- The client verbalized “Matagal din ang panahon bago ako
inatake ulit ng asthma. Ngayon na nga lang ulit sumumponmg
ng ganitong katindi ang asthma ko. Bago kasi ako isugod dito sa
ospital, nakalanghap ako ng pamatay sa ipis tapos sa bahay,
nag-insenso sila kaya intake ako ng asthma ko. Siguro isama na
rin natin na pagod din ako. Tapos nanikip na ang dibdib ko tapos
sinugod na nila ako dito sa ospital.”

9. Operation
--According to the client, she doesn’t gone any operations

D.FAMILIAL HISTORY
--According to the client, they have family history of
Bronchial Asthma in her father’s side
E. PHYSICAL ASSESSMENT

GENERAL NORMS ACTUAL FINDINGS INTERPRETATION AND


APPEARANCE ANALYSIS

1. Relaxed, erect Slouched/bent Interpretation:


Posture/Gait posture; posture Not normal
coordinated Analysis:
movement This observation
(pg. 531, is most seen with
Fundamentals of dyspnea,
Nursing by advance chronic
Kozier, 7th lung disease and
edition) air trapping,
Older adults acute and
(middle age) chronic
assume a (Luckmann and
stooped forward Sorensen
bent posture, Medical-Surgical
hips and knees Nursing, pg. 650)
are some what Slouched posture
flexed. Arms are and a slow
raised because shuffling gait
arms are bent at suggested
the elbow. A depression or
person normally physical
walks with arms discomfort
swinging freely (Fundamentals of
at the sides with Nursing, 7th
head and face edition, Barbara
leading the body Kozier, pg 425)
(pg. 519,
Fundamentals of
Nursing by
Potter and
Perry)

2. Skin Color Healthy Pallor; Interpretation:


appearance weakness; Not normal
GENERAL NORMS ACTUAL FINDINGS INTERPRETATION AND
APPEARANCE ANALYSIS
Skin color may obvious illness Analysis:
be pink, tan, Skin color and
brown, olive or temperature
yellowish particularly that
depends on the of the lips and
race. With a nail beds. The
normal supply of color of the lips
oxygen, the nail and nail beds is
beds, the tongue an indicator of
and the lips tissue perfusion
appear pinkish- (passage of blood
red in color through the
(Fundamentals vessels) Pale,
of Nursing, 7th cyanotic, cool
edition, Barbara and moist skin
Kozier, pg 538) may be a sign of
circulatory
problems (pg.
914,
Fundamentals of
Nursing by
Kozier. 7th
edition). The
color and
appearance of
the skin and nails
may reflect
insufficient
delivery of
oxygenated
blood to the
tissue because of
respiratory
dysfunction (pg.
419,
Fundamentals of
Nursing by
GENERAL NORMS ACTUAL FINDINGS INTERPRETATION AND
APPEARANCE ANALYSIS
Craven and
Hirnle, 4th
edition)

3. Personal Clean, neat No foul body Interpretation:


Hygiene/ odor, neat Normal
Grooming Analysis:
Personal hygiene
is the self care by
which people
attend to such
functions as
bathing, toileting,
general body
hygiene, and
grooming.
Hygiene is highly
personal matter
determined by
individual values
and practices. It
involves care of
the skin, hair,
nails, teeth, oral
and nasal
cavities, eyes,
ears, and
perineal-genital
areas (pg. 698,
Fundamentals of
Nursing by
Kozier, 7th
edition)
Hygiene is the
observance of
health rules
relating to these
GENERAL NORMS ACTUAL FINDINGS INTERPRETATION AND
APPEARANCE ANALYSIS
self-care
activities (pg.
704,
Fundamentals of
Nursing by
Craven and
Hirnle, 4th
edition)

4. Nutritional The state of Malnourished; Interpretation:


Status nutrition is often general Not Normal
reflected in a appearance is Analysis:
person’s listless, Loss of weight
appearance. appears may be
Although the acutely or generalized as a
most obvious chronically ill result of
physical sign of inadequate
good nutrition is caloric intake or
a normal body may be seen in
weight with to loss of muscle
respect to mass with
height, body disorders that
frame, and age, affect protein
other tissues synthesis. (pg.
can serve as 68)
indicators of Nutritional
good nutritional problems in the
status and elderly often
adequate intake occur or are
of specific precipitated by
nutrients; these such illnesses as
include the hair, pneumonia and
skin, teeth, urinary tract
gums, mucous infections. Acute
membranes, and chronic
mouth and diseases may
tongue, skeletal affect the
GENERAL NORMS ACTUAL FINDINGS INTERPRETATION AND
APPEARANCE ANALYSIS
muscles, metabolism and
abdomen, lower utilization of
extremities, and nutrients, which
thyroid gland. already are
General altered by the
appearance is aging process
alert and (pg. 75) (Brunner
responsive (pg. & Suddarth’s
71-72, Brunner Textbook of
& Suddarth’s Medical-Surgical
Textbook of Nursing, Volume
Medical-Surgical 1, 10th edition by
Nursing, Volume Smeltzer and
1, 10th edition by Bare)
Smeltzer and
Bare)

5. Age Adulthood ages The age of the Interpretation:


Appropriaten ranges from 25 client is 56 Normal
ess to 66 years. years old. As a Analysis:
According to Erik middle adult, Erikson believes
Erikson’s she has that the greater
Theory, the concern with the task
central task is others, talks achievement, the
generativity with the healthier the
versus patients in the personality of the
stagnation. The same ward person
indicators of (Fundamentals of
positive Nursing, 7th
resolution are edition, Barbara
creativity, Kozier, pg 357)
productivity and
concern for
others. The
indicators of
negative
resolution are
GENERAL NORMS ACTUAL FINDINGS INTERPRETATION AND
APPEARANCE ANALYSIS
self-indulgence,
self-concern,
lack of interests
and
commitments.
(Fundamentals
of Nursing, 7th
edition, Barbara
Kozier, pg 357)

6. Verbal Understandable, The client has Interpretation:


Behavior moderate pace; logical Normal
exhibition of sequence of Analysis:
thought though, has a Verbal
association; sense of reality communication is
logical and able to largely conscious
sequence; make understand because people
sense; has choose the words
sense of reality they use. The
(Fundamentals words use varies
of Nursing, 7th among
edition, Barbara individuals
Kozier, pg 531) according to
culture,
socioeconomic
background, age
and education.
Countless
possibilities exist
for the way ideas
are exchanged.
An abundance of
words can be
used to form
messages (pg.
423,
Fundamentals of
GENERAL NORMS ACTUAL FINDINGS INTERPRETATION AND
APPEARANCE ANALYSIS
Nursing by
Kozier, 7th
edition)

7. Non-verbal No distress The client’s Interpretation:


behavior noted in facial affect/mood is Normal
expression; the appropriate in Analysis:
client’s the situation. Nonverbal
affect/mood is communication
appropriate to includes
situation gestures, body
movement, use
of touch and
physical
appearance,
adornment.
Nonverbal
behavior is
controlled less
consciously than
verbal behavior
MEASUREMENTS NORMS ACTUAL FINDINGS INTERPRETATION AND
ANALYSIS

