I CAN’T BREATHE

IF BREATHING IS
WITHOUT
2
A Case Presentation On

BRONCHIAL ASTHMA
RLE-32
Aldwin Batugal
Roswell Tristan Blancaflor
Donald Paloma
Jerimar Miranda
Earl Omar Tumanguil
Marie Natie Adrian Gelacio
Krishan Soriano
Xiao Xiao Zheng (Sunny)

INTRODUCTION
 Asthma is a chronic illness involving the respiratory system in which the
airway occasionally constricts, becomes inflamed, and is lined with excessive
amounts of mucus, often in response to one or more triggers. These episodes
may be triggered by such things as exposure to an environmental stimulant (or
allergen) such as cold air, warm air, moist air, exercise or exertion, or emotional
stress. In children, the most common triggers are viral illnesses such as those
that cause the common cold. This airway narrowing causes symptoms such as
wheezing, shortness of breath, chest tightness, and coughing. The airway
constriction responds to bronchodilators. Between episodes, most patients feel
well but can have mild symptoms and they may remain short of breath after
exercise for longer periods of time than the unaffected individual. The symptoms
of asthma, which can range from mild to life threatening, can usually be
controlled with a combination of drugs and environmental changes.

Signs and symptoms

 Dyspnea
 Wheezing
 Coughing
 Inability for physical exertion
 Shortness of breath
 Tachypnea
 Tachycardia
 Overinflation of the chest (barrel chest)
 Cyanosis (severe attacks)
 Chest pain
 Loss of consciousness

Diagnosis

Asthma is defined simply as reversible airway obstruction. Reversibility occurs

either spontaneously or with treatment. The basic measurement is peak flow
rates.

In many cases, a physician can diagnose asthma on the basis of typical

findings in a patient's clinical history and examination. Asthma is strongly
suspected if a patient suffers from eczema or other allergic conditions—
suggesting a general atopic constitution—or has a family history of asthma.
While measurement of airway function is possible for adults, most new cases are
diagnosed in children who are unable to perform such tests. Diagnosis in children
is based on a careful compilation and analysis of the patient's medical history
and subsequent improvement with an inhaled bronchodilator medication. In
adults, diagnosis can be made with a peak flow meter (which tests airway
restriction), looking at both the diurnal variation and any reversibility following
inhaled bronchodilator medication.

Testing peak flow at rest (or baseline) and after exercise can be helpful,
especially in young asthmatics who may experience only exercise-induced
asthma. If the diagnosis is in doubt, a more formal lung function test may be
conducted. Once a diagnosis of asthma is made, a patient can use peak flow
meter testing to monitor the severity of the disease.

In the Emergency Department doctors may use a capnography which

measures the amount of exhaled carbon dioxide, along with pulse oximetry
which shows the amount of oxygen dissolved in the blood, to determine the
severity of an asthma attack as well as the response to treatment.

There is no cure for asthma. Doctors have only found ways to prevent attacks
and relieve the symptoms such as tightness of the chest and trouble breathing.

Treatment

 Identifying stimulants (pets, aspirin, allergens, smoking)

 Bronchodilators
 Antihistamines

For mild persistent disease (more than two attacks a week)

 Low dose inhaled glucocorticoids

 Oral leukotriene modifier (mast cell stabilizer)
 Theophylline

Relief medication

 Fast acting bronchodilators

 Metered dose inhalers (MDIs)
 Nebulizers

Emergency treatment

When an asthma attack is unresponsive to a patient's usual medication, other

treatments are available to the physician or hospital:

• oxygen to alleviate the hypoxia (but not the asthma per se) that results
from extreme asthma attacks;
• nebulized salbutamol or terbutaline (short-acting beta-2-agonists), often
combined with ipratropium (an anticholinergic);
• systemic steroids, oral or intravenous medications (prednisone,
prednisolone, methylprednisolone, dexamethasone, or hydrocortisone).
• other bronchodilators that are occasionally effective when the usual drugs
fail:
o intravenous salbutamol
o nonspecific beta-agonists, injected or inhaled (epinephrine,
isoetharine, isoproterenol, metaproterenol);
o anticholinergics, IV or nebulized, with systemic effects
(glycopyrrolate, atropine, ipratropium);
o methylxanthines (theophylline, aminophylline);
 o inhalation anesthetics that have a bronchodilatory effect
(isoflurane, halothane, enflurane);
o the dissociative anaesthetic ketamine, often used in endotracheal
tube induction
• intubation and mechanical ventilation, for patients in or approaching
respiratory arrest.
• Heliox, a mixture of helium and oxygen, may be used in a hospital setting.
It has a more laminar flow than ambient air and moves more easily
through constricted airways

