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Name: Mr. XXER
Age: 18 years old
Gender: Male
Status: Single
Religion: Roman Catholic
Adress: Brgy.Ibabang Dupay Lucena City
Occupation: None
Significant others: Mr.YYER
Admission Date: January 11, 2012
Admission Time: 10:46 AM
Chief Complaint: Difficulty of breathing
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The patient XXER is brought to the emergency area of Quezon Medical Center, with a chief
complaint of DOB. His Respiratory rate is 43 breaths per minute. As an initial action the chart is
accomplish and vital sign is taken. Oxygen cannula is prescribed to the patient SO. The staff and we thestudent nurse waits for the cannula. Then the oxygen is administered and the patient started to calm,
but with noted respiratory depression and use of accessory muscle also. According to the patient SO the
DOB of patient started at 9:00 am while he is taking a stick of cigarette. From that the DOB of patient
continue until he is brought by his brother at the hospital. The patient DOB can be considered severe as
assessing his RR, its pattern is rapid inspiration and expiration.
The patient has not been hospitalized before according to his brother, the patient SO also told
that the patient DOB is his only problem in terms of health. His brother also mentioned that the only
illness that his brother acquired for the past weeks or months is only simple cough, colds and mild fever
which he treated with over the counter drugs only.
Patient Mother
Patient Father
Patient Brother
Patient
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The patient lives in lucena city, their house is compose of concrete and wood as his brother
describe, although the conversation is short because of dilemma of his brother because of his death. We
can still concur that the patient surrounding may further trigger the patient illness because of the dust
coming from construction mill near on their house as his brother describe. His brother able to describe
his lifestyle to the physician upon hearing it we can also analyze that the patient habit of escaping meal
and taking a pack of cigarette instead may further trigger the situation of the illness itself.
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General:
Mildly Conscious Irritated Restless Respiratory distress The patient is fatigued, weak, shortness of breath noted
Vital signs:
Temperature: 36.8 C axillary Pulse: 71 beat per minute Blood pressure: 150/90 mmHg Respiratory rate: 42 breathe per minute Height: Wight: estimated 50 kg
Skin:
Dry Cold and clammy Pale and bluishin color No rashesorlesion noted
Head: Without masses noted With palpable bruiseon occiput area
Eyes: With pale conjunctivae With whitishsclera With goodvision acuity
Ears:
With goodhearing With minimaldry discharge Upper pinna in line witheye cantus With firm cartilage With good pinna recoil
N
With nasal congestion With whitish discharge
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Chest/breast:
Withlabored breathing Dyspnea noted With abnormal rise and fallof chest With wheeze sound heard upon
auscultation With noted use of accessory muscle on
breathing
Abdomen: With normal bowelsound Without rashesseen on abdomen
Genital:
With normalelimination pattern With normaldefecation pattern
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The upper respiratory tract consists of the nose, sinuses, pharynx, larynx, trachea, and epiglottis.
The lower respiratory tract consists of the bronchi, bronchioles and the lungs.
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:
y Ventilation is movement of gases from the atmosphere into and out of the lungs. This isaccomplished through the mechanical acts ofinspiration and expiration.
y Diffusion is a movement of inhaled gases in the alveoli and across the alveolar capillarymembrane
y Perfusion 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, coordinatesrespiratory rhythm and regulates the depth of respirations
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The normal functions of respiration O2 and CO2 tension and chemoreceptors are similar in childrenand adults. However, children respond differently than adults to respiratory disturbances; major areas
of difference include:
y Poor tolerance of nasal congestion, especially in infants who are obligatory nose breathers upto 4 months of age
y Increased susceptibility to ear infection due to shorter, broader, and more horizontallypositioned Eustachian tubes.
y Increased severity or respiratory symptoms due to smaller airway diametersy A total body response to respiratory infection, with such symptoms as fever, vomiting and
diarrhea.
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BBBRRROOONNNCCCHHHIIIAAALLL AAASSSTTTHHHMMMAAA
DDeeffiinniittiioonn
A condition of the lungs characterized by widespread narrowing of the airways due to spasm of
the smooth muscle, edema of the mucosa, and the presence of mucus in the lumen of the bronchi and
bronchioles. Bronchial asthma is a chronic relapsing inflammatory disorder with increased
responsiveness of trachea broncheal tree to various stimuli, resulting in paroxysmal contraction ofbronchial airways which changes in severity over short periods of time, either spontaneously or under
treatment.
CClliinniiccaall MMaanniiffeessttaattiioonn
The three most common symptoms of asthma are cough, dyspnea, and wheezing. In some
instances cough may be the only symptoms. An asthma attack often occurs at night or early in the
morning, possibly because circadian variations that influence airway receptors 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 narrow airway that the patient cannot cough it up.
PPrreevveennttiioonn
Patient with recurrent asthma should undergo test to identify the substance that participate thesymptoms. Patients are instructed to avoid the causative agents whenever possible. Knowledge is the
key to quality asthma care.