Temperature Normal adult As of Interpretation:


temperature November 20 Normal
axillary: 35.8° C 2006 Analysis:
to 37.0° C 8:00pm Normal adult
(pg. 444, 36.5° C temperature
Fundamentals of ranges from 35.8°
Nursing by C to 37.0° C. it is
Craven and not uncommon for
Hirnle, 4th adult/elderly
edition) persons to have
body temperature
less than 36.4° C
because normal
temperature
drops as persons
ages. (pg. 414-
415,
Fundamentals of
Nursing by Craven
and Hirnle, 3rd
edition)

Pulse Rate The normal pulse 8:00pm 80 Interpretation:


rate of an adult: beats per Normal
60-100 beats per minute Analysis:
minute (pg. 485, The normal range
Fundamentals of of the pulse in an
Nursing by adult is 60 to 100
Kozier, 7th beats per minute
edition) (p. 424,
fundamentals of
Nursing by Craven
and Hirnle, 3rd
edition). As the
age increases, the
MEASUREMENTS NORMS ACTUAL FINDINGS INTERPRETATION AND
ANALYSIS
pulse rate
gradually
decrease (p. 496,
Fundamentals of
Nursing by Kozier,
7th edition)

Respiratory The normal 8:00pm 21 Interpretation:


Rate respiratory rate breaths per Not Normal
of an adult: 12- minute Analysis:
20 breaths per Normal breathing
minute (pg. 444, is automatic and
Fundamentals of involuntary. At
Nursing by rest, the normal
Craven and adult respiratory
Hirnle, 4th rate is 12 to 20
edition) breaths per
minute.
Respiratory rate
changes with age.
Tachypnea is an
abnormally fast
respiratory rate
(usually above 20
breaths per
minute in adult)

Blood Systolic 8:00pm Interpretation:


Pressure Diastolic 130/70 mmHg Normal
90.140 60- Analysis:
90 In adults, the
(pg. 444, trend is toward
Fundamentals of gradually
Nursing by increasing systolic
Craven and and diastolic
Hirnle, 4th blood pressure
edition) with aging. In
MEASUREMENTS NORMS ACTUAL FINDINGS INTERPRETATION AND
ANALYSIS
part, this trend is
due to increased
systematic
vascular
resistance,
reflecting arterial
narrowing and
decreased vessel
elasticity due to
atherosclerotic
vessel disease.
The increase in
systolic pressure
is proportionally
greater than the
increase in
diastolic pressure
(pg. 463,
Fundamentals of
Nursing by Craven
and Hirnle, 4th
edition)

BODY PARTS NORMS ACTUAL FINDINGS INTERPRETATION AND


ANALYSIS

Skin Varies from light Pallor Interpretation: Not


to deep brown; Normal
from ruddy pink; Analysis:
from yellow Pallor is the result
overtones to of inadequate
olive circulating blood
(pg. 538, or hemoglobin and
Fundamentals of subsequent
Nursing by reduction in tissue
Kozier, 7th oxygenation (pg.
edition) 535,
BODY PARTS NORMS ACTUAL FINDINGS INTERPRETATION AND
ANALYSIS
Fundamentals of
Nursing by Kozier,
7th edition)

Mouth/ Oral -Uniform pink - lips has visible Interpretation: Not


Cavity color margins Normal
Lips -Soft, moist, - symmetrical Analysis:
smooth texture - pale in color Pallor is the result
-Symmetry of - no edema of inadequate
contour circulating blood
-Ability to purse or hemoglobin and
lips subsequent
(Fundamentals in reduction in tissue
Nursing, Barbara oxygenation (pg.
Kozier, pg. 563) 535,
Fundamentals of
Nursing by Kozier,
7th edition)

Thorax Interpretation: Not


Anterior -Quite rhythmic -tachypnea Normal
Thorax and effortless -wheezes at Analysis:
respirations right lung field Dyspnea is a sign
(Fundamentals in of serious disease
Nursing, Barbara of the airway,
Kozier, pg. 578) lungs, or heart.
(www.medterms.c
om)
Tachypnea may
be necessary for a
sufficient gas-
exchange of the
body
(www.wrongdiagn
osis.com)
BODY PARTS NORMS ACTUAL FINDINGS INTERPRETATION AND
ANALYSIS
Possible cause of
air passing
through a
constricted
bronchus as a
result of secretion,
swelling or tumor
(Fundamentals in
Nursing, Barbara
Kozier, pg. 575)

F. PATTERNS OF FUNCTIONING

I. Psychological Health

1. Coping Pattern
According to the client, whenever she has problems, solving it
right away is the solution. “Gusto ko kasi kapag may problema
ako nilulutas ko na kaagad hindi pinatatagal pa”

ANALYSIS: Coping maybe described as dealing with problems


and situations, or contending with them successfully. Coping
strategies varies among individuals and are often related to the
individual’s perception of stressful events. A person’s coping
strategies often change with a reappraisal of a situation.
(Fundamentals of Nursing by B. Kozier, 7th edition, p 1020)
INTERPRETATION: Effective Coping Pattern

2. Interaction Pattern
According to the client, they are six in the family—she, her
husband and 4 siblings. Their relationship, she described, is
harmonious. If there are problems in the family, they solve it all
together and they communicate well to each of the family
members.

ANALYSIS: Interaction patterns involve ways of expressing


affection, love, sorrow, anger and other feelings and thought in
most significant family in person and life. Openness of
communication with all family members develops the family’s
ability to function as a cooperative, growth producing unit.
(Fundamentals of Nursing by B. Kozier, 7th edition, p 671)
INTERPRETATION: Effective Interaction Pattern

3. Cognitive Pattern
The highest formal education of the client was 2nd year high
school. She stated that she has short term memory gap. She
verbalized “Madali akong makalimot. Minsan sasabihin ko na
lang makakalimutan ko pa. Matanda na kasi. Pero mabilis naman
ako maka pick up kapag tiuturuan ako”

ANALYSIS: Changes in the cognitive function of middle adults are


rare except with trauma or illness. The middle aged adults are
able to continue learning new skills and can reflect on the past
and current experience and can imagine, anticipate, plan and
hope. (Fundamentals of Nursing by Potter and Perry, 3rd edition,
Vol.1 p 821)
INTERPRETATION: Proper cognitive pattern

4. Self Concept
The client verbalized “Matagal din bago ako intake ulit ng
asthma ko. Ngayon may asthma na ako ulit, limitado na ang
galaw ko kasi mahirap na baka umatake ulit at lumala.” She also
added that after discharge, she will continue her work as a
vendor, “Pero siyempre hindi na ako dapat tulad ng dati kasi nga
may limitasyon na.”

ANALYSIS: Self concept is an individual’s perception of self. It


includes self esteem (an individual’s perception of self worth)
and body image (perception of physical self). Self concept
influences individual’s health behaviors in that people think
highly themselves will tend to take care of themselves. On the
other hand, a person with a negative self concept will engage in
reckless or self destructive behaviors that endanger health.
Persons with a low self concept frequently ignore their own
needs because they are perceived to be less important than the
needs of other people. (Nursing Fundamentals by R. Daniels p
854)
INTERPRETATION: Healthy Self Concept

5. Emotional Pattern
According to the client she is bored upon hospitalization but it
somehow relieved by visitations of her relatives and talking to
the other patients in the ward.

