Transcript I. DEMOGRAPHIC DATA - DR.Ahmed Abanamy Hospital

Prepared by:
Airen L. Jamago
LTI- Male Department
 SKIN
- warm, slightly dry, hair evenly
distributed
 HEAD - symmetric skull, no flaking of
scalp, no lesions and tenderness
 EYES - no redness and discharges, sclera
white and clear, pupils reactive to light and
accommodation
 NOSE AND SINUSES - nasal septum
straight, not perforated, no discharged,
NGT present

THORAX AND LUNGS - thorax is symmetric,
chest expansion is decrease due to muscle
weakness, bony prominences are marked,
there is loss of subcutaneous tissue, no
tenderness, wheezes audible upon
auscultation

UPPER EXTREMITIES - decorticate position,
arms are unable to abduct and adduct

NAILS - convex in curvature, rough, with
slightly delayed capillary refill
III. PATIENT HISTORY
RTA
Sep.
26,2011
Known to
have asthma
and DM
RMH
Oct.
5,2011
PATIENT
X
Ward
Oct.
24,2011
• Dec. 7,2011 semi- conscious, unable to
speak and follows command,
quadriphlegic, on NGT and diaper
• Shortness of breath---low O2 sat.--tracheostomy tube ( Jan. 12, 2013)
• VS stable with seldom episodes of
desaturation
STIMULI
inflammation
bronchospasm
Airway hyperresponsiveness
Asthma symptoms
STIMULI
(allergen, irritant, virus, cold air, exercise etc.)
Activation of Inflammatory cells
Migration into airways and activation of more
inflammatory cells
Airway
hyperresponsiveness
Airway
obstruction
Asthma
symptoms
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Frequent cough, especially at night
Losing your breath easily or shortness of breath
Feeling very tired or weak when exercising
Wheezing or coughing after exercise
Feeling tired, easily upset, grouchy, or moody
Decreases or changes in lung function as
measured on a peak flow meter
Signs of a cold or allergies (sneezing, runny
nose, cough, nasal congestion, sore throat, and
headache)
Trouble sleeping
Severe wheezing when breathing both in and
out
 Coughing that won't stop
 Very rapid breathing
 Chest pain or pressure
 Tightened neck and chest muscles, called
retractions
 Difficulty talking
 Feelings of anxiety or panic
 Pale, sweaty face
 Blue lips or fingernails

Identify and minimize contact with
asthma triggers.
Understand and take medications
as prescribed.
Monitor asthma to recognize signs
when it is getting worse.
Know what to do when asthma
gets worse.

