INTRODUCTION Asthma is a chronic inflammatory disorder of the airways resulting in bronchospasm, which be completely or partially reversed with or without

specific therapy. Airway inflammation is the result of interactions between various cells, cellular elements and cytokines. Asthma is one of the most common disease

globally affecting about 300million people. This condition is likewise prevalent among Filipinos. International Statistics by country for asthma showed that 5.5 million (15.6%) Filipinos are afflicted with asthma. Asthma differs from other obstructive lung diseases in that it is largely reversible, either spontaneously or with treatment. Patients with asthma may

experience symptoms free periods alternating with acute exacerbations that last from minutes to hours or days. Asthma is the most common disease of childhood and can occur at any age. Despite increased knowledge regarding the pathology of asthma and the development of better medications and management plans, the death rate from the disease continues to increase. For most patients, asthma is a disruptive disease, affecting school and work attendance, occupational choices, physical activity and general quality of life. Allergy is the strongest predisposing factors for asthma. Chronic exposure to airway irritants or allergens also increases the risk of asthma. Common allergens can be seasonal (grass, tree, and weed pollens) or perennial (eg, mold, dust, roaches, animal dander.) Common trigger s for asthma symptoms and exacerbations include airway irritants (eg, air pollutants, cold, heat weather changes, strong odors or perfumes, smoke), exercise, stress or emotional upset, sinusitis with postnasal drip, medications, viral respiratory tract infections, and gastroesophageal reflux. Most people who have asthma are sensitive to a variety of triggers. A persons asthma changes depending on the environment, activities, management practices, and other factors. The three most common symptoms of asthma are cough, dyspnea, and wheezing. In some instances, cough may be the only symptom. An asthma attack often occurs at night or early in the morning, possibly because of circadian variations that influence airway receptor thresholds.

An asthma exacerbation may begin abruptly but most frequently is preceded by increasing symptoms over the previous few days. There is cough, with or without mucus production. At times the mucus is so tightly wedged in the narrowed airway that the patient cannot cough it up. There may be generalized wheezing, first on expiration and then possibly during inspiration as well. Generalized chest tightness and dyspnea occur. Expiration requires effort and becomes prolonged. As the exacerbation progresses, diaphoresis, tachycardia, and a widened pulse pressure may occur along with hypoxemia and central cyanosis (a late sign of poor oxygenation). Although life threatening and severe hypoxemia can occur in asthma, it is relatively uncommon. The hypoxemia is secondary to a ventilation-perfusion mismatch and readily responds to a supplemental oxygenation. Symptoms of exercise-induced asthma include maximal symptoms during exercise, absence of nocturnal symptoms, and sometimes only a description of a choking sensation during exercise. Patients with recurrent asthma should undergo tests to identify the substances that precipitate the symptoms. Possible causes are dust, dust mites, roaches, and certain types of cloth, pets, horses, detergents, soaps, certain foods, molds, and pollens. If the attacks are seasonal, pollens can be strongly suspected. Patients are instructed to avoid the causative agents whenever possible. Knowledge is the key to quality asthma care. National guidelines are available for the care of patients with asthma. Unfortunately, not all health care providers follow them. Asthma exacerbations are best managed by early treatment and education, including the use of written action plans as part of any overall effort to educate patients about self management technique especially those with moderate or severe persistent asthma and those with a history of severe exacerbations. Quick acting beta2-adrenergic agonist medications are first used for prompt relief of airflow obstruction. Systemic corticosteroids may be necessary to decrease airway inflammation in patients who fail to respond to inhaled beta-adrenergic medications. In some patients, oxygen supplementation may be required to relieve hypoxemia associated with moderate to severe exacerbations. In addition, response to treatment may be monitored by derail measurements of lung function.

Evidence from clinical trials suggests that antibiotic therapy whether administered routinely or when suspicion of bacterial infection is low, is not beneficial for asthma exacerbations. Antibiotics may be appropriate in the treatment of acute asthma exacerbations in patients with co-morbid conditions (e.g. fever, and purulent sputum, evidence of pneumonia, suspected bacterial sinusitis.

OBJECTIVES GENERAL OBJECTIVE 1. To fully learn about the underlying processes involved in Bronchial Asthma in Acute Exacerbation, its etiological process, complications, and treatments for its prevention and termination.

SPECIFIC OBJECTIVES 1. To identify the causes of Bronchial Asthma in Acute Exacerbation. 2. To enumerate the signs and symptoms of the disease. 3. To trace the anatomy and physiology of the system involved. 4. To trace the pathophysiology of the disease. 5. To identify the different ways of treating the disease. 6. To inform how the disease can be treated.