ANALYSIS: Cooperative or friendly, expressive feelings


appropriate to the situation, verbalizes positive things regarding
others and the future. Express positive coping mechanism.
(Nurses Handbook of Health Assessment, Janet Weber, pg. 513)
Emotional states such as depression and anger affect a client’s
perception and degree of risk taking behavior. These emotional
states alter a client’s thinking pattern and reaction time (Nursing
Fundamentals by R. Daniels p 874)
INTERPRETATION: Effective Emotional Pattern

6. Family Coping Patterns


The client verbalized that if there are any misunderstandings,
her family talks it over and the last word will be coming from the
head of the family, her husband. When there are sick family
members, they see to it that they attended the need of the sick
member.

ANALYSIS: Family coping mechanisms are the behaviors families


use to deal with stress or changes imposed from either within or
without. (Fundamentals of Nursing by B. Kozier, 7th edition, p
193) Because chronic illness lasts longer than acute illness, it
can influence the family to a greater extent. People with
chronically ill children, parents, or other family members may
express negative feelings about themselves such as guilt,
inadequacy, failure, rejection and helplessness. The family may
be in denial initially as members struggle with the shock of the
illness. (Fundamentals of Nursing by Craven and Hirnle, 4th
edition, p 1282)
INTERPRETATION: Effective Family Coping Pattern
II. Socio Cultural Health

1. Cultural pattern
According to the client, the social values she was brought up
to were respect, sense of responsibility, fear of God. The
traditions in her family are Christmas, Birthday, New Year and
Holy week.

ANALYSIS: The value placed on children and elders within a


society is culturally derived. (Fundamentals of Nursing by Craven
and Hirnle, 4th edition, p212) The family passes on patterns of
daily living and lifestyles to offspring. Cultural rules, values, and
beliefs give people a sense of being stable and able to predict
others (Fundamentals of Nursing by Kozier, 7th edition p 178)
INTERPRETATION: Proper Cultural Pattern

2. Significant relationship
According to the client, her family is the significant persons in
her life. They have harmonious relationship with her family and
relatives

ANALYSIS: Family influences on health care because health is


defined uniquely by each client’s culture. Family is often major
care givers of their relatives. Lack of social support from family
or significant others results in psychological and spiritual
isolation, which negatively impacts a person’s physiological
state. Thus, it is important to help clients identify, strengthen,
and use their social support systems. Sometimes, families need
guidance to optimize health behaviors. (Nursing Fundamentals
by R. Daniels p849-851)
INTERPRETATION: Effective Significant Relationship

3. Recreational Pattern
The client verbalized “Kapag wala akong trabaho, nood lang
ako ng TV o kaya naman naglilinis ng bahay. Iyan lang naman
ang kadalasang ginagawa ko kapag nasa bahay ako. Minsan
nakikipagkwentuhan sa mga kapitbahay.”
ANALYSIS: Leisure time is important for normal social
development and adjustment (Nursing assessment and Health
Promotion by Murray and Zentner, 5th edition, p 386)
INTERPRETATION: Proper Recreational Pattern

4. Environment
The client verbalized, “Sa bahay kasi naninigarilyo din ang
asawa ko.” She also added “Kasi ugali na kasi ng anak kong
babae na maglagay ng insenso sa altar kapag gabi, di ko lang
pinapansin pero nitong nakaraan kapag naaamoy ko yung usok
medyo nahihrapan akong huminga tapos kapag nangyari iyon,
iinom ako ng gamot.”

ANALYSIS: A safe environment is one which people can function


safely and in one in which they obtain a sense of security.
(Fundamentals of Nursing by Kozier, 7th edition p 480)
INTERPRETATION: Poor Environment

5. Economic
According to the client when she was still strong, she was
working. She worked as a vendor. “Sapat naman ang kinikita
naming mag-asawa. Nakakakain naman kami 3 beses isang
araw at saka ngayong may sakit ako, nakakabili naman kami ng
gamot na kailangan ko.”

ANALYSIS: Financial resources increase the ability to provide the


necessary commodities for health and well being. (Nursing
Fundamentals by R. Daniels p 855)
INTERPRETATION: Adequate Economic Finances

III. SPIRITUAL PATTERN

1. Religious beliefs and practices


According to the client, praying is her religious practice since
she is at the hospital.

ANALYSIS: In middle age, people tend to be less dogmatic about


religious beliefs and religion often offers more comfort to the
middle aged person than it did previously. People in this age
group often relies on spiritual beliefs to help them deal with
illness, death and tragedy (Fundamentals of Nursing by Kozier,
7th edition p 400)
INTERPRETATION: Proper practice of religious beliefs

2. Values and valuing


According to the client God and family are the most important
persons in her life.

ANALYSIS: Values can be described as the outcome of an


individual‘s effort to apply universal moral laws to his everyday
life. Values are more personal, and provide meaning and
direction. (Fundamentals of Nursing practice by Narrow and
Buschle, 2nd edition p 84)
INTERPRETATION: Proper valuing
G.ACTIVITIES OF DAILY LIVING

ACTIVITIES OF BEFORE DURING INTERPRETATION AND


DAILY LIVING HOSPITALIZATION HOSPITALIZATION ANALYSIS

Nutrition The client The client Interpretation:


verbalized, verbalized, Normal
“Kadalasan isda “Kung ano ung Analysis:
at gulay ang binibigay na The middle-aged
kinakain namin. pagkain dito sa adult should
Minsan may hospital, un ang continue to eat a
karne din.” She kinakain ko healthy diet,
also added that pero di ko rin following the
she eats 3 meals nauubos. Sabi recommended
per day and ng doktor bawal portions of the five
drinks 7 to 8 sa akin ung food groups with
glasses everyday mga gatas at special attention
itlog kasi to protein, calcium
makati iyon.” and limiting
She also added cholesterol and
that she drinks caloric intake. Two
1.5 liters of or three liters of
water everyday. fluid should be
included in the
daily diet. During
the late middle
age, they may
determine that
certain foods
disagree with
them. Clients
should be advised
to develop
sensible eating
habits and avoid
fried or fatty foods
(p. 1181,
Fundamentals of
ACTIVITIES OF BEFORE DURING INTERPRETATION AND
DAILY LIVING HOSPITALIZATION HOSPITALIZATION ANALYSIS
Nursing by Kozier,
7th edition)
Allergies induced
by a
hypersensitivenes
s of the individual.
Allergies reaction
is a process that is
injuries and
renders the
individuals
sensitivity to the
antigens. (p.492,
Williams, Jesse F.
1950. Personal
Hygiene Applied,)

