THE PATIENT WITH BRONCHIAL ASTHMA

A Case Study
Presented to
the Clinical Instructors
AUP College of Nursing
Silang, Cavite

In Partial Fulfillment
of the Requirements in
N301 Promotive and Preventive
Nursing Care Management

Presented by:
Sherilyn Magararu
Ely Ren Mendoza

Date Submitted:
August 20, 2009
 INTRODUCTION

The main function of the respiratory system is to move air

into the lungs so that oxygen can enter the body and carbon

dioxide can be exhaled. Several pulmonary disorders can affect

the airways. Their pathophysiology differs but these diseases

are characterized by limited airflow. Airflow is limited when

air walls are thickened, airway lumen is obstructed by

secretions, increasing resistance, and smooth muscle of the

airways is activated, causing bronchoconstriction. Limited

airflow increases the work of breathing and residual volume of

the lungs as air is trapped behind narrowed or collapsed airways.

Asthma is a chronic inflammatory respiratory disorder that

in children, inflammation causes recurrent episodes of wheezing,

breathlessness, chest tightness and cough, especially at night

or in the early morning. These asthma episodes are associated

with airflow limitation or obstruction that is reversible either

spontaneously or with treatment. (Hockenberry, 2005) Asthma

usually begins in childhood or adolescence, but it also may

first appear during adult years. While the symptoms may be

similar, certain important aspects of asthma are different in

children and adults. Children born to families with history of

allergies or asthma are more likely to have asthma. Children who

live in urban areas, where there is a higher incidence of air

pollution, or live in a home that has high levels of dust mites

or cigarette smoke, are also at a higher risk for asthma.

Infants born prematurely or who suffer lung damage shortly after

birth are also more likely to have asthma. (Lemone, 2004)

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

(http://respiratory-lung.health-cares.net/asthma-prevention.php).

Bronchial asthma is usually intrinsic (no cause can be

demonstrated), but is occasionally caused by a specific allergy

(such as allergy to mold, dander, dust). This case study is a

thorough learning about Bronchial Asthma, which contains a study

about the normal physiology of the respiratory system,

pathological physiology of the disease, a thorough assessment of

the patient with said illness, applied nursing care plans to

patients having this kind or disease, and discharge planning to

a patient to limit the recurrence of the attack or if not proper

management and care to be given during the time of asthma attack.

A. Significance of the study

Lower airway problems directly affect gas exchange and have

serious consequences. Many of these problems are chronic and

progressive, requiring major changes in person’s lifestyles.

Such airway problem includes Bronchial Asthma which is a serious

problem and could probably lead to death if proper precautions

are not observed. This study is made so that every reader or

listener of the case study and research will gain enough

knowledge and understand Bronchial asthma, its cause,

manifestations, treatment, and preventions. This study points

and focuses on the significance of reaching out to the awareness

of every individual who may have this kind of disease and to the

member of the health care team and share to them the proper ways

on how to effectively care to patients suffering from this

problem.

B. Objectives of the Study

At the end of the case-presentation the student will be

able to:

1. Know what Bronchial Asthma is all about.

2. Apply the knowledge that they have learned in the floor.

 CHAPTER II
PATIENT DATABASE
A. Demographic Data

Our patient’s name is Maimi. She is 3 years old. Her

birthdate is on April 29, 2006. She lived in 273 Blk. 19 Brgy.

Addition Hills, Welfare Vine, Mandaluyong City. Her parents are

Sun Ye and Jo Kwon. They are Roman Catholic. Her doctor is Dr.

Black. She was admitted 3:00 am, July 12, 2009. She was

diagnosed of Bronchial Asthma with Acute Exacerbation.

B. Nursing History

1. Gordon’s Functional Health Pattern

a. Health Perception-Health Management

She is a very active and playful child. She doesn’t

have any allergies on any foods.

b. Nutritional-Metabolic

She doesn’t have any special diet but she is taking

Celeen for her vitamin. At home, as verbalized by the

mother, she can eat all of the food served. She didn’t

have difficulty of swallowing, and started solid food

as the main composition of the food of the patient.

c. Elimination Pattern

She did not experience any decrease in defecating or

difficulty of urinating. Her bowel elimination pattern

 is once a day even during her stays at the hospital.

