St. Anne College Lucena Inc.

Diversion Road G- Gulang

Lucena City

In Partial Fulfillment for Academic Requirements

In Related Learning Experience
A Case of BAIAE

Prepared by:
Joy Rachel D. Tabernilla
BSN III-A

Presented to:
Shiela Galang, R.N.

July, 2010
 TABLE OF CONTENTS

I.
OBJECTIVES………………………………………………………….........
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a. General Objectives
b. Specific Objectives

II. PATIENT PROFILE…………………………………………………….2

a. Biographical data of the patient
b. Clinical data of the patient

III. HISTORY…………………………………………………………...........2
a. Nursing History
i. Chief Complain
ii. Admitting Diagnosis
iii. Physical Examination
iv. Final Diagnosis
b. Present Health History
i. 24 hours recall of events
ii. Signs and symptoms experienced by the patient
c. Past Health History
i. Hospitalizations
ii. Surgical Managements
iii. Allergies
1. Foods
2. Drugs
iv. Others
d. Family Health Background
i. Health tree

IV. NUTRITION………………………………………………………….......4
a. 24 hours food recall
b. Regular/Routine diet
c. Intake and output
d. Vices and habits

V. DISEASE ENTITY………………………………………………………..4
a. Definition
b. Etiology
c. Anatomy of the organ involved

VI. MANAGEMENT…………………………………………………………..6
a. Nursing Management
b. Pharmacologic Management

VII. LABORATORY…………………………………………………………....7
a. Blood analysis

VIII. PATHOPHYSIOLOGY…………………………………………………..8

IX. NURSING CARE PLAN

X. Discharge Plan……………………………………………………………8

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I. OBJECTIVES

a. GENERAL OBJECTIVES:
In the light of knowledge, the main goal of the study is to develop
skills, knowledge and right attitude about the case asthma. Through this,
we could be able to share it with our fellow students.

b. SPECIFIC OBJECTIVES:

 To define the case and its effects to human body.

 To enhanced our knowledge and learning regarding the disease
identity.
 To have a complete details or background about the patients
profile and nutritional status.
 To review the anatomy and physiology of the client, specifically
the lungs.
 To develop skills regarding the care of patient with appendicitis
asthma and its managements.

II. PATIENT PROFILE

a. Biographical data of the patient

Name: R.A.C.
Age: 45years old
Gender: Female
Date of Birth: October 28, 1964
Civil Status: Married
Nationality: Filipino
Address: Zaballero Subd. , Lucena City
Religion: Roman Catholic
Educational Attainment: College Graduate
Occupation: PNB

b. Clinical data of the patient

Diagnosis: BA r/o sinusitis
Chief Complain: DOB
Diet: hypoallergenic diet
Room: Sapphire NS3
Attending Physician: Angelito Erwin Reyes, M.D.
Date and Time of Admission: July 6, 2010 at 2:58pm
Case #: 462647
Membership: PM Valucare
Type of admission: New
Hospital: St. Anne General Hospital

III. HISTORY
a. Nursing History

i. Chief Complain: DOB

ii. Admitting Diagnosis: BA r/o sinusitis

iii. Physical Examination:

GENERAL ASSESMENT:
 conscious and coherent
 cooperative
 with pinkish conjunctiva

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  with dry pinkish lips
 with none productive cough
 with symmetrical chest expansion
 with pinkish nail beds

iv. Final Diagnosis:

BAIAE, URTI

b. Present Health History

i. 24 hours Recall of Events

The night before the admission, the patient with her

family had dinner together, had plenty of ice cream after.
The next morning, she had feel difficulty of breathing, colds
and non-productive cough yet she went to her work at PNB.
During work, she had headache. She then take Seretide one
to relief her feelings. Then few hours after had severe
difficulty of breathing hence consuted at SAGHI.

ii. Signs and symptoms experienced by the patient

 Non productive cough

 Colds
 Headache
 DOB

c. Past Health History

i. Hospitalizations:
January 2009 @ Mt. Carmel – Asthma
Year 2008 – twice, asthma

ii. Surgical Managements: none

iii. Allergies
1. Allergy- stress, insects, dusts
2. Drugs: no known allergies

d. Family Health Background

-asthma - heart problem

y/o

asthma
asthma

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LEGEND:
- Male - female - patient

- Deceased - alive and well

IV. NUTRITION

a. 24 hour food recall

24 hours prior to admission patient had taken the following

foods:
 Dinner– rice, meat
- ice cream
 Breakfast- rice, fish
 Lunch- rice with chicken inasal
The patient daily consumption was more on carbohydrates, some
protein with some fats.

b. Regular/Routine diet

Patient regular diet was more on meats or processed foods.

c. Intake and output

The patient daily intake of fluids was about 1 to 2 liters with

the corresponding normal output.

d. Vices and habits

The patient had sedentary lifestyle. Because of her work,

she was used to do a lot of things at home.

