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MARIANO MARCOS STATE UNIVERSITY
College of Health Sciences
Batac, Ilocos Norte
A CASE ANALYSIS:
BRONCHIAL ASTHMA
IN ACUTE EXACERBATION
Submitted to:
MRS. MAXIMA JOHANNA L. RAFOLS
MRS. RUTH T. LAYAOENClinical Instructors
Submitted by:
MARY ANN C. ALLAUIGAN
JENNIFER B. AQUE
HAYDEN MAY S. BALTAZAR
CARISSA B. DAYOAN
RICHILDA S. ERLANDEZ
DANNI RICA S. GAZMEN
MADELYN C. MACADANGDANG
GERALDINE C. RAMOS
CHRISTINE V. REYES
CHATY P. SIBUCAO
ARISTOTLE S. TABIOSRICHELLE Q. VALITE
CELSO C. VILLANUEVA
MARIA ALELI A. YANOSBSN IVC, GROUP III
January 27, 2005
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TABLE OF CONTENTS
Title Page - - - - - - - - - - -1
Table of Contents- - - - - - - - - -2
I. ANATOMY AND PHYSIOLOGY - - - - - -3
Respiratory System - - - - - - - -3
II. PATHOPHYSIOLOGY - - - - - - - -8
Readings- - - - - - -- - - -8
Paradigm - - - - - - - - -12
III. PERSONAL DATA- - - - - - - - -13
IV. FAMILY BACKGROUND - - - - - - - -14
V. HEALTH HISTORY- - - - - - - - -15
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Family Health History- - - - - - - -15
Past Health History - - - - - - - -16
Present Health History- - - - - - - -17
VI. DEVELOPMENTAL DATA- - - - - - - -17
VII. PATTERNS OF FUNCTIONING- - - - - - -19
VIII. LEVEL OF COMPETENCIES- - - - - - -21
IX. PHYSICAL ASSESSMENT- - - - - - - -25
X. ON GOING APPRAISAL - - - - - - - -26
XI. LABORATORY AND DIAGNOSTIC PROCEDURES- - - -29
XII. MEDICAL MANAGEMENT- - - - - - - -36
XIII. DRUG STUDY- - - - - - - - - -38
XIV. NURSING CAREPLAN- - - - - - - -43
XV. GENERAL EVALUATION - - - - - - -49
XVI. IMPLICATION OF THE STUDY - - - - - -50
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I. ANATOMY AND PHYSIOLOGY OF RESPIRATORY SYSTEM
The respiratory system contains the structures through with oxygen comes into the body to reach
the bloodstream, and through which carbon dioxide and water vapor leaves. These structures include the
lungs and the airways or air passages connected with them.
Gas exchange is the primary function of the respiratory system. The respiratory system takes
oxygen from the atmosphere, transport oxygen into the lungs, exchanges oxygen for carbon dioxide in the
alveoli, and returns carbon dioxide in the air.
Besides its major function, exchanging carbon dioxide and oxygen, the respiratory system also
supports all vital functions. The respiratory system helps maintain the bodys acid base balance to ensure
as table hydrogen ion concentration. Moreover, the system warms inhaled air, filters air thru the nasal
hairs, and distributes air through the vocal cords to allow speech.
STRUCTURES OF THE RESPIRATORY SYSTEM
UPPER AIRWAY
The upper airway consist the nose the nasal cavity, pharynx and larynx. Major functions of the
upper airway are (1) air conduction to the lower airway to the gas exchange; (2) protection to the lower
airway from foreign matters; and (3) warming filtration and humidification of inspired air.
Nose and Nasal Cavity
The term nose usually refers to the visible structure that forms a prominent feature of the face and
also can refer to the internal nasal cavity. The bridge of the nose consists of the nasal bones and
extensions of the frontal and maxillary bones, but most of the nose is composed of cartilage. The rigid
bone and cartilage are covered with connective tissue and skin.
The nasal cavity extends from the external openings in the nose to the pharynx, and it is divided
by the nasal septum into the right and left sides. The external openings to the nasal cavity are the external
nares and nostrils, and the internal openings from the nasal cavity into the pharynx are the internal nares.
The external nares lead to a cavity called vestibule. The vestibule is lined interiorly with skin and
hair (called vibrissae). The vibrissae filters foreign object and prevent them from being inhaled. The
posteriors vestibule is lined with mucus membrane. This membrane is composed of columnar epithelial
cells, which secretes mucus. Along the side of the vestibule are turbinate. The turbinate are mucus
membrane covered projections. They contain a very rich blood supply from the external and internal
carotid arteries, and they warm and humidify inspired air.
Paranasal sinuses are open areas within the skull. They are anmed from the bones in which they
lie frontal, ethmoid, sphenoid, and maxillary. Passageways from the paranasal sinuses drain into the
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nasal cavities. The nasolaryngeal ducts, which drain tears from the surface of the eyes, also drain into the
nasal cavity.
Pharynx
The pharynx is a funnel-shaped tube that extends from the nasal cavities to the larynx, where it
becomes continuous with the esophagus. The pharynx is the common passageway of both the digestive
and respiratory system. It receives air from the nasal cavity and air, food, and water from the mouth.
Inferiorly, the pharynx leads to the opening of the respiratory system (opening into the larynx) and the
digestive system (the esophagus). The pharynx can be divided into three regions, the nasopharynx, and
the laryngopharynx.
The nasopharynx is the superior portion of the pharynx and extends from the internal nasal cavity
to the level of the uvula, a soft process that extends from the posterior edge of the soft palate. The soft
palate forms the floor of the nasopharynx. The nasopharynx is lined with a mucus membrane similar to
that of the nasal cavity. The auditory tubes open into the nasopharynx, and the posterior portion of the
nasopharynx contains the pharyngeal tonsils, which aid in defending the body against infection. The soft
palate and uvula are elevated during swallowing, and this movement results in the closure of the
nasopharynx, which prevents food from passing from the oral cavity into the nasopharynx.
On the other hand, oropharynx extends from the uvula to the epiglottis. The oral cavity opens into
the oropharynx. Thus food, drink, and air all pass through the oropharynx. The oropharynx is lined with
stratified squamous epithelium, which protects against abrasion.
The laryngopharynx extends from the epiglottis to the lower margin of the larynx. The
laryngopharynx, like the oropharynx, is lined with stratified squamous epithelium.
Larynx
The larynx or the voice box is that part of the respiratory tract between the pharynx and the
trachea, containing the vocal cords. It consists of an outer casing of nine cartilages that connected to each
other by muscles and ligaments. Six of the nine cartilages form three pairs of cartillages, and three
cartillages are upaired.
One unpaired cartilage is the epiglottis, which consists of elastic cartilage rather than hyaline
cartilage. Its inferior margin is attached to the thyroid cartilage anteriorly, and the superior part of the
epiglottis projects as a free flap forward the tongue. During swallowing, the epiglottis covers the opening
of the larynx and prevents materials from entering it. The thyroid cartilage is another unpaired cartilage.
The thyroid cartilage (or Adams apple) is known to be the largest cartilages composing the larynx. The
unpaired cricoid cartilage is the most inferior cartilage of the larynx. It forms the base of the larynx where
the other cartilages rest.
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The six paired cartilages are stacked in two pillars, each consisting of three cartilages, between
the cricoid and thyroid cartilages on the posterior portion of the larynx.
Two pairs of ligaments extend from the posterior surface of the thyroid cartilage to the paired
cartilages. The superior pair forms the vestibular folds, or false vocal cords, and the inferior pair
composes the vocal folds, or true vocal cords. The true vocal cords are involved in voice production. Air
moving past the true vocal cords causes them to vibrate, producing sound. The force of air moving past
the true vocal cords controls the loudness and the tension of the true vocal cords controls the pitch of the
voice.
LOWER AIRWAY
The lower airway (tracheobronchial tree) is composed of the trachea, right anf left main stem
bronchi, segmental bronchi, sub segmental bronchi, and terminal bronchioles. The major functions of the
lower airway include (1) conduction of air through the many branches of airways to the alveolar level; (2)mucociliary clearance; and (3) production of pulmonary surfactant.
Trachea
The trachea (windpipe) ia a thin-walled tube of cartilaginous and membranous tissue descending
from the larynx to the bronchi and carrying air to the lungs. It is about 1 inch wide and 4-5 inches long,
reinforced with 15-20 C-shape pieces of cartilage.
The C-shape cartilages form the anterior and lateral sides of the trachea, and they protect the
trachea and maintain an open passageway of air. The posterior wall of the trachea has no cartilage and
consists of a ligamentous membrane and smooth muscle.
The trachea is lined pseudostratified columnar epithelium that contains numerous cilia and goblet
cells. The cilia propel mucus produced by the goblet cells and foreign particles toward the larynx, where
they enter the esophagus and are swallowed.