Her way of breathing is better than she is at home,

and she could go to comfort room with assistance of

mother (with IV), read books, and eat all food served.

d. Activity-Exercise Pattern

Our patient loves to play bahay - bahayan and running.

She independently wears her dress but with assistance

from her mother. She can go to the bathroom, whenever

she wants to urinate and defecate but her mother still

washes her anus after defecating. She goes schooling

in prep-school and playing or socializing, talking,

mingling with her classmates.

e. Sleep-Rest Pattern

She experience difficulty of sleeping while admitted

in the hospital. Before her admission, she sleeps as

early as 10 in the evening and wakes at 8 in the

morning. During her hospitalization, she sleeps at 10

and wakes at 8 in the morning. She also sleeps one

hour in the afternoon. During night when her asthma

attacks, she can’t breathe normally usually having a

hard time of breathing so her sleep during night is

disturbed during her hospitalization period.

f. Sexuality-Reproductive Pattern
g. Cognitive-Perceptual

She neither has hearing difficulties nor eye problems.

She has a good memory for learning activities in

school like problem solving and her mother makes

decisions for her during medications, treatments, etc.

and she also learns easily.

h. Self Perception – Self Concept

She’s feeling better every time she is asked how she

feels. Her illness makes her feel worthless because

she cannot do anything. She is very anxious every time

her asthma attacks.

i. Role relationship

She lives with her family and depends on her parents

for her needs. She misses her siblings and likes to

talk about them. In their house she can easily express

what she wants or needs but during her hospitalization

time her parents didn’t knew what are the needs that

she wanted or needed because of her condition.

j. Coping – Stress Tolerance

She always wants her mother to be beside her because

she provides all that she needs and she cries whenever

she can’t get something that she wants. She always

 wanted to go home right away but because of the

doctors order they can’t go home right away, so the

only thing she can do is to cry.

k. Recreational

Our patient is a very playful child, she loves to

explore and play with her friends almost everyday,

usually playing for 2 hours. She does also running as

her favorite sport but now that she has Asthma, her

mother forbids her to run and play at the dusty places.

l. Value and Beliefs

They are Roman Catholic. She verbalized that she knows

God loves her and He will wash her illness away so

that she can go home. The parents react patiently to

their daughters needs, and they supported all what

their child needs.

2. Developmental Tasks

a. Sigmund Freud ( 1 ½ to 3 years ) Anal Stage

- Anus and bladder are the sources of pleasure (sensual

satisfaction, self control). Major conflict: Toilet Training.

- Our patient knows how to control urination in the

hospital. She tells her Mom, “Ihi ako”, same as when she wants

to defecate. She can participate in the toilet training. The

parents are happy for the improvements of the patient according

to its condition.

b. Erik Erikson (Early Childhood, Autonomy vs. Shame and Doubt)

- Self Control without loss of self esteem. Ability to

cooperate and to express oneself, compulsive self restraint and

compliance, willfulness and defiance.

- Our patient is a shy girl, but she can participate to her

playmates as verbalized by her mother. She loves to play such as

bahay - bahayan, and tagu-taguan. But sometimes, her mother

would tell her that she should not run or play because she might

get tired and it may cause asthma.

c. Havighurst (Middle Childhood)

- Learning physical skills necessary for essay for ordinary

games, building wholesome attitudes toward oneself as a growing

organism, learning to get along with age-mate, achieving

personal independence, learning to distinguish right from wrong

and develops conscience (Kozier et. al, 2008).

- Our patient hides from his mother whenever she does

something wrong and admits it whenever she’s asked. Sometimes

she would just cry in fear when her mother gets angry.

d. Jean Piaget (Preconceptual Phase)

- Uses an egocentric approach to accommodate the demands of

an environment. Everything is significant and relates to “me”,

explores the environment. Language development is rapid and

associates words with objects.