V. Disease Entity

a. Definition

Asthma is a common chronic inflammatory disease of the

airways characterized by variable and recurring symptoms, airflow
obstruction, and bronchospasm. Symptoms include wheezing,
cough, chest tightness, and shortness of breath.

b. Etiology

Common triggers of asthma can be classified as follows :

A. Allergens (Individual specific)

i Outdoor allergens
* Pollens - from grass & trees
* Molds - of some fungi
ii Indoor Allergens
* House dust mites

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 * Dander (or flakes) -from the skin, hair or feathers of warm -
blooded pets (dogs, cats, birds, rodents, etc.)
* Molds -harboured in Vacuum cleaners, Air-con- ditioners,
Humidifiers.
* Insects -Cockroach
iii Food Allergens
Rarely cause an asthma attack. Though some of foodstuffs
may cause allergic manifestations in some people. it is not wise to
band allergy producing foods in general for an asthmatic. Avoid
those specific foods which evokes an asthma/allergy attack within
few minutes or hours after intake. Commonly allergy-producing
foods are:
* Beef, Prawn, Hilsha and some other fishes, sea-foods, duck
egg, some vegetables, nuts, etc.
* Food additives, e.g. metabisulphite, tartrazine.

B. Irritants (More generalized)

i Tobacco smoke
ii Wood smoke
iii Strong odours, perfumes and sprays, cosmetics, paints, cooking
(especially with spices)
iv Air-pollutants - Smoke and toxic gases from automobiles and
factories.

C. Upper respiratory tract infection - viral infections, common cold

D. Exercise - strenuous physical activities.
E. Certain Drugs - e.g. b-blockers (even eye drops), Aspirin,
NSAIDS etc.
F. Changes in season, weather and temperature- An asthma attack
is likely if temperature lowers for 30C or more than the previous
day.
G. Stress i. Emotion - e.g. Laughing, Sobbing, Mental depression

c. Anatomy of the organ involved

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 The function of the respiratory system is to give us a surface area for
exchanging gases between the air and our circulating blood. It moves that air to
and from the surfaces of the lungs while it protects the lungs from dehydration,
temperature changes and unwelcome pathogens. It also plays a part in making
sounds such as talking, singing, other nonverbal sounds and works with the
central nervous system for the ability to smell.

Upper Respiratory

The upper respiratory system consists of the nostrils (external nares),

nasal cavity, nasal vestibule, nasal septum, both hard and soft palate,
nasopharynx, pharynx, larynx and trachea. Within the nostrils, course hairs
protect us from dust, insects and sand. The hard palate serves to separate the
oral and nasal cavities. There is a protective mucous membrane that lines the
naval cavities and other parts of the respiratory tract. It is secreted over the
exposed surfaces and then the cilia sweeps that mucus and any microorganisms
or debris to the pharynx, so it is swallowed and then destroyed in stomach acids

Lower Respiratory

The trachea branches off into what is known as the bronchi (more
commonly called bronchial tubes). These two main bronchi have branches
forming the bronchial tree. Where it enters the lung, there is then secondary
bronchi. In each lung, the secondary bronchi divides into tertiary bronchi and in
turn these divide repeatedly into smaller bronchioles. The bronchioles control the
ratio of resistance to airflow and distribution of air in our lungs. The bronchioles
open into the alveolar ducts. Alveolar sacs are at the end of the ducts. These
sacs are chambers that are connected to several individual alveoli, which makes
up the exchange surface of the lungs.

The Lungs

The human respiratory system has two lungs, which contain lobes
separated by deep fissures. Surprisingly, the right lung has three lobes while the
left one has only two lobes. The lungs are made up of elastic fibers that gives it
the ability to handle large changes in air volume. The pleural cavity is where the
lungs are located. The diaphragm is the muscle that makes up the floor of the
thoracic cavity and plays a major role in the pressure and volume of air moving in
and out of the lungs.

