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CASE STUDY: Bronchial Asthma In Acute Exacerbation

I. INTRODUCTION A. DEFINITION Asthma (from the Greek , sthma, "panting") is the common chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm. Symptoms include wheezing, coughing, chest tightness, and shortness of breath. Asthma is clinically classified according to the frequency of symptoms, forced expiratory volume in 1 second (FEV1), and peak expiratory flow rate. Asthma may also be classified as atopic (extrinsic) or non-atopic (intrinsic). It is thought to be caused by a combination of genetic and environmental factors. Treatment of acute symptoms is usually with an inhaled short-acting beta-2 agonist (such as salbutamol). Symptoms can be prevented by avoiding triggers, such as allergens and irritants, and by inhaling corticosteroids. Leukotriene antagonists are less effective than corticosteroids and thus less preferred. Its diagnosis is usually made based on the pattern of symptoms and/or response to therapy over time. The prevalence of asthma has increased significantly since the 1970s. As of 2010, 300 million people were affected worldwide. In 2009 asthma caused 250,000 deaths globally. Despite this, with proper control of asthma with step down therapy, prognosis is generally good.

ETIOLOGY: Asthma commonly results from hyperresponsiveness of the trachea and bronchi to irritants. Allergy influences both the persistence and the severity of asthma, and atopy or the

CASE STUDY: Bronchial Asthma In Acute Exacerbation

genetic predisposition for the development of an IgE-mediated response to common airborne allergens is the most predisposing factor for the development of asthma.

CLASSIFICATION: 1. Extrinsic Asthma called Atopic/allergic asthma. An allergen or an antigen is a foreign particle which enters the body. Our immune system over-reacts to these often harmless items, forming antibodies which are normally used to attack viruses or bacteria. Mast cells release these antibodies as well as other chemicals to defend the body.

Common irritants:

Cockroach particles Cat hair and saliva Dog hair and saliva House dust mites Mold or yeast spores Metabisulfite, used as a preservative in many beverages and some foods Pollen

2. Intrinsic asthma called non-allergic asthma, is not allergy-related, in fact it is caused by anything except an allergy. It may be caused by inhalation of chemicals such as cigarette smoke or cleaning agents, taking aspirin, a chest infection, stress, laughter, exercise, cold air, food preservatives or a myriad of other factors.


CASE STUDY: Bronchial Asthma In Acute Exacerbation

Smoke Exercise Gas, wood, coal, and kerosene heating units Natural gas, propane, or kerosene used as cooking fuel Fumes Smog Viral respiratory infections Wood smoke Weather changes

SIGNS AND SYMPTOMS: 1. Non Productive to Productive Cough 2. Dyspnea 3. Wheezing on expiration 4. Cyanosis 5. Mild apprehension and restlessness 6. Tachycardia and palpitation 7. Diaphoresis

CLINICAL MANIFESTATIONS: 1. Increased respiratory rate 2. Wheezing (intensifies as attack progresses) 3. Cough (productive)

CASE STUDY: Bronchial Asthma In Acute Exacerbation

4. Use of accessory muscles 5. Distant breath sounds 6. Fatigue 7. Moist skin 8. Anxiety and apprehension 9. Dyspnea

Bronchial asthma in Acute Exacerbation

Bronchial asthma acute exacerbation is actually another term for a chronic asthma attack. During bronchial asthma acute exacerbation bronchial tubes tighten instantly and make it very hard for the air to flow through them. This is a very difficult situation because a person suffering from the attack cannot breathe, and can enter a stage of shock.

Many things are considered a trigger for a bronchial asthma acute exacerbation. These things are allergens (pet hair, pollen, smoke, dust etc), air pollution and air toxins, hard physical activity and stress and anxiety.


As of 2009, 300 million people worldwide were affected by asthma leading to approximately 250,000 deaths per year.


CASE STUDY: Bronchial Asthma In Acute Exacerbation

It is estimated that asthma has a7-10% prevalence worldwide. As of 1998, there was a great disparity in the prevalence of asthma across the world, with a trend toward more developed and westernized countries having higher rates of asthma, with as high as a 20 to 60-fold difference. Westernization however does not explain the entire difference in asthma prevalence between countries, and the disparities may also be affected by differences in genetic, social and environmental risk factors. Mortality however is most common in low to middle income countries, while symptoms were most prevalent (as much as 20%) in the United Kingdom, Australia, New Zealand, and Republic of Ireland; they were lowest (as low as 23%) in Eastern Europe, Indonesia, Greece, Uzbekistan, India, and Ethiopia.