-In our patient, during the care, she always talks about

her older siblings and her desire to play with them. She is able

to express her thoughts and losses her egocentric (selfish)

thinking which already made evident that she already passed

initiative thought phase as positive resolution.

3. Health History

a. Past and Present History

History of Present Illness

 The patients past history of illness was said to be in the

father’s side.

 The patient was diagnosed with bronchial asthma since 2008

given Salbutamol nebulization as necessary.

 2 days prior to admission, the patient experienced non

productive cough, watery nasal discharge, and (-) fever,

and decreases in appetite.

 1 day prior to admission, the patient experienced

difficulty of breathing, excessively vomit once and 3 doses

given Salbutamol at Tunasan Health Center every 4 hours.

 Few hours prior to admission, they went to Ospital ng

Muntinlupa for consultation, the patient experienced

persistence of difficulty of breathing.

 She is a fully immunized child, complete BCG, DPT, OPV, and

Hepa B immunization.

 When she reached 1 year of age, she disregards to drink

milk but instead she started to eat solid foods like rice,

etc.
 CHAPTER III
THE DISEASE ENTITY

A. The Medical Diagnosis with chief complaints

The National Heart, Lung and Blood Institutes’ Second

Expert Panel on the Management of Asthma defined Bronchial

Asthma as a “chronic inflammatory disorder of the airway in

which many cells and cellular elements play a role...” (Porth

2002: 639).

It is defined as a lung disease characterized by airway

obstruction that is reversible, airway inflammation and

increased airway responsiveness to a variety of stimuli. It

occurs in about 5.4% to 7.5% (15 million to 17 million) of the

population and is common among children and adults alike.

Asthma is the most common chronic disease if childhood.

High-risk population includes African-Americans, inner city

dwellers, and premature or low-birth weight children. (Kopstead

and Banasik, 2005: 538)

A number of factors can contribute to an asthmatic attack,

including allergens, respiratory tract infections,

hyperventilation, cold air, exercise, drugs and chemicals,

hormonal changes and emotional upsets, airborne pollutants, and

gastroesophageal reflux.

Inhalation of allergens is the most common cause of asthma.

Persons with allergic asthma often have other allergic disorders

such as hay fever, hives, and eczema. (Porth 2002: 640). In

terms of symptoms, asthma is defined as paroxysms of diffused

wheezing, dyspnea, and cough, resulting from spasmodic

contractions of the bronchi. Wheezing is caused by vibration in

narrowed airways which act like the vibrating reed of an

instrument, yielding a musical sound. Sputum is often thick,

tenacious, scant and viscid or sticky. Physical findings vary

with the severity of the attack. A mild attack may be associated

with a random monophonic respiratory wheezing associated with

airway narrowing. The area in which they are heard best is

indicative of the area of obstruction. Tachycardia is the early

sign of hypoxemia. In the severe state, the patient may appear

cyanotic, agitated, restless, and confused. (Kopstead and

Banasik, 2005: 586)

B. Theoretical Background

The pulmonary system function to (1) ventilate the

alveoli, (2) diffuse gases into and out of the blood, and

(3) perfuse the lungs so that the organs and tissues of the

body receive blood that is rich in oxygen and low in carbon

dioxide. Each component of the pulmonary system contributes

to one or more of these functions.

The central nervous system responds to neurochemical

stimulation of ventilation and sends signal to the chest

wall musculature. The response of the respiratory system to

these impulses is influenced by several factors that impact

the mechanisms of breathing and, therefore, impact the

adequacy of ventilation. Gas transport between the alveoli

and pulmonary capillary blood depends on a variety of

physical and chemical activities. Finally, the control of

the pulmonary circulation plays a role in the

appropriate distribution of blood flow. (Huether & McCane)