VI. MANAGEMENT
a. Nursing Management

The main focus of nursing management is to actively assess the air way
and the patient response to treatment. The immediate nursing care of patient
with asthma depends on the severity of the symptoms. A calm approach is an
important aspect of care especially for anxious client and one’s family.

• This requires a partnership between the patient and the health care
providers to determine the desire outcome and to formulate a plan which
include;

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 • the purpose and action of each medication
• trigger to avoid and how to do so
• when to seek assistance
• the nature of asthma as chronic inflammatory disease

b. Pharmacologic Management

 Hydrocortisone (Pharmacort) 100mg thru IV q 8 hours x 3 doses ANST(-)

 Zertin 300mg 1 cap BID
 Seretide 250 mg/25 mg 2 puffs BID(gargle after use)
 Risek 20 mg/tab 1 tab OD
 Celcoxx 100mg/cap 1 cap BID
 Chorpheniramine maleate 1 tab TID

VII. Laboratory

a. Blood analysis

Hematology (07- 06, 2010@2:55pm)

SPECIFICATION RESULTS NORMAL RANGE INTERPRETATION

Hematocrit 0.30 F 0.37-0.45 =anemia,

hemodilution

Hemoglobin 10 F – 12-15 g/dL =anemia, fluid

retention

WBC 10.3 5-10X10^9/L =infection, tissue

necrosis

Platelet 413 150-400 x = IDA

10^g/dL

Urinalysis (07-07, 2010 @ 12pm)

TEST RESULT NORMAL RANGE INTERPETATION

Glucose ++++ Negative DM, cushing’s
syndrome
Leukocyte + Negative
Pus cells 10-15/hpf 0-2/hpf pyoria
Epithelial cells Many Few
Bacteria Few none Renal disease

X-ray (07-06, 2010)

Clear lung fields.

Normal heart shadow.
Diaphragm osseous stractures, soft tissues are intact.
Impression:
Essentially normal chest findings.

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 VIII. Pathophysiology

Colds,
Exposure to allergens stress

s/sx:
Inflammation of the airway Dob, non-productive
cough, cough
colds

Increase constriction of the smooth muscle

Hypersecretion of mucus in the bronchial tree Causing mucosal

edema

dyspnea

IX. Discharge Plan

M- medication instructed to the patient to take at home:

 Antamin 1 tab 3x a day for 5 days
 Sereride 250mg/25mg, 2 puffs 2x a day (gargle after use)
 Zertin 300mg/cap 2x a day for 5 days
 Ultramix 1gm/tab 1 tab 2x a day
 Celcoxx 100mg/cap 1 cap if in pain
 Prednisone 1 tab 2x a day for 7 days after meal

E- Environment or exercise suited for the management and prevention of asthma

like:
 Provision of therapeutic environment
 Avoidance of things/materials that could aggravate condition

T- treatment that may develop a well resistance fot the management of asthma:
 Taking the necessary drug for asthma like antihistamins & nasal
decongestants

H- health teachings for the prevention & care of patient with asthma:
 Action of medications
 Ways to avoid & prevent asthma attack
 Nature & cause of asthma
O- OPD
 Encouraged patient to have her follow up check up on July 15, 2010 @ St.
Anne Clinic
D- diet
 Avoidance of food that could aggravate asthma like allergens, foofs such
as shrimps or crab and others.

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Name of Patient: Carrasco, Ruth C. Age: 45 Sex: F
Attending Physician: Dr. E. Reyes Room: Sapphire

DATE/TIME REMARKS

07/09/’10 >received sitting on chair with ongoing IVF of PNSS

7am 1 L x KVO @ 150cc level, inserted @ right
metacarpal vein, infusing well
>no redness & swelling noted on IV insertion site
>conscious & coherent
>V/S taken & recorded
>NPI established throughout the shift
S> “Nahihirapan akong huminga,” as verbalized by
the patient.
O>dyspnea
>chest tightness
>non-productive cough
>DOB
A> Ineffective airway clearance r/t bronchostriction,
increased mucus production & respiratory infection
as evidence by DOB, colds, dyspnea &
nonproductive cough.
P> After 8 hours of nursing intervention the patient
will maintain or improve airway clearance as
evidence by absence of signs of respiratory distress.
I>encouraged verbalization of feelings
>routine assessment done
>adequately hydrate the patient
>teach & encourage the use of diaphragmatic
breathing and coughing exercises
> instruct to avoid bronchial irritants such as
cigarette, smoke, aerosols, extremes of temperature
& fumes
> teach early signs of infection that are to be
reported to the clinician immediately
>administer medication as ordered
E> At the end of 8 hours nursing interventions,
patient verbalized, “ok na ang paghinga ko, hindi na
ako nahihirapan”.
>needs attended
>seen at frequent intervals
>endorsed