Elimination The client The client Interpretation:


verbalized that verbalized that Normal
she defecates she urinates 3 Analysis:
and urinates times to 6 times Elimination from
regularly and a day and the urinary and
there is no defecates 2 intestinal tracts is
burning or foul times a day. essential to rid the
smell in her She also body of wastes
urine. She also verbalized, and materials in
added that she “Buo naman excess of bodily
doesn’t take any ang dumi ko.” needs. Healthy
medications to adults excrete
increase her 1200ml-1700ml of
bowel movement urine in each 24
hour period.
However, this
amount may vary,
depending on
several factors.
Regular
ACTIVITIES OF BEFORE DURING INTERPRETATION AND
DAILY LIVING HOSPITALIZATION HOSPITALIZATION ANALYSIS
elimination of
bowel wastes
products is
essential for
normal body
functioning.
Because bowel
function depends
on the balance of
several factors,
elimination
pattern and habits
vary among
individuals (p. 356
and p. 366,
Fundamentals of
Nursing by Eliner
V. Fuerst & p.
1437,
Fundamentals of
Nursing by Potter
and Perry, 5th
edition)
The normal color
of the stool is
brown, formed
soft, and semi-
solid, moist, in
consistency,
cylindrical in
shape.
(Fundamentals of
Nursing by Kozier,
page 1227)

Exercise The client The client Interpretation:


and verbalized that verbalized, Normal
ACTIVITIES OF BEFORE DURING INTERPRETATION AND
DAILY LIVING HOSPITALIZATION HOSPITALIZATION ANALYSIS
Physical walking and “Wala ako Analysis:
Activities working is her masyadong For exercise to be
form of exercise exercise dito effective. It should
kasi lagi lang be regular and
ako dito sa sustained.
higaan. Minsan Generally,
naglalakad ako exercising at least
kapag papunta thrice a week is
ng CR. advised. (p. 104,
Stretching lang Fundamentals of
minsan ang Nursing by Kozier).
ginagawa ko” Limitations to
movement may be
medically
prescribed for
some health
problems (p. 1067,
Fundamentals of
Nursing by Kozier,
7th edition)
Many middle-aged
adults may not
include exercise in
their lifestyle
because many of
the activities or
routine chores
that provided
exercise in the
past have been
stream lined by
modern devices
that save time and
require little if any
energy.
(Fundamentals of
Nursing by Kozier ,
ACTIVITIES OF BEFORE DURING INTERPRETATION AND
DAILY LIVING HOSPITALIZATION HOSPITALIZATION ANALYSIS
p 635)

Hygiene The client She has sponge Interpretation:


verbalized that baths everyday Normal
she takes a bath and brushes her Analysis:
everyday, brush teeth twice a Behaviors of
her teeth twice a day. The client mankind that
day. verbalized produce improve
“Kaya ko and maintain
naman punasan health and that
ang sarili ko protects and
pero defends health or
nagpapatulong prevent diseases
din ako sa anak are the forced and
ko.” persuaded
practices of
hygiene. (p. 3,
Principles of
Hygiene by
Thomas Storey,
1935) bathing
provides
relaxation and
comfort and it
gives most people
a sense of well
being (p. 704,
Fundamentals of
Nursing by Craven
and Hirnle, 4th
edition) Cleaning
baths are given
chiefly for hygiene
purposes (p. 705,
Fundamentals of
Nursing by Kozier,
7th edition) Proper
ACTIVITIES OF BEFORE DURING INTERPRETATION AND
DAILY LIVING HOSPITALIZATION HOSPITALIZATION ANALYSIS
diet and tooth and
mouth care should
be evaluated and
reinforced to
adolescents and
adults. Thorough
brushing of the
teeth is important
in preventing
tooth decay (p.
726,
Fundamentals of
Nursing by Kozier,
7th edition)

Substance The client She don’t drink Interpretation:


Abuse verbalized that alcoholic Normal
she is an beverages and Analysis:
occasional don’t smoke Drugs or
smoker but substance use is
stopped for ten appropriately
years. She also taken as
drinks alcohol 2 prescribed or
to 3 times a generally
week consuming recommended as
only 1 bottle. its intended
physiological or
psychological
effects.
(Fundamentals of
Nursing by Potter
and Perry pg.
1574)

Sleep and The client The client Interpretation:


Rest verbalized that verbalized, Normal
she sleeps 4 to 5 “Nakakatulog Analysis: Sleep
ACTIVITIES OF BEFORE DURING INTERPRETATION AND
DAILY LIVING HOSPITALIZATION HOSPITALIZATION ANALYSIS
hours. “Vendor naman ako ng requirements and
kasi ako kaya mataga-tagal. patterns vary with
minsan puyat o Nagigising ako individual and
kaya naman minsan tuwing change with age
kulang sa tulog gabi pero (Community
pero nababawi nakakatulog din Health Nursing by
ko rin kapag wala naman ako Stantope and
ako masyado kaagad Lancaster p. 607).
ginagawa sa Middle aged adult
bahay.” generally maintain
sleep pattern
established at
younger age. They
usually sleep 6 to
8 hours per night
(Fundamentals of
Nursing by Kozier,
7th edition, p.
1116)

H.PATIENT’S CONCEPT OF HEALTH, ILLNESS AND HOSPITALIZATION


The ideal health status is one in which people are successful in
achieving their full potential regardless of any limitations they
might have. The person with a chronic illness or disability may
still be able to achieve a desirable level of wellness. The key to
wellness is to function at the highest potential within the
limitations over which there is no control.
The client views her role as a sick person as a vulnerable
person who seek help and proper care. She expects support and
proper care management and calmness to those people who care
for her. She said that her illness should be treated with the help of
medicines and proper care management. She wants to know the
things that are necessary for her and health promotion. She also
verbalized, “Alam ko naman na may asthma ako kasi simula pa
bata ako meron na ako noon. Mahirap nga lang kasi ngayon
limitado na ang gagawin ko kasi baka atakihin ulit ako. Marami na
namang bawal.”
Her hospitalization now at Pres. Diosdado Macapagal Memorial
Medical Center is her major hospitalization because she’s been
staying there for almost a week and her past check ups in health
center are not a form of hospitalization.

ANALYSIS: The patients expect the nurse to be thoughtful,


understanding and accepting of him. Patients are critical of
behavior that is primitive or judgmental. He expects the nurse to
orient him in the health agency. Nearby everyone is afraid of the
unknown and to be left alone without orientation can be a
frightening experience. He also expects the nurse to provide an
explanation of his care. Health practitioners who ignore this
aspect of care are often referred to as cruel and unkind
(Fundamentals of Nursing, 7th edition, pp. 277-278)