 CHAPTER IV

THE MANAGEMENT

A. Diagnostic Test results & Significance

NAME OF TEST NORMALVALUE RESULTS SIGNIFICANCE

Complete Blood Count RBC: 4-6 x 10/L 4.28 Increased segmenters

(July 12,2009- 6:59 am) Hct: 0.37- 0.47 0.36 (mature neutrophils)

Purpose: CBC is ordered to Hgb: 110- 160 gm/L 111 reflect a bacterial

aid in the detection of WBC: 5-10 x 10 /L 11.3 infection since this

anemias; hydration status; Lymphocytes:0.25-0.35 0.25 are the body’s first

and as part of routine Segmenters: 0.50-0.65 0.74 line of defense against

hospital admission test. The Eosinophil: 0.01-0.06 0.01 acute bacterial

differential WBC is invasion.

necessary for determining Lymphocytes are

the type of infection. decreased during early

acute bacterial

infection and only

increase late in
bacterial infections

but continue to

function during the

chronic phase.
 Generic/Trade Classification Indication/ Dosage Mechanism of Nursing

Name Purpose Action Consideration

1.Salbutamol Bronchodilator Relief of Tablet: Stimulates Assessment

s bronchospasm 1-2 mg beta-2 - Assess

in bronchial 3-4x/day receptors of cardio-

asthma, Syrup: ½ bronchioles by respiratory

chronic -1 tsp. increasing function:

bronchitis, 3-4x/day levels of cAMP BP, heart

emphysema and which relaxes rate and

other smooth muscles rhythm and

reversible, to produce breath

obstructive bronchodilatati sounds

pulmonary on. Also cause - Determin

diseases. Also CNS e history

useful for stimulation, of previous

treating cardiac medication

bronchospasm stimulation, and ability

in patients increase to self

 with co- dieresis, medicate to

existing heart skeletal muscle prevent

disease of tremors, and additive.

hypertension. increased - Monitor

gastric acid for

secretion. evidence of

Longer acting allergic

than reaction

isoproterenol. and

paradoxical

bronchospas

m.
2. Prednis steroids Allergic and 5-60 mg/ Immediately and Assessment

one inflammation 2-4 completely - Obtain

conditions, divided converted to baseline

i.e., in doses active weight, BP,

bronchial prednisolone in and

asthma and the liver. The electrolyte

skin anti- levels and

disorders, inflammatory monitor

ophthalmic effects maybe periodicall

diseases, due to y during

rheumatic inhibition of therapy.

disorders, prostaglandin - Assess

organ synthesis. It patient’s

transplant, also inhibits condition

neoplastic GI the migration before

and nervous of leukocytes therapy and

disorders. In and macrophages regularly

conditions to the site of thereafter

responsive to inflammation as to monitor

glucosesteroid well as drug

therapy, as in inhibits effectivene

adrenocortical phagocytosis ss.

insufficiency. and lososomal - Monitor

enzyme release. for

The possible

immunosuppressa drug

nt effect maybe induced

due to adverse

reduction in reactions.

the number of T - Monitor

Lymphocytes, plasma

monocytes and cortisol

eosinophils. levels

during long

term

therapy.
3. Hy Anti pyretic Treatment of IM/IV Glucocorticoid - Assess

drocortisone primary or 0.186-1 with anti patient’s

secondary mg/kg 2- inflammatory condition

adrenal cortex 3x/day effect because before

insufficiency, of its ability starting

rheumatic to inhibit therapy and

disorders, prostaglandin reassess

collagen synthesis, regularly.

diseases, inhibit - Monitor

dermatologic migration of patients

disease, macrophages, weight, BP,

allergic leukocytes, and glucose and

states, fibroblasts at electrolyte

allergic and sites of levels.

inflammatory inflammation, - Monitor

ophthalmic phagocytosis weight,

processes, and lysosomal input and

respiratory enzyme release. output

disease, It can also ratio, urine

hematologic cause the output and

disorders, reversal of increasing

neoplastic increased edema.

diseases, capillary Report

edematous permeability. hypertension

states, GI, , edema,

multiple cardiac

sclerosis, symptoms or

tuberculous weekly

meningitis, weight gain

trichinosis of >5 lbs.

with - Assess

neurologic or carefully

myocardial for signs of

involment. infection
 especially

fever and

WBC count

because the

drug masks

infection

symptoms.

