Introduction The hardest years in life are those between ten and seventy.

Symptoms of different diseases are starting to manifest as people become older. When people experience a lot of symptoms that may mean detrimental to ones health, it increases their anxiety causing them to avoid seeking medical advices. Avoidance of seeking medical advices may result to aggravation of certain illness. This is a case of Patient E. L. A. from Imus, Cavite City. She was admitted at the Medical Center of Imus with a diagnosis of Bronchial Asthma in Acute Exacerbation. Bronchial asthma is a disease caused by increased responsiveness of the tracheobronchial tree to various stimuli. The result is paroxysmal constriction of the bronchial airways. Bronchial asthma is the more correct name for the common form of asthma. The term 'bronchial' is used to differentiate it from 'cardiac' asthma, which is a separate condition that is caused by heart failure. Although the two types of asthma have similar symptoms, including wheezing (a whistling sound in the chest) and shortness of breath, they have quite different causes. Asthma is a chronic, inflammatory disease in which the airways become sensitive to allergens (any substance that triggers an allergic reaction). Several things happen to the airways when a person is exposed to certain triggers:

The lining of the airways become swollen and inflamed. The muscles that surround the airways tighten. The production of mucus in increased, leading to mucus plugs.

All of these factors will cause the airways to narrow, thus making it difficult for air to go in and out of your lungs, causing the symptoms of asthma.Sometimes, the only symptom is a chronic cough, especially at night, or coughing or wheezing that occurs only with exercise. Some people think they have recurrent bronchitis, since respiratory infections usually settle in the chest in a person predisposed to asthma. This case was selected for the study because it caught the curiosity and interest of the students and since the class is currently taking the course of Nursing Care Management 102 which focuses on Curative and Rehabilitative Nursing Care and Management with clinical focus on Medical Surgical Nursing. These conditions impose challenges to us, nurses; how could we render safe and satisfying care to clients suffering from conditions such as these? In this comprehensive study, we had utilized nursing process to identify the actual and potential problems observed in the client and formulated interventions to minimize or eliminate such problems.

CHIEF COMPLAINT OR REASON FOR VISIT The client had been admitted in the Medical Center Imus with chief complaint of persistent coughing with difficulty of breathing PATIENTS PROFILE

NAME: AGE: DATE OF BIRTH: GENDER: ADDRESS: DATE OF ADMISSION: TIME OF ADMISSION: DIAGNOSIS: CHIEF COMPLAINT: HOSPITAL:

MRS. E. L. A. 55 y/o October 12, 1956 Female Imus, Cavite August 20,2011 11:42 A.M Bronchial Asthma in Acute Exacerbation Persistent cough and Difficulty of breathing Medical Center Imus

NURSING HEALTH HISTORY History Present Illness The first symptom started last 1990 when she was pregnant on her 1st child but subsided when her baby was aborted. Her doctor prescribed her home medications in case symptoms re occur. Past Medical History According to the pt., her childhood illnesses are chickenpox, mumps, and measles. Her immunization is complete. She had allergic reaction with seafoods. Regarding accidents, injuries and illness, our patient recalls none in particular that would require hospitalization. She presently takes salbutamol inhaler and celestamine as her medications.

Family History of Illness

Grandm other

Grandfa ther

Old Age
Mother Father

Old Age

HTN,TB and DM

HPN, Asthma and DM(borderline)

Daughter Daughter

Son

AE

Daughter

Son

Daughter

Son

Heart attack Heart attack

VA Alive Heat attack Alive (Asthma, HTP,HPN)

Alive

Alive

Health-Perception and Health Management Her perception of her own health is good but not that great because of her intermittent weakness and difficulty of breathing. She always makes sure to exercise daily to become fit for work. She is aware of her diagnosis and prognosis so she makes sure to make her medications available. Now, she plans to, first, limits her food intake slowly, second, to loose weight, third, to never forget to skip meals and last is not to over work. Nutritional-Metabolic Pattern She had her usual eating pattern of rice, vegetables and fish and dislikes food that triggers her allergy (sea foods) and oily foods. She usually forgets to eat on time because of work, and lately her appetite increases, resulting in weight gain. During her hospitalization, her appetite decreases, but she still tries to comply on her needed diet (DAT) but still she begun to loose weight gradually. She does not drink any vitamins and slimming aids.

Eliminating Pattern She had a normal urine and bowel movement everyday. She urinates 3-5x a day, with a light yellow color and aromatic in odor. She defecates in routine (every morning when she wakes up) once a day with characteristics of formed and dark brown in color. While she was hospitalized, there is a slight change in the frequency but not that alarming, because she explained that it is just normal because she is not comfortable of the environment. Activity-Exercise Pattern She is able to perform activities of daily living. She exercises by means of walking everyday and she thinks this help a lot in maintaining a healthy lifestyle. She doesnt get tired easily before her asthma attack begun. 2 weeks ago she started to have difficulty of breathing and dizziness because of the bathroom deodorizer her son placed in the restroom because of foul odor. Since then she felt weakness, dizziness and difficulty of breathing. When she is hospitalized, she wasnt been able to exercise like before because of lack of space (she is always in bed resting) Sleep-Rest Pattern She sleeps 5-6 hours a day, finds no difficulty in falling asleep and waking up feeling rested. Her sleeping pattern is continuous until her asthma attack broke. She drinks coffee 2-3 x a week, same goes with drinking caffeinated beverages in small amount (approximately 1 cup). She snores but never experienced sleep walking and sleep apnea. She never tried to medicate sleeping pills. While she is hospitalized, she developed poor sleeping habit (2-3 hours). Cognitive-Perceptual Pattern She has sensory deficit, specifically on her eyes. (R-225 L-175). She often experience memory lapses. She verbalized tolerance of pain. Self-Perception and Self Concept Pattern She value herself so much for the sake of her only son. She wants to see her son in a stable state. When she was hospitalized she tried to gain her health back immediately. Role-Relationship Pattern She plays the role of father and mother to her son. She wasnt been able to fully care for her son while she was hospitalized.