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Name of Patient: Talay, Marieta Age: 55 Sex: F
Attending Physician: Dr. E. Reyes Room: 333

DATE/TIME REMARKS

07/14/’10 >received sitting on chair with ongoing IVF of PNSS

7am 1 L x KVO @ 650cc level, inserted @ right
metacarpal vein, infusing well
>no redness & swelling noted on IV insertion site
>conscious & coherent
>afebrile
>V/S taken & recorded
>NPI established throughout the shift
S> “Medyo nahihilo ako,” as verbalized by the
patient.
O>slight weak & pale in appearance
>irritable
>with complain of dizziness
A> Risk for injury related to developmental aging.
P> At the end of 8 hours nursing intervention, the
patient verbalized good therapeutic regimen & seen
free from injury.
I>encouraged verbalization of feelings
>routine assessment done
>provide safety measures to avoid injury
>encouraged to use relaxation technique
>Provide therapeutic environment
>encouraged significant others to watch out patient
carefully
>instruct oatient to eat nutritious foods & drink plenty
of fluids
>administer medication as ordered
E> After 8 hours nursing interventions, patient seen
comfortably sleeping& free from injury.
>needs attended
>seen at frequent intervals
>endorsed

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Name of Patient: Ocfemia, Eugenia Age: 57 Sex: F
Attending Physician: Dr. Guinto, Dr. Yap Room: Emerald

DATE/TIME REMARKS

07/15/’10 >received lying on bed with ongoing IVF of D5NM 1

7am L x 60gtt/mins @ 100cc level, inserted @ left
metacarpal vein, infusing well
>no redness & swelling noted on IV insertion site
>conscious & coherent
>with foley catheter draining bonto yellow urine,
scanty in amount
>with epidural cathter, intact in place
>afebrile
>V/S taken & recorded
>NPI established throughout the shift
S> “Sumasakit na ang opera ko,” as verbalized by
the patient.
O>slight weak in appearance
>with facial mask
>with surgical dressing on right upper quadrant of
abdomen, dry & intact
>with pain scale of 6/10
A> Alteration in comfort, pain secondary to post
surgical procedure done.
P> At the end of 8 hours nursing intervention, the
patient report lessen pain.
I>encouraged verbalization of feelings
>routine assessment done
>provide safety measures to avoid injury
>encouraged to use relaxation technique
>Provide therapeutic environment
>impart health teachings:
a. proper positioning
b. proper wound care
c. importance of adequate rest periods
d. strict adherence to treatment regimen
>above IVF consume & followed by D5LRS 1 L x 8
hours
>administer medication as ordered
E> After 8 hours nursing interventions, patient was
able to verbalized less pain as evidence by latest
pain scale of 4/10.
>needs attended
>seen at frequent intervals
>endorsed

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Name of Patient: Ocfemia, Eugenia Age: 57 Sex: F
Attending Physician: Dr. Guinto, Dr. Yap Room: Emerald

DATE/TIME REMARKS

07/16/’10 >received sitting on chair with ongoing IVF of D5LRS

7am 1 L x KVO @ 360cc level, inserted @ left metacarpal
vein, infusing well
>no redness & swelling noted on IV insertion site
>conscious & coherent
>afebrile
>V/S taken & recorded
>NPI established throughout the shift
S> “Ok na naman ang pakiramdam ko, kahit sa tahi
ko,” as verbalized by the patient.
O>disrupted skin layers
>wound area warm to touch
>with surgical dressing on right upper quadrant of
abdomen, dry & intact
A> Impaired skin integrity related to disrupted skin
layers secondary to post surgical procedure.
P> At the end of 8 hours nursing intervention, the
patient participoate in treatment and prevention of
complications.
I>encouraged verbalization of feelings
>assess/inspect incision site for redness, swelling or
signs of evisceration
>keep the incision site clean & dry, carefully change
dressing
>impart health teachings:
a. support the surgical site when moving
b. importance of proper wound care
c. take foods rich in vitamin C, proteins & minerals
d. strict adherence to treatment regimen
>administer medication as ordered
E> After 8 hours nursing interventions, patient had
complied with the teachings & do actions.
>needs attended
>seen at frequent intervals
>endorsed

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