Asthma affects approximately 7% of the population of the United States and 5% of people in the United Kingdom. Asthma causes 4,210 deaths per year in the United States. In 2005 in the United States asthma affected more than 22 million people including 6 million children. It accounted for nearly 1/2 million hospitalizations that same year. More boys have asthma than girls, but more women have it than men. In England, an estimated 261,400 people were newly diagnosed with asthma in 2005; 5.7 million people had an asthma diagnosis and were prescribed 32.6 million asthma-related prescriptions.


There are no available nationwide data published on asthma prevalence. However, the limited reports gathered showed a prevalence of 12% in children aged 13-14 years and 1722% in older age groups.


CASE STUDY: Bronchial Asthma In Acute Exacerbation

LOCAL PREVALENCE Three thousand two hundred and seven children in Metro Manila aged 13-14 years participated in the International Study of Asthma and Allergies in Children (ISAAC). Participants accomplished a 12-month prevalence of self-reported asthma symptoms from written questionnaires and from video questionnaires. The results showed that approximately 12% and 8% prevalence based on responses to the written questionnaires and to the video questionnaires respectively. In a subsequent study, 12.3% of the same population reported wheezing. A local study estimating the prevalence of asthma and allergies in adults was completed in Malolos, Bulacan in 1998. One thousand five (1,005) adults (ages 18-44 years) were interviewed using a pre-tested questionnaire adapted from the European Community Health Survey (ECHRS) and the ISAAC. The study showed a prevalence of 17.2% for asthma and 49.9% for allergy among adults. Another study conducted at the Lung Center of the Philippines reported a prevalence of 22% in adults.

D. REASONS FOR CHOOSING THE DISEASE We choose Bronchial Asthma in Acute Exacerbation as our case to be studied because we want each and all of us whether men and women, children and adult to be aware of the possible causes of the disease and the prevention and management of patient with such respiratory disease. Moreover, we are all at our teenage year and smoking as major causes of BAIAE is very common addiction of most teenagers.


CASE STUDY: Bronchial Asthma In Acute Exacerbation

II. OBJECTIVES A. GENERAL OBJECTIVES Within 8 hours of exposure at World Citi Medical Center (WCMC) 7th floor ward, we, BSN III-A Group 2 student nurses from World Citi Colleges (WCC) Antipolo campus aim to use our knowledge, skills, and attitude to render holistic care to our client as well as convey information with regards to the promotion and maintenance of health in order for our client to achieve possible wellness state and carry out activities of daily living.

B. SPECIFIC OBJECTIVES Knowledge >To know how this respiratory disease affects patients life. >To identify the problem of the patient >To formulate exact and effective nursing care plan to the patient >To review the normal anatomy and physiology of the respiratory system >To discern the pathophysiology of the disease Skills >To improve our ability to handle respiratory disease and to enhance our skills to the applications of our knowledge. >To provide health teachings and nursing interventions

CASE STUDY: Bronchial Asthma In Acute Exacerbation

Attitude >To establish good nurse-patient relationship with our client and to improve the level of our communications to our patient and staff nurses. >To build rapport with the patient

III. SIGNIFICANCE OF THE STUDY To patient with Bronchial Asthma in Acute Exacerbation: >To acquire necessary knowledge related to their health condition. >To be able to manage them when pain and abnormalities related to the disease occurs. >To be able to understand the treatment that the health care providers offer in their recovery process. >To promote prevention of the disease

To staff nurses: >To properly indentify the needs of the patient >To be able to render nursing care and information to the patient through the application of the nursing skills. >To apply their knowledge and skills when caring to patients with pelvic organ prolapsed.


CASE STUDY: Bronchial Asthma In Acute Exacerbation

To nursing students: >To properly assess patients who are manifesting the disease. >To be knowledgeable in the treatment they are providing them. >To be able to provide more health teachings in the prevention of the disease.