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE: nahihirapan akong huminga as

Ineffective airway clearance related retained bronchial to

After 8 hours of nursing

>Elevate head of the bed position hours or change every 2

>to

take

advantage

After 8 hours of

gravity decreasing pressu nursing on the Diaphragm and enhancing drainage of /ventilation to different lung segments interventions the client have a patent airway

interventions the client will have a patent airway clearance.

verbalized by the client.

clearance.

OBJECTIVE: > conscious > coherent > difficulty in

secretions as manifested by difficulty of breathing.

>keep allergen

environment free (eg,

breathing > ( +) productive cough > cyanosis

dust, feather, pillows, smoke)

>encourage breathing

deep and >to maximize effort

coughing exercises

>assessed condition

patients

PATHOPHYSIOLOGY
Exercise, cold exposure to allergen, ingestion of aspirin, pulmonary infection, inhaled irritants, stress

IgE Production

Re-exposure to antigen

Release pre-formed mediators that open tight junctions between

Antigen enter the Mucosa

Activation of mucosal mast cells and

Mediators: Histamine, SRS-A, prostaglandin, Bradykinines Leukotines

Airway Hyper responsiveness

Vascular Permeability

Bronchospasm

Edema

Further release of leukocytes (Neutrophils ,Eosinophil, Basophil,

No. Of mucus by Goblet cell, in mucosa and hypertrophy of submandibular glands

Basement membrane underlying the mucosal Epithelium is thickened and there is hypertrophy

Chest

Wheezes

Intense inflammation of Bronchial walls

Productive cough

Peak Flow Variability

Shortness of breath

PATHOPHYSIOLOGY Environmental factors interact with inherited factors to caused asthmatic reactions with associated bronchospasms in asthma bronchial lining over react to various stimuli, causing episodic smooth muscle spasm that severely constrict the airways. On subsequent exposure to antigen, mast cells degranulate and release mediators. Mast cells in the lungs interstitium are stimulated to release histamine and Leukotrienes. Histamine attaches to receptor sites in larger bronchi, where

causes swelling of smooth muscles. Mucus membrane become inflamed, irritated and swollen. The patient may experience dyspnea, prolonged expiration and an increased respiratory rate. Leukotrienes attached to the receptor site in the smaller bronchi and can cause local swelling of the smooth muscle. Leukotrienes also caused prostaglandin to travel through the blood stream to the lungs, where they enhance the histamines effect. A wheeze maybe audible during coughing the higher the pitch, the narrower the bronchial lumen. Histamines stimulates the mucos

membranes to secrete excessive mucusto further narrow the bronchial lumen. Goblet cells secrete viscous mucus that is difficult to cough out resulting in coughing, rhonchi, increase pitch wheezing and increases respiratory distress. Mucosal edema and thicken secretions further block the airways. On inhalation, the narrow bronchi lumen can still expand slightly, allowing air to reach the alveoli. On exhalation, increase intrathoraxic pressure closes the bronchial lumen. The following signs and symptoms are possible to occur. Sudden dyspnea, wheezing and tightness in the chest

PATIENTS PROFILE Case no: Name of the patient: Address: Birthday: Birthplace: Age: Sex: Civil Status: Religion: Occupation: Citizenship: Attending Physician: 21837 Patient X Villa de Lipa, Maraouy, Lipa City September 6, 1967 Pola O.R Mindoro 44 years old Female Married Roman Catholic Librarian (De La Salle Lipa) Filipino Dr. Marjorie Reyes Felix, MD

CHIEF COMPLIANT The patient is complaining of difficulty of breathing.

HISTORY OF PRESENT ILLNESS The patient was diagnosed with bronchial asthma since she was young. Two days prior to admission, the patient experienced non productive cough, watery nasal discharge, and (-) fever and decreases in appetite. One week prior to admission, the patient experienced difficulty of breathing and she experienced it fewer at night that caused of feeling fatigue during the day.

HISTORY OF PAST ILLNESS During her childhood, she suffered from minor illness such as fever, cough and colds, she has a complete immunization status, she has no allergies when it comes to food or medications. She also doesnt experience of having an accident that might endanger her life or death. And she undergo a TAHBSO surgery.

FAMILY HISTORY In the father side of the client, they have a history of being Asthmatic. My father and my husband are smoker said by the client

LIFESTYLE AND HEALTH PRACTICE The client never tried to smoke cigarettes or other tobacco products, but the people around her environment are smokers like her father and her husband. No use of alcohol reported. According to her she is exposed to some environmental conditions that can affect her breathing, because she is a librarian maybe she can inhale dust that came from the book. Their house also is near from the highway. She is exposed to the air pollution coming from the vehicle. In her eating habits, she is always eating carbohydrates, high cholesterol and some fruits. Her rest and sleep pattern was not good because of her frequent coughing at night.