4. Am Anti-pyretic Treatment of IV/IM 15 Binds to - Assess

ikacin infection mg/kg/da bacterial patient for

caused by y in 2 ribosomal signs and

susceptible or 3 subunit to symptoms of

strains of divided cause infection,

microorganisms doses misreading of including

, especially the genetic characterist

gram negative code which ics of

bacteria. leads to wounds,

inaccurate sputum,
peptide urine,

sequence of stool, WBC

protein >10,000/mm3,

synthesis and earache,

bacterial temp; obtain

death. baseline

information

before and

during

treatment.

- Assess

for allergic

reaction:

rash,

urticaria,

pruritus,

and
hypotension.

- Assess

for

overgrowth

of

infection:

perineal

itching,

fever,

malaise,

redness,

pain,

swelling,

drainage,

rash,

diarrhea,

change in
cough,

sputum
 CHAPTER IV

THE MANAGEMENT

B. Course in the Ward

Date, Time, and Doctors Order Nurse’s Observation

Hospital Day and Management

July 12, 2009  Please admit to the  Admitted a 3

2:45 am pedia ward A yr old girl

 Ensure consent for carried by

admission and mother.

assistance  With a chief

 TPR every shift complaints of

difficulty of
 NPO/TFV
breathing
 Laboratory:
 Vital Signs
• CBC to be follow up
taken and
–to know whether
recorded
the illness is
- patient have
caused by an
increase
infection/
respiratory rate
microorganism or
caused by
not.
3:25 am
constricted airways
• Chest x-ray to be
 follow up that causes

- there’s a blockage difficulty of

in the bronchus that breathing.

causes  S/E by Dra.

bronchoconstriction Gahol with orders

that leads to airway made

trapping.  Consent for

 IVF: admission signed

• D5 0.3 NaCl  1 D5 0.3 NaCl

350 cc/ml to run #50cc at 39-40

at 39-40 mcgtts/min hooked

mcgtts/min and regulated at

• Hydrocortisone desired route

95-IV every 6  Follow up

hours route
3:30 am
• Salbutamol  Rendered

nebulized, 1 neb  Afebrile

every 2 hours
 Medication
• Combivent
prescription
nebulized, neb
 NPO TFV
every 6 hours
 TPR every
• I&O every
shift
shift
 • Oxygen  Oxygen

inhalation at 3-5 inhalation at 3-5

LMP via face mask LPM via face mask

 Inform prior to  Hydrocortisone

admission 45 mg given TIV

4:20 am
 Watch out for  Please inform

invert signs and prior of

symptoms admission

 Note for any

introduced signs

and symptoms and

refer

 Please refer

 Fixed and

brought to Pedia

Ward A

 Endorsed

 Received

patient for pedia

carried by her

mother and

allowed by ND

with ongoing IVF

at 320 ml

 Conscious

 Ongoing oxygen

inhalation at 3-5

LPM via Face mask

 Follow up CBC

 Follow up

chest x-ray

 Rendered

nebulization

 Admission care

rendered

 Placed

comfortably on

bed

 Vital Signs

taken and

recorded

 Medication

given at PER

 Never attended

 Ordered
 Received

patient on bed

with IVF at 150

cc level

 Conscious

 On NPO TFV

 With ongoing

oxygen inhalation

at 3-5 LMP via

face mask

 Follow up CBC

 Follow up

chest x-ray

 Rendered

nebulization

 S/E by Dr.