IV. SCOPE AND DELIMITATIONS We had our duty at World Citi Medical Center (WCMC) 7th floor, in Quezon City last January 30, 2012. We were able to assess the patients condition but not that holistic due to lack of time and chances and the irritable feelings of our patient due to her condition but through keen observations, little participation of the client, patients chart and records. We are able to gather certain information needed to formulate this case study. The study lasted about 8 hours of exposure with the patient. Our client, Mrs. E.M. is suffering from Bronchial Asthma in Acute Exacerbation (BAIAE) which we will be dealing with this study. This includes its CAUSES and PREVENTION for the wellness of our patient.


CASE STUDY: Bronchial Asthma In Acute Exacerbation

V. NURSING HISTORY Name Age Gender Birthday Weight Height Religion Nationality Address Occupation Status Hospitalization Case Numver Date of Admission Chief Complain Attending Physician Admitting Diagnosis Final Diagnosis : Ms. EM : 36 y/o : Female : Jan 1, 1976 : 59 kg (129.8 lbs) : 157 cm : Catholic : Filipino : Quezon City : Plain Housewife : Married : (-) : 191944 : January 26, 2012 : fever and cough and colds : Dr. Agustin : Bronchial Asthma In Acute Exacerbation, Hypertension : Bronchial Asthma In Acute Exacerbation, Hypertension

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CASE STUDY: Bronchial Asthma In Acute Exacerbation

A. History of Present Illness Patient is known asthmatic and was maintained on seretide and salbutamol Turbohaler PRN, last attack was 1 year ago. One week PTC, patient had on and off episode of fever; Temp is 39 C with nonproductive cough and night time awakening, > 4x/week and shortness of breath. Patient just took paracetamol and salbutamol but to no avail. This prompted consult.

B. Past Medical History (+) Hypertension (-) DM (+) BA

C. Family History (+) Hypertension (Father/Mother) (+) Asthma (Father)

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CASE STUDY: Bronchial Asthma In Acute Exacerbation


Social Status Mrs. E.M. 36 years old born on Jan 1, 1976 is a plain housewife. She resides at Quezon City together with her husband and with her 3 kids. Shes the one who takes care of her 2 daughters and her 1 son. She sometimes goes out of their house to talk with her neighbors. She does not stay too long along the streets because she tends to have an attack whenever she inhales street dust.

Mental Status Mrs. E.M. is oriented to time, place, events and person. She is able to recall recent and past events in her life. She is able to read and write and can speak in English and Tagalog. She is responsive and answers to the questions being asked.

Emotional State Mrs. E.M. says that she feels a little stressed because of her confinement. Also, she is somewhat irritable because of her condition.

Sensory Perception Vision Hearing Mrs. E.M. only uses reading glasses. Mrs. E.M.s hearing ability is okay because she is able to answers our questions without us repeating it. Smell N/A

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CASE STUDY: Bronchial Asthma In Acute Exacerbation

Taste Touch

Mrs. E.M. claims that she can taste every food she is being offered. Mrs. E.M. responds to our touch.

Motor Ability Mrs. E.M. is lethargic and a bit weak. She can move freely in her bed but she needs help from her companion when sitting up and going to the bathroom.

Nutritional Status Before Mrs. E.M. was admitted she states that she eats at least three times a day. She is not picky with food. Her meal normally includes fish, pork, and vegetables. She is a normal beverage drinker.


= lbs. / inch2 X 703 =

130 lbs. / 61.81 inches2 x 703

130 lbs. / 3820.5 inches x 703

23. 92 (NORMAL)
Underweight Normal Overweight Obese Below 18.5 18.5 24.9 25 29.9 Above 30

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CASE STUDY: Bronchial Asthma In Acute Exacerbation

Body Temperature DATE TIME BODY TEMPERATURE (C) Jan. 31, 2012 8:00 AM 12: 00 PM Feb. 1, 2012 8:00 AM 12:00 PM 37. 1 C 37.3 C 36. 2 C 36.6C

Respiratory Status DATE TIME RESPIRATORY RATE (cpm) Jan. 31, 2012 8:00 AM 12:00 PM Feb. 1, 2012 8:00 AM 12:00 PM 21 cpm 18 cpm 19 cpm 17 cpm