 Assist
him to relax as much as
possible.
 Administer oxygen via nasal
cannula to ease breathing and to
increase arterial oxygen saturation
during an acute asthma attack.
 Adjust oxygen according to the
patient’s vital functions and ABG
measurements.
 Administer drugs and I.V. fluids as
ordered.
 Combat
dehydration with I.V. fluids until the
patient can tolerate oral fluids, which will
help loosen secretions.
 Encourage
the patient to express his fears
and concerns about his illness.
 Encourage
the patient to identify and
comply with care measures and activities
that promote relaxation.
 Decreased
ability to exercise and take
part in other activities
 Lack of sleep due to night time
symptoms
 Permanent changes in the function of
the lungs
 Persistent cough
 Trouble breathing that requires
breathing assistance (ventilator)
 DEATH
1. Ineffective airway clearance related to mucus
2.
3.
4.
5.
accumulation.
Impaired Gas Exchange related to altered
oxygen supply, obstruction of airways by
secretions, bronchospasm.
Ineffective breathing pattern related to
decreased lung expansion.
Hyperthermia related to underlying infection
in the lungs.
Impaired nutrition less than body
requirements related to inadequate intake.
ASSESSMENT
Subjective: N/A
Objective:
-(+)wheezing
-Tachypnia
bilateral
-(+) secretions
characterized
by: thick,
greenish in color,
approx. amount
5-8cc q
suctioning
-Frequent
coughing
NURSING
DIAGNOSIS
Ineffective
Airway
Clearance
related to
accumulation of
mucus.
OBJECTIVES
After 12 hrs. of
nursing
intervention the
patient will be
able to expel
secretions
effectively.
After 3-5 days of
nursing
intervention the
patient will
maintain clear
airway.
NURSING
INTERVENTION
1. Position with
the head of the
bed elevated,
head aligned
properly in
straight position.
2. Change
position
frequently.
3. Keep patient
environment free
from source of
allergens, such
as dust, powder,
smoke.
RATIONALE
-Proper
positioning
facilitate
effective
passage of air
through the
lungs and
provide good
aeration of lung
segments.
- Changing of
position aids in
mobilization of
secretions that
may ease
expectoration of
secretions.
-Precipitators of
allergic type of
respiratory
reactions that
can trigger or
exacerbate
onset of acute
episode.
EVALUATION
Goal met.
-Patient
maintained a
patent airway
and
demonstrated
signs of
reduction in
respiratory
secretions.
-Displayed
decreasing
amount of
secretions.
4. Provide
chestphysiothera
py BID for 5 days
as indicated by
treatment.
5. Nebulize with
pulmicort |+
atrovent every 6
hrs. as ordered.
6.Administer
mucolytics 10 ml
x 7 days as
ordered
CPT helps in
mobilization of
secretions
-Nebulization
may be used to
open constricted
airways and
liquefy
secretions.
-Facilitates
liquefaction and
removal of
secretions
ASSESSMENT
Subjective: NA
Objective:
-with slightly
delayed
capillary refill (4
secs.)
-episodes of
frequent
desaturation
approx. 2-4x/
shift
-(+) clubbing of
fingernails
NURSING
DIAGNOSIS
OBJECTIVES
Impaired Gas
Exchange
related to altered
oxygen supply,
obstruction of
airways by
secretion,
bronchospasm.
After 12 hrs of
nursing
intervention the
patient will be
free from
episodes of
desaturation as
manifested by
oxygen
saturation of 95100%.
After 3-5 days of
nursing
intervention the
patient will
demonstrate
improved
ventilation and
adequate
oxygenation of
tissues as
evidenced by
normal
respiratory rate
(20bpm), and
good breathing
NURSING
INTERVENTION
1.Provide
adequate rest.
RATIONALE
-To decrease
oxygen
demand.
2.Keep
environment
free of allergen.
-To prevent
irritation of
bronchial walls.
3.Administer
oxygen as
ordered.
-To increase
oxygen of the
patient.
4. Nebulize the
patient as
ordered.
-To promote
bronchodilation.
5. Administer
meds. As
ordered
-To promote
curative aspect
EVALUATION
GOAL MET.
Patient is free
from
desaturation
episode as
manifested by
O2 sat. of 99%.
ASSESSMENT
NURSING
DIAGNOSIS
OBJECTIVES
Subjective: NA
Ineffective
Breathing
Pattern related
to airway
constriction
secondary to
bronchial
asthma
After 12 hrs. of
nursing
intervention the
patient will
demonstrate
breathing in
normal rate,
depth & rhythm.
Objective:
-(+) dyspnea
-shortness of
breath
-increased work
of breathing,
use of
accessory
muscles
-(+) nasal
flaring
-decrease O2
sat.
After 3-5 days
of nursing
intervention the
patient will
experience no
cyanosis,
dyspnea and
normal range
O2 saturation.
NURSING
INTERVENTION
1. Maintain a
clear airway,
suction PRN,
CPT as
indicated.
2. Elevate the
head and help
change the
position.
3.Nebulize with
pulmicort |+
atrovent,
administer
mucolytics as
ordered
4. Collaboration
-Provide
supplemental
oxygen
RATIONALE
-Helps in
mobilization of
secretions.
-Changing of
position aids in
mobilization of
secretions that
may ease
expectoration of
secretions.
-Nebulization
may be used to
open
constricted
airways &
liquefy
secretions as
well as the
mucolytics.
-maximize
breath and
reduce labor
EVALUATION
GOAL MET.
Demonstrated
normal
breathing, no
cyanosis and
dypnea, and
normal O2
saturation.

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Asthma is a chronic inflammation of the bronchial
tubes (airways) that causes swelling and
narrowing (constriction) of the airways.
The bronchial narrowing is usually either totally
or at least partially reversible with treatments.
The most common chronic illness in children,
affecting one in every 15.
It involves only the bronchial tubes and usually
does not affect the air sacs or the lung tissue.
The narrowing that occurs in asthma is caused by
three
major
factors:
inflammation,
bronchospasm, and hyperreactivity.
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Allergy can play a role in some, but not all,
asthma patients. Many factors can precipitate
asthma attacks and they are classified as either
allergens or irritants.
Symptoms include shortness of
breath,
wheezing, cough, and chest tightness.It is usually
diagnosed based on the presence of wheezing
and confirmed with breathing tests.
Chest X-rays are usually normal in asthma
patients.
Avoiding precipitating factors is important in the
management of asthma.
Medications can be used to reverse or prevent
bronchospasm in patients with asthma.