Mainstem Bronchi
The main stem bronchi are also called primary or main brochi. They are subdivisions of the
trachea branching off from the tracheal bifurcation. One main stem bronchus enters each lung. These
tubular passages conduct air between the trachea and the pulmonary bronchi. Like the trachea, the walls
of the bronchi contain cartilaginous rings and are covered with ciliated mucous lining.
Because of the location of the heart in the thoracic cavity, the left primary bronchus is more
horizontal than the right primary bronchus. The right primary bronchus is also shorter and wider so
foreign objects that enter the trachea usually lodge in the right primary bronchus.
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Segmental and Subsegmental Bronchi
Segmental and subsegmental bronchi are also referred to as secondary bronchi or bronchial tubes.
They are subdivisions of main bronchi and spread in an inverted treelike formation, branching through
each lung. These tubular passages convey air within the lung between the main stem bronchi and the
bronchioles.
Terminal Bronchioles
Terminal bronchioles are the last airways of the conducting system and also the smallest
subdivisions of bronchi. Segmented bronchi divide into smaller bronchioles within the broncho-
pulmonary segments. The final branches of bronchioles, i.e., respiratory bronchioles, communicate
directly within clusters of alveoli. The smooth muscles of the bronchioles are supplied by both divisions
of the autonomic nervous system, the sympathetic (promoting relaxation) and the parasympathetic
(promoting contraction).
LUNG PARENCHYMA
The lung is metabolically very active and accounts for approximately 10 percent of oxygen
consumption. The lung parenchyma is the working area of lung tissue, consisting of millions of alveolar
units. Alveoli, small air sacs at the end of the respiratory bronchioles, permit exchange of oxygen and
carbon dioxide. The entire alveolar is made up of respiratory bronchioles, alveolar ducts, and alveolar
sacs. Gas exchange actually begins in the respiratory bronchioles.
It is estimated there are 24 million alveoli at birth. By the time the person is 8 years old, the
number of alveoli has increased to the adult number of 300 million. The total working alveolar surface
area is approximately 70-80 sq.m. The large number of alveoli and the large surface area are necessary to
meet both resting and exercise oxygen requirements. Each alveolar unit is supplied with 9-11
prepulmonary and pulmonary capillaries. The blood supply for these capillaries comes from the right
ventricle of the heart. The major function of the lung parenchyma is the passage and exchange of
molecular oxygen and carbon dioxide from the pulmonary capillaries and alveoli.
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LUNGS
The lungs lie within the thoracic cavity on either side of the heart. They are light, spongy, porous,
elastic, and cone-shaped. The lungs inflate with expiration and deflate (but do not completely collapse)
with expiration. They extend from the diaphragm to just above the clavicles. The base of the lungs rests
on the diaphragm, while the apex (top) extend above the first rib. The hilus or the hilum (root of the
lung) is a notch or depression in the medial surface of the lung where the main stem bronchus,
pulmonary blood vessels, and nerves enter the lung. The lungs lie free within the thorax and are attached
only at the hilus.
The two
lungs are separated
by a space
the
mediastenum. Each
lung is divided
into superior and
inferior lobes by an
oblique fissure.
The right lung is further
divided by a
horizontal fissure, which bound as middle lobe. The right lung, therefore, lies three lobes, whereas the
left lobe has only two. In addition to these five lobes that are externally visible, each lung can be
subdivided into about ten smaller units called broncho-pulmonary segments. Each broncho-pulmonary
segment represents the portion of the lung that is supplied by a specific tertiary bronchus.
Lungs are made of elastic tissue with a tendency to recoil. They are capable of stretching if a
pulling force is exerted on them from outside or if they are blown up (inflated) from within. Normally
the elastic fibers of the lung are partially stretched all the time, thus, filling the lung chamber. Lung
parenchyma (essential functional parts) is a network of air tubes and blood vessels, honeycombed with
air-filled sacs (alveoli).
PLEURAE
The pleurae are membranes protectively covering each lung and lining the thoracic cavity. The
two pleural layers are (1) the parietal pleural, lining the inner surface of the chest wall and covering the
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coastal, diaphragmatic, and mediastinal surfaces of the thorax, and (2) the visceral pleura, hugging the
contours of the lung tissue, including the fissures between the lobes of the lungs.
The pleura are continuous with one another and form a closed sac. Normally, there is no space
between them. A potential space exists called the pleural space (pleural cavity). A thin film (only a few
ml) of serous fluid (pleural fluid) is present in the pleural space acting as a lubricant. It also causes the
moist pleural membrane to adhere somewhat, the cohesion producing a tensile strength or pulling force
that helps hold the lungs in an expanded position. It is through (a) muscular energy exerted on the thorax,
and (b) changes between the relationship of intrathoracic and atmospheric pressures that gasses are able to
move in and out of the lungs.
The pressure within the lungs and thorax must be less than atmospheric pressure for inspiration to
occur. Gas flows from an area of higher pressure to one of a lower pressure. As the diaphragm and inter-
coastal muscles work to enlarge the size of the thorax, intrathoracic pressure decreases below atmospheric
pressure and air moves into the lungs. During the exhalation, inspiratory muscles relax and the elastic
recoil of the lung tissue, along with a rise in the intrathoracic pressure, causes air to move out of the lung.
The viseral pleura (which lines the lungs) adhere to the parietal pleura. As the chest wall moves,
the parietal pleura (attach to the arterial wall of the thorax) carry the visceral pleura along with it. This
mechanism simultaneously pulls the lung downward as the diaphragm descends. This counteracts the
elastic recoil of the lung tissue.
II. PATHOPHYSIOLOGY
A. Readings
A pulmonary disease characterized by reversible airway obstruction, airway inflammation, and
increased airway responsiveness to a variety of stimuli.
Airway obstruction in asthma is due to a combination of factors that include spasm of airway
smooth muscle, edema of airway mucosa, increased mucus secretion, cellular (especially eosinophilic and
lymphocytic) infiltration of the airway walls, and injury and desquamation of the airway epithelium.
Bronchospasm due to smooth muscle contraction used to be considered the major contributor tothe airway obstruction. But now, inflammatory disease of the airways is known to play a critical role,
particularly in chronic asthma. Even in mild asthma, there is an inflammatory response involving
infiltration, particularly with activated eosinophils and lymphocytes but also with neutrophils and mast
cells; epithelial cell desquamation also occurs. Mast cells seem important in the acute response to inhaled
allergens and perhaps to exercise but are less important than other cells in the pathogenesis of chronic
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inflammation. The number of eosinophils in peripheral blood and airway secretions correlates closely
with the degree of bronchial hyperresponsiveness.
Typically, all asthmatics with active disease have hyperresponsive (hyperreactive) airways,
manifest as an exaggerated bronchoconstrictor response to many different stimuli. The degree of
hyperresponsiveness is closely linked to the extent of inflammation, and both correlate closely with the
severity of the disease and the need for drugs. However, the cause of hyperresponsive airways is not
known. Structural changes in the airways may contribute to it. For example, desquamation of epithelium
(due to eosinophil major basic protein) results in a loss of epithelium-derived relaxing factor and of
prostaglandin E2, both of which reduce contractile responses to bronchoconstricting mediators. Neutral
endopeptidases responsible for metabolizing bronchoconstricting mediators (eg, substance P) are
produced by epithelial cells and are also lost when the epithelium is damaged. Another possible cause of
airway hyperresponsiveness is airway remodeling resulting in a small increase in airway thickness.
Many inflammatory mediators in the airway secretions of patients with asthma contribute to
bronchoconstriction, mucus secretion, and microvascular leakage. Leakage, a constant component of
inflammatory reactions, leads to submucosal edema, increases airway resistance, and contributes to
bronchial hyperresponsiveness. Inflammatory mediators are either released or formed as a consequence of
allergic reactions in the lungs; they include histamine and products of arachidonic acid metabolism
(leukotrienes and thromboxane, both of which can transiently increase airway hyperresponsiveness). The
cysteinyl leukotrienes, LTC4 and LTD4, are the most potent bronchoconstrictors yet studied in humans.
Platelet activating factor is no longer thought to be an important mediator of asthma.
T-cell activation of the allergic response is a key event in the inflammation that characterizes
asthma. T cells and their secretory products (cytokines) perpetuate airway inflammation. Cytokines
produced by one particular lineage of lymphocytes, the CD4Th2 (helper) T cells, promote growth and
differentiation of inflammatory cells, activate them, induce their migration into the airways, and prolong
their survival there. The principal cytokines involved include interleukin (IL)-4, which is necessary for
IgE production; IL-5, which is a chemoattractant for eosinophils; and granulocyte-macrophage colony-
stimulating factor, which is similar to IL-5 in its effects on eosinophils but less potent.
Cholinergic reflex bronchoconstriction probably occurs in the acute response to inhalation of
irritant substances; however, neuropeptides released from sensory nerves in an axon reflex pathway may
be more important. These peptides, which include substance P, neurokinin A, and calcitonin gene-related
peptide, cause vascular permeability, mucus secretion, bronchoconstriction, and bronchial vasodilation.
The pathophysiologic changes described above lead to varying degrees of airway obstruction and
to ventilation that is typically nonuniform. Continued blood flow to some hypoventilated areas causes
ventilation/perfusion imbalance, resulting in arterial hypoxemia. Early in an attack, a patient typically
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compensates by hyperventilating the unobstructed areas of the lung, resulting in a decrease in PaCO 2. As
the attack progresses, the capacity for hyperventilation is impaired by more extensive airway narrowing
and muscular fatigue. Hypoxemia worsens, and PaCO2 begins to rise, leading to respiratory acidosis. At
this point, the patient is in respiratory failure.
Symptoms and Signs
The frequency and severity of symptoms vary greatly from person to person and from time to
time in the same person. Some asthmatics have occasional episodes that are mild and brief. Others have
mild coughing and wheezing much of the time, punctuated by severe exacerbations after exposure to
known allergens, viral infections, exercise, or nonspecific irritants. Psychologic factors, particularly those
associated with crying, screaming, or hard laughing, may precipitate symptoms.
Usually, an attack begins acutely with paroxysms of wheezing, coughing, and shortness of breath
or insidiously with slowly increasing manifestations of respiratory distress. However, especially in
children, an itch over the anterior neck or upper chest may be an early prodromal symptom, and dry
cough, particularly at night and during exercise, may be the sole presenting symptom. An asthmatic
usually first notices dyspnea, cough, shortness of breath, and tightness or pressure in the chest and may
hear wheezes. The cough during an acute attack sounds tight and generally does not produce mucus.
Except in young children, who rarely expectorate, tenacious mucoid sputum is produced as the attack
subsides.
Physical examination: During an acute attack, the patient shows varying degrees of respiratory
distress, depending on the severity and duration of the episode. Tachypnea and tachycardia are present.
The patient prefers to sit upright or even leans forward, uses accessory respiratory muscles, is anxious,
and may appear to struggle for air. Chest examination shows a prolonged expiratory phase with relatively
high-pitched wheezes throughout inspiration and most of expiration. The chest may appear hyperinflated
due to air trapping. Coarse rhonchi may accompany the wheezes, but fine crackles are not heard unless
pneumonia, atelectasis, or cardiac decompensation is also present.
During more severe episodes, the patient may be unable to speak more than a few words without
stopping for breath. Fatigue and severe distress are evidenced by rapid, shallow, ineffectual respiratory
movements. Cyanosis becomes apparent as the attack worsens. Confusion and lethargy may indicate the
onset of progressive respiratory failure with CO2 narcosis. In such patients, less wheezing may be heard
on auscultation, because extensive mucous plugging and patient fatigue result in marked reduction of
airflow and gas exchange. A quiet-sounding chest in a patient having an asthma attack is an alarm that the
patient may have a severe respiratory problem that can quickly become life threatening.
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The most reliable signs of a severe attack are dyspnea at rest, the inability to speak, cyanosis,
pulsus paradoxus (> 20 to 30 mm Hg), and use of accessory respiratory muscles. Severity is most
precisely assessed by measuring arterial blood gases.
Between acute attacks, breath sounds may be normal during quiet respiration. However, fine
wheezes may be audible during forced expiration or after exercise. Low- to moderate-grade wheezing
may be heard at any time in some patients, even when they feel asymptomatic. With long-standing severe
asthma, especially if dating from childhood, chronic hyperinflation may affect the chest wall, eg,
producing a squared off thorax, anterior bowing of the sternum, or a depressed diaphragm.
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BSN-IVC,G3
13B. Paradigm
EMOTIONALSTRESS
EXERCISE RESPIRATORYTRACT INFECTION
ALLERGENS,
IRRITANTS, FOODS,DRUGS,
OCCUPATION
Modification of vagal
efferent activity and
activation of brainendorphines
Hyperemia
Increase minuteventilation
Microvasculatureengorgement
Epithelial damage
Stimulation of IgE
Activation of mastcells
Release of chemicalmediators
Leukotrienes
Hypersecretion ofmucus
Histamine, bradykinin,prostaglandin
Attracts WBC (neutrophils,
eosinophils and lymphocytes andincrease cellular permeability
Edema on mucus membrane
BRONCHOSPASM
BRONCHOCONSTRICTION
Increase work of breathing
RestlessnessTachypnea and dyspnea
TachycardiaFalring of alae nasi
DiaphoresisCold clammy skin
WheezingRetractions
Pallor to cyanosis
Use of Accessorymuscles
Exhaustion
Slow, shallow respiration
Retention of CO2Hypoxia, Hypoxemia
Respiratory acidosiss/s: headache, dyspnea, fine tremors, HPN,
tachycardia, vasodilation
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III. PERSONAL DATA
Name:Ang Khit
Age: 58 years old
Date of Birth:September 28, 1946
Place of Birth:Dingras, Ilocos Norte
Sex: Female
Civil Status: Widow
Religion:Bathle Community Church
Nationality: Filipino
Address: #4 Laoag City
Educational Attainment:High School Level
Occupation:Housekeeper
Chief Complaint: Difficulty of Breathing
Diagnosis:
Admitting: Bronchial Asthma with Acute Exacerbation
Final: Bronchial Asthma with Acute Exacerbation
Inductive period of Hospitalization:
Date of Admission:January 1, 2005
Admitting Physician:Dr. Magcalas / Dr. Catcatan
Ward & Room:Medicine 4F, Room 409 Alley
Category:Service
Hospital Number: 754953
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IV. FAMILY BACKGROUND
Members Position Relationship
with the
Head
Age Sex Civil
Status
Residence Occupation Religion Educationa
Attainmen
Hi-ngal Eldest
child
Daughter 37 F M Hong
Kong
Domestic
Helper
Bathle
Community
Church
College
Graduate
(Commerce
Rharek Second
child
Daughter 35 F M Hong
Kong
Domestic
Helper
Bathle
Community
Church
High Schoo
Graduate
Ah-nangsab
Thirdchild
Daughter 32 F S HongKong
DomesticHelper
BathleCommunity
Church
CollegeGraduate
(BSIT)
Uh-yhek Fourthchild
Son 30 M M Laoag City Tricycledriver
BathleCommunity
Church
VocationalGraduate
Sa-whaw Fifth
child
Son 21 M M Laoag City Tricycle
driver
Bathle
Community
Church
High Schoo
Graduate
Phle-mas Sixth
child
Daughter 15 F S Laoag City Student Bathle
Community
Church
High Schoo
Level
Approximate Income: P 10, 000.00
Main source of income: Foreign Aid (from the daughters in Hong Kong)
Ang Khits family is an extended type since her all her four children who are married are staying
in their family house, sharing all the resources available.
The main source of living of her family comes from her 3 children in Hong Kong working as
domestic helpers. Her married children holds their own money however, they also contributes on the
different need s in their house.
According to Ang Khit, shes the one who budgets the money given by her children and in-laws
for all the things needed in their house including the food, groceries, electric bills, water bills,
transportation and other miscellaneous.
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In terms of decision making, shes usually the one who makes decision when it comes with their
properties. However, it its already in terms of financial and health, its already her children with their
husbands.
V. HEALTH HISTORY
A. Family Health History
According to Ang Khit, there are only two hereditary diseases present in their family that
includes diabetes mellitus and asthma. Her husband died because of his diabetes. Her parents and
grandparents did not die of any kind of disease but due to old age as claimed by her.
Ang Khit also revealed that they had experienced having cough, colds, fever during extreme
temperatures (hot and cold weathers), headache, stomachache, toothache and body ache. They usually
manage them with over the counter drugs such as Decolgen for cough, Neozep for colds, Paracetamol
for fever, Alaxan for headache, body ache and toothache, and Kremil-S for stomachache. They also had
experienced some infectious and communicable diseases such as chicken pox, measles, mumps and
sore eyes. They manage chicken pox by applying singkamas on the vesicles to relieve irritation; for
measles, they let her wear black color clothes for they believe that this will lessen the irritation; and for
mumps, they applying akot-akot on the affected area. For other managements for these diseases, she
identified bedrest, enough sleep and adequate nutrition as their practices.
They also utilize herbal medicines such as oregano decoction and lagundi decoction for cough,
boiled guava leaves for cleaning wounds, ampalaya leaves for an-an and kutsay leaves for boils.
Ang Khit pointed out that they directly go to private clinics or to the nearest hospital for severe
cases. She stressed out that they doesnt believe in ghost, bad spirits, witchcraft, herbolaryos, and
arbolaryos. But she stated that she often consults a hilot whenever there are sprains and dislocated
bones, and claimed to be effective.