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CASE STUDY: Bronchial Asthma In Acute Exacerbation

Circulatory Status DATE TIME BLOOD PRESSURE (mmHg) Jan. 31, 2012 8:00 AM 12:00 PM Feb. 1, 2012 8:00 AM 12:00 PM 120/80 mmHg 120/80 mmHg 120/80 mmHg 120/80 mmHg

Elimination Pattern DATE Jan. 31, 2012 Feb. 1, 2012 URINE 3 2 STOOL 1 0

Reproductive Status Mrs. E.Ms first menstrual period was when she was 10 years old. She got married at the age of 24 years old. She has 3 children (2 girls/1 boy) with 2 years gap each. She is sexually active.

Sleep Pattern Mrs. E.M. stated that she normally sleeps 4-6 hours/day, after she was admitted she has some difficulty in sleeping because of the nurses coming in and out of her room and

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CASE STUDY: Bronchial Asthma In Acute Exacerbation

sometimes she has difficulty of breathing. She usually watches television at home during rest hours and also during admission.

State of Skin and Appendages Mrs. E.M. has fair skin. Her wavy hair is up to her shoulders. Her lips are not dried and slightly brownish in color. Nails are trimmed.

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CASE STUDY: Bronchial Asthma In Acute Exacerbation


FLORENCE NIGHTINGALE: Environmental Theory

Florence Nightingale (1820-1910), considered the founder of educated and scientific and widely known as "The Lady with the Lamp" wrote the first nursing notes that became the basis of nursing practice and research. The notes, entitled Notes on Nursing: What it is, what is not (1860), listed some of her theories that have served as foundations of nursing practice in various settings, including the succeeding and in the field of Nursing. Nightingale is considered the first nursing theorist. One of her theories was the Environmental Theory, which incorporated the restoration of the usual health status of the nurse's clients into the delivery of it is still practiced today.

Nightingale's theory was show to be applicable during the Crimean war along with other nurses she had trained, took care of injured soldiers by attending to their immediate needs, when communicable disease and rapid spread of disease were rampant in this early period in the development of disease-capable medicines. The practice of environment configuration according to patient's health or disease condition is still applied today, in such cases as patients infected with suffering from who need minimal noise to calm them and a quiet environment to prevent seizure-causing stimulus.

In environmental effects she stated in her nursing notes that nursing "is an act of utilizing the environment of the patient to assist him in his recovery" (Nightingale
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CASE STUDY: Bronchial Asthma In Acute Exacerbation

1860/1969) that it involves the nurse's initiative to configure environmental settings appropriate for the gradual restoration of the patient's health, and that external factors associated with the patient's surroundings affect life or biologic and physiologic processes, and his development.

Major Concepts and Definitions Environment - concepts of ventilation, warmth, light, diet, cleanliness and noise. She focus o the physical aspect of environment.

She believed that "Healthy surroundings were necessary for proper nursing care."

5 essential components of healthy environment: 1. Pure air 2. Pure water 3. Efficient drainage 4. Cleanliness 5. Light

Concerns of Environmental Theory 1. Proper ventilation focus on the architectural aspect of the hospital. 2. Light has quite as real and tangible effects to the body. Her nursing intervention includes direct exposure to sunlight.

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CASE STUDY: Bronchial Asthma In Acute Exacerbation

3. Cleanliness and sanitation. She assumes that dirty environment was the source of infection and rejected the "germ theory". Her nursing interventions focus on proper handling and disposal of bodily secretions and sewage, frequent bathing for patients and nurses, clean clothing and hand washing. 4. Warmth, quiet and diet environment. She introduces the manipulation of the environment for patient's adaptation such as fire, opening the windows and repositioning the room seasonally, etc. 5. Unnecessary noise is not healthy for recuperating patients. 6. Dietary intake. 7. Petty management proposed the avoidance of psychological harm, no upsetting news. Strictly war issues and concerns should not be discussed inside the hospital. She includes the use of small pets of psychological therapy.

Nursing Metaparadigm

Nursing Nursing is very essential for everybody's well-being. Notes on nursing focus on the implementation and rendering efficient and effective nursing care.

Person The patient is the focus of the environmental theory. The nurse should perform the task for the patient and control environment for easy recovery. She practices nurse-patient passive relationship.