Sexuality-Reproductive Pattern Her husband died 3 months ago. She was not sexually active since 2009. She said that since she was old, sex is not important anymore. All throughout of her life, she had 5 pregnancies but only 1 lived and the rest was accidentally aborted. Coping and Stress Management Financial problem was her usual stressor. She turns to God when problems occur. Though she is faithful she sometimes suffers from hopelessness because of trials she is encountering such as her illness. During her hospitalization, she prays more often to comfort her soul.

Value-Belief in Life She have a lot of faith in God, attends to seminars and other activities regarding to her advocacy of her religion. PHYSICAL ASSESSMENT WHAT TO ASSESS BODY BUILT POSTURE AND GAIT General appearance HYGIENE AND GROOMING BODY ODOR SIGNS OF DISTRESS AFFECT OR MOOD SPEECH TEMPERATURE PUSE RATE RESPIRATORY RATE BLOOD PRESSURE COLOR SYMMETRY OF COLOR EDEMA SKIN LESIONS MOISTURE TEMPERATURE SKIN TURGOR NAIL CURVATURE TEXTURE NAILBED COLOR SURROUNDING TISSUE CAPILLARY REFILL ACTUAL FINDINGS Proportionate Relaxed and erect Coordinated Clean and neat No odor Labored breathing Cooperative Understandable 36.7 Axillary 97 27 140/90 Brown Uneven No edema Smooth Dry Uniform Good Convex 160 Smooth Pinkish Intact Less than 4 seconds

Vital Signs

Skin

Head

DISTRIBUTED THICKNESS TEXTURE AND OILINESS BODY HAIR SIZE AND SHAPE CONTOUR FACIAL FEATURES FACIAL MOVEMENT EYESBROWS EYELASHES EYELIDS CONJUNCTIVA CORNEA PUPILS PERIPHERAL VISION EXTRAOCULAR MOVEMENT VISUAL ACUITY PINNA

Evenly distributed Thickness Silky Absent leg hair Normocephalic Smooth Symmetrical symmetrical Evenly distributed Equally distributed Intact 15-20 involuntary blinks Shiny Transparent Black Equal in size PERLLA Intact Coordinated

Eyes

Ears EAR CANAL HEARING ACUITY EXTERNAL NOSE Nose NASAL CAVITY UVULA OROPHARYNX Pharynx TONSILS GAG REFLEX LIPS TEETH Neck GUMS

Difficulty Uniform color with skin Symmetrical Aligned Dry cerumen Intact Symmetric Uniform color Patent In midline Pink Smooth Pink Smooth Intact Soft Symmetrical Movable Missing Dental caries Pinkish Moist

 TONGE Chest and lungs

Mouth

Heart

PALATE MUSCLES MOVEMENT RANGE OF MOTION MUSCLE STRENG LYMPH NODES TRACHEA THYROID GLAND CAROTID PULSE JUGULAR VEINS BREATHING PATTERN SHAPE AND SYMMETRY SPINAL ALIGNMENT RESPIRATORY EXCURTION FREMITUS PERCUSSION SOUND BREATH SOUND BREATH SIZE AND SHAPE SKIN AREOLA NIPPLES PRECORDIUM HEART SOUND

Midline Movable Pinkish Light pink Equal in size Coordinated Full Equal Not palpable In midline Not visible Symmetrical pulse Not visible Dyspnea APL ratio 1:1

Aligned Decreased Decreased Dull Wheeze Unequal Smooth Round Round Pulsations S1 louder at S2 at base Unblemished Distended Distended Symmetrical Normoactive dull Equal Firm Equal Grade 3 Full

SKIN INTEGRITY Abdomen CONTOUR BOWEL SOUNDS PERCUSSION MUSCLE SIZE MUSCLE TONE MUSCLE STRENGTH

Back and Extremities

RANGE OF MOTION

Diagnostic Test and Description CBC (Complete Blood Count) Common blood test that measures the ff: 1. Number of RBCs 2. Number of WBCs 3. Total amount of Hgb in the blood 4. Fraction of the blood composed of RBCs (Hct) Also provides information about the ff. measures: 1. Average RBC size (MCV) 2. Hgb amount per RBC (MCH) 3. Amount of Hgb relative to the size of the cell (Hgb concentration) per RBC (MCHC) I:

Indication and Contraindication Used to diagnose and manage numerous diseases. It can reflect problems with fluid volume (such as DHN) or loss of blood. It can show abnormalities in the production, lifespan and destruction or chronic infection, allergies and problems with clotting. It isolates and counts the 7 types of cells found in the blood: 1. Neutrophil s 2. Eosinophil s 3. Basophils 4. RBCs 5. Lymphocy tes 6. Monocytes

Client Preparation and Post Procedure Instruction CP: There is no special preparation for Complete Blood Count PPI: Discomfort or bruising may occur at the puncture site. Applying pressure to the puncture until the bleeding stops to help reduce bruising. Warm packs relieve discomfort. Some people feel dizzy or faint after blood has been drawn and should be treated by resting for a while. Assess the puncture site for S/Sx of infection,subcutaneou s redness, pain, swelling and tenderness.

Normal Findings Hgb: F: 120 160 g/L

Actual Finding 126

Clinical Significance Patients Hgb is in normal range. Patients Hct is in normal range. RBC is low.Decrease RBC count can mean bleeding or anemia.

Hct: F: 0.37 0.47g/L

0.37

RBC count: F: 4.0 5.5x10^^/L

3.96

Platelet: 142-424

Adequate

Neutrophil: 0.51 -0.57

0.88

Adequate Platelet count. Low Platelet count can lead to Bleeding and excessive blood loss. High Finding Reveals Local Infection

 Platelet count

7. Platelet Lymphocyte: 0.25 0.33 0.12

High Finding Reveals Viral Infection. While of the finding was low it can mean high risk for infection.

Diagnostic Test and Description Serum: Creatinine The creatinine test is used to measure the amount of creatinine in the blood. Because creatinine is a nonprotein end-product of creatine phosphate, which is used in skeletal muscle contraction, the daily production of creatine, and the following product, creatinine, depends on muscle mass, which fluctuates very little. Creatinine is excreted entirely by the kidneys, and therefore is directly related to renal function. When the kidneys are functioning normally, the serum creatinine level should remain constant and normal. I:

Indication and Contraindication

Client Preparation and Normal Post Procedure Findings Instruction CP: 46 - 92 umol/L To measure the level Any form of of the waste product strenuous exercise creatinine in a should be strictly person's blood. avoided for at least To assess the 48 hours prior to the Lymphocyte: functioning of the test. 0.25 0.33 kidneys. Meat and other highTo monitor the protein foods should progress of a kidney be restricted for about disease and to assess 24 hours before the a patient's response test. to treatment. Patient is asked to To tell if a person is drink adequate suffering from amounts of fluids. severe dehydration. Tea or coffee is best To watch out for avoided as they renal toxicity in promote urine patients who may be formation and loss of susceptible to kidney body salts. damage, and are on medicines that could in some cases affect PPI: the kidneys Monitor the adversely. venipuncture site for It may also be bleeding and signs indicative of of infection.. bleeding in the digestive or respiratory tract.

Actual Finding

Clinical Significance

64 umol/L

Normal creatinine level indicates that the kidney is functioning well.

Diagnostic Test and Description Serum: Urea This test determines the level of urea nitrogen in the blood. Urea is produced when proteins are metabolised or broken down. Elevated levels of serum urea can be a sign of kidney disease, liver disease or dehydration. Urea is the chief end product of protein metabolism.

Indication and Contraindication I: To evaluate kidney function and aid in diagnosing kidney disease. To assess for dehydration.

Client Preparation and Post Procedure Instruction CP: The patient should avoid diet high in meat. Explain to the patient that he may experience slight discomfort from the tourniquet and needle puncture.

Normal Findings 2.5 6.1 mmol/L

Actual Finding

Clinical Significance Patients Urea is in normal range reveals no malfunction in kidnye, liver or no signs of dehydration.

5.9 mmol/L

PPI: Monitor the venipuncture site for bleeding and signs of infection.

Diagnostic Test and Description Serum: Potassium This test measures the amount of potassium in the blood. K+ helps nerve and muscles communicate. It also helps move nutrients into cells and waste products out of cells. K+ level in the blood are mainly controlled by the hormone aldosterone

Indication and Contraindication

Client Preparation and Post Procedure Instruction

Normal Findings

Actual Finding

Clinical Significance

I: CP: To determine whether Avoid/discontinue taking concentration is drugs that may interfere/ within normal limit. affect the test. To help evaluate an electrolyte imbalance. To monitor chronic or acute PPI: hyperkalemia or Monitor the hypokalemia. venipuncture site for 8. bleeding and signs of infection.

]3.5 5.3 mmol/L

3.5 5.3 mmol/L

Patiens K+ is in normal range reveals no signs of hyperkalemia and hypokalemia.

Diagnostic Test and Description

Indication and Contraindication

Chest X-ray I: A chest x ray is a procedure used to used to help diagnose and evaluate organs and plan treatment for various structures within the conditions, including: chest for symptoms Lung disorders such as of disease. pneumonia, Chest x rays include emphysema, views of the lungs, tuberculosis and lung heart, small portions cancer of the Heart disorders such as gastrointestinal tract, congestive heart failure thyroid gland, and (which causes the heart the bones of the to enlarge) chest area. Fractures (breaks) of X rays are a form of the bones in the chest, radiation that can including the ribs and penetrate the body collarbone, as well as and produce an breaks in the bones of image on an x-ray the upper spine film. Reasons for shortness Another name for the of breath, a bad or film produced by x persistent cough, or rays is radiograph. chest pain CI: Pregnant women

Client Preparation Normal Actual Findings Clinical and Post Procedure Findings Significance Instruction CP: Informed consent Organs are Infiltrates are noted Infiltrations in should be signed. not enlarged. in RIGHT lower lungs can remove all lung mean infection jewelry and any Bones dont or Mucus. other objects have any containing metal. deformity Suspicious Empty the Suspicious density density can bladder before Trachea is in is seen in RIGHT mean your X-ray midline apex inflammation unless otherwise process in the instructed by apex your doctor. Heart is not Normal Findings enlarged PPI: Diaphragm and rest of the structures are unremarkable

Impression: Pneumonitis Right lower lung, Suspiscious density RIGHT apex for apicolordotic view

Diagnostic Test and Description Serum: Na Measures the concentration of Na in the blood.

Indication and Contraindication I: Used in Dx and Tx of Aldosteronism (excessive secretion of the hormone aldosterone), diabetis insipidus (chronis excretion of large amount of dilute urine, accompanied by extreme thirst, adrenal hypertension and addisons disease Dehydration, inappropriate antudiuretic hormone secretion or other involving electrolyte imbalance

Client Preparation and Post Procedure Instruction CP: Discontinue drugs that may interfere with the test. Do not stop or change medications without doctors knowledge.

Normal Findings 135. 148. mmol/L

Actual Finding

Clinical Significance Patients NA is in normal range however Increase NA can be interpreted as dehydration while decrease in NA can be interpreted as hypervolemia

140.6 mmol/L

PPI: Monitor the venipuncture site for bleeding and signs of infection.

Diagnostic Test and Description I: FBS (Fasting Blood Sugar) - Fasting blood sugar level is one of the tests used to diagnose diabetes mellitus

Indication and Contraindication

Client Preparation and Post Procedure Instruction CP:

Normal Findings

Actual Finding

Clinical Significance

Used to diagnose diabetes mellitus (another being the oral glucose tolerance test) and in person with symptoms of osmotic diuresis

Overnight fasting (24 hours)

Glucose (4.1 - 5.9 mmol/L)

11.7 mmol/L

Patients blood glucose is High reveals Diabetes melitus

Diagnostic Test and Description Lipid Profile -Lipid profile is a group of tests that are often ordered together to determine risk of coronary heart disease. They are tests that have been shown to be good indicators of whether someone is likely to have a heart attack or stroke caused by blockage of blood vessels or hardening of the arteries (atherosclerois). The lipid profile typically includes: I:

Indication and Contraindication

Client Preparation and Post Procedure Instruction CP:

Normal Findings

Actual Finding

Clinical Significance

The lipid profile are considered to Dx other known risk factors of heart disease to develop a plan of treatment and follow-up

Patient need to fast for 9-12 hours before having blood drawn; only water is permitted PPI: Monitor the venipuncture site for bleeding and signs of infection.

Cholesterol (0.0 5.2 mmol/L)

6.6 mmol/L

High cholesterol level means patient is hypertensive or at risk for hypertension.

HDLC (1.0 1.5 mmol/L)

Normal 1.7 mmol/L

LDLC ( 0.0 3.36 mmol/L)

4.35 mmol/L

Increase in LDL reveals that more lipoproteins were promoting bad cholesterol in the cell risk for cardiovascular diseases.

Triglycerides (0.0 1.69 mmol/L

Normal 1.06 mmol/L

Diagnostic Test and Description URINALYSIS Urinalysis provides important clinical information about kidney function and helps diagnose diseases like diabetes.

Indication and Contraindication I: general health screening to detect renal and metabolic diseases diagnosis of diseases or disorders of the kidneys or urinary tract monitoring of patients with diabetes CI: to patient with distended urinary bladder secondary to urethral obstruction because of the possibility of leakage of urine into the abdomen with puncture of a compromised bladder wall.

Client Preparation and Post Procedure Instruction CP: Have identification available. Obtain the names and dosages of any medications you have taken or are currently taking, both prescription and nonprescription. Avoid heavy exercise or activity at least one hour prior to exam as this may cause inaccurate urine results DRINK A LARGE GLASS OF WATER 1 HOUR PRIOR TO EXAM.

Normal Findings

Actual Finding

Clinical Significance

Physical: Color Pale yellow to amber Transparency Hazy pH 4.5 - 8

Light Yellow Normal

Hazy

Normal

5.0 Specific gravity 1.003-1.035 Chemistry: Protein Negative Sugar +2 Microscopic: Pus cells- 0-5/hpf 0.50/hpf Rbc-1-3/hpf Epithelial cells Mucus Threads 1.010

Normal Normal

Normal Glycosuria (excess sugar in urine) generally means diabetes mellitus Normal

1/hpf Few Few Normal Normal Normal

ANATOMY AND PHYSIOLOGY OF RESPIRATORY SYSTEM

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 trachea or windpipe is a tube that extends from the lower edge of the larynx to the upper part of 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. 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. Avleoli 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. How they work Air enters your lungs through a system of pipes called the bronchi. These pipes start from the bottom of the trachea as the left and right bronchi and branch many times throughout the lungs, until they eventually form little thin-walled air sacs or bubbles, known as the alveoli. The alveoli are where the important work of gas exchange takes place between the air and your blood. Covering each alveolus is a whole network of little blood which are vessel called capillaries,

very small branches of the pulmonary arteries. It is important that the air in the alveoli and the blood in the capillaries are very close together, so that oxygen and carbon dioxide can move (or diffuse) between them. So, when you breathe in, air comes down the trachea and through the bronchi into the alveoli. This fresh air has lots of oxygen in it, and some of this oxygen will travel across the walls of the alveoli into your bloodstream. Travelling in the opposite direction is carbon dioxide, which crosses from the blood in the capillaries into the air in the alveoli and is then breathed out. In this way, you bring in to your body the oxygen that you need to live, and get rid of the waste product carbon dioxide.

PATHOPHYSILOGY OF BRONCHIAL ASTHMA

Predisposing Factors * Genetics *Race * Age * Gender

Precipitating Factors * Environmental factors (change in temperature) * Atmospheric pollutants (perfume, smoke, etc.) * allergens (pets) exercise, stress on emotional upset, chemicals, Medications

1 gE stimulations Mast cell degranultation Asthma attack Chemical mediators are released

Histamine prostaglandin bradikinin

Increased airway resistance Mucus inflammation bronchospasm secretion -- accessory muscle breathing -- Nasal flaring -- tachypnea --tachycardia Impaired mucociliary function Increase mucus production Slowed clearance of mucus mucus becomes increasingly viscous -- wheezing --Paroxysmal dyspnea Respiratory muscles works harder Muscle fatigue and exhaustion

Altered O2-CO2 Respiratory alkalosis Hypoxemia

Prioritization of the Problems Problem 1. Ineffective airway clearance RT increased mucus production AEB wheezing, dyspnea, and cough. Priority HIGH (Life Threatening) Explanation Nurses should prioritize the clients problem according to ABCD (Airway, Breathing, Circulation, Deformities) Respiration is vital to the optimal functioning of the human body, with alteration in the breathing pattern it could be detrimental to the clients health that could lead to death if left untreated. Excess fluid volume can result in imbalances that may lead to complications which are not readily life threatening.

2. Ineffective breathing pattern r/t presence of secretions AEB productive cough and dyspnea.

MEDIUM (Health Threatening)

3. Ineffective tissue perfusion r/t to high glucose level secondary to presence of atheroma in aorta

MEDIUM (Health Threatening)

--------------------------------

4. Risk for Activity Intolerance r/t imbalance between oxygen supply and demmand

LOW (Needs Minimal Attention)

As a risk diagnosis, infection can be prevented and the signs and symptoms are not yet evident if proper nursing management is done.

LOW (Needs Minimal Attention)

---------------------------

ASSESSMENT

NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION

PLANNING

SELECTED INTERVENTION

ACTUAL INTERVENTION

RATIONALE

EVALUATION

Subjective: mejo hirap pa rin akong huminga as verbalized by the patient Objective: wheezing upon inspiration and expiration dyspnea coughing, sputum is yellow and sticky infiltration in R lower lung tachypnic RR: 27cpm

Ineffective airway clearance RT increased mucus production AEB wheezing, dyspnea, and cough

The presence of a foreign microorganism triggers the B lymphocyte to produce antibodies that are specific to that antigen. These antibodies then attach to mast cells in the lungs. The mast cells with the antibody attaches to the antigen and begins to degranulate. This degranulation causes the release of certain chemical mediators, namely, histamine, bradykinin, prostaglandin, and leukotriene. These chemical mediators cause bronchospasm leading to bronchoconstriction, increased vascular permeability leading to

After 8 hours of nursing intervention the Patient will improve airway clearance AEB decrease mucus production

Pace and schedule deep breaths by emphasizing slow inhalation, holding end inspiration pace and schedule activities providing adequate rest periods Assess airway patenc y Administer m edications asindicated:

Adequately hydrate the pt. Teach and encourage the use of diaphragmatic breathing and coughing exercises. avoid bronchial irritants such as cigarette smoke, aerosols, extremes of temperature, and fumes. Position patient in semi- or highFowlers position

Systemic hydration keeps secretion moist and easier to expectorate . These techniques help to improve ventilation and mobilize secretions without causing breathlessn ess and fatigue. Bronchial irritants cause bronchoco nstriction and increased mucus

Goal met, At the end of 8 hours shift patient has manifested decrease mucus production

fluid leakage from the lung vasculature and increased mucus production. These lead to swelling of the bronchi, mucus buildup that plugs the airway and decreased bronchial diameter. This causes an increased airway resistance and a constricted pathway for air. Air cannot pass effectively and this manifests as a whistling sound. Coughing is a way to expel the obstruction (mucus plug) while dyspnea is a manifestation of the increased airway resistance.

production, which then interfere with airway clearance. Positioning helps maximize lung expansion

ASSESSMENT

NURSING DIAGNOSIS Ineffective breathing pattern r/t presence of secretions AEB productive cough and dyspnea

SCIENTIFIC EXPLANATION Presence of secretions in the bronchi will result into a blockage of air that will enter the body and thus producing insufficient air needed by the body. And inability to maintain clear airway. This obstruction is further heightened by bronchospasm due to the contraction of the smooth muscles in the bronchi. This is caused by parasympathetic stimulation of the muscarinic2 receptors as well as by chemical mediators released in response to the presence of allergen.

PLANNING

SELECTED INTERVENTION Encourage deep breathing and coughing exercises. Encourage opportunities for rest and limit physical activities. Demonstrate diaphragmatic and pursed-lip breathing.

ACTUAL INTERVENTION INDEPENDENT:

RATIONALE

EVALUATION

Subjective: mejo hirap pa rin akong huminga as verbalized by the patient

Objective: wheezing upon inspiration and expiration dyspnea coughing, sputum is yellow and sticky tachypnea RR: 27cpm infiltration in R lower lung

After 8 hours of nursing intervention Patient will manifest signs of decreased respiratory effort AEB absence of dyspnea

To obtain baseline data Serve to track important changes to check for the presence of adventitious breath sounds To minimize difficulty in breathing

assess pt.s condition VS monitor and record Auscultate breath sounds and assess airway pattern Elevate head of the bed and change position of the pt. every 2 hours. Encourage increase in fluid intake Reinforce low salt, low fat diet as ordered.

Goal met, After 8 hours of nursing shift the patient was able to decreased respiratory effort

To prevent fatigue.

To mobilize secretions

ASSESSMENT

NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION

PLANNING

SELECTED INTERVENTION

ACTUAL INTERVENTIO N

RATIONALE

EVALUATION

Subjective: may highblood na talaga ako dati pa as verbalized by the patient

ineffective tissue perfusion r/t to high glucose level secondary to slight atheromatous aorta.

Objective: Elevated BP (140/90) RR: 27 cpm CXR result: slight atheromatous in aorta FBS result: high glucose level (11.7mmo/L) High cholesterol level (6.6 mmol/L)

Decrease in oxygen resulting in the failure to nourish the tissues at the capillary level. (Tissue perfusion problems can exist without decreased cardiac output; however, there may be a relationship between cardiac output and tissue perfusion)

After 8 hours of nursing intervention, clients circulation status will maintain perfusion and blood pressure will decrease from 140/90 to 120/80

Encourage frequent rangeof-motion (ROM) Assess for redness, edema, and discomfort in calf. Monitor hemoglobin (Hgb), hematocrit (Hct), and coagulation studies Instruct to decrease intake of glucose Administer anti hypertensive drug as ordered

Monitor vital signs, palpate peripheral pulses routinely, and evaluate capillary refill and changes in mentation. Encourage early ambulation; discourage sitting and dangling legs at the bedside. Instructed to eat low fat and low salt diet Instruct to have enough res on semi fowlers position

Indicators of circulatory adequacy. Sitting constricts venous flow, whereas walking encourages venous return To reduce edema that may activate rennin angiotensinaldosterone system Sodium tends to be excreted at faster rate

After 8 hours of nursing shift patients blood pressure decreased from 140/90 to 120/90

ASSESSMENT

DIAGNOSIS

SCIENTIFIC EXPLANATION

PLANNING

SELECTED INTERVENTION

RATIONALE

EVALUATION

Subjective: dati pa ko nagkaka highblood as verbalized by the patient Objective: Weakness Easily fatigue

Risk for Activity Intolerance r/t imbalance between oxygen supply and demand secondary to weakness

Activity intolerance is a state in which an individual has insufficient physiological energy to endure or complete required or desired daily activities.

After series of nursing interventions, the pt. will verbalize willingness to and demonstrate participation in activities.

Assess motor function. Note contributing factors to fatigue. Ascertain ability to stand and move about. Assess emotional or psychological factors Plan care with rest periods between activities Increase activity/exercise gradually such as assisting the patient in doing PROM to active or full range of motions. Provide adequate rest periods. Elevate arm and hand Place knees and hips in extended position

To identify causative factors. To identify precipitating factors. To identify necessity of assistive devices. Stress and/or depression may increase the effects of illness. To reduce fatigue

Minimizes muscle atrophy, promotes circulation, helps to prevent contractures

To replenish energy. and increase activity tolerance

ASSESSNEBT Subjective: mabilis na talaga ko mapagod ngayon as verbalized by the patient Objective:

NURSING DIAGNOSIS Readiness for enhanced self-health management r/t

SCIENTIFIC EXPLANATION Activity intolerance is a state in which an individual has insufficient physiological energy to endure or complete required or desired daily activities.

PLANNING After series of nursing interventions, the pt. will verbalize willingness to and demonstrate participation in activities.

SELECTED INTERVENTION Monitor VS. Assess motor function. Note contributing factors to fatigue. Evaluate degree of deficit. Ascertain ability to stand and move about. Assess emotional or psychological factors Plan care with rest periods between activities Increase activity/exercise gradually such as assisting the patient in doing PROM to active or full range of motions. Provide adequate rest periods. Elevate arm and hand

RATIONALE For baseline data. To identify causative factors. To identify precipitating factors. To identify severity. To identify necessity of assistive devices. Stress and/or depression may increase the effects of illness. To reduce fatigue Minimizes muscle atrophy, promotes circulation, helps to prevent contractures To replenish energy. and increase activity tolerance

EVALUATION

Drug Name/Dosage Generic: Prednisone

Action Enters target cells and binds to intracellular corticosteroid receptors, thereby initiating many complex reactions that are responsible for its antiinflammatory and immunosuppressive effects.

Indication General: Replacement therapy in adrenal cortical insufficiency Hypercalcemia associated with cancer Short-term management of various inflammatory and allergic disorders, such as rheumatoid arthritis, collagen diseases (eg, SLE), dermatologic diseases (eg, pemphigus), status asthmaticus, and autoimmune disorders Hematologic disorders: thrombocytopenia purpura, erythroblastopenia Ulcerative colitis, acute exacerbations of multiple sclerosis and palliation in some leukemias and lymphomas Trichinosis with neurologic or myocardial involvement

Adverse Reaction Vertigo, headache, paresthesias, insomnia, convulsions, psychosis, cataracts, increased intraocular pressure, glaucoma (long-term therapy) Hypotension, shock, hypertension and CHF secondary to fluid retention, thromboembolism, thrombophlebitis, fat embolism, cardiac arrhythmias Na+ and fluid retention, hypokalemia, hypocalcemia Amenorrhea, irregular menses, growth retardation, decreased carbohydrate tolerance, diabetes mellitus, cushingoid state (longterm effect), increased blood sugar, increased serum cholesterol, decreased T3 and T4 levels, HPA suppression with systemic therapy longer than 5 days Peptic or esophageal ulcer, pancreatitis, abdominal distention, nausea, vomiting, increased appetite, weight gain (long-term therapy) Hypersensitivity or anaphylactoid reactions

Nursing Consideration Administer once-a-day doses before 9 AM to mimic normal peak corticosteroid blood levels. Increase dosage when patient is subject to stress. Taper doses when discontinuing high-dose or long-term therapy. Do not give live virus vaccines with immunosuppressive doses of corticosteroids.

Brand: Orasone

Classification:

Pt.s Dosage: 2 tabs P.O. tid

Drug Name/Dosage Ipratropium Bomide/ Salbutamol (albuterol sulfate)

Action Ipratropium bromide is an anticholinergic (parasympatholytic) agent. Anticholinergics prevent the increases in intracellular concentration of Ca++ which is caused by interaction of acetylcholine with the muscarinic receptors on bronchial smooth muscle. Inhibit vagallymediated reflexes by antagonizing the action of acetylcholine, the transmitter agent released at the neuromuscular junctions in the lung. Albuterol beta2adrenergic are the predominant receptors on bronchial smooth muscle, recent data indicate that there is a population of beta2-receptors in the human heart which

Indication General: Indicated for use in patients with chronic obstructive pulmonary disease (COPD) on a regular aerosol bronchodilator who continue to have evidence of bronchospasm and who require a second bronchodilator

Adverse Reaction Body as a WholeGeneral Disorders Headache Pain Influenza Chest Pain Gastrointestinal System Disorders Nausea Respiratory System Disorders (Lower) Bronchitis Dyspnea Coughing Respiratory Disorders Pneumonia Bronchospasm Respiratory System Disorders (Upper) Upper Respiratory Tract Infection Pharyngitis Sinusitis Rhinitis

Nursing Consideration Use cautiously in patients with cardiovascular disorders. Syrup is available for children as young as age 2. Inhaler may be used 15 minutes before exercise to prevent exerciseinduced bronchospasm. Patient may use tablets and inhaler at the same time. Monitor for toxicity. Warn the patient about the risk of paradoxical bronchospasm and if it occurs, stop drug immediately. Teach patient to use the inhaler correctly: Shake it, clear the throat, expel as much air as possible from the lungs, inhale deeply while releasing the drug from the inhaler, hold breath for several seconds.

Brand: Combivent , Duavent

Classification: Bronchodilator Aerosol Pt.s Dosage: Combivent Inhalation Aerosol is two inhalations four 4x a day. The total number of inhalations should not exceed 12 in 24 hours. It is recommended to test-spray three times before using for the first time and in cases where the aerosol has not been used for more than 24 hours.

comprise between 10% and 50% of cardiac beta-adrenergic receptors

Use of a spacer may improve delivery. Wait for 2 minutes between puffs of inhaler. If the patient is also using a steroid inhaler, use the bronchodilator first, then wait 5 minutes before using the steroid. Wash the canister with warm water and soap at least once a week.

Drug Name/Dosage Generic: Hydrocortisone Brand: Cortizan,Drugmakers Biotech Hydrocortisone,Efficort, Hydrotropic, Hydrotropic Injection, Lacticare-Hc Lotion, Pharex Hydrocortisone SodiumSuccinate, SoluCortef

Action Glucocurticoid w/ antiinflammatory effect because of its ability to inhibit prostaglandin synthesis inhibits migration of site of macrophages, leucocytes & fibroblasts at sites of inflammation, phagocytosis and lysosomal enzyme release.It can also cause the reversal of increased capillary permeability.

Indication General: Treatment of primary or secondary adrenal cortex insufficiency, rheumatic disorders, collagen diseases, dermatologic disease, and allergic states, allergic & inflammatory ophthalmic processes respiratory disease, hematologic disorders (idiopathic Thrombocytopenic purpura) neoplastic disease, edematous states (resulting from neprotic syndrome, GI disease ulcerative colitis &sprue).

Adverse Reaction Depression, flushing, sweating headache, mood changes, hypertension, circulatory collapse, thromboplebitis, embolism, tachycardia, edema, thrombophlebitis, embolism, tacky cardia, edema, fungal infections, blurred vision, errythemia, tromboembolism.

Nursing Consideration Assess Patients Condition before starting therapy and reassess regularly Monitor weight, blood pressure, glucose and electrolyte levels. Monitor weight input output of the patient. Assess mental status: affect, mood, behavioral changes, aggression.

Classification: Anti-inflammatory

Pt.s Dosage: Adult:5-30 mg 2x/4x a day;IM/IV 100-250 mg (succinate), 50-100 mg IM as needed.

Drug Name/Dosage Generic:

Action

Indication General: Hypertension (HTN) and/or angina (vasospastic or chronic stable) with dyslipidemias in patients for whom treatment with both amlodipine and atorvastatin is appropriate. See literature. (Amlodipine: indications include hypertension, vasospastic angina. Atorvastatin: indications include use in patients with multiple risk factors, but no clinical evidence of, coronary heart disease, to reduce risk of MI and reduce risk of revascularization procedures and angina; treatment of hypercholesterolemia to reduce elevated total-C, LDL-C, apo B, and TG and to increase HDL-C; elevated triglycerides; dysbetalipoproteinemias;

Adverse Reaction Edema, dizziness, palpitation, flushing, fatigue, constipation, dyspepsia, abdominal pain, drowsiness, myopathy, elevated liver enzymes, rhabdomyolysis with renal dysfunction.

Nursing Consideration Patient should avoid activities requiring coordination until drug effects are realized, as drug may cause headaches. Instruct patient to report signs & symptoms of rhabdomyolysis(myalgias, dark urine, arthralgias,fatigue). Patient should not drink alcohol while taking drug.

Amlodipine is a dihydropyridine Amlodipine/Atorvastatin calcium antagonist (calcium ion antagonist or slowBRAND: channel blocker) that Amcal, Amlodipine inhibits the besylate,Valsartan transmembrane Classification: influx of calcium Calcium channel ions into vascular blocker + HMG-CoA smooth muscle and reductase inhibitor. cardiac muscle Pt.s Dosage: 5mg tab PO OD

Drug Name/Dosage Generic: Cefuroxime

Action For the treatment of many different types of bacterial infections such as bronchitis, sinusitis, tonsillitis, ear infections, skin infections, gonorrhea, and urinary tract infections.

Indication General: For dermatologic infections, caused by S. aureus, S. pyogenes -fights bacteria in the body. - is used to treat many different types of bacterial infections

Adverse Reaction Diaper rash, diarrhea, difficulty breathing or swallowing, hives, itching, painful sores in the mouth or throat, severe skin rash, stomach pain, upset stomach, vaginal itching and discharge, vomiting, wheezing;

Nursing Consideration It should be taken by meals to prevent GI disturbances. Do a skin test or determine if the patient has hypersensitivity to cefuroxime.

BRAND: Ceftin

Classification: Bactericidal/Antibacterial

Pt.s Dosage:

DRUG NAME/DOSAGE Generic: Azithromycin Brand: Zithromax Classification: macrolide and antibiotic.

ACTION Azithromycin binds to ribosomal receptor sites of susceptible organisms. It inhibits protein synthesis.

INDICATION General: Azithromycin is used for the treatment of mild to moderate infections of upper respiratory tract and lower respiratory tract infections, uncomplicated skin or skin structure infections, and sexually transmitted diseases. It prevents disseminated Mycobacterium avium complex.

ADVERSE REACTION Superinfections Acute intestinal nephritis

Pt.s Dosage: 500mg/tab; 1 tab P.O. OD

NURSING CONSIDERATION Question for history of hepatitis, allergies to azithromycin or erythromycin. May give tablets without regard to food. Check for GI discomfort, nausea, and vomiting. Determine pattern of bowel activity and stool consistency. Monitor hepatic function tests, assess for hepatotoxicity: malaise, fever, abdominal pain, and GI disturbances. Evaluate for superinfection: genital/anal pruritus, sore mouth or tongue, moderate to severe diarrhea.

DRUG NAME/DOSAGE Generic: Ansimar

ACTION Adrenergic bronchodilators and phosphodiesterase inhibitors both. Work by increasing intracellular level of cyclic-3, 5-adenosine monophosphate (cAMP); adrenergics by increasing production and phosphodiesteraseinhibitorsby decreasing breakdown. Increased levels of cAMP produce bronchodilation. Corticosteroids act by decreasing airway inflammation. Anticholinergics(ipratropium) produce brondhodilation by decreasing intracellular levels ofcyclicguanosine monophosphate (cGMP). Leukotriene receptor antagonistsandmast cell stabilizers decrease the release of substances that can contribute tobronchospasm.

INDICATION General: Bronchial asthma & pulmonary disease w/ spastic bronchial component.

Brand: Zuellig

Classification:

ADVERSE REACTION Nausea, vomiting, epigastric pain, cephalalgia, irritability, insomnia, tachycardia, extrasystole, tachypnea, hyperglycemia, albuminuria.

Pt.s Dosage: Adult 1/2 tab. bid

NURSING CONSIDERATION Use with caution in patients with hypoxemia, hyperthyroidism, liver disease, renal disease, in those with history of peptic ulcer and in elderly. Frequently, patients with CHF have markedly prolonged drug serum levels following discontinuation of Ansimar. Assess for allergic reaction Assess for breath sounds

DISCHARGE PLANNING Medicines Teach the patients about medication purpose, dosage, route, and possible side effects of all prescribed medications. Advise the client to continue the medication as prescribed by the physician. Emphasize compliance and strict adherence to dosage and the time of intake of the medicines to attain the desired therapeutic effects. Make sure that the client and the support system understands the medication regimen, can read the instructions, can open the container, and is prepared to adjust to postural hypotensive effects of antihypertensive medications (change position slowly, use supportive devices) Explain the consequences of not strictly adhering to the drug regimen. Instruct the patient not to alter doses of medications and emphasize the importance of continuous medication. Report immediately for any unusual symptoms

Exercise/ Environment Instruct patient to avoid extraneous exercise and heavy work load. Instruct the patient to perform deep breathing and coughing exercises to help expel secretions and leg exercise to facilitate blood circulation. Instruct the patient to maintain a clean environment conducive to health for immediate recovery and maintenance of health. Instruct the SOs to maintain the patients physical environment free of fire, health and safety hazards; provide adequate heating, cooling and ventilation; provide adequate electrical service; and provide for patients access and mobility with adequate patient space and storage facilities. When activity is required, the patient needs to be taught how to pace himself to not become short of breath. Treatment Advise the patient to comply with the treatment regimen Instruct the SOs to encourage the patient to comply with the treatment regimen

Health teaching Advise patient to avoid strong odor/perfumes. Advise patient to avoid extreme temperature and air pollutants. Instruct patient to read ingredient labels on food packages and know if it can triggers asthma. Advice the SOs to take the time to listen to the patients needs and anticipate physical care needs to reduce the burden on the patient.

Educate client and/or SOs to elevate heels of the bed by using pillows. Instruct the SOs to help position the patient by sitting them up in bed for maximal lung expansion Teach the patient how to use the diaphragm for maximal lung expansion. Explain to the patient that pursed lip breathing helps reduce the feeling of breathlessness and controls the respiratory rate. Instruct patient to report immediately if having shortness of breath. Teach the patient and family how to measure blood pressure. Advice the patient and support system to monitor vital signs. Instruct the patient to consult first the physician or physical therapist to learn which exercises are appropriate and how to do them. Educate the patient range-of-motion exercises to help reduce stiffness and maintain or increase proper joint movement and flexibility as well as improve overall circulation.

Out patient Patient will be advised to go back in the hospital in specific date to have a follow-up check up. Consult doctor for any problems or complications encountered. Educate the patient and family, this will help reduce anxiety and allow them to be active participants in their care. Provide written and verbal instructions at the patient/ familys level of understanding Verbally explain instructions to patient/family and provide them with a written copy concerning medications, diet, activity, treatments, follow up appointments, signs and symptoms to observe for, when to contact the doctor and care of incisions, wounds, etc. Instruct to keep records of all appointments and write down any questions the patient may have so patient will remember to ask questions during patients next visit. Ascertain that patient has follow up care arranged at discharge. Diets Reinforced to maintain Low Salt and Low Fat diet. Low Allergen Diet Spirituality Advise relatives to maintain a therapeutic, satisfying and caring relationship with the patient . Advise the relatives to support the patient in religious practice.

References: Read more: http://wiki.answers.com/Q/What_is_bronchial_asthma#ixzz1W2zhLVCh Handbook of Nursing Diagnosis 13 edition by Lynda JuallCarpenito Moyet