For the immunization of the family members, Ang Khit cannot really tell if her husband had
received one. She cannot also remember if they have a complete immunization but she was very much
sure that they had received one, she just cant remember what kind of immunization it was.
Ang Khit disclose that her in-laws are smoker consuming one pack of cigarette (hope) per day.
Ang Khit stated that they had tried to talk to them and encourage them to stop smoking but they were
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not listening to the them. Every night, they are also drinking one cuatro cantos of Ginebra San Miguel
but she claimed that there were no troubles that usually happens between them.
The family prefers to eat vegetables and fish, however they also buy meat when they have extra
money. The family drinks water from their well. They also drink coffee every morning sometimes
softdrinks when theres an occasion. There were no allergies identified in the family.
B. Past Health History
According to Ang Khit, she experienced having common illnesses during her childhood days
such as fever, colds, cough, stomachache, headache, and flu. These illnesses were managed by taking
in over the counter drugs such as Paracetamol for fever, Neozep for colds, Decolgen for cough, Kremil-
S for stomachache, and Alaxan for headache. She also uses herbal plants such as oregano decoction
plus breast milk for cough, and kutsay for minor wounds.
Ang-Khit also had experienced having chicken pox, measles, and mumps. They manage her
chicken pox by applying singkamas on the vesicles to relieve irritation; for measles, they let her wear
black color clothes for they believe that this will lessen the irritation; and for mumps, they applying
akot-akot on the affected area.
Ang Khit doesnt know if she had received any immunizations. She also claimed that she doesnt
have any allergies to foods and drugs except for the dust and other allergens ands irritants present in the
environment because this triggers her asthma. Ang Khit is fond of drinking coffee with at least three
cups of day Shes also fond of drinking juice and softdrinks. Ang Khit is also fond of eating raw fishes,
salty and fatty foods, and vegetables but dislikes beef very much.
According to her, this is her second hospitalization next to her hospitalization in 1980 also in
MMMH and MC with a diagnosis of Bronchial Asthma. She was then stayed at the hospital for one
week, given due medication and was relieved. In this time, she was give Theophyllin 200 mg twice a
day as her maintenance medication and nebulization as needed.
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C. Present Health History
Ang Khit is a diagnosed case of Bronchial Asthma (since 1980) with an intake of theophylline
200 mg BID and PRN nebulization.
According to Ang Khit, her asthma usually occurs once a month depending on the situation. She
pointed out that shes usually having asthmatic attack when exposed to dust, fumes, smoke, pollens, and
other environmental irritants and allergens. No hospitalizations or consultations to private were usually
done during these times because according to her, her maintenance medication usually relieves her
discomfort.
Three weeks prior to admission, the client started coughing accompanied by colds and difficulty
of breathing . Ang Khit self medicated with theophylline and nebulization which afforded relief.
One day prior to admission, she developed severe difficulty of breathing. She again nebulized
three times at home and afforded slight relief. However, few minutes prior to admission, difficulty of
breathing worsens prompting her for consultation, hence admission.
According to her, the attack of her asthma was caused by the smoke of the firecrackers during the
celebration of the New Years Eve.
VI. DEVELOPMENTAL DATA
ERIK ERICKSON
Just as physical growth patterns can be predicted, certain psychosocial tasks must be mastered in
each developmental stage. According to Erickson's theory of psychosocial development, the middle age
or adulthood stage (25-65 years old) is the stage in which our patient has to accomplish a certain task,
which isgenerativity, the tendency to produce orstagnation, the tendency to stand still.
Ang Khit, having the age of 58 belongs to middle adulthood. Her developmental task is
generativity where in she is expected to develop an attitude of creativity and productivity in all aspect.
Stagnation on the other hand, suggests a lack of psychosocial movement or growth. When generativity
also is not achieved, the individual may turn into self- indulgence, self-concern and lack of interest and
commitment and eventually, crisis would exist.
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In addition, at this stage, she is expected to develop attitude-establishing priority of needs,
concern for others through transmitting good values to the next generation.
Relating this to our client's life in terms of creativity and concern for others, Ang Khit claimedthat she is very concerned to her family and to other people. Her secret according to her in establishing
good interpersonal relationship with other people is to be honest, trustworthy, and be good always. She
considers her family as her source of inspiration that's why she wants them to have a very good future.
She also stressed out that her source of happiness is her family, she is very supportive and caring
to her children and grandchildren Though sometimes she becomes lonely when she remember her
husband who died at the age of 52, however she said that maybe it is the will of GOD.
Ang Khit achieved certain task under generativity in the sense that she stated that she is happy
and contented with her life and willing to abreast the best that she can be for the good of his family.
ROBERT HAVIGHURST
In Havighurst theory of developmental task, biologic changes become apparent during middle
age. There is an important milestone in which both physiological and psychological adjustment must be
made for successful personal development. The following are the tasks he must achieved:
1. Achieving adult civic and social responsibility
2. Establishing and maintaining an economic standard of living
3. Assisting teenage children to become responsible and happy adults
4. Developing adult leisure-time activities
5. Relating oneself to ones spouse as a person
6. Accepting and adjusting to the physiologic changes of middle age
7. Adjusting to aging parents
Basing from these criteria, Ang Khit is performing her tasks. In fact, as what have stated they
have good relationship with her husband when he was still living. She is responsible enough looking for
the welfare of her family that even shes already old, she still finds a way to help her children in their
daily living.
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Aside from being a good mother of six she is also a good provider and mentor to her children.
She wanted them to be trained well and to become better individuals wherein as claimed by Phle-mas,
her mother achieved this goal.
When there are civic activities in the barangay such as Oplan Dalus, meeting of the WomensOrganization, Bingo social, etc. she finds time to support the said activity She utilizes her leisure time
listening to AM radio specially on news and drama.
Ang Khit admitted that she is getting older, and she finds her becoming more matured and more
knowledgeable for as she believes that experience is the best teacher.
ANALYSIS:
Based on the information we gathered, we believed that Ang Khit is normally developinganalogous to Erickson and Havighurst's theories. She is doing well with the tasks he is expected to
possess and to perform.
Moreover, if he continuously carries out these tasks, most definitely, he would be able to move to
the next stage and could perform the succeeding task. Though her condition sometime gives her
problem and makes her worried, it did not serve as a hindrance to attain the different tasks expected of
her.
VII. PATTERNS OF FUNCTIONING
Patterns Before Illness During Illness During
Hospitalization
Analysis
1. Eating Breakfast
Time: 5-7 am
Food content &
amount:
3-4 pcs. Pandesal
1 fried & 1 cup
rice 1 cup rice & 2
pcs. longganisa
Breakfast
Time: 6-7 am
Food content &
amount:
3-4 pcs.
pandesal
1 fried egg & 1cup rice
1 cup rice & 2
pcs.
longganisa
Breakfast
Time: 8 am
Diet:
Food content &
amount:
2 slices bread & 1
banana
There is a change of
the clients food
intake during
hospitalization
because of he
asthma wherein
there is a
bronchospasm tha
lead to different
problems such as for
activity intolerance,
ineffective breathing
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pattern, etc., tha
decreases her
appetite to eat. And
in addition, it is very
much hard to eat for
the client since shes
having difficulty of breathing and was
striving for oxygen.
Lunch
Time: 12:00 pm
Food content &
amount:
1 cup rice, serving
vegetable ( in any
type) or I cup rice& 3-4 [pcs. Meat
9matachbox
size)/ I cup rice
and 2 pcs. Fish
(medium size)
1 banana
Lunch
Time: 12:00 pm
Food content &
amount:
1 cup rice, serving
vegetable ( in any
type) or I cup rice& 3-4 [pcs. Meat
9matachbox
size)/ I cup rice
and 2 pcs. Fish
(medium size)
1 banana
Lunch
Time: 12:00-1:00 pm
Food content &
amount:
1 cup rice, I serving
squash (ginisa), I
pc. Fish (mediumsize)/ 2 pcs. Meat
(matchbox size)
Dinner
Time: 6:00 pm
Food content &amount:>1 cup rice, serving
vegetable (in any
type), 3-4 pcs. Meat
(matchbox size) 2pcs. Fish (medium
size)
Dinner
Time: 6:00 pm
Food content &amount:>1 cup rice, serving
vegetable (in any
type), 1 pcs, fish
(medium size)
Dinner
Time: 5:00-6:00 pm
Food content &amount:>1 cup rice, I serving
vegetable (in any
type), 2 pcs. Meat
(matchbox size)
Snack
Time: 9 10 AM /
3 4 PM
Food content &amount:
> any home made
delicacies
Snack
Time: 9 10 AM /
3 4 PM
Food content &amount:
>2-3 pcs, bread
Snack
Time: 10 AM
Food content &
amount:>1 pack sky flakes
2. Drinking Content: water, coke ,
orange juice, coffe
>5-7 glass of water
>1 cup of coffe
>1 glass juice
Amount:
approximately 1200-
1600ml/day
Content: water, coke ,
orange juice, coffe
>5-7 glass of water
>1 cup of coffe
>1 Amount:
approximately 1200-
1600ml/day glass
juice
Content: water
milk/coffe
>5-7 glass of water
>1 cup of milk/coffe
Amount approximately
1000-1200ml/day
In drinking pattern
there is slight
decrease during
hospitalization
because of the
presence of ashma,
due to easy
fatigability
3. Bladder Frequency: 7times a
day( 6times atdaytime & once at
night)
Color : pale yellow
Characteristic: clear
Frequency 7times a
day( 6times atdaytime & once at
night)
Color : pale yellow
Characteristic: clear
Frequency: 5-6 times a
day( 5times at daytime& once at night)
Color : pale yellow
Characteristic: clear
Amount
There is a
significant change inthe bladder
elimination of the
client. There is a
decrease in urine
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Amount
approximately: 1200-
1400ml/day
Amount
approximately: 1200-
1400ml/day
approximately: 1100-
1300ml/day
output as observe in
the during
hospitalization. This
is brought by the
decrease fluid intake
by the client.
4. Bowel Frequency: once a
day (every morning)Color: Brownish
Consistency: semi
formed
Amount :normal
Frequency: once a
day (every morning)Color: Brownish
Consistency: semi
formed
Amount :normal
Frequency: She only
defecated once onJanuary 3, 2005.
There is significant
change on the bowelelimination because
there is a lesser fluid
intake and lesser
mobility.
5. Bathing/
Grooming
Frequency:
> complete bath in
the morning
> sponge bath before
going to bed
Frequency:
> complete bath in
the morning
> sponge bath before
going to bed
Frequency:
> sponge bath every
morning
There is a
significant change in
bathing pattern
during
hospitalization
because patient is
not able to take a
bath by herself due
to easy fatigability.
She have her sponge
bath every morning
with the aid of her
daughter.
6. Sleeping Duration: 9 hours
Time of sleepingand awaking
>9 pm to 6 am
Characteristic:
> continuous
Nape time: 1-2 hours
Duration: 9 hours
Time of sleeping andawaking
>9 pm to 6 am
Characteristic:
> continuous
Nape time: 1-2 hours
Duration: 10 hours
Time of sleeping andawaking
>9 pm to 7 am
Characteristic:
> with interruptions
Nape time: 1-3 hours
There is no change
in sleeping patternexcept for thecharacteristic during
hospitalization that
there is a
interruptions for
medical purposes.
But there is also a
longer sleeping and
nape time.
VIII. LEVELS OF COMPETENCIES
Patterns Before Illness During Illness During
Hospitalization
Analysis
Physical Ang Khit then can
meet her physical
needs and active in
At home, her
activities of daily
living have been
In the hospital, she
usually stayed on bed
during her
There is a decrease in
the physical
competency of our
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performing her
activities of daily
living. At home, she
was able to do any
household chore such
as cleaning the house,
dishwashing, andothers. After doing
the entire household
chore, she goes to
their store andmanages it. She also
sees to it that she was
properly groomed
whenever she goes
out of their house and
before going to their
store.
limited such as
cleaning the house,
dishwashing, and
others. She could
still do these kind of
household chores
but then she musthave to stop and
take a rest at the
middle of her
activity since sheexperiences
difficulty of
breathing. She could
no longer also go to
their store because
she claimed to us
that her condition
worsens everytimeshe was exposed to
smokes. Since their
store is not nearby
their house, she has
to travel then to go
to there but because
of her condition she
could no longer
manage their store.
She was also afraidthat those smokes
that she inhalesmight have
triggered her
condition. Still she
made mention to us
that she was able to
maintain her proper
grooming.
hospitalization. She
claimed to us that
sometimes she able
also to go for a walk
along the ward. She
could still do proper
grooming but asks herdaughter to assist her
because she feels
weaker when she was
already confined inthe hospital. She also
told us that she
sometimes gets tired
especially when is
coughing
continuously.
client due to her
present condition
(asthma) that causes
different problems
such as difficulty of
breathing, body
weakness, and easyfatigability which
disables her to do her
usual routines.
Emotional Ang Khit is an
expressive type of
person andemotionally stable.
She laughs and smile
at things that are of
interest to her . She is
happy and satisfied
with her life because
her family is very
supportive to her and
At home, she is still
emotionally stable
and she is notirritable and
sensitive. She could
still hold her temper
during the presence
of her illness. Even if
she gets tired and
feels weak for some
time, she dont still
During her stay in the
hospital, she told us
that she gets irritatedfor quite some time
especially when some
of the
watchers/visitors in
the hospital are noisy.
This usually causes
her sleeping time to
be disrupted. And as
A deviation of
emotion was noted to
our client particularlywhen she was already
confined in the
hospital. Her
irritability was
mainly brought about
by her condition
(frequent coughing)
and by the noise in
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she is also very open
to her family and
friends. She is a type
of person who can
hold her temper
whenever she got
angry or irritated.According to her,
whenever she had
any misunderstanding
to anybody or toanyone on their
family, shed rather
go out to calm her
self and at the same
time to avoid their
problem to become
more complicated.
gets easily irritated.
However, our client
claimed that she
believes that all the
members of her
family will
understand her unexpected behavior
if even there might
come a time that
theyll be havingsome conflict during
her illness.
she has not slept well
during the night, she
awakes to be irritated
during the day. She
also stated that her
condition also
contributes to her being irritable one
since everytime she
was on the middle of
rest periods, she wasalso easily disrupted
by her frequent
coughing.
her environment.
Social According to ourclient, she has a lot of
friends in their place.
She also claimed that
she is fond of
attending social
gatherings and loves
to interact and make
friends to the people
whom she come
across with. She alsotold us that there
were times when she
was already in their
house, some of theirneighbors needs her
help, she always offer
a help for as long as
shes able to give. In
addition, she also
participates in
barangay programs
such as clean andgreen and meetings.
During the course ofher illness at home,
she was still able to
interact and make
friends especially
with their
neighbors.
However, she
claimed to us that
she seldom go out
already since herillness was triggered
by some
environmental
factors particularlysmokes. She still
makes sure that
whenever their
neighbors needs her
help for as long as
shes able to give.
Lastly, she also told
us that she seldom participates to
barangay programs
such as clean and
green and
meetings.
In the hospital, shestill do her best to
socialize with other
people particularly to
us and her fellow
patients but not that
much anymore since
she feels weak for
quite some time.
However, during our
interaction with her,she frequently
experiences cough
and she believes that
this contributes to theway she feels that
sometimes she gets
tired upon long time
of talking to us.
There is nosignificant change on
the social life of Ang
Khit except to the
fact that she can no
longer went house to
house for
socialization. In the
hospital, though shes
confined on bed, she
still sees to it that shemakes friends with
the other clients and
watchers, and also to
student nurse whousually interacts with
her.
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Mental Ang Khit is a person
who easily
understands /
comprehend of what
is being explained/
instructed to her. Sheis well oriented about
events, time, place,
person, and what is
happening aroundher. However, even if
she was already
aware that those
smokes triggered her
condition she inhales.
Sometimes she still
goes to their store and
manages it eventhough she knows the
fact that her condition
worsens everytime
she goes out and
inhales smoke
pollutants.
At home she
already avoided
those things which
she was already
aware that
contributes to theworsening of her
condition. She
started to avoid these
risk factorstriggering her
condition when she
had already
submitted her self for
consultation at
Dingras District
Hospital.
In the hospital, due to
the fact that she has
already been aware/
she had already
realized the effects of
inhaled smokes, she just follow what the
doctor ordered for the
betterment of her
health. She is still ableto recall the past
events that happened
in her life before and
during the course of
her disease. However,
during the assessment,
the client was restless,
lethargic and slightlyconfused.
The mental status of
our client has
changed. Before and
during her illness, she
was oriented of what
is happening. Herknowledge about her
disease causation has
increased as a result
of health educationdone by the members
of the health team.
She was able to
answer the questions
and share relevant
information therefore,
she is still mentally
stable, no alterationin the patients
mental competency.
The restlessness,
lethargy and
confusion of the
client during the
assessment are just
some of the
manifestations of
asthma.
Spiritual Our client strongly
believes in God and
has a very strong
faith in her. She alsoattends church
services every
Sunday. She also
claimed that within
their family, they
pray to God before
their meals as a way
of thanking Him forthe food and
blessings He had
given.
She still have faith in
God and she didnt
blame God for the
things that arehappening to her,
instead she accepted
it wholeheartedly
and pray to God to
help her and guide
her everyday. She
believed that God is
always at her side.
During her
hospitalization, she
wasnt able to attend
their church servicesalready but still didnt
forget to pray. She
also claimed that her
faith in God has
always been strong
and kept on praying
for faster recovery
from her illness, blessings for her and
her family and for
them ( her family) to
have more patience
and strength in taking
good care of her.
Her spiritual life has
not changed even
though she doesnt
attend their churchservices already due
to her condition. She
still has strong faith
in God. She always
pray to Him. This is
due to the fact that
since she was a child,
her parents moldedher to be a good
Christian which she
carried until now that
she already old.
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IX. PHYSICAL ASSESSMENT
Date of Assessment: January 01, 2005 @ 2 PM
General Appearance:
Position on Bed: Sitting on bed leaning forward
Intravenous Fluid: D5NSS 1L at 700 cc level regulated to 32 gtts/min
Gadgets: with Oxygen inhalation via nasal cannula regulated 4 5 LPM
Appearance: with difficulty of breathing, anxious and restless
Height: 53 Weight: 59 kg
Body temp. 37.4o
C PR: 98 bpm
RR: 30 bpm BP: 130/80 mmHg
Head to Toe Assessment:
Skin: with light brown complexion; with cold clammy skin; on diaphoresis; with fine skin turgor
(due to aging process); with minimal scars noted on upper and lower extremitites; no
open wounds noted, no edema noted.
Hair: withwhite and gray hairs; fine, smooth and silky; proportionally distributed; no baldness, lice
and dandruff noted.Nails: with short and dirty nails; with pale nailbeds on both extremities; with fine capillary on both
extremities; no clubbing noted.
Head: normoephalic; round in shape; no lesion and masses noted, no scars noted.
Face: symmetrical; with few moles irregularly distributed; no masses, lesions nor irregularity noted.
Eyes: with pinkish palpebral conjunctiva; with whitish to reddish sclera, pupils normally constrict
when exposed with increasing light and accommodation; with poor visual acuity (cannot
read without corrective glasses); extraocular muscles are intact, symmetrical.
Ears: with moderately clean external canal; with good hearing acuity (can understand statementsclearly); no lesions, masses nor discharges noted.
neither blisters noted.
Nose: symmetrical, with flaring of nares noted; no lesions, masses nor discharges noted.
Lips: with pinkish lips; moist, smooth, symmetrical in contour and shape; no lesions, dryness, cracks
Oral cavity: with pinkish gums and tongue; with only 2 remaining teeth (incisors).
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Neck: with symmetrical movement; no palpable lymph nodes noted; no masses nor lesions noted.
Chest and Lungs: with symmetrical movement; with difficulty of breathing; with chest retraction;
with wheezing breath sound and rales upon auscultation (upper lobes), increase in
respiratory rate (30bpm); with use of accessory muscles.
Heart: with regular rhythm; no bigeminal heart beat noted during auscultation; increase in cardiac
rate (99).
Abdomen: with slightly convex abdomen; with normal bowel sound; no tenderness noted; no lesions
nor masses noted.
Extremities
Upper extremities: with symmetrical movement; with good muscle tone; with good fine and
gross motor; able to flex and extend, circumduct arms.
Lower extremities: with symmetrical movement; able to flex and extend legs.
CNS: Restless, lethargic and slightly confused
X. ON GOING APPRAISAL
The on going appraisal was started the day when Ang Khit was admitted at MMMH & MC
until she was discharged.
January 1, 2005
At 6:30 in the morning, the client was admitted to ER with a chief complain of difficulty of
breathing. She was seen and examined by Dr. Catcatan. After history taking and thorough
examination, she was then admitted to MMMH and MC at 7:00 in the morning.
Dr. Catcatan ordered as follows: TPR every shift and record pls; DAT; CBC typing;; chest X-
ray; 12 lead ECG; stat serum Na, K, Cl, stat BUN and creatinine. She was also for vital signs
monitoring every 2 hours and record. Also she was for oxygen inhalation at 4-5 liters per minute.
At 7:15 AM, she was admitted to fourth floor room 409-Alley in medicine department. She
was placed comfortably on bed and immediately given oxygen inhalation. Nebulization was done
twice and at 7:30, an IVF of D5NSS 1L at full level was inserted as venoclysis regulated to 16
gtts/min.
At 10:00 AM, she was seen and examined by Dr. Magcalas, however, there were no new
orders made.
All throughout the day, she complained of difficulty of breathing and was given attention
with.
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All her recorded BP and boy temperature were within the normal range except for the
respiratory rate and pulse rate which are above normal.
VS 8 AM 10 AM 12 PM 2 PM 4 PM 6 PM 8 PM 10 PM
Btemp. 37.4 37.2 36.9 37.4 36.8 37.2 37.1 37
CR 101 105 103 99 95 92 91 80
RR 35 33 30 30 29 27 30 37.1
BP 130/80 120/70 120/80 110/80 120/90 110/80 110/70 120
Urine: 6 Stool: 0
January 2, 2005
She spent most of the time lying on bed in semi-fowlers position, awake. With an IVF of
D5NSS I L at 70 cc level regulated to 16gtts/min, infusing well. After few minutes, at 7 AM, previous
IVF was consumed and was replaced with the same IVF and regulation With no difficulty of
breathing noted.
The client was seen and examined by Dr. Catcatan during the rounds with new orders made
and carried out such as to continue medication and new medications were prescribed such as
Bambuterol 16mg/tab OD.
She was also able to eat all her meals served for breakfast, lunch and dinner.
All her vital signs are already within normal.
VS 8 AM 12 PM 4 PM 8 PM 12 AM
Btemp. 36 36.6 37 37 36.3
CR 82 88 68 76 75
RR 23 22 22 21 22
BP 130/80 120/70 120/80 110/80 120/90
Urine: 6 Stool: 0
January 3, 2005
She spent most of the time lying on bed in semi-fowlers position, awake. With an IVF of
D5NSS I L at 500 cc level regulated to 16gtts/min, infusing well. With no reported complaint of
difficulty of breathing.
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She was seen and examined by Dr. Torralba with new orders made and carried out such as
continue medications. And also the X-ray result was referred to the doctor.
She was also able to eat all her meals served for breakfast, lunch and dinner.
All her vital signs are within normal.
January 4, 2005
The client spent lying on bed most of the time. No complaint of difficulty of breathing and other
complains.
At 9:00 in the morning, the client was seen and examined by Dr. Magcalas and ordered MGH
with home medications.
At 1:00 in the afternoon, the client went home per stretcher accompanied by relatives.
VS 8 AM 12 PM 4 PM 8 PM 12 AM
BTemp. 36.6 36.8 36.9 36.6 36.7
CR 72 76 74 79 78
RR 21 20 21 19 22
BP 120/70 120/70 120/70 110/60 80/60
Urine: 3 Stool: 0
VS 8 AM 12 PM 4 PM 8 PM 12 AM
Btemp. 36.2 36.8 36.7 36.6 37.1
CR 88 88 72 82 68
RR 21 21 22 21 21
BP 120/80 120/80 130/80 120/80 130/80
Urine: 5 Stool: 1
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XI. LABORATORY AND
DIAGNOSTIC PROCEDURES
1.X-ray
Indications: As part of routine screening procedure; when pulmonary disease is suspected; tomonitor the status of respiratory disorder and abnormalities; to confirm
endotracheal or tracheostomy tube placement; after traumatic chest injury; in any
other situation in which radiographic information helps in the management of a
respiratory problem.
Result:
Chest X-ray is a procedure done to determine if there are any abnormalities of the lungs
including the heart. It provides information about the chest that may not be available through other
assessment means. Also, they often graphically illustrate the cause of respiratory dysfunction. Chest
films may reveal abnormalities when there are no physical manifestations of pulmonary disease. In
posteanterior (PA) position, the x-ray beam penetrates from posterior.
Nursing Responsibilities:
1. Make a laboratory request and forward it to the x-ray room.
2. Explain the procedure and its importance to the patient and significant others in order to
get their cooperation.
3. Instruct the patient to remove any radiopaque objects such as jewelry or metal buttons
above the waist. Metals appear in the x-ray results and would tend to give a false result.
4. Accompany the patient to have someone that assists him.
5. Instruct the to hold his breath and to remain still when performing the procedure.
6. Follow-up result and refer to the physician to evaluate the condition of the patient.
2. Electrocardiogram
Date taken: January 1, 2005
Examination desired: CXR-PA
Requesting Physician: Dr. Catcatan
Result: Pneumonitis bases more on the right
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Date Performed: January 1, 2005
Result: Available but no remarks
This electrophysiologic test is used primarily to screen for and diagnose a variety of cardiac
conditions as well as to monitor the hearts response to therapy. The electrocardiogram (ECG) isfrequently used to diagnose abnormal heart rhythms, conduction disturbances, hyperthropy of
cardiac chambers, myocardial infarction and ishemia, and pericarditis. An ECG measures
electrical flow through the heart by using electrodes applied painlessly to the chest wall and
limbs.
Nursing Responsibilities:
1.Explain the procedure to gain cooperation.
2.Assure that there is no pain with this test.
3.Remove any metal and jewelries on the clients body.4.Instruct the patient to lie still on his back while ECG machine is recording the hearts
activity.
5.Explain that the chest will need to be exposed during the electrode placement. Drape
female client as much as possible during placement.
6.After the procedure, wipe off electrode paste or jelly.
7.Educate the patient and family a heart healthy diet.
3. Hematology or Complete Blood Count (CBC)
Date performed: January 1, 2005
Normal Value Found Value Analysis
Hemoglobin 110-160 127 Normal
Hematocrit 0.38-0.54 .0.40 Normal
RBC 4.5-5.5 4.2 Normal
MCV 80-100 89 Normal
MCH 27-32 30 Normal
MCHC 31-35 34 Normal
WBC 5-10 10.5 Normal
Neutrophils .50-.70 0.75 Increased
Lymphocytes .20-.40 0.23 Normal
Eosinophils 0.01 0.04 0.02 Normal
Platelet coutns 150 - 400 226 Normal
A complete blood count is one of the most routinely preferred test in clinical laboratory
and one of the most valuable screening and diagnostic technique. It identifies the total number of
blood cells (WBC,RBC, and platelets) as well as the hemoglobin, hematocrit (percentage of
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blood consisting of RBCs) and RBC indices. The CBC may reveal considerable data about the
patient including diagnosis, prognosis, treatment response and recovery.
Purpose: CBC was done as a part of hospital routine to evaluate other abnormal conditions.
Procedure:
1. Perform a venipuncture and collect a blood sample in a 7 ml lavender top-tube.
2. Fill the collection tube completely and invert it gently several time to adequately
mix the sample with the anti-coagulants.
a. Hemoglobin
Hemoglobin is the main component of RBC which contains iron and which makes up
95% of the cell mass. It delivers oxygen through circulation to body tissues and returns
carbon dioxide from tissues to lungs.
A decreased in the normal value of hemoglobin indicates a decrease oxygen carrying
capacity of the blood that affects the transport of oxygen between lungs and tissues and
eventually affects cellular activities.
Indication: This test is done to determine anemia and other disease related abnormal
Hemoglobin concentrated in the blood and oxygen carrying capacity.
Analysis:Normal
b. Hematocrit:
Hematocrit is a measure of the packed cell volume of red cells, expressed as a percentage
of the total blood volume. It indicates relative proportions of plasma and RBCs (volume of
RBCs/L whole blood).
Indication: It is done to determine the space occupied by pack RBC. It is expressed as the
percentage of red cells in a volume of per blood and also to determine the
hydration of patient.
Analysis:Normal
c. Red Blood Cells (RBC)
RBC (Red blood cell) count is a count of the erythrocytes in a specimen of whole blood.
Erythrocyte is the major cellular element of the circulating blood. It is a reddish biconcave
disk that contains hemoglobin confined within a lipoid membrane. Its principal function is to
carry hemoglobin to provide oxygen to tissues.
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Indication: This test determines the total number of RBC found in a cubic millimeter of
blood. It is an important measurement in the determination of anemia.
Analysis:Normal
d. Mean Corpuscular Volume (MCV)This is an evaluation of the average volume of each red cell derived from the ratio of
volume of the packed red cells to the total number if RBC. It also describes the individual red
cell size. It is expressed in cubic microns.
Indication: These test determines if there is a deviation of the RBC production and important
in the determination of anemia.
Analysis:Normal
e. Mean Corpuscular Hemoglobin (MCH)This is an estimate of the amount of Hemoglobin in an average erythrocytes, derived
from the ratio between the amount and Hemoglobin and in the number of erythrocytes
present. It is related to MCV because weight of a red blood cell increases when the amount of
hemoglobin increases and therefore its size increases.
Indication: To determine the ratio of amount of Hemoglobin and the number of erythrocytes
present.
Analysis:Normal
f. Mean Corpuscular Hemoglobin Concentration (MCHC)
This is an estimation of the concentration of hemoglobin in grams per 100 ml of packed
red blood cells, derived from the ratio of the hemoglobin to the hematocrit. This is an average
concentration of hemoglobin in RBCs. It measures the portion of hemoglobin in an average
cell. It is the ratio of the weight of hemoglobin to the volume of the red blood cells.
Indication: To determine the concentration of Hgb
Analysis: Normal
g. White Blood Cells (WBC)
This is one of the formed elements of the circulating blood system. WBC is needed to
depend against invading microorganisms through phagocytosis to produce or transport and
distribute Anti bodies to help maintain immunity. WBC count is a test that counts the total
number of WBCs in 1cubic mm of peripheral venous blood.
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Indication: This test is done to determine the presence of infection, inflammation and also
serves as a useful guide to the severity of the disease process.
Analysis:Normal
h. Neutrophils
Neutrophils are the circulating white blood cells they are the first one to launch at the site
of injured tissue. They are also essential for phagocytosis and proteolysis by which bacteria,
cellular debris, and solid particles are removed and destroyed. It is essential in preventing or
limiting bacterial infection via phagocytosis. The protective function of neutrophils include
phagocytosis where foreign particles were degraded pyrogen are released that causes fever by
acting on the hypothalamus to set the bodies thermostat at the higher level.
Indication: This test determines the presence of infection and inflammation.
Analysis: Increased because in asthma, there will be an release of chemical mediators that
attracts the neutrophils and activation of its production.
i. Lymphocytes
These are small agranulocytic leukocytes originating from fetal stem cells and developing
in the bone marrow. Lymphocytes normally comprise 25% of the total WBC count but
increase in number in response to infection. It is the integral component of immune system
and helps in the antibody production. These cells are the source of serum immunoglobulins
and of cellular immune response and play an important role in immunologic reactions.
Indication: It determines the presence of infection and inflammation.
Analysis: Normal
j. Eosinophils
A granulytic bilobed leukocyte somewhat larger than a neutrophil. It is characterized by
large numbers of coarse refractile cytoplasmic granules that stain with the acid dye eosin.
Indication: This test determines the presence of infection and inflammation.
Analysis:Normal
k. Platelet Count
It is the total number of platelets in circulation. Platelet is the smallest of the cells in the
blood. These are disk-shaped and contain no hemoglobin. They are essential for the
coagulation of blood.
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Indication: This test measures the total number of platelets in circulation.
Analysis: Normal
Nursing Responsibilities:
1. Fill up laboratory request and send to laboratory to inform the medical technologist2. Inform patient about the type of the procedure and its purpose to gain her cooperation and
also to increase his awareness regarding the procedures that will be done to her.
3. Follow up results, attached to the chart of the patient and refer it to the Physician to
inform the abnormality of the found value and to evaluate the condition of the patient.
4. Blood Chemistry
Date Performed: January 1, 2005
Result Normal Value Analysis
Creatinine 58.9 44.2-150.3 mmol/L Normal
Urea Nitrogen 6.4 1.7 8.3 mmol/L Normal
Sodium 138.4 133 150 mmol/L Normal
Potassium 3.40 3.4 5.3 mmol/L Normal
Chloride 100.0 96 106 mmol/L Normal
a. Creatinine
This is a substance formed from the metabolism of creatine (nitrogenous compound
produced by metabolic processes in the body) commonly found in blood, urine, and muscle
tissues. Therefore, its formation and release are relatively constant and proportional to the
amount of muscle mass present. Because creatinine is filtered in the glomeruli but not
secreted into the tubules from the blood or reabsorb from the tubules into the blood, its blood
values depend closely on the GFR (glomerular filtration rate). Creatinine is the end product
of muscle energy metabolism. In normal function, level of creatinine, which is regulated and
excreted by the kidneys, remains fairly constant in the body. Serum creatinine levels reflect
the glomerular filtration rate (GFR). Serum creatinine is often used as a screening measure to
evaluate kidney/renal function.
Indication: This test measures the effectiveness of renal function. It is used to diagnose
impaired renal function.
Analysis:Normal
b. Urea Nitrogen
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Urea, the end product of protein and amino acid metabolism in the liver, enters the blood
and passes to the kidneys for excretion. The blood urea nitrogen is, therefore, an indicator of
both the metabolic function of the liver and the excretory function of the kidney.
Indication: Blood urea nitrogen measures renal function and hydration.
Analysis:Normal
c. Sodium
This is one of the most abundant elements in the ECF. Consequently, sodium is the
primary determinant of ECF osmolality. Sodium ions are involved in acid-base balance,
water balance, the transmission of nerve impulses, and the contraction of muscles. Sodium is
the chief electrolyte in interstitial fluid, and its interaction with potassium as the main
intracellular electrolyte is critical to survival.
Indication: This test measures the ability of the kidneys to maintain fluid-electrolyte balance.
Analysis: Normal
d. Potassium
Potassium in the body constitutes the predominant intracellular cation, with only 2%
found in the extracellular space, helping to regulate neuromuscular excitability and muscle
contraction. It also functions in maintaining normal acid-base balance.
Indication: This test measures the effectiveness of renal function. Because the renal system
must function to maintain K balance, because 80% of the K is excreted daily from the body
by way of the kidneys; the other 20% is lost through the bowel and sweat glands. The kidneys
are the primary regulators of K balance and accomplish this by adjusting the amount of K that
is excreted in the urine.
Analysis: Normal
e. Chloride
Chloride is the major anion of the ECF. It is found more in interstitial and lymph fluid
compartments than in blood. Chloride is also contained in gastric and pancreatic juices as
well as in sweat. Na and Cl in water make up the composition of the ECF and assist in
determining osmotic pressure. The serum level of chloride reflects a change in dilution or
concentration of the ECF and does so in direct proportion to Na.
Indication: This test measures the effectiveness of renal function.
Analysis: Normal
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Nursing Responsibilities:
1. Fill up laboratory request and send to laboratory to inform the medical
technologist.
2. Inform client about the type of the procedure and its purpose to gain her cooperation and also to increase her awareness regarding the procedures that will be done to
her.
3. Reemphasize NPO (since the client is already in NPO).
4. Follow up results, a ttached to the chart of the patient and refer i t to the
Physician to inform the abnormality of the found value and to evaluate the condition of the
patient.
XII. MEDICAL MANAGEMENT
A. Intravenous Therapy
IVF therapy was given to the patient because it is an efficient method of supplying fluids
and electrolytes directed to the extracellular components especially the venous system. IVF was
also used to supply or provide nutrients and also a way of drug administration.
Purpose: The choice if IV solution depends on the purpose of the administration. Generally
fluids are administered to achieve one or more of the following goals:
To provide water, electrolytes and nutrients to meet daily requirements
To replace water and correct electrolyte imbalance
To administer medications and blood products
IV solutions contain dextrose or electrolyte mixed in various proportion with water. Pure-
electrolyte-free water never administered IV because it rapidly enters the Red Blood Cells and
causes them to rupture.
Indication: IV is used as an avenue for IV drug administrationand to supply or provide nutrients
to our patient.
Nursing Responsibilities:
1. Verify doctors order
2. Inform the patient about the procedure to gain cooperation
3. Know the type, amount, and indication of IV therapy
4. Always use aseptic technique when handling IV solutions to prevent further
infection
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5. Check for IVsolutions and needles for potency
6. Regulate IV flow properly to maintain proper hydration
7. Asses for infiltration on the IV site such as swelling, heat and pain around vein at
the infusion site or proximal to it may indicate thrombophlebitis
8. Change the solution container to prepare it empties to prevent embolism
9. Place the pad in proper slot to prevent needle displacement or removal during
movement
B. Diet Therapy
DAT (Diet as Tolerated)
Indication:
it was ordered to our client to supplement necessary nutritional needs or to meet optimum
nutrition for him to function well and increase resistance
Nursing Responsibilities
1. Check the doctors order
2. Transcribe the order in the diet list of the patient and inform the dietician
3. Inform the patient of what is to be included in the patients meal, which is all
foods except those for dark colored foods and beverages
4. Encourage patient to eat foods which are not spicy to avoid gastric irritation
C. OXYGEN THERAPY
Administration of oxygen above 21% which is prescribed by the physician who specifies
the specific concentration, method, and liter flow per minute.
Oxygen colorless, odorless, tasteless, and dry gas that support the combustion
Indications:
1. To deliver oxygen, adequate to meet the body cells needs
2. To provide high humidity
3. To allow uninterrupted delivery of oxygen while patients ingest foods/fluids.
4. It was given to client with difficulty of breathing, this will help client by supplying enough
oxygen needed by the body to facilitate efficient breathing.
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Oxygen Inhalation via Nasal Cannula
- Is a method of administering oxygen
- simple device that can be inserted into the nares for delivery of oxygen and that allows
the client to breath through her mouth or nose.
- it does not interfere with the clients ability to eat or talk.
Nursing Responsibilities:
1. Verify the order of the doctor to prevent error
2. Position the patient in moderate high back rest to allow the full expansion of the lungs and to
establish a better flow of air movement
3. Before administering the O2 equipment wash your hands- to reduce transmission of
microorganism.
4. Open source of O2 before insertion of O2 device to check if the device is functioning
5. Lubricate nares with water soluble lubricant to soothe the mucus membrane
6. Place No Smoking Sign at the bedside to avoid possible danger like fire.
7. Provide good oro-nasal hygiene to prevent infection and promote relaxation
D. Vital Signs Taking
- Vital Signs Taking every four hours
- Frequent assessment of the vital signs provides information about the development or
progress of deterioration of patients condition.
Nursing Responsibilities:
1. Explain the purpose to gain cooperation.
2. Monitor vital signs including blood pressure, cardiac rate and respiratory rate for a full
minute and body temperature.
3. Record vital signs and refer for abnormalities especially if higher and lower than normal.
XIII. DRUG STUDY
A. Generic Name: Albuterol (Salbutamol)
Brand Name: Ventolin
Classification: Bronchodilator
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Dosage, Route and Frequency: 2.5 cc + NSS 1.5cc every 4 hours
Mechanism of Action:
Relaxes bronchial and vascular smooth muscle by stimulating beta - 2 receptors.
Desired Effect:
Albuterol is a short-acting, beta-adrenergic bronchodilator drug used for relief andprevention of bronchospasm. It is also used to prevent exercise-induced bronchospasm.
Side Effect / Adverse Reaction:
CNS: tremor, nervousness, dizziness, insomnia, headache, hyperactivity, weakness, CNS
stimulation, malaise.
CV: tachycardia, palpitations, hypertension.
EENT: dry and irritated nose and throat (with inhaled form), nasal congestion, epistaxis,
hoarseness.
GI: heartburn, nausea, vomiting, anorexia, bad taste in mouth, increased appetite.
Metabolic: hypokalemia.
Musculoskeletal: muscle cramps.
Respiratory: bronchospasm, cough, wheezing, dyspnea, bronchitis, increased sputum.Other: hypersensitivity reactions.
Nursing Responsibilities:
1. Check Doctors order.
2. Observe the 10 Rs.
3. Teach patient to perform oral inhalation correctly.
Clear nasal passages and throat.
Breathe out, expelling as much air from lungs as possible.
Place mouthpiece well into mouth as dose from inhaler is released, and inhales
deeply. Hold breath for several seconds, and exhale slowly.
4. Tell patient to wash inhaler every after used.
5. Do bronchial clapping after nebulization.
6. Instruct patient to do deep breathing and coughing exercise.
7. Warn patient about possibility of paradoxical bronchospasm. Tell him to stop drug
immediately if it occurs.
B. Generic Name: Bambuterol
Brand Name: Bambec
Classification: Sympathomimetics bronchodilator
Dosage, Route & Frequency: 10 mg 1 tab od & hs
Mechanism of Action:
Closely resembles the response to stimulation of adrenergic nerves, it exert a peripheral
inhibitory action on smooth muscle thus decreasing bronchial constriction.
Indication:
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Bronchial asthma, chronic bronchitis, emphysema, and other lung diseases, where
bronchospasm is complicating factor.
Desired Effect:
This drug is given to our client because it decreases bronchial constriction; dilate the
bronchioles thereby allowing airway clearance.
Side Effects:
headache
tonic muscle cramps
palpitations
Nursing Responsibilities:
1. Take with food or after meal to decrease gastric irritation
2. Check for adverse reactions. Discontinue drug and notify physician.
3. Decrease irritants and increase hydration.
4. Teach the following:
a. breathing techniques
b. coughing techniques
c. nebulization
d. if it is given over a long period of time, cumulative effect
takes place takes place thus medication becomes ineffective.
C. Generic Name: Ambroxol
Brand Name:
Classification: Mucolytic
Dosage, Route and Frequency: 75 mg cap OD
Mechanism of Action:
Ambroxol is a metabolite of bromhexine, which liquefies and changes the structure of
bronchial secretions, reduce viscosity of sputum and promotes the expectoration of blocked-up
secretions and also eases cough.
Desired Effect:
This drug is given to the patient to relieve cough and loosens the phlegm.Side Effect/Adverse Reaction:
- stomatitis
- nausea
- rhinorrhea
- bronchospasm
- bronchial/tracheal irritation
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- drowsiness
Nursing Responsibilities:
1. Check doctors order.
2. Observe the 10 Rs.
3. Patient must be taught on how to cough out effectively.
4. Check proper disposal of secretions.
5. Encourage increase in fluid intake.
6. Cough should not be suppressed if productive.
7. Observe for bronchial spasm, wheezing and increased congestion.
8. drug must always be found at hand in case of bronchospasm.
D. Generic Name: Theophylline
Brand Name:Classification: Bronchodilator