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CASE STUDY: Bronchial Asthma In Acute Exacerbation

Health Health is the being well and using every power that the person has to the fullest extent. A healthy body can recuperate and undergo reparative process. Environmental control uplifts maintenance of health.

Environment People would benefit from the environment.

Importance of Environmental Theory

Practice 1. Disease control 2. Sanitation and water treatment 3. Utilized by modern architecture in the prevention of "sick building syndrome" applying the principles of ventilation and good lighting. 4. Waste disposal 5. Control of room temperature. 6. Noise management.


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CASE STUDY: Bronchial Asthma In Acute Exacerbation

1. Principles of nursing training. Better practice result from better education. 2. Skills measurement through licensing by the use of testing methods, the case studies.

Research 1. Use of graphical representations like the polar diagrams. 2. Notes on nursing.

The Analysis

Simplicity: The theory is simply explained as the nurse, patient and environment interacts with each other. There are dangers in the environment and benefits from the good environment. The roles of environmental management to patient recovery are greatly emphasized. Manipulating the environment to prevent diseases. Nurse-patient relationship focuses on cooperation and collaboration. Her care focus on eating patterns and food preferences of the patients, provision of comfort, protection from emotional distress and conservation of energy.

Generality: The universality of the concepts provides general guidelines and is still applicable and relevant today.

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CASE STUDY: Bronchial Asthma In Acute Exacerbation


The Human Respiratory System

The Pathway

Air enters the nostrils passes through the nasopharynx, the oral pharynx through the glottis into the trachea into the right and left bronchi, which branches and rebranches into bronchioles, each of which terminates in a cluster of alveoli

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CASE STUDY: Bronchial Asthma In Acute Exacerbation

Only in the alveoli does actual gas exchange takes place. There are some 300 million alveoli in two adult lungs. These provide a surface area of some 160 m2 (almost equal to the singles area of a tennis court and 80 times the area of our skin!).

In mammals, the diaphragm divides the body cavity into the

abdominal cavity, which contains the viscera (e.g., stomach and intestines) and the

Thoracic cavity, which contains the heart and lungs.

The inner surface of the thoracic cavity and the outer surface of the lungs are lined with pleural membranes which adhere to each other. If air is introduced between them, the adhesion is broken and the natural elasticity of the lung causes it to collapse. This can occur from trauma. And it is sometimes induced deliberately to allow the lung to rest. In either case, reinflation occurs as the air is gradually absorbed by the tissues. Because of this adhesion, any action that increases the volume of the thoracic cavity causes the lungs to expand, drawing air into them.

During inspiration (inhaling),


The external intercostal muscles contract, lifting the ribs up and out.
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The diaphragm contracts, drawing it down.

During expiration (exhaling), these processes are reversed and the natural elasticity of the lungs returns them to their normal volume. At rest, we breathe 1518 times a minute exchanging about 500 ml of air.

In more vigorous expiration,

o o

The internal intercostal muscles draw the ribs down and inward The wall of the abdomen contracts pushing the stomach and liver upward.

Under these conditions, an average adult male can flush his lungs with about 4 liters of air at each breath. This is called the vital capacity. Even with maximum expiration, about 1200 ml of residual air remain. The table shows what happens to the composition of air when it reaches the alveoli. Some of the oxygen dissolves in the film of moisture covering the epithelium of the alveoli. From here it diffuses into the blood in a nearby capillary. It enters a red blood cell and combines with the hemoglobin therein. At the same time, some of the carbon dioxide in the blood diffuses into the alveoli from which it can be exhaled.

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CASE STUDY: Bronchial Asthma In Acute Exacerbation

Composition of atmospheric air and expired air in a typical subject. Note that only a fraction of the oxygen inhaled is taken up by the lungs. Component N2 (plus inert gases) O2 CO2 H2O Atmospheric Air (%) Expired Air (%) 78.62 20.85 0.03 0.5 100.0% 74.9 15.3 3.6 6.2 100.0%

The ease with which oxygen and carbon dioxide can pass between air and blood is clear from this electron micrograph of two alveoli (Air) and an adjacent capillary from the lung of a laboratory mouse. Note the thinness of the epithelial cells (EP) that line the alveoli and capillary (except where the nucleus is located). At the closest point, the surface of the red blood cell is only 0.7 m away from the air in the alveolus. (Reproduced with permission from Keith R. Porter and Mary A. Bonneville, An Introduction to the Fine Structure of Cells and Tissues, 4th. ed., Lea & Febiger, 1973.)