PATIENT’S PROFILE

Name: OCA

Address: Libag Norte, Tuguegarao City

Birthday: October 07, 1952

Birthplace: Cabagan, Isabela

Age: 55 years old

Gender: Male

Civil Status: Married

Nationality: Filipino

Religion: Roman Catholic

Date of Admission: November 14, 2007

Time of Admission: 11:15am

Attending Physician: Dr. R. Soliman

Admitting Diagnosis: Bronchial Asthma in Acute Exacerbation

Principal Diagnosis: COPD

Final Diagnosis: Bronchial Asthma

Initial vital Signs:

Blood Pressure- 100/80mmHg

Temperature- 36.7 ºC
Pulse Rate- 127 bpm
Respiratory Rate- 28cpm

NURSING HISTORY

PAST MEDICAL HISTORY

According to patient Oca he lived a typical Filipino life. Due to poverty he had
problems not only financially but also medically rooting up from his childhood. He didn’t
have the needed vaccinations or even knowledge or access to these. In mild health
alterations he usually relies to OTCs like Neozep, Biogesic, Alaxan and any means
necessary for treatment (albularyos, herbal medicine). In his youthful days he didn’t
really mind going to the health centers and free medical missions for check-ups and
health assessments because he wasn’t aware he was asthmatic. He lived the “bad boy”
type of life walking around with two packs of cigarette and won’t head home without
finishing all. He would drink liquor as long as there’s some to drink. It was on September
of the year 1999 when he knew he has asthma he was then prescribed to take asthmasalon
tablets when he experiences difficulty of breathing. Late in his adult years, Oca went for
check-up and was diagnosed with pulmonary tuberculosis. “Sa katunayan nalaman ko
may ganito akong karamdaman siguro pito hanggang walong taon na ang nakakaraan.”,
the patient said. Now he believes and knows that it is not good for him to tire himself or
add up more illness to what he already has. He now goes for check up at Milagros
Hospital at Cabagan Isabela, thrice a year.

HISTORY OF PRESENT ILLNESS

Three days prior to admission, the patient experienced sharp stabbing pain at the
chest. At the same time, he also experienced on and off difficulty of breathing. He also
had cough with yellowish phlegm and he just rested without taking any medication or any
means of managing these. “Binalewala ko kasi to kaya lumalaya”, Oca said. He then
went for consultation at People’s Emergency Hospital and the physician diagnosed him
of having bronchial asthma. The physician then decided that Oca needs to be admitted.

FAMILY HISTORY
 Patient Oca said that both his mother and father side has asthma. He said he was
particularly fortunate for having no other lung associated disease. “Mahilig kasi ako
magsigarilyo at alam ko yun ang rason kung bakit nagkaganito ito” Oca added. A history
of hypertension was present on his maternal side and no particular disease or illness on
his paternal side. The patient then boasts that his family has a strong immune system and
no certain cause of mortality was due to disease or illness. He then added “Kung pwede
lang lahat kami ay mamatay dahil sa pagtanda e di maayos, masarap mabuhay eh”.

Gordon’s 11 Functional Health Pattern

Date of Interview:
November 22, 2007

1. Health-Perception-Health Management Pattern

Before hospitalization: According to the patient, he believes that health is

characterized by a strong body and the absence of sickness. He said that
one is able to maintain health by following a balanced diet and adequate
rest. He also believes in albularyos or hilots, he added,”Basta kung anung
meron diyan dapat paniwalaan na kung kaya’t sinubukan ko ang
pagpunta sa kanila kung may nararamdaman ako at gipit sa pera.
Naiibsan naman ang nararamdaman ko pagkatapos kung pumunta sa
kanila.” He also believes in taking medications when getting sick with or
without consultation furthermore he said that healing occurs with the
effectivity of the medications accompanied by luck of the person.

During hospitalization: According to the patient his condition now is the

opposite of being healthy, he complies to his medication regimen and
when he feels that he cant breathe he frequently massages his chest to
relieve the short-stabbing pain that he’s feeling. ”Pag hindi na ako
makahinga at walang nurse eh minamasahe ko nalang ng ganito.
(massages his chest.)”

2. Nutritional-Metabolic Pattern

Before hospitalization: According to the patient, “Pakonti-konti lang ang

kinakain ko noon dahil sa klase ng trabaho ko.” Patient Oca added that he
drinks a cup of coffee in the morning or sometimes 3 sips within one cup
is enough. He loves to eat vegetables such as talong and kamatis, he
prefers fish more than meat. And taking snacks in the afternoon depends
only if someone would serve or give. He drinks 6-8 glasses a day. He also
 takes vitamin supplements like centrum, “Gusto ko kasing maging
complete”, he added. He doesn’t have any allergies on food and he does
not like those that taste sweet and spicy.