LABORATORY EXAMINATONS

LABORATORY EXAM Hemoglobin

NORMAL VALUE Female:12.0-16.0g/dl

RESULT 13.9

INTERPRETATION

This shows that the hemoglobin is in normal range.

Leukocyte number

5-10x10 9/l

3x10 9/l

This indicates low level of concentration hyponatremia

Lymphocytes Volume

0.24-0.45

0.26

Lymphocytes is slightly lower than normal range which may reduce resistance in fighting against infection

White Blood Cells

5,00010,000 cu/mm

11,000 cu/mm

Above normal count signifies presence of infection

Thrombocytes

150,000450,000/mm3

206,000/mm3

Normal

COURSE IN THE WARD

June 24, 2011, 12:40pm, - it was ordered to admit the patient to the room of choice under the service of Dr. Marjorie Reyes Felix, MD. The consent was

secured. Hypoallergenic diet was advised and IVF 1L x 12 hours was also ordered. Laboratory examination was ordered such as: complete blood count, chest X-ray, Urinalysis, and HBa1C. Levofloxacin 500 mg IV once a day, Fluimucil 600 mg tablet in glass of water once a day, Seretide 500 mg discussed 1 puff twice a day was ordered and carried out by the staff nurse.

June 25, 2011, 3:10pm, - the patient was given Metformin twice a day and acetyl salicylic acid due to positive diabetes mellitus. Negative allergy against

medicines was proven. Seen and examined by the attending physician. IVF rate maintained.

June 26, 2011, IVF rate was maintained during five cycles. Salbutamol was ordered in two inhalations every 4 to 6 hours. Other medications are continued as ordered.

ANATOMY AND PHYSIOLOGY OF RESPIRATORY SYSTEM

The upper respiratory tract consists of the nose, sinuses, pharynx, larynx, trachea, and epiglottis. bronchioles and the lungs. The lower respiratory tract consists of the bronchi,

The major function of the respiratory system is to deliver oxygen to arterial blood and remove carbon dioxide from venous blood, a process known as gas exchange. The normal gas exchange depends on three processes such as ventilation which is movement of gases from the atmosphere into and out of the lungs. This is accomplished through the mechanical acts of inspiration and expiration, diffusion which is a movement of inhaled gases in the alveoli and across the alveolar capillary membrane, and perfusion which is movement of oxygenated blood from the lungs to the tissues. Control of gas exchange involves neural and chemical process. The neural system, composed of three parts located in the pons, medulla and spinal cord, coordinates respiratory rhythm and regulates the depth of respirations. The

chemical processes perform several vital functions such as: regulating alveolar ventilation by maintaining normal blood gas tension, guarding against hypercapnia (excessive CO2in the blood) as well as hypoxia (reduced tissue oxygenation caused by decreased arterial oxygen [PaO2]. An increase in arterial CO2 (PaCO2) stimulates ventilation; conversely, a decrease in PaCO2 inhibits ventilation, helping to maintain respirations (through peripheral chemoreceptors) when hypoxia occurs.

The normal functions of respiration O2 and CO2 tension and chemoreceptors are similar in children and adults. however, children respond differently than adults to respiratory disturbances; major areas of difference include: poor tolerance of nasal congestion, especially in infants who are obligatory nose breathers up to 4 months of age, increased susceptibility to ear infection due to shorter, broader, and more horizontally positioned eustachian tubes, increased severity or respiratory symptoms due to smaller airway diameters, a total body response to respiratory infection, with such symptoms as fever, vomiting and diarrhoea.

Assessment
Subjective: Nahihirapan akong huminga as verbalized by the patient Objective: wheezing upon inspiration and expiration dyspnea tachycardia chest tightness suprasternal retraction productive cough

Nursing Diagnosis
Ineffective airway clearance RT bronchoconstri ction, increased mucus production, and respiratory infection AEB wheezing, dyspnea, and cough

Planning
After 5-6 hours of nursing intervention The Patient will maintain/impro ve airway clearance AEB absence of signs of respiratory Distress

Intervention
1. Adequately hydrate the pt.