Central Control of Breathing

The rate of cellular respiration (and hence oxygen consumption and carbon dioxide production) varies with level of activity. Vigorous exercise can increase by

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2025 times the demand of the tissues for oxygen. This is met by increasing the rate and depth of breathing. It is a rising concentration of carbon dioxide not a declining concentration of oxygen that plays the major role in regulating the ventilation of the lungs. Certain cells in the medulla oblongata are very sensitive to a drop in pH. As the CO2 content of the blood rises above normal levels, the pH drops [CO2 + H2O HCO3 + H+], and the medulla oblongata responds by increasing the number and rate of nerve impulses that control the action of the intercostal muscles and diaphragm. This produces an increase in the rate of lung ventilation, which quickly brings the CO2 concentration of the alveolar air, and then of the blood, back to normal levels. However, the carotid body in the carotid arteries does have receptors that respond to a drop in oxygen. Their activation is important in situations (e.g., at high altitude in the unpressurized cabin of an aircraft) where oxygen supply is inadequate but there has been no increase in the production of CO2.

Local Control of Breathing

The smooth muscle in the walls of the bronchioles is very sensitive to the concentration of carbon dioxide. A rising level of CO2 causes the bronchioles to dilate. This lowers the resistance in the airways and thus increases the flow of air in and out.

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Bronchial Asthma In Acute Exacerbation

-Gender -Age -Family History -Race

-Viral Respiratory Infections -Allergen exposure (animal dander, dust, pollen, etc.) -change in Weather -Exercise -Smoke ( fr. Vehichles, smokers ect.)

Exposure to different pathogens

Entry of allergens

Release of Immunoglobulin E (IgE)

Release of different chemical mediators

Mast cell degranuation

Release of the different inflammatory chemical mediators



Histamine, Bradykinin, and other inflammatory mediators

Release of eosinophils (to combat allergen)

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CASE STUDY: Bronchial Asthma In Acute Exacerbation

Inflammatory Process

Mucus Production

Increase Vascular Permeability

Direct stimulation of vagal efferents

Mucosal Edema


Further edma

More release of other inflammatory mediators

Epithelial damage

Decrease Ciliary Function

Mucus Hypersecretion

Increase airway responsiveness

Wheezing, continuous coughing, feelings of chest tightness

Dyspnea, moist skin, tachypnea

Fatigue, Anxiety

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The bronchi and bronchioles are very responsive to irritants, leading to contraction of the smooth muscles (bronchoconstriction), inflammation with edema (swelling), and increased secretion of thick mucous. These changes can block the airways, totally or partially, interfere with the air flow and oxygen supply. In extrinsic asthma, the allergic reaction causes release of chemical mediators like histamine that causes the bronchospasms, edema and increased mucous secretion. This reaction also stimulates tha vagus nerve, causing a reflex bronchoconstriction. The second stage of the allergic reaction occurs a few hours later. During this stage, the increased leukocytes (white blood cells) released additional chemical mediators that cause tissue damage. Left untreated, frequented and prolonged attack can lead to chronic asthma later in life. The mechanisms behind intrinsic attacks are not fully understood.

Partial obstruction of the smaller airways results in air trapping with hyperinflation of the lungs. Air passes into the areas distal to the obstruction (alveoli), but are only partially exhaled. Since exhalation is a passive process, less force is available to move air out, and forced expiration often collapses the bronchial wall, creating a further barrier to exhalation. The residual volume (air left in the lungs after exhalation) increases and as a result. It becomes harder to inhale fresh air or to cough to effectively remove the mucous. To better understand the air trapping, try this experiment. Take several breaths and exhale only partially before inhaling again. After a few breaths you will see how hard it is to inhale, or to cough. This is what an asthma attack feels like.