During hospitalization: According to the patient his doctor advised him to

limit intake of food that go against his hypoallergenic diet. “Sinabi sa akin
na iwasan ko nang kumain ng isda at pagkain na malansa” he added. He
drinks only about 450ml of water each day (approximately 2 cups) but
drinks one glass of milk when he wants to drink some. In his hospital stay
he only eats twice a day, one in the morning and one in the evening.

3. Elimination Pattern

Before hospitalization: Oca verbalized voiding approximately 800ml

summed up on 3 times of regular urination per day (about 250 ml per
urination). His urine is yellow amber in color and has a clear appearance.
He said “Dapat makontrol mo ang pag-ihi mo kung drayber ka, bago ka
magmaneho dapat nakaihi ka na”. He defecates once a day usually in the
morning. His stool is foul, dark, and semi-formed also depending on what
he ate the previous day. And he doesn’t have any difficulty in urinating
and defecating.

During hospitalization: Oca is ambulatory so he voids and defecates with

assistance . He voids approximately 300ml of slightly turbid urine per day.
He said that within his 8 day stay in the hospital he only defecated 3
times and his stool is foul, dark, and semi-hard. He then said “Walang
problema sa sakit ng tiyan o pag-ihi basta nahihirapan ako huminga
nanghihina na ako gawin ang kung ano”

4. Activity-Exercise Pattern

Before hospitalization: The patient was a driver of the Ting family’s Deltra
Bus here in Tuguegarao for 15 years. He said “wala ako masyadong
ginagawa na hiwalay sa trabaho”. He does not perform any household
chore or any typical leisure work such as gardening and cleaning house
premises. He just sits back and watches television when he is not on
travel. He considers walking around as his form of exercise.

During hospitalization: When hospitalized, the patient can’t do what he

usually does. He said that his actions/movements are limited. He
performs ROM exercises cooperatively to monitor how his lungs respond
to certain movements. Since there’s not much to do he only lies and
sometimes sits on his bed and reads the newspaper. He listens to music
when he feels like it. Oca also enjoys the company of close friends and
family as he said “masaya talaga kung sama-sama”
.
5. Cognitive-Perceptual Pattern

Before hospitalization: He has sensory deficit (visual) due to his age but
does not wear pair of eyeglasses because they don’t have money to buy.
He is able smell and taste food well and is able to respond to stimuli. He
can hear well as he added “dapat marunong ka makinig sa problema ng
sasakyan kung drayber ka e, kung may ibang tunog kahit mahina lang
dapat ayusin na”. The patient said that he only finished Grade 4 due to
poverty but is able to read and write.

During hospitalization: He can’t identify small letters (about that of font

12) with his naked eye only. He is still able smell and taste food well and
is able to respond to stimuli. He can still hear well. He is able to answer
open-ended questions concisely and is aware of events happening outside
the hospital (family events and country issues).

6. Sleep-Rest Pattern

Before hospitalization: The patient said that he seldom have long hours of
sleep because of his work as a driver. He said “ang umaga niyo e gabi ko
e at ang gabi niyo e umaga ko, ganun ang buhay drayber”. He sleeps
utmost 5 hours daily after work. He seldom takes a nap in the afternoon.
His sleep pattern was disrupted because of his kind of work. He doesn’t
have any preference on where to sleep, as he added “kahit saan na kahit
matigas pa, basta mahangin o may electric fan”.

During hospitalization: He is not able to sleep well because of frequent

monitoring of v/s and some medication plus condition check-ups. He
seldom takes a nap in the afternoon but takes time to compensate for the
lack of sleep. “Kapag wala nang bisita at wala naman masyadong nurse
na nagbibigay ng gamot at nagbbp e nakakatulog ako”, he concluded.

7. Self-Perception-Self-Control Pattern

Before hospitalization: The patient is frank and has a high self-esteem.

When asked on how he sees himself before he said “ok naman ako dati,
palakbay lakbay lang, parang hari nga ako e” He is proud of his children
and grandchildren and considers them as his achievements.

During hospitalization: He realizes the seriousness of his condition as

evidenced by his willingness to participate in necessary activities (ROM
exercises) that are needed for his recovery. He said that he doesn’t have
that much control on himself anymore, “bahala na ang mga doctor, nurse
at Diyos”.

8. Role-Relationship Pattern
 Before hospitalization: He is the breadwinner of the family and has a good
relationship with his family, friends, neighbors, fellow drivers, and boss.
He loves to mingle with different kinds of people. Moreover, when conflict
arises, he wants to resolve it immediately with the help of his children and
wife. He values the existence of a great social support especially in times
of need. As he said “madali lahat kung tulung-tulong, at pangit naman
kung may kaaway ka”.