I. LABORATORY AND DIAGNOSTIC EXAMINATION

DIAGNOSTIC NORMS ACTUAL RESULTS INTERPRETATION AND


EXAM ANALYSIS

Urinalysis Reference Actual Interpretation: The


Values Findings urine color,
Color: light Color: Yellow appearance, pH and
straw to dark Appearance: microscopic
amber slightly hazy examination are
Appearance: Odor: considered not normal
clear aromatic while the odor, specific
Odor: pH: acidic gravity, protein and
aromatic Specific glucose are considered
pH: 4.5-8.0 Gravity: 1.015 normal.
Specific Protein: trace Analysis:
Gravity: Glucose: Color of the urine
1.005-1.030 negative changes can results
Protein: 2-8 Microscopic from diet, drugs and
mg/dl; Examination: many diseases (pg.
negative RBC: 2-3/hpf 395, Diagnostic Test).
reagent strip Pus: 3-5/hpf Color is affected by
test; trace Epithelial concentration of urine.
Glucose: cells: many Tea colored urine is
DIAGNOSTIC NORMS ACTUAL RESULTS INTERPRETATION AND
EXAM ANALYSIS
negative Mucus due to blood in the
Ketones: threads: light urine. Bright yellow
negative Bacteria: few urine may be
(Handbook of secondary to vitamin
Laboratory intake. Dark yellow
and urine is a sure indicator
Diagnostic that there is
Test with dehydrated indicated
Nursing and that the fluid
Inplication, 5th consumption must be
edition, pg. increased. When water
343) loose from the body
exceeds water intake,
Microscopic the kidneys need to
Examination: consume water making
RBC: 0-2/high the urination more
power field concentrated with
WBC: 0-5/high waste products and
power field subsequently dark in
Epithelial color. Yellow colored
cells: 0-5/high urine is possible of
power field pyuria, and infection.
(Handbook of (Medical Surgical
Diagnostic Nursing by Bare and
Test, 3rd Smeltzer pg.1263)
edition, pg. Turbid urine may
329) contain red or white
cells, bacteria, fat or
chyle and may reflect
renal infection (pg. 395,
Diagnostic Test, 2004
by Lippincott Williams
and Wilkins). Urine
turbidity may result
from urinary tract
infections (pg. 180, A
Manual of Laboratory
DIAGNOSTIC NORMS ACTUAL RESULTS INTERPRETATION AND
EXAM ANALYSIS
and Diagnostic Test, 7th
edition). A normal pH is
7. A pH < 7 indicates
acid urine and > 7
indicates alkaline urine.
Acid urine ph is
associated with renal
tuberculosis, pyrexia,
phenylketonuria,
alkaptonuria and
acidosis. (Diagnostic
Tests, A Prescriber’s
Guide to Selection and
Interpretation by
Lippincott Williams and
Wilkins, p.395) Due to
carbohydrate
malabsorption, fat
malabsorption and
disaccharides
deficiency. (A Manual of
Laboratory and
Diagnostic Tests, 7th
edition by Lippincott
William and Wilkins,
p.279)Normally, freshly
voided urine has a faint
odor owing to the
presence of volatile
acids. It is not generally
offensive. Fresh urine
from most persons has
a characteristic
aromatic odor (pg. 396,
Diagnostic Test).
Specific gravity is an
indication of the
DIAGNOSTIC NORMS ACTUAL RESULTS INTERPRETATION AND
EXAM ANALYSIS
relative proportions of
dissolved solid
components to the total
volume of the
specimen and reflects
the relative degree of
concentration or
dilution of the
specimen.
(www.intensivecaring.c
om) In a healthy renal
and urinary tract
system, urine contains
no protein or only trace
amount (pg. 191, A
Manual of Laboratory
and Diagnostic Test).
Sugar, usually absent
from the urine, may
appear under normal
conditions (pg. 329,
Handbook of Diagnostic
Test, 3rd edition)
Red blood cells in the
urine can be due to
vigorous exercise or
exposure to toxic
chemicals. Bloody urine
can also be a sign of
bleeding in the
genitourinary tract as a
result of systemic
bleeding disorders,
various kidney
diseases, bacterial
infections, parasitic
infections including
DIAGNOSTIC NORMS ACTUAL RESULTS INTERPRETATION AND
EXAM ANALYSIS
malaria, obstructions in
the urinary tract,
scurvy, subacute
bacterial endocarditis,
traumatic injuries, and
tumors.
A high number of
white blood cells in the
urine is usually a
symptom of urinary
tract infection. A large
number of cells from
tissue lining (epithelial
cells) can indicate
damage to the small
tubes that carry
material into and out of
the kidneys.
(www.healthatoz.com)

Hematology Reference Actual Interpretation: Not


Values: Findings: normal
Neutrophils: Neutrophils: Analysis:
0.40-0.60 0.79 Increase in
Lymphocytes: Lymphocytes: Neutrophils: severe
0.20-0.40 0.13 bacterial disease,
(Diagnostic diabetic acidosis,
Testing and infarctions, increase in
Nursing acute, severe
Implications, inflammation,
4th edition) malignancies
(Diagnostic Testing and
Nursing Implications,
4th edition)
Decreased in
Lymphocytes: indicates
lymphopenia.
DIAGNOSTIC NORMS ACTUAL RESULTS INTERPRETATION AND
EXAM ANALYSIS
(Medical Surgical
Nursing by Bare and
Smeltzer pg. 876)
Possible cause of sepsis
and immunodeficiency
disease.
(Fundamentals of
Nursing by Kozier pg.
759)

J. IMPRESSION/DIAGNOSIS
The admitting diagnosis is Bronchial Asthma in Acute
Exacerbation

K. COURSE IN THE WARD


The patient was admitted in Female Medical Ward 364 bed
letter B. She has intravenous fluid (Balanced Multiple
Maintenance Solution 5% Dextrose) hooked, laboratory works up
done (urinalysis, hematology and radiological report). She was
given salbutamol as nebulizer and Cefuroxime Sodium as
antibiotics

II. CLINICAL DISCUSSION OF THE DISEASE

A. ECOLOGIC MODEL

(1) Hypothesis
There are many unanswered questions about the role of host
factors in disease. A potentially harmful change in any of the
components of the system may not lead to detectable
diseases.
(2) Predisposing Factors
A. Host
a. Age: 54 years old
b. Sex: Female
c. Race: Asian
d. Nationality: Filipino
e. Behaviors:
f. Heredity: they have family history of Bronchial Asthma in
her father’s side
B. Agent
Allergens—pollutants and fume of insecticides
C. Environment
Physical: exposure and inhalation of pollutants and fume of
insecticides; exposure to smoke from cigarette

B. Ecologic Model

The Epidemiological Triangle

Host
(susceptible host)

Agent: Environment:
(Allergens) Exposure to indoor
and outdoor allergens
Analysis

In medicine, we focus on the human and the forces within


him and within the environment that influence his state of
health. From this viewpoint, the human is the host organism;
other organisms are considered only as they relate to human
health. However, the organism alone is not sufficient to
account for the outbreak and cannot therefore be considered
“the cause”. An additional set of factors, environmental
conditions, also determine whether effective transmission of
disease can occur in any given situation. These factors include
degree of contact, level of hygienic practices, and presence of
other organisms.
When a factor must be present for a disease too occurs, it is
called the agent of that disease. Many, but not all, of he known
agents of disease are located in the biologic environment. In
keeping with the ecological view presented above, an agent is
considered to be a necessary but not sufficient cause of
disease because suitable conditions of the host and
environment must also be presented for disease to develop. It
is customary to divide the factors affecting the development of
disease into two groups, host factors (intrinsic) and factors in
the environment (extrinsic). Host factors affect susceptibility to
disease; factors in the environment influence exposure and
sometimes indirectly affect susceptibility as well. The
interactions of these two sets of factors determine whether or
not disease develops. . (Mausner and Bahn Epidemiology—An
Introductory Text by Judith Mausner and Shira Kramer, 2nd
edition pages 27-28)