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CASE STUDY: Bronchial Asthma In Acute Exacerbation

Total obstruction of the airway results when mucous plugs completely block the airflow in an already narrowed passage. This leads to atelectasis (collapse of the alveoli). The air left in the alveoli diffuses out and is not replaced. This could lead to collapse of the lung. Both a partial and total obstruction will lead to hypoxia. Oxygen levels are further depleted by the increase demand by the muscles of respiration and by the stress of the individual fighting for air. Hypoxemia causes vasoconstriction if the pulmonary blood vessels, slowing blood flow and increasing the workload of the right side of the heart.

With repeated acute asthma attacks, irreversible damage occurs in the lungs. The bronchial walls become thickened, and fibrous tissue resulting from the frequent infections that follow attacks develops in atelectic areas. Because it is impossible to remove all of the tiny mucous plugs in the small airways, complications are common following frequent episodes of asthma.

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A. Laboratory Test

URINALYSIS (January 27, 2012)

NORMAL RANGE Physical exam Color Pale yellow to amber

Clear to slightly hazy





characteristic Chemical exam Specific gravity Protein Sugar Microscopic exam RBC Pus cells

slightly turbid


1.003 - 1.040 Negative negative

1.010 negative negative

Normal Normal Normal

4 /HPF 2 to 3 HPF

4-6/HPF 0-2/ HPF

Normal normal

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HEMATOLOGY REPORT (January 28, 2012)

REFERENCE VALUE WBC Count Lymphocytes RBC Count Hemoglobin Hematocrit 5 10 10^3/uL 0.25 0.50 3.80 5.8 10^6u/L 115.00-160.00 g/dL 0.37 0.47 %



8.7 0.22 4.18 132 .41%

Normal Decreased. Normal Normal Normal

B. Nursing Care Plan

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C. Drug Study

Nursing Considerations and Name of Drug Action Indication/Contraindication Responsibilities

Levopront 15ml / TID

The medication with drug Levopront yet to materialize

Indicated with: Symptomatic treatment of cough dry

-Should be taken on an empty stomach (Take between meals.)

unproductive cough with pharyngitis, influenza, pneumonia, bronchial asthma, emphysema lungs.
Contraindicated with: hypersensitivity, the excess rate, expressed violation of the liver

-Instruct patient to increase oral fluid intake -instruct patient not to perform tasks that require alertness

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Name of Drug

Action The phenylpropanolamine HCl is a sympat homimetic amine with achemical structure and pharmacological actions similar to the ephedrine, but with fewer central stimulant effects. It is a vasoconstrictor with decongestant action on the nose and upper respiratory tract mucous membranes. It


Nursing Considerations and Responsibilities

-Administer the medication with a full glass of water after a Indicated with: Urinary incontinence, relive symptoms of some allergic disorders such as asthma and have fever. Contraindicated with: Patients with high blood pressure, over activity of the thyroid gland, coronary heart disease or diabetes, or who are taking antidepressant drugs meal or snack. The tablet can be broken in half. However, the whole or half tablet should be swallowed whole. -Assess for kidney disease, heart disease, lung disease, asthma, emphysema, high blood pressure, an overacti ve thyroid, diabetes, glaucoma, prostatetrouble, depression, any allergies of the patient. -Caution patient not to exceed recommended doses.

Nafarin A 1 Tab BID

directly and indirectly stimulates the a- and b-adrenergic receptors. It exerts this last action by allowing the norepinephrine liberation (noradrenaline) from its storage sites. Its action on the a-receptors in the respiratory tract mucosa produces vasoconstriction, which results in the decrease of the mucosa edema and the consequent increase of the nasal air flow.

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XI. DISCHARGE PLANNING/ PROGNOSIS Medications: Administer prescribed medications, such as bronchodilators, anti-inflammatory, and antibiotics Give paracetamol if have fever

Exercise: Patient will verbalize need importance of exercise and demonstrate proper initiation of appropriate exercise. Advise the patient to exercise daily for good and healthy body.

Treatment: Respiratory therapy Combivent neb q6 T.I.D

Health Teaching: Increase fluid intake Eat a balance healthy diet. Proper hygiene

Out patient follow up: Diet: It is recommended to eat hypoallergenic diet. Advised the patient to have a follow up check up based on the discharge plan of the doctor for him.

Spiritual: Advise patient to pray so that God will help him in her daily life and bring forth more blessings.

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