MMeeddiiccaall MMaannaaggeemmeenntt
There are two general process of asthma medication: quick relief medication for immediate
treatment of asthma symptoms and exacerbations and long acting medication to achieve and
maintain control and persistent asthma. Because of underlying pathology of asthma is inflammation,control of persistent asthma is accomplish primarily with the regular use of anti inflammatory
medications.
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variability. Cromolyn sodium and nedocromil are mild to be moderate anti-inflammatory agents
that are use more commonly in children. They also are effective on a prophylactic basis to prevent
exercise-induced asthma or unavoidable exposure to known triggers. These medications arecontraindicated in acute asthma exacerbation.
`Long acting beta-adrenergic agonist is use with anti-inflammatory medications to control asthma
symptoms, particularly those that occur during the night these agents are also effective in the
prevention of exercise-induced asthma.
y Quick reliefmedicationShort acting beta adrenergic agonists are the medications of choice for relief of acute symptoms and
prevention of exercise-induced asthma. They have the rapid onset of action. Anti-cholinergic may have
an added benefit in severe exacerbations of asthma but they are use more frequently in COPD.
NNuurrssiinngg MMaannaaggeemmeenntt
The main focus of nursing management is to actively assess the air way and the patient response to
treatment. The immediate nursing care of patient with asthma depends on the severity of thesymptoms. A calm approach is an important aspect of care especially for anxious client and ones
family.
y This requires a partnership between the patient and the health care providers to determine thedesire outcome and to formulate a plan which include;
y the purpose and action of each medicationy trigger to avoid and how to do soy when to seek assistancey the nature of asthma as chronic inflammatory disease
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Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation
Subjective:
Nahihirapan akong
huminga as
verbalized by the
patient
Objective:
y wheezing uponinspiration and
expiration
y dyspneay tachycardiay chest tightnessy suprasternal
retraction
y restlessnessy irritated
P: Ineffective
breathing pattern
E: r/t presence of
secretions of
productive cough
and dyspnea
secondary to acute
attack of bronchial
asthma in acute
exacerbation
S: as manifested by
dyspneic movement
and RR of 42bpm
After 4-5 hours of
nursing
intervention
Patient will
manifest signs of
decreased
respiratory effort
Assess pt.sgeneral condition Auscultate breath
sounds and
assess airway
pattern
Elevate head ofthe bed and
change position
of the pt. every 2
hours.
Encourage deepbreathing and
coughing
exercises.
Demonstratediaphragmatic
and pursed-lip
breathing to the
patient.
Encourageincrease in fluid
intake Encourage
opportunities for
rest and limit
physical activities.
Reinforce lowsalt, low fat diet
as ordered.
Toobtainbaselinedata to check forthe
presenceof
adventitiousbreathsounds
To minimizedifficulty in
breathing
To maximizeeffort for
expectoration.
Todecrease airtrapping and for
efficientbreathing.
To preventfatigue.
To preventsituationsthat
will aggravatethe condition
To mobilizesecretions.
Goal not metpatient
remained in
respiratory
distress,
respiratory
effort increase
every hour
until the limit
reach and the
patient expired
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Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation
Subjective:
Nahihirapan akong
huminga as
verbalized by the
patient
Objective:
y wheezing uponinspiration and
expiration
y dyspneay tachycardiay chest tightnessy suprasternal
retraction
y productivecough
y restlessnessy irritated
P: Ineffective
airway clearance
E: Related To
broncho
constriction,
increased mucus
production on the
bronchiole area and
tracheal area
S: as manifested by
wheezing uponauscultation,
dyspnea, and
cough
After 5-6 hours of
nursing
intervention the
Patient will
maintain/improve
airway clearance
and there will be a
absence of signs of
respiratory distress
Adequatelyhydratethe pt.
Teach andencouragetheuseofdiaphragmatic
breathing andcoughing
exercises. I
nstruct ptto avoidbronchialirritantssuch as cigarette
smoke, aerosols,extremesof
temperature, andfumes.
Teachearly signsofinfectionimmediately.
y Increasessputumproduction
y Changein colorofsputum
y Increasedthicknessof
sputum
y Increased SOB,tightnessof chest,
or fatigue
y Increasedcoughing
y Feveror chills
Systemichydration keeps
secretion moist
and easier to
expectorate.
Thesetechniques help
to improve
ventilation andmobilize
secretions
without causing
breathlessness
and fatigue.
Bronchialirritants causebroncho
constriction and
increased
mucus
production,
which then
interfere with
airway
clearance.
Minorrespiratory
infections that
are of no
consequence to
Goal not metpatient
remained in
respiratory
distress,
respiratory
effort increase
every hour
until the limit
reach and the
patient expired
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Asorderedperform postural
drainage withpercussion and
vibration in themorning and at
night asprescribed.
the person with
normal lungs
can producefatal
disturbances in
the lungs of an
asthmatic
person. Early
recognition is
crucial.