Orea with orders

made and carried

out

 Needs attended

 Endorsed
  Received

4:20 am patient in bed

6:59 am  Please follow up
with 80 cc level
CBC with Platelet
of #1 D5 0.3NaCl
count
350 at 39-40
 Continue medication
mcgtts/min
and management
 Conscious
 Refer to the
 NPO TFV
Doctor.
 With ongoing
 Dx:
oxygen inhalation
• CBC
5:20 pm  May start regular at 3-5 LMP via

soft diet. face mask

 Follow up
 Please refer
chest x-ray
accordingly.
 Rendered

nebulization
July 13, 2009  Continue regular
 S/E by Castro
7:40 am diet for age.
within moderate
3:30 am  IVF to 1L D5MB to
bed rest
run at 45-50
 Hooked #2 D5
mcgtts/min
IMB 800 cc at 49-
 Follow up x-ray
50 mcgtts/min
result
  Continue medication  Soft diet

and management  D5-IMB 80 cc

 Please refer to be run at 49-

July 14, 2009  Continue diet for
50 mcgtts/min
8:45 am age
 Oxygen
 Please follow up
inhalation
chest x-ray result
ongoing
 Start ampicillin
 Chest x-ray
250 mg TIV every 6
 Nebulization
hours with ANST (-)
 D5-IMB 800cc
 Decrease Salbutamol
at 49-50
mcgtts/min
neb to every 6 hours
 S/E by doctor
 Decrease combivent

neb to every 8 hours  Afebrile

 May discontinue  Endorsed

Hydrocortisone  Received
patient with IVF
 Start prednisone with 70 cc level
of #2 D5 IMB 800
10mg/5ml cc at 49-50
mcgtts/min
3 ml BID x 1 day
 Conscious
3ml OD x 1 day taken
 Regular soft
DIC diet

 Please refer  #3 D5 IMB 1L

WITH 49-50
accordingly mcgtts/min
4:10 pm  IVF to be follow:
 D5IMB 1L to run at 43-  Hooked

44 mcgtts/min  Medications
July 15, 2009  Continue Salbutamol given
7:35 am nebulization  Endorsed

 Discontinue

Combivent

 Continuediet for

age

 CPT after

nebulization

 Continue present

medication and

management

 Refer accordingly
8:30 am  May start Amikacin

80 mg TIV every 12

hours (ANST)

 May start Immuzinc

syrup 1 tsp. per orem

 Please refer

accordingly
11:30 am  IVF to follow D5IMB

to run at 43-44

mcgtts/min
July 16, 2009  Increase
7:25 am nebulization of

Salbutamol every 4

hours

 Repeat CBC with

Platelet count

 May give Prednisone

3 ml p.o. accordingly

 Continue present

medication and

management

 If with normal

result and still

afebrile, possible,

 CPT after neb

 Please refer

accordingly
9:25 am  Decrease Salbutamol

nebulization to every

6 hours

 Start Combivent neb

every 6 hours

 Hold Prednisone

 Refer
Discharge Summary

Nursing Goals Orders Rationale

Medication
Patient will be compliant to • Compliance to medications
continued medication regimen will enhance fast recovery
from illness.

Exercise
Patient will verbalize need Exercise enhances blood
importance of exercise and circulation, proper body
demonstrate proper alignment and improves sense
initiation of appropriate of well being.
exercise.

Treatment Together with medication,

Patient will know treatment will speed up
appropriate treatment development of patient’s
regimen and verbalize condition.
compliance.

Hygiene

Outpatient

Diet

Spiritual
 BIBLIOGRAPHY

Doenges(2006). Nursing Care Plans 7th Edition.

Gulanick, Klopp, Galanes, Gradishar, Puzas(1994). Nursing Care

Plans 3rd Edition.

Cahill, Matthew(1994). Illustrated Manual of Nursing Practice 2nd

Edition.

Timbly, B.R. & Smith, N.E.(2005). Essentials of Nursing Care of

Adults and Child Lippincott Williams & Wilkins, Co.

Behrman, Richard E.(1992). Textbook of Pediatrics 14th Edition

W.B. Saunders Company

Nurses Pocket Guide 11th Edition, 2008

PPD’s Nursing Drug Guide 2nd Edition, Malan Press, Inc., 2008

http://www.drugs.com

http://www.proteases.org