Specific substances that cause allergic responses can affect


respirations, sometime severely. The body attempts to rid itself
of substances perceived as harmful by releasing chemical
mediators that cause an inflammatory response. Substances
that trigger an inflammatory response are called allergens.
Almost any substance can be allergen: pollens, dust, and foods
are common allergy triggers. The allergic response precipitates
a series of events that lead to tissue damage.
Hay fever is the result of allergies confined to the nose and
upper airways. Symptoms include dripping nose, itchy eyes and
swollen mucous membrane; they are annoying and
uncomfortable but not life-threatening. When allergic
responses take place in the lungs, breathing difficulties are far
more severe. Small airways became edematous, mucous
production increases, and inflammatory chemical mediators
cause bronchospasm. These are the hallmarks of common
allergic asthma. Severe and uncontrolled allergic asthma can
be fatal. (Fundamentals of Nursing by Craven and Hirnle, 4th
edition page 813)=
Healthy people exposed to air pollution often experience
stinging of the eyes, headache, dizziness, coughing and
choking. People who have a history of existing lung disease and
altered respiratory function experience varying degrees of
respiratory difficulty in a polluted environment. Some are
unable to perform self-care in such an environment.
(Fundamentals of Nursing by Kozier, 7th edition page 1295-
1296)

C. Conclusion and Recommendations


Reducing exposure to allergens that can trigger
bronchoconstriction and inflammation is an important preventive
measure. Nurses can be instrumental in working with the client
and family to identify individual asthma triggers and motivate the
family to restructure the environment to limit allergen exposure.
(Fundamentals of Nursing by Craven and Hirnle, 4th edition page
826)

L. ANATOMY AND PHYSIOLOGY


The respiratory system is situated in the thorax, and is
responsible for gaseous exchange between the circulatory
system and the outside world. Air is taken in via the upper
airways (the nasal cavity, pharynx and larynx) through the lower
airways (trachea, primary bronchi and bronchial tree) and into
the small bronchioles and alveoli within the lung tissue.
The respiratory system is an intricate arrangement of spaces
and passageways that conduct air from outside the body into
the lungs and finally into the blood as well as expelling waste
gasses. This system is responsible for the mechanical process
called breathing, with the average adult breathing about 12 to
20 times per minute.
When engaged in strenuous activities, the rate and depth of
breathing increases in order to handle the increased
concentrations of carbon dioxide in the blood. Breathing is
typically an involuntary process, but can be consciously
stimulated or inhibited as in holding your breath.
Nostrils/Nasal Cavities
During inhalation, air enters the nostrils and passes into the
nasal cavities where foreign bodies are removed, the air is
heated and moisturized before it is brought further into the
body. It is this part of the body that houses our sense of smell.
Sinuses
The sinuses are small cavities that are lined with mucous
membrane within the bones of the skull.
Pharynx
The pharynx or throat carries foods and liquids into the
digestive tract and also carries air into the respiratory tract.
Larynx
The larynx or voice box is located between the pharynx and
trachea. It is the location of the Adam's apple, which in reality is
the thyroid gland and houses the vocal cords.
Trachea
The chest and conducts air between the larynx and the lungs.
Lungs
The lungs are the organ in which the exchange of gasses
takes place. The lungs are made up of extremely thin and
delicate tissues. At the lungs, the bronchi subdivides, becoming
progressively smaller as they branch through the lung tissue,
until they reach the tiny air sacks of the lungs called the alveoli.
It is at the alveoli that gasses enter and leave the blood stream.
The lungs are divided into lobes; The left lung is composed of
the upper lobe, the lower lobe and the lingula (a small remnant
next to the apex of the heart), the right lung is composed of the
upper, the middle and the lower lobes.
Bronchi
The trachea divides into two parts called the bronchi, which
enter the lungs.
Bronchioles
The bronchi subdivide creating a network of smaller branches,
with the smallest one being the bronchioles. There are more
than one million bronchioles in each lung.
Alveoli
The alveoli are tiny air sacks that are enveloped in a network
of capillaries. It is here that the air we breathe is diffused into
the blood, and waste gasses are returned for elimination.
M. PATHOPHYSIOLOGY/SCHEMATIC DIAGRAM OF THE DISEASE
The underlying pathology of asthma is reversible and diffuse
airway inflammation. The inflammation leads to obstruction from
the following: swelling of the membranes that line the airways
(mucosal edema), reducing the airway diameter; contraction of
the bronchial smooth muscle that encircles the airways
(bronchospasm), causing further narrowing; and increased
mucus production, which diminishes airway size and may
entirely plug the bronchi.
The bronchial muscles and mucus glands enlarge; thick
tenacious sputum is produced; and the alveoli hyperinflate.
Some patients may have airway subbasement membrane
fibrosis. This is called airway “remodeling” and occurs in
response to chronic inflammation. The fibrotic changes in the
airway lead to airway narrowing and potentially irreversible
airflow limitation.
Cells that play a key role in the inflammation of asthma are
mast cells, Neutrophils, eosinophils, and lymphocytes. Mast
cells, when activated, release several chemicals called
mediators. These chemicals, which include histamine,
bradykinin, prostaglandins and leukotrienes, perpetuate the
inflammatory response, causing increased blood flow,
vasoconstriction, fluid leak from vasculature, attraction of white
blood cells to the area and bronchoconstriction. Regulation of
these chemicals is the aim of much of the current research
regarding pharmacologic therapy for asthma.
Further, alpha- and beta2-adrenergic receptors of the
sympathetic nervous system are located in the bronchi. When
the alpha-adrenergic receptors are stimulated,
bronchoconstriction occurs; when the beta2-adrenergic receptors
are stimulated, bronchodilation results. The balance between
alpha and beta2 receptors is controlled primarily by cyclic
adenosine monophosphate (cAMP). Alpha-adrenergic receptor
stimulation results in a decrease in cAMP, which leads to an
increase of chemical mediators released by the mast cells and
bronchoconstriction. Beta2-receptor stimulation results in
increased levels of cAMP, which inhibits the release of chemical
mediators and causes bronchodilation. (Medical-Surgical Nursing
Volume 1 by Smeltzer and Bare page 588)
Figure 1-1 Pathophysiology of Asthma

Predisposing Factors
Atopy Causal Factors Contributing Factors
Female Gender Exposure to indoor and Respiratory infections
outdoor allergens Air pollution
Occupational sensitizers Active/passive smoking
Other (diet, small size at birth)

Inflammation

Hyperrensponsiveness of Airflow limitation


airways

Symptoms
Wheezing
Risk Factors for exacerbations Cough
Allergens Dyspnea
Respiratory infections Chest tightness
Exercise and hyperventilation
Weather changes
Exposure to sulfur dioxide
Exposure to food, additives, medications
N.DRUG STUDY

GENERIC ACTION BRAND CLASSIFICATION INDICATION CONTRAINDICATIO SIDE EFFECTS/ NURSING


NAME NAME NS ADVERSE RESPONSIBILITY
REACTIONS

ALBUTEROL Synthetic Salbutam autonomic To relieve Pregnancy Body as a Assessment &


sympathomi ol nervous bronchospas (category C), Whole: Drug Effects
metic amine system agent; m lactation. Use Hypersensit • Monitor
and beta- associated of oral syrup ivity therapeuti
moderately adrenergic with acute in children reaction. c
selective agonist or chronic <2 y. CNS: effectiven
beta2- (sympathomim asthma, Tremor, ess which
adrenergic etic); bronchitis, anxiety, is
agonist with bronchodilator or other nervousnes indicated
comparative (respiratory reversible s, by
ly long smooth obstructive restlessness significant
action. Acts muscle airway , subjective
more relaxant) diseases. convulsions improvem
prominently Also used to , weakness, ent in
on beta2 prevent headache, pulmonary
receptors exercise- hallucinatio function
(particularly induced ns. CV: within 60–
smooth bronchospas Palpitation, 90 min
muscles of m. hypertensio after drug
bronchi, n, administra
uterus, and hypotension tion.
vascular , • Monitor
supply to bradycardia for: S&S of
skeletal , reflex fine
muscles) tachycardia tremor in
than on . Special fingers,
beta1 Senses: which may
(heart) Blurred interfere
receptors. vision, with
GENERIC ACTION BRAND CLASSIFICATION INDICATION CONTRAINDICATIO SIDE EFFECTS/ NURSING
NAME NAME NS ADVERSE RESPONSIBILITY
REACTIONS
Minimal or dilated precision
no effect on pupils. GI: handwork;
alpha- Nausea, CNS
adrenergic vomiting. stimulatio
receptors. Other: n,
Inhibits Muscle particularl
histamine cramps, y in
release by hoarseness children 2–
mast cells. 6 y,
(hyperacti
vity,
excitemen
t,
nervousne
ss,
insomnia),
tachycardi
a, GI
symptoms
. Report
promptly
to
physician.
• Lab tests:
Periodic
ABGs,
pulmonary
functions,
and pulse
oximetry.
• Consult
physician
about
GENERIC ACTION BRAND CLASSIFICATION INDICATION CONTRAINDICATIO SIDE EFFECTS/ NURSING
NAME NAME NS ADVERSE RESPONSIBILITY
REACTIONS
giving last
albuterol
dose
several
hours
before
bedtime, if
drug-
induced
insomnia
is a
problem.

Patient &
Family
Education
• Review
directions
for correct
use of
medicatio
n and
inhaler
• Avoid
contact of
inhalation
drug with
eyes.
• Do not
increase
number or
frequency
of
GENERIC ACTION BRAND CLASSIFICATION INDICATION CONTRAINDICATIO SIDE EFFECTS/ NURSING
NAME NAME NS ADVERSE RESPONSIBILITY
REACTIONS
inhalations
without
advice of
physician.
• Notify
physician
if albuterol
fails to
provide
relief
because
this can
signify
worsening
of
pulmonary
function
and a
reevaluati
on of
condition/t
herapy
may be
indicated.
• Note:
Albuterol
can cause
dizziness
or vertigo;
take
necessary
precaution
s.
GENERIC ACTION BRAND CLASSIFICATION INDICATION CONTRAINDICATIO SIDE EFFECTS/ NURSING
NAME NAME NS ADVERSE RESPONSIBILITY
REACTIONS
• Do not use
OTC drugs
without
physician
approval.
Many
medicatio
ns (e.g.,
cold
remedies)
contain
drugs that
may
intensify
albuterol
action.

CEFUROXIM Semisynthet Kefurox, antiinfective; Infections Hypersensitivi Body as a Assessment &


E SODIUM ic second- Zinacef antibiotic; caused by ty to Whole: Drug Effects
generation second- susceptible cephalosporin Thrombophl • Determine
cephalospor generation organisms s and related ebitis (IV history of
in antibiotic cephalosporin in the lower antibiotics; site); pain, hypersensi
with respiratory pregnancy burning, tivity
structure tract, (category B), cellulitis (IM reactions
similar to urinary lactation site); to
that of the tract, skin, superinfecti cephalosp
penicillins. and skin ons, orins,
Resistance structures; positive penicillins,
against also used Coombs' and
beta- for test. GI: history of
lactamase- treatment of Diarrhea, allergies,
producing meningitis, nausea, particularl
GENERIC ACTION BRAND CLASSIFICATION INDICATION CONTRAINDICATIO SIDE EFFECTS/ NURSING
NAME NAME NS ADVERSE RESPONSIBILITY
REACTIONS
strains gonorrhea, antibiotic- y to drugs,
exceeds and otitis associated before
that of first media and colitis. therapy is
generation for Skin: Rash, initiated.
cephalospor perioperativ pruritus, • Lab tests:
ins. e urticaria. Perform
Antimicrobia prophylaxis Urogenital culture
l spectrum (e.g., open- : Increased and
of activity heart serum sensitivity
resembles surgery), creatinine tests
that of early Lyme and BUN, before
cefonicid. disease. decreased initiation
Preferentiall creatinine of therapy
y binds to clearance. and
one or more periodicall
of the y during
penicillin- therapy if
binding indicated.
proteins Therapy
(PBP) may be
located on instituted
cell walls of pending
susceptible test
organisms. results.
This inhibits Monitor
third and periodicall
final stage y BUN and
of bacterial creatinine
cell wall clearance.
synthesis, • Inspect IM
thus killing and IV
the injection
bacterium. sites
GENERIC ACTION BRAND CLASSIFICATION INDICATION CONTRAINDICATIO SIDE EFFECTS/ NURSING
NAME NAME NS ADVERSE RESPONSIBILITY
REACTIONS
Partial frequently
cross- for signs
allergenicity of
between phlebitis.
other beta- • Report
lactam onset of
antibiotics loose
and stools or
cephalospor diarrhea.
ins has been • Monitor for
reported. manifestat
ions of
hypersensi
tivity.
Discontinu
e drug and
report
their
appearanc
e
promptly.
• Monitor
I&O rates
and
pattern:
Especially
important
in severely
ill patients
receiving
high
doses.
Report any
GENERIC ACTION BRAND CLASSIFICATION INDICATION CONTRAINDICATIO SIDE EFFECTS/ NURSING
NAME NAME NS ADVERSE RESPONSIBILITY
REACTIONS
significant
changes.

Patient &
Family
Education
• Report
loose
stools or
diarrhea
promptly.
• Report any
signs or
symptoms
of
hypersensi
tivity
III. NURSING PROCESS

A. PROBLEM LIST

DATE OF NURSING DATE DATE DATE


ONSET PROBLEM IDENTIFIED RESOLVED INACTIVE

November Ineffective November November November


15, 2006 airway 15, 2006 15, 2006 15, 2006
clearance
related to
diffuse
airway
inflammatio
n

November Ineffective November November November


20, 2006 airway 20, 2006 20, 2006 20, 2006
clearance
related to
secretions
in the
bronchi
RATE NURSING PROBLEMS CUES JUSTIFICATION
IDENTIFIED

1 Ineffective INTERACTION: This is an actual


airway clearance The client problem that
related to diffuse verbalized requires
airway “Bago ako immediate
inflammation isugod dito sa attention. It is
ospital, the chief
nakalanghap complaint of the
ako noon ng patient and the
pamatay ng ipis other nursing
tapos sa bahay problems occur
nag-insenso sila in relation to
kaya inatake the presence of
ako ng asthma this problem.
ko. Nanikip na
ang dibdib ko
tapos ayun na,
sinugod na nila
ako dito”

OBSERVATION:
On and off
difficulty of
breathing
(DOB).
Patient looks
restlessness,
pale weak

MEASUREMENT
Respiratory
Rate: 23
breaths per
minute
RATE NURSING PROBLEMS CUES JUSTIFICATION
IDENTIFIED

2 Ineffective INTERACTION This is an actual


airway clearance The client problem which
related to verbalized, is an effect of
secretions in the “Hindi ko the prioritized
bronchi mailabas ang problem above.
plema ko Interventions
ngayon” are available
“Nakakahinga and possible for
naman ako this problem
pero medyo
hirap”

OBSERVATION
Difficulty
vocalizing
Wheezes at
right lung field
Pale

MEASUREMENT
Respiratory
Rate: 21
breaths per
minute
B. NURSING CARE PLAN

CUES NURSING ANALYSIS/ HEALTH GOALS AND NURSING RATIONALE EVALUATION


DIAGNOSIS IMPLICATION OBJECTIVES INTERVENTIONS

INTERACTION Ineffective IMMEDIATE GOAL:


The client airway CAUSE After 8 hours
verbalized, clearance Secretions in of shift, Mrs.
“Hindi ko related to the bronchi Ventura will
mailabas ang secretions in be able to
plema ko the bronchi INTERMEDIAT expectorate/
ngayon” E CAUSE clear
“Nakakahinga Contraction of secretions
naman ako the bronchial readily
pero medyo smooth muscle EFFECTIVENESS
hirap” that encircles OBJECTIVES 1. Was the client
the airways a. Encourage Adequate able to promote
OBSERVATIO (bronchospasm (1) Provide fluid (2,000- hydration systemic fluid
N ) and teach the 3,000ml/day) thins hydration?
Difficulty client the within level of secretions,  yes __no
vocalizing ROOT CAUSE importance of cardiac which
Wheezes at Diffuse airway adequate tolerance prevents 2. Was the client
right lung field inflammation hydration mucus from able to cough to
Pale plugging mobilize the
HEALTH airways. secretions
MEASUREME IMPLICATION (Fundamental yes __no why?
NT Retained s of Nursing
Respiratory secretions by Craven 3. Was the client
Rate: 21 increased the and Hirnle, 4th able to be
breaths per work breathing edition page monitor
minute and may b. Monitor 861) regarding to his
contribute to client’s input respiratory
atelectasis and and output Evaluate functioning?
hypoxemia. hydration yes __no why?
(Fundamentals status of
CUES NURSING ANALYSIS/ HEALTH GOALS AND NURSING RATIONALE EVALUATION
DIAGNOSIS IMPLICATION OBJECTIVES INTERVENTIONS
of Nursing by client EFFICIENCY
Craven and (Fundamental Was the
Hirnle, 4th s of Nursing interventions
edition page by Craven done within the
828) and Hirnle, 4th time frame?
Shallow c. Avoid milk edition page  yes __no why?
respirations and milk 861)
inhibit both products APPROPRIATENE
diaphragmatic Milk products SS
excursion and tend to Were the
lung a. Deep thickens interventions
distensibility. breathing secretions suitable to the
The result of (2) Position every 2 hours client?
inadequate and  yes __no why?
chest encourage To facilitate
expansion is client to lung aeration,
pooling of cough to thereby ACCESSIBILITY
respiratory promote preventing Were the
secretions, mobilization atelectasis interventions
which of secretions and acceptable to
ultimately pneumonia the client?
harbor (Fundamental  yes __no why?
microorganism b. Huff s of Nursing
s and promote coughing by Kozier, 7th ADEQUACY
infection edition page Were the
(Fundamentals 903) interventions
of Nursing by adequate to
Kozier, 7th Prevent meet the client’s
edition page airway needs?
1301) collapse  yes __no why?
Mucus that is (Fundamental
hard to s of Nursing
expectorate by Craven
promotes and Hirnle, 4th
CUES NURSING ANALYSIS/ HEALTH GOALS AND NURSING RATIONALE EVALUATION
DIAGNOSIS IMPLICATION OBJECTIVES INTERVENTIONS
infection edition page
because the 861)
bacteria it This
traps have technique
time to helps keep
multiply. your airway
Mucous plugs open while
in the airways moving
can lead to secretions up
atelectasis and and out of the
decreased c. Assist client lungs.
oxygenation to a sitting (Fundamental
(Fundamentals position with s of Nursing
of Nursing by head slightly by Kozier, 7th
Craven and flexed, edition page
Hirnle, 4th shoulders 1303)
edition page relaxed, and
827) knees flexed Lying flat
causes the
abdominal
organs to shift
toward the
chest,
crowding the
lungs and
making it
more difficult
to breathe
(Fundamental
s of Nursing
by Kozier, 7th
edition page
1327)
Permits deep
CUES NURSING ANALYSIS/ HEALTH GOALS AND NURSING RATIONALE EVALUATION
DIAGNOSIS IMPLICATION OBJECTIVES INTERVENTIONS
inspiration
and forceful
abdominal
contractions
necessary for
coughing
a. Monitor (Fundamental
rate, rhythm, s of Nursing
(3) depth, and by Craven
Respiratory effort of and Hirnle, 4th
monitoring respirations edition page
861)

Provide basis
for evaluating
adequacy of
ventilation
b. Monitor (Fundamental
client’s ability s of Nursing
to cough by Kozier, 7th
effectively edition page
1327)

Respiratory
tract
infections
alter the
amount and
character of
secretions. An
ineffective
cough
compromises
airway
CUES NURSING ANALYSIS/ HEALTH GOALS AND NURSING RATIONALE EVALUATION
DIAGNOSIS IMPLICATION OBJECTIVES INTERVENTIONS
clearance and
prevent
mucus from
c. Institute being
respiratory expelled
therapy (Fundamental
treatments s of Nursing
(e.g. by Kozier, 7th
nebulizer) as edition page
needed 1327)

A variety of
respiratory
therapy
treatments
may be used
to open
constricted
airways and
liquefy
secretions
(Fundamental
s of Nursing
by Kozier, 7th
edition page
1328)
C. DISCHARGE PLANNING

MEDICATION
Θ Continue medications prescribed by the physician
Θ Salbutamol: Adult: PO 2–4 mg 3–4 times/day, 4–8 mg
sustained release 2 times/day
Inhaled 1–2 inhalations q4–6h
EXERCISE
Θ Deep breathing and Coughing Exercise
TREATMENT
Θ Continue medications prescribed by the physician.
Θ Provide adequate rest periods
HEALTH TEACHINGS
Θ Teach the client to do purse-lip breathing and relaxation
techniques
Θ Maintain a dust-free environment
Θ Reduce exposure to pollen
OUT PATIENT FOLLOW-UP
Θ Notify the health care provider when respiratory infection
occurs
Θ Make appropriate referrals to home health agencies for
assistance in obtaining medical and assistive equipment
DIET
Θ Hypoallergenic Diet
Θ Increased fluid intake to thin bronchial secretions

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