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

Evaluation
Goal met By verbalization of the patient of Ok na po ang aking paghinga, hindi na ako nahihirapan

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

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

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

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

4. Teach early signs of infection that are to be reported to the clinician immediately. Increases sputum production Change in color of sputum Increased thickness of sputum Increased SOB, tightness of chest, or fatigue Increased coughing Fever or chills

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

- Increased fluid intake to 3000 ml/ day. Provide warm or tepid liquids. Collaborative:

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

DISCHARGE PLANNING

Medication
Continue medications prescribed by the physician Salbutamol: adult: PO 2-4 mg 3-4 times per day, 4-8 mg sustained release two times a day Inhaled 1-2 inhalations every 4-6 hours

Exercise
Deep breathing and coughing exercise

Treatment
Continue medications prescribed by the physician Provide adequate rest periods

Health teaching
Teach the client to do purse-lip breathing and relaxation techniques Maintain a dust-free environment Reduce exposure to pollen

Out patient follow up

Notify the health care provider when respiratory infection occurs Make appropriate referrals to home health agencies for assistance in obtaining medical and assistive equipment

Diet
Hypoallergenic diet Increased fluid intake to thin bronchial secretion PHYSICAL ASSESSMENT
Parts Skin Technique Inspection Palpation Normal Findings Skin is brown and generally equal No edema Good skin turgor No lesion Temp. is warm & Cool Clean, smooth Pink to light No lesion No dandruff Symmetrical in movement & Position Face is Symmetrical Normocephalic Symmetrical in Position Sclera is white & Glossy PERRLA Equal in size Symmetrical No swelling or Discharges Symmetrical No inflammation Air can be felt in both nare Tongue is at Midline Abnormal With rushes Pale Actual Findings Normal Significance Indicates hydration

Nails

Inspection

brown nail beds

Normal

For sufficient blood supply

Hair

Inspection

Even in distribution Not symmetric

Normal

Head

Inspection

Normal

Head inspection may indicate brain damages

Eyes

Inspection

Brisk reaction to Light Pale conjunctiva

Normal

To determine the cability for light sensitivity

Ears

Inspection

Unequal

Normal

Nose

Inspection Palpation

Asymmetrical

Normal

Nasal obstruction may increase difficulty of breathing

Mouth & Throat

Inspection

Cracked lips Tongue is pale Dental caries Present Asmmetrical

Missing tooth

Sores may indicate presence of microorganisms related to BAIAE

Neck

Inspection Palpation

Symmetrical with normal ROM No jugular vein Distention Trachea is visible at the midline No nodule

None

Lymph nodes are not palpable

Breast & Axilla

Inspection Palpation

One breast is slightly larger No nipple discharge No masses No lymph nodes palpated

Nipple discharge Presence of masses and lymph nodes

None

Chest

Inspection Palpation Auscultation

Normal contour Tactile fremitus Bronchial breath sounds Limited chest excursion Color is consistent with the body

Poor contour Wheezes

Wheezes

May indicate BAIAE

Abdom en

Inspection

No lesion or any abnormal findings Bowel sounds is normo- active (13/min) No tenderness Limited ROM Slightly limited ROM May indicate body malaise

Extremities

Inspection

Norma hair distribution No edema No swelling Capillary refill around 1-3 seconds

DRUG STUDY
GENERIC NAME BRAND NAME CLASSIFICATION INDICATIONS CONTRA INDICATION allergy to floutoquinolones, lactation. Use cautosly with renal dysfunction, seizures and emergenxy NURSING INTERVENTION levaquin LEVOFLOXACI N 500mg IV Antibacterial Acute s bacterial caused by sta exacerbation of chronic bronchitis caused by staphylococcus aureus, s.,pneumomiae, m. catarrhalis.h. parainfunce adjunct to diet and exercise to lower blood in patiets with type 2 diabetes Reconstituted solution should be clear,slightly yellow and free of particulate matter -Levoploxacin shouldonly b be administered by slow infusion because a rapid be bolus administration t that result in hypotension. -dont mix with other drugs

METFORMIN HYDROCHLOR IDDE 1tab, bid, oral

Glucophage, glucophagexe

Ntidiabetic

Adjunct to die and exercise to lower blood glucose in patients with type 2 diabetes

Contarindicated with allergy to metformin, CHF, diabetes complicate by fever,

Monitor urine or serum glucose levels frequently to ermine affecting of drug and discharge

Albuterol hydrochloride

salbutamol

Antaasthmatic

Relief for bronchospasm in patients with with reversible obstructive airway disease

Contarindicated with allergy toalbuterol, tachycardia, caused by digitalis intoxication,

Use minimal doses for normal and nominal periods, drug tolerance prolongd use -maintaining beta a drenergic bladder on h andby in case cardiac arrhythmia occur.