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Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation
Subjective:
Hirap na hirap na
talaga ako huminga
as verbalized by the
patient
Objective:
y Weaknessy Agitatedy Restlessy irritated
P: Risk for Activity
Intolerance
E: r/t decrease
oxygen supply on
the tissue and
muscle in the body
S: as manifested by
distress RR of 42
bpm, increasing
gasping for air as
seen on patient
After 8 hours of
nursing
intervention the
patient will
participate willingly
in necessary/
desired activities
such as deep
breathing exercises.
Assess motorfunction.
Notecontributingfactorsto
fatigue. Evaluatedegree
ofdeficit. Ascertain abilitytostand andmove about.
Assessemotionalor
psychologicalfactors
Plan care withrest periodsbetweenactivities
Increaseactivity/exercise
gradually suchas assisting the
patientin doingPROM to active
or full rangeofmotions.
Provideadequate rest
periods.
Toidentifycausativefactors.
Toidentifyprecipitating
factors. Toidentify
severity. Toidentifynecessity ofassistive
devices. Stress and/or
depression mayincreasethe
effectsofillness.
To reducefatigue
Minimizesmuscle atrophy,
promotescirculation,
helpsto preventcontractures
To replenishenergy.
Goal not met patient
activity continue to
lessen due to
weakness, patient
became unconscious,
patient is try to
revive, patient severe
distress lead him to
his expiration
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Assist clientindoing self care
needs Elevate arm and
hand Place knees and
hipsin extendedposition
To promoteindependence
andincreaseactivity
tolerance Promotes
venous Maintains
functionalposition
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Name of drug Classification IndicationMechanism of
actionContraindication
Adverse
Reaction
Nursing
responsibility
Epinephrine Anesthetic localand general
Adult: Per ml prepcontains lidocaine
HCl 20 mg andepinephrine 5
mcg. Dosagedepends on
several factors
such as route,type andextentofsurgical
procedure,duration of
anesthesia andpatient's condition
and age. Maxdose of lidocaine
given withepinephrine: 7mg/kg and not
>500 mg.Child: 3 mth-12
yr: Per ml prep
contains lidocaineHCl 20 mg andepinephrine 5
mcg. Dosagedepends on
several factorssuch as route,
Lidocaine is alocal anesthetic
which decreasespermeability of
sodium ions,blocking
induction and
conduction ofnerve impulses.Combination
withepinephrine
restrictssystemic spread
of lidocaine,vascular
absorption andits duration oflocal anesthetic
effect.
Tachycardia,hypertension,
cerebralarteriosclerosis,
ischemic heartdisease,IV admin,
anaesthetizes
digits orappendages,myasthenia gravis.
Severity ofadverse effects
in CNS andCVS aredirectly
related to bloodlevels of
lidocaine; the
effects are morelikely to occurafter systemic
administrationrather than
infiltration;dizziness;
muscletwitching; local
anesthetic ofmouth/throatimpairs
swallowing andincreases the
riskof aspiration
(patientscautionedagainsteating or
drinking for 3-4hr system of
neonate;erythema;
pigmentation;
Regular-release:May be taken
with or withoutfood. (Avoid
grapefruit juice1 hr beforeor 2
hr after a dose.)
Extended-release: Shouldbe taken with
food. (Avoidgrapefruit juice
1 hr beforeor 2hr after a dose.
Avoid taking w/high fat meals.
Swallow whole,do notcrush/chew.)
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Hydrocortisone Corticosteroidhormone
Parenteraltherapyof acute adrenal
corticalinsufficiency,
acutehypersensitivity
reactionslikestatus
asthmaticusoranaphylactic
drug allergy incombination with
epinephrine, asadjuncttosevere
acutetraumatic shock;
forinitialIVtreatmentof
generalized,recurrentlupus
eyrthematodes.
Producingrelation effect
on smoothmuscle
Hypersensitivityto corticosteroids,
keratitis,herpetica, acute
psychoses andlatent, curedor
manifesttuberculosis,
gastrointestinalulcer,
hypertension,osteoporosis,
myasthenia gravisand renal
insufficiency.
Corticosteroids,like
hydrocortisone,mightimpair
balance betweenwater and
electrolytesleading to fluid
retention andhypertension,
hypokalemiaand congestive
heart failure.Muscular
atrophy andosteoporosis
may occur.Gastrointestinal
ulcers associatedwith
hemorrhagehaveoften been
reported. Thereis a negative
nitrogen balance
dueto proteincatabolism andhealing wounds
isimpaired.Psychic
disturbances andconvulsions
Beforetreatmentinitiation,itis
recommendedtoperform an
ECG,usTSHassay andserum
potassiummeasurement.
Undesirableeffects (see
AdverseReactions) are
usually doserelated;
therefore,careful attention
should be paidtodeterminethe
minimumeffective
maintenancedosein orderto
avoidorminimize
undesirable
effects.Patientsshouldbeinstructedto
avoidexposuretosun ortouse
protectivemeasuresduring
therapy.
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