During hospitalization: He is no longer the breadwinner of the family; he

has still good relationship with his children even if some are far from him.
He said that distance is not a hindrance. He believes that someday they
will come together and all are healthy. He said “mas pinatibay lang ng
nangyaring ito ang samahan naming pamilya, kahit gipit na e
nasustentuhan nila ang pamamalagi ko dito gaya ng pagpapalaki ko sa
kanila”.

9. Sexuality-Reproductive Pattern

Before hospitalization: He has an active sexual life. He has 3 children from

his wife and another from another woman. He had coitarche when he was
14 years old. He said “kung kaya pa at pwede di ayos” jokingly. He said
that there are a lot of factors that are needed but the most important
thing both should have is love.

During hospitalization: He has an inactive sexual life due to his age and
present condition. He said that now that he is like that he believes that
one can express himself not only through contact but by respect, love and
loyalty

10. Coping-Stress Tolerance

Before hospitalization: He used to smoke 2 packs of cigarette a day. He

started this when he was about 20 years old. He used to drink liquor on
special occasions such as birthdays and fiestas at an estimated of 1 case
of red horse. Whenever he feels stressed he also drinks 2 bottles of red
horse. When he encounters problems he consults his children and wife.

During hospitalization: He already stopped drinking liquor and smoking

because of present condition. He said that he tries to convince himself
that he understands the things that are happening to him to be able
reduce the stress that he is experiencing at present because of his
illness.

11. Value-Belief Pattern

Before hospitalization: The patient is a Roman Catholic. He seldom

attends mass but he prays always.
 During hospitalization: He strongly believes in miracles and power of
God. The Lord is his source of strength.

PHYSICAL ASSESSMENT

Date: November 22, 2007

Time: 5 pm

General Appearance

The patient was clean and tidy during the interview. He was conscious and
coherent and was oriented to time, date, place and persons. He was sitting in
bed with ongoing IVF #2 Eurosol M in D5W at 100 cc level patent and
infusing well at the right peripheral vein.

Initial Vital Signs:

PR- 127 bpm
RR- 28 cpm
BP- 100/80 mmHg
Temperature- 36.8°C
 Area Techniques Normal Actual
Analysis
Assessed Used Findings Findings
SKIN
Color Inspection Fair, Tan, Dark Tan Normal
Texture Palpation Smooth, soft Smooth, soft Normal
Turgor Inspection Skin snaps When pinched, Due to aging
back it slowly snaps
immediately back
when pinched
Hair Inspection Evenly Evenly Normal
Distribution distributed distributed
Temperature Palpation Warm to touch Warm to touch Normal
Moisture Palpation Dry, skin folds Dry skin Due to aging
are normally
moist
NAILS
Color of Inspection Pink and Clean Pink Normal
nailbed
Texture Palpation Smooth Smooth Normal
Shape Inspection Convex Convex Normal
curvature
Nail Base Inspection Firm Firm Normal
Capillary Refill Blanch Test 2-3 seconds 2-3 seconds Normal
time
HAIR
Color Inspection Black (varies) Black but Normal, due to
slightly going aging
to white
Distribution Inspection Evenly Evenly Normal
distributed distributed
Moisture Inspection Neither Neither Normal
excessively dry excessively dry
nor oily nor oily
Texture Inspection Silky, resilient Silky, resilient Normal
HEAD
Scalp Inspection Symmetrical Symmetrical Normal
Symmetry
Skull Size Inspection Normocephalic Normocephalic Normal
Shape Inspection Round Round Normal
and
Palpation
Nodules/ Palpation Absence of Absence of Normal
Masses nodules and nodules and
masses masses
FACE
Symmetry Inspection Symmetrical Symmetrical Normal
Facial Inspection Symmetrical Symmetrical Normal
Movement
Skin color Inspection Fair, Tan, Dark Tan Normal
EYES
Eyebrows Inspection Symmetrically Symmetrically Normal
aligned, equal aligned, equal
movement movement
Eyelashes Inspection Slightly curved Slightly curved Normal
upward upward

Eyelids Inspection Smooth, tan, Smooth, tan, Normal

do not cover do not cover
 Anatomy of the Respiratory System

The Respiratory System

 Also means ventilation (the movement of air into and out of the
lungs); for respiration
 Gas exchange (O2 and CO2) between air and the blood and between
the blood and the tissue
 Cellular transfusion
 Regulates blood pH

Nose

Nasal Cavity

Pharