PAPER OF ASTHMA CASE STUDY

Compiled to Fulfill Adult Nursing Task

Oxigenation Module

Created by :

Sitha R. Amanatunnisa G2B 009 031

Destya D. Pangestika G2B 009 044

Mitsalina Maulida Hafidz G2B 009 050

Safina Aprillia G2B 009 059

Class A092

NURSING SCIENCE PROGRAM

FACULTY OF MEDICINE

DIPONEGORO UNIVERSITY

OCTOBER, 2010

1st CHAPTER

PREFACE

A. Background

Asthma is a worldwide health problem, both in developed and in

developing countries. In addition, asthma is a disease known in the community.

This is different about a century ago, for asthma disease was first discovered

and is still relatively rare. In the 1970s, more and more asthma sufferers are

found, this disease can be deadly even for reasons that are unclear. In the

United States for example, if heart disease and cancer are still occupying the

top position in the list of diseases spreading death, the lung disease is now

ranked third. And among the categories of lung diseases are fatal, chronic

asthma, including one of them.

WHO’s data (World Health Organization) indicates the number of asthma

sufferers in Indonesia ranges from 3-8 percent, or 6-16 million of the 200

million population. Another survey from various hospitals showed the number

of asthma sufferers in some provinces, namely Bali (2.4 percent), East Java (7

percent), Jakarta for the children (16.5 percent), Malang for children (22

percent) , East Jakarta for adults (18.3 percent), and Central Jakarta (7 percent).

Asthma is a chronic airway inflammatory disease involving various

immune cells, especially mast cells, epithelial cells, and the increased response

of the airways (bronchial hipereaktivitas) to various stimulants. Asthma can be

mild and do not interfere with the activity, but can be settled and not disturbs

daily activities and even activities reduce the quality of life.

But unfortunately, not all aspects of the pathophysiology of asthma as a

whole is understood to arise from the opinions of some doctors and the public

that asthma is a disease that is simple and easily treated, assuming that

management is the main thing is particularly bronchodilator drugs. Then show

habits of physicians and patients to overcome the symptoms of asthma are

particularly against the symptoms of shortness of breath and wheezing with

drug use and instead of managing asthma in full.

B. The Goals

This paper has eleven points to pass the goal of learning objective,

namely:

1. Students can find out the definition of asthma.

2. Students can find a variety of causes of asthma.

3. Students can find out all kinds of asthma.

4. Students can find out stages of asthma.

5. Students can find out three reactions in the pathology of asthma.

6. Students can learn how to forced expiratory.

7. Students can find pictures of X-Ray lungs

8. Students can learn the tools used in the investigation of asthma.

9. Students can learn the process of bronchial provocation test.

10. Students can find a variety of asthma medications.

11. Students can learn how to diagnose asthma and nursing interventions.

2 nd CHAPTER

LITERATURE REVIEW

A. Definition and types of Asthma

Asthma is a chronic disease characterized by recurrent attacks of

breathlessness and wheezing, which vary in severity and frequency from

person to person. Asthma is divided into two categories, namely :

1. Extrinsic or allergies

Marked by allergic reactions caused by factors specific trigger, such as dust,

animals, influenza virus, pneumonia,Mycoplasma, food, cigarettes and

drugs.

2. Non allergic

Characterized by non-allergic reaction which reacts to triggers that are not

specific or unknown, such as cold air or can also be caused by respiratory

infections , emotion, exercise, and environmental pollution. Asthma attacks

became more severe and often in line with the passage of time and can

develop into chronic bronchitis and emphysema. Some patients will

experience asthma combined.

B. How a proper forced expiratory test is to be performed.

The function of proper force expiratory test is to know how the condition

of respiratory system then it identified how long someone can not breath and

how much the carbon dioxide volume of force respiration process. This way is

suitable for identifying asthma patient and reducing the symptom of asthma. A

kind of proper forced expiratory test is the buteyko method. The Buteyko

method has five steps, they are :

a. Sit, relax, breathing regularly during 30 second

b. Inpiration and expiration as usuall

c. Close your nostril and start a stopwatch

d. Don’t breath until you feel oxigenation needs then breath maximally

e. See the stopwatch. How long you didn’t breath. It is you control pause time.

After we have done the buteyko method, we analysize how long we can not

breath. These are the result of proper forced expiratory test :

Control pause time The meaning of forced expiratory time

Less than 10 second Someone has respitory system disorder

10 – 25 second He/she should be more attention to check up

30 – 40 second Good respiratory system

More than 60 second It is en excellent respiratory system and its so

healthy

From that test, we can know the difference between forced expiratory

volume and vital capacity. Forced expiratory volume in one second (FEV 1.0)

is the volume of air that can expiratoried during the first second expiratory vital

capacity in the determination. Then, Peak flow is the patient's maximum speed

of expiration, or also called peak expiratory flow rate (PEFR or PEF) and

normally value is 250/250. Whereas vital Capacity (VC) is maximum volume

of air that can be spent during a one-time breathing after maximum inspiration.

Vital capacity is usually about 80% of the total lung capacity (4800 ml). Vital

capacity (VC). This is the amount of air (in liters) moved out of the lung during

normal breathing. The patient is instructed to breathe in and out normally to

attain full expiration.

C. Pathophisiology of asthma

These are three primary pathologic reactions:

a. The bronchi muscles do vasoconstriction (stricture of bronchi muscle).

Because the duct of air is too narrow, so the airs have difficulty to out

from the body. It can make wheezing voice, because the duct and air have

friction.

b. In bronchi, there is some of mucosa. If the mucosa is too much, it can

make edema so the airway is disturbed. The air will get difficulty to out

from the body in bronchi area, because there is edema. So, the person who

has this condition will be feeling congested. In edema bronchi, there is

much substance like histamine, leukotrien, and serotonin.

c. The third is cough effect. In gland of bronchial, there are so much mucosa

fluids. Because the mucosa fluids is abnormal, it can make hyper secrets.

This condition make production of mucosa has abnormal, so the cilia

difficult to move. It can make cough as effect of body from the abnormal

mucosa production.

A person who has allergy have ability to make much antibody Ig E in big

volume. This antibody can make allergy reaction if the reaction with

specification of antigen. In asthma, this antibody patch in mast cell which the

location in lung interstitial that is have relation with bronchial and small

bronchi.

If the person inhale allergen so the antibody of Ig E will be increase,

allergen will reaction with antibody in mast cell. This condition can make mast

cell will be releasing many substance like histamine, anafilaksis (acute allergy

reaction) that is slow reaction (leukotrient), and bradikinin.

The merger effect from all of this factors will be releasing local edema in

small bronchia’s wall and mucus secretion in bronchial lumen and spasm of

bronchial artless muscle so it can make person will get difficulty in breath.

D. Recognize chest x-ray changes seen with asthma

the normal lungs the asthma lungs

In the picture above shows a picture torax in normal circumstances. In the

state of asthma torax look bigger and expanded. This is caused by

inflammation resulting in swelling. And the white shadows in the asthma lungs

are the mucus and the eudema. Beside that, the asthma patient has chest

deformity become a barrel chest. And it is the barrel chest picture :

E. Recognize the signs and symptoms of asthma

To evaluate signs :

a. Chest deformity

Functional residual capacity and residual lung volume to be greatly

increased during an asthma attack due to difficulties expiratory air

out of lungs. This can cause the barrel chest.

b. Cyanosis

Cyanosis effects is a blue color of the skin and nails may occur

from lack of oxygen.

c. Chest and stomach pain

Those happened because the abdomen and thorax’s muscle involve

during respiration process.

The chest is bigger because there are so many carbon dioxide.

To evaluate symptoms :

a. Cough

In uncomplicated asthma, cough is only noticeable when the attack

subsided and coughing helps remove accumulated secretions.

b. Dyspnea

Breathing felt tight and difficult. Functionally, an asthmatic airway

to act as if the neural beta-adrenergiknya (which helps maintain the

airway to remain patent) is not competent.

c. Orthopnea

Difficulty breathing in a state of supine

d. Phlegm (sputum) production

Bronchial gland hipersecret

e. Wheezing

Turbulence of air currents and vibrations bronchial mucus resulting

in an audible wheezing sound during an asthma attack, but the

physical signs are also seen prominently in obstructive airway

problems. In symptomatic asthma, breathing faster than normal

(although this is likely to increase resistance to air flow) due to

constriction or spasm of bronchial muscle.

The causes of asthma

a. Children at Risk

Children can have asthma easily because their immune still low

and sensitive.

b. Allergies

Allergies because of various allergens. Allergens can be divided in

three kinds, they are :

· Inhalan, that enter into respiratory systems (dust, bactery, and

pollution)

· Ingestan, , that enter into mouth (food and drug)

· Contactan, , that enter into skin contact (jewellery and watch)

c. Environmental Factors

From traffic pollution or high ozone levels, has been repeatedly

associated with increased asthma morbidity and has a suggested

association with asthma development that needs further research

d. Obesity

Obesity causes a 50% increase in asthma incidence. This is due to

adipose tissue (fat) diminishing respiratory function. Adipose

tissue also leads to a pro-inflammatory state which has been

associated with non-eosinophilic asthma

e. Pregnancy

During pregnancy, VC respiration still same but it happen

improvement of tidal capacity from 450 cc become 600 cc because

progesteron hormone effect toward respiratory systems resistence

so the mother has to increase ventilation.

f. Stress

Rather than stress directly causing the asthma symptoms, it is

thought that stress modulates the immune system to increase the

magnitude of the airway inflammatory response to allergens and

irritants

g. Genes

Over 100 genes have been associated with asthma in at least one

genetic association study.

F. Some of the equipment necessary for an exercise test

These are eight equiment for asthma test, such as :

1. Peak Flow

Peak Flow is probably the simplest test that you can

use to see how well your asthma is doing and will be

an integral part of your asthma care plan. Peak flows

can easily be done at home with an inexpensive device called a peak flow

meter. Peak flow measure how quickly air can be blown out of your lungs.

It is important for you to learn how to use your peak-flow-meter

appropriately.

2. Spirometry

Spirometry is slightly more complicated than peak

flow in that it is usually done in your doctors office and measures both how

much and how quickly air moves out of your lungs. It is important in both

the diagnosis and management of asthma over time.

3. Complete Pulmonary Function Testing

Your asthma care provider may want to determine your

lung volumes and diffusing capacity. This is often done if your asthma

diagnosis is unclear. The test requires you to sit inside a special box that

helps determine how much air you breathe in and out.

Lung Volumes: Your asthma care provider may order body

plethysmography test to determine your lung volumes. Asthma may cause

certain changes in lung volumes that will assist your asthma care provider

in diagnosing or treating your asthma.

Diffusion Capacity: Diffusion capacity measures how well oxygen flows

from the lungs into your blood. Poor diffusion indicates damage to the

lung where the oxygen and blood meet in the lungs. Diffusion capacity is

usually normal in asthmatics.

4. Chest X-Ray

A chest x-ray is a test commonly preformed for

patients who wheeze. An asthma care provider will usually order one to

make sure there is not some other condition that may be causing your

symptoms like a lung infection.

5. Bronchoprovocation Challenge Testing

When your asthma provider orders a

bronchoprovocation test, you will inhale a specific substance through a

nebulizer, often methacholine or histamine. This is done to see if your lungs

become irritated, hyperresponsive, and lead to the development of asthma

symptoms. The test has a high negative predictive value. This means that if

the test is negative it is unlikely you have asthma.

6. Pulse Oximetry

Pulse oximetry is a non-invasive way to measure

oxygenation of blood or how well oxygen is being exchanged between the

lungs and the blood. A sensor is placed on the fingertip or other thin part of

the body with blood vessels close to the skin. The sensor measures changes

in wavelengths of light and is able to estimate oxygenation in the blood.

7. Arterial Blood Gas (ABG)

An arterial blood gas (ABG) is an arterial blood

sample used to determine how well blood is oxygenated -- a marker for

oxygen exchange between the lungs and the blood. Commonly, a blood

sample will be obtained from one of the arteries near your wrist. This test

may likely be preformed during an acute asthma exacerbation and is more

reliable than pulse oximetry.

8. Allergy Testing

The relationship between allergies and asthma has

been known for a long time. Allergens you normally breathe in can increase

the inflammatory reaction and hyperresponsiveness in your lungs. However,

your doctor cannot reliably determine if a particular allergen is responsible

for your symptoms on clinical grounds alone. Because of this, your asthma

care provider may recommend allergy testing. Not all asthmatics are tested.

But if you have persistent asthma, your asthma care provider will probably

recommend testing.

G. The bronchoprovocation test

Bronchoprovocation tests help asthma care providers make a diagnosis of

asthma. In general, you will inhale a nebulized solution or preform exercise to

see if you develop symptoms of asthma or airflow obstruction measured by

spirometry. If you develop either, your airways are hyperresponsive. Your

asthma care provider may challenge you with methacholine, histamine, cold

air, and exercise.

A common scenario for asthma care providers to order

bronchoprovocation testing is if you have symptoms that suggest asthma, but

normal spirometry testing and no response to rescue medications. Obstruction

of airflow in your lungs can be provoked by inhaling aerosols known to elicit

asthma symptoms and cause airway narrowing and irritation.

The procedure to do bronchoprovocation tests are you will begin by

inhaling a nebulized aerosol with one of the previously mentioned agents as if

you were taking a normal breathing treatment. The nebulized treatments will be

repeated at specific time increments. You will preform spirometry before and

after each nebulized treatment, and your asthma care provider will look at the

decrease in FEV1.

A decline in FEV1 of 20% from your baseline reading is considered a

positive test. If your asthma care provider suspects asthma, you may be started

on an asthma treatment. Hyperresponsiveness reliably discriminates between

patients with asthma from patients without asthma. Bronchoprovocation testing

has a high negative predictive value. Thus, if you have a negative test, it is

unlikely you have asthma.

H. The values are most often used when testing for asthma

The value, it means that what are the point should we get to identify

asthma. The values are peak flow, heart beat, respiratory beat, the sign and

symptom of asthma, and may be we have to know about blood pH, ABG

values, PCO2, PO2, and Sa O2. Those addition value used to diagnose the

probability to gets hiperventilation, alcaliosis respiratoric condition, or other

obtructive respiration diseases.

I. The appropriate nursing diagnosis of an asthmatic patient for chronic treatment

or for an acute attack

Asthma is clinically classified according to the frequency of symptoms and

peak expiratory flow rate. These are the classification of asthma stadium :

Studium Frequency of symptoms Peak Flow (PF)

Intermiten Less than twice a month PF > 80 %

Mild persisten More than once a week PF > 80 %

Moderate persisten Every day PF 60 – 80%

Severe persisten Continually PF < 60 %

If the patient suffer asthma until the most dangerous studium, especially in

severe persisten, so he/she gets accute asthma. But if the patient gets asthma

in long time, it means he/she gets cronic asthma. The medication is a kind of

treatment ways to help the patient. The medication of asthma divided in two

group, namely :

1. Reliever medicine: obat pereda, pelega, atau obat serangan.

2. Controller medicine : obat pengendali, obat pencegah, obat profilaksis.

This medicine is used for reducing cronic repiratoric inflamation. In other

reference, we found the different name :

1. Quick relief medication -> accute

bronkodilator (antikolenergik, metilksantin); kortikosteroid oral (sistemic)

2. Long term medication -> chronic

inhalasi steroid, long action beta-2-agonis, sodium kromoglikat,

nedokromil, etc.

J. The commonly used nursing interventions

A number of nursin interventions are commonly used throughout all

community settings and more often than in acute care settings. Mc Closkey and

Bulechek identified nursing intervention such as :

1. Medication administration : preparing, giving, and evaluating the

effectiveness of prescription and nonprescription drugs.

2. Health education : developing and providing instruction and learning

experiences to facilitate voluntary adaptation of behaviour conductive to

health in individuals, families, groups, or communities.

3. Health system guidance : facilitating a patient’s location and use of

appropriate health service.

K. The evaluation related to the implementation in asthma

It is a table that explain the intervention to evaluate the bronchospasme

condition in asthma patient.

No. Independent Rational

1. Auscultation of breath sounds,

record the sound of breath.

e.g wheezing

Some degree of spasm

bronchus occurs with

airway obstruction and

can / does not manifest

the breath advertisius.2. Review / monitor frequency

respiratory, record the ratio of

inspiration / expiration.

Tachipnea usually exist in

a few degrees and can be

found on the acceptance

or during stress / a

No. Independent Rational

3. Write down the degree of

dyspnea,

anxiety, respiratory distress,

drug use aids.

Place a comfortable position

in patients, for example:

elevate head of bed,

sitting on the back bed.

Respiratory dysfunction is

variable that depends on

acute stage of the process

cause treatment

hospital.

4. Place a comfortable position

in patients, for example:

elevate head of bed,

sitting on the back bed.

Elevation head place

facilitate sleep function

breathing with

using gravity.

5. Maintain environmental

pollution

minimum, eg dust, smoke etc.

Type allergy triggers

breathing can trigger

acute episode.

6. Increase fluid intake

up to 3,000 ml / day

appropriate cardiac tolerance

provide warm water.

Hydration help

lower viscosity

secretions, the use of liquid

warm can reduce

viscosity of secretions,

the use of warm fluid

to reduce spasm

bronchus.

7. Collaboration to give the

medication in accordance with

Relaxes smooth muscle and

reduce spasm road

indication of bronchodilators.

breath, wheezing, and production

mucosa.

3 rd CHAPTURE

DISCUSSION OF CASE STUDY

A 37 y/o black female with a history of asthma, presents to the Emergency

Rate (ER) with tachypnea, and acute shortness of breath with audible

wheezing. Patient has taken her prescribed medications of Cromolyn Sodium

and Ventolin at home with no relief of symptoms prior to coming to the ER. A

physical exam revealed the following: HR 110, RR 40 with signs of accessory

muscle use. Auscultation revealed decreased breath sounds with inspiratory

and expiratory wheezing and pt was coughing up small amounts of white

sputum. SaO2 was 93% on room air. An arterial blood gas (ABG) was ordered

with the following results: pH 7.5, PaCO2 27, PaO2 75.

An aerosol treatment was ordered and given with 0.5 cc albuterol with 3.0

cc normal saline in a small volume nebulizer for 10 minutes. Peak flows done

before and after the treatment were 125/250 and auscultation revealed loud

expiratory wheezing and better airflow. 20 minutes later a second treatment

was given with the above meds. Peak flows before and after showed

improvements of 230/360 and on auscultation there was clearing of breath

sounds and much improved airflow. RR was 24 at this time and HR 108.

Symptoms resolved and patient was given prescription for inhaled steroids to

be used with current home meds. Instruction was given for use of inhaled

steroids and the patient was sent home.

Diagnosis 1 :

HR 110 -> 60 – 100 : takikardi RR 40 -> 16 – 24

Peak flows 125/250 -> 250/250

Asthma studium : severe persisten PF < 60 % and symptoms continually

:: classified patients in severe acute asthma (severe persisten) ::

Diagnosis 2 :

VALUES TEST RESULT NORMAL

pH 7,5 7,34 – 7,44

PCO2 27 35 - 45

PO2 75 85 - 116

Sa O2 93 % 95 – 98 %

Viewed from the table above, show that patients experienced hyper

ventilation. Low levels of CO2 make the exchange with O2 gas becomes

less. As a result patients have tachypnea (rapid breathing and deep) as the

body's attempt to restore blood pH to normal. Beside that, the patient’s

blood is alkaline pH and PCO2 and PO2 below normal so that carbon

dioxide levels in the blood becomes low.

So, the patient also suffers respiratory alkaliosis.

Intervention / Treatment :

From the case we can conclude about the nursing intervention is

medication administration that :

a. Patient get medication of asthma : 0,5 cc albuterol and 3,o normal saline in

nebulizer with small volume during 10 minutes, albuterol is belong to

pharmacology therapy and quicker-relief type.

b. Albuterol can relax the muscles in respiratory duct so the respiratory duct

will be wider than before and the patient can breath easier. Then after 20

minutes, the patient get that medicine. Next the peak flow meter measures

that the peak flow condition become normal 230/360, before is 125.250.

c. So, we can see the nursing intervention was given is right. That patient can

be better.

Management :

Management: Describe Medication Roles

1. How Medications work

a. Long-term medications reduce inflammation

b. Short-term medications rescue from bronchospasm

2. Emphasize Long-term medications as key to control

Management: Skill Training

1. Inhaler use

2. Monitoring methods

a. Symptom monitoring

b. Peak Flow meter

c. Early recognition of exacerbation

3. Written action plan

a. Stepwise plan for exacerbations

b. When and how to take Rescue medications

Management: Control Measures for Environmental Allergens

See Environmental Allergen and avoid them, such as :

1. Animal Dander

1. Remove animal from house

2. Keep animal out of patient's bedroom

3. Install Filter on bedroom air duct

2. House-Dust mites

1. Encase mattress and pillow in impermeable cover

2. Wash bedding weekly in hot water

3. Reduce indoor humidity <50%

3. Cockroaches

1. Set traps

2. Preventative measures

4. Indoor Mold

1. Fix leaks and other water sources of mold growth

2. Reduce indoor humidity to <50%

3. Clean

4 th CHAPTER

CLOSING

A. Conclusion

Oxigenation need is so important in the life. One of a respiratory disorder

kind is asthma. Asthma is a worldwide health problem. It happened in

whole the world and can be suffered by children until elders. From

pathophisiology of asthma, we can see how dangerous asthma occurs. It

disturbs the repiration process. Nowdays, the health provider have used

many ways to help patient asthma to identify, to cope, and to management

asthma. If their ways is right so the patient can be helped.

B. Recommendation

However medical practice have known how to diagnose, give intervention,

and management asthma, we as nursing science students should be able to

do the researches so that asthma problem can be reduced. Beside that,

nursing intervention not only is published to the asthma patients and their

family, but also give health education to public. If we can do the best and

collaboration with nursing profession or other health provider, it is not just

a dream to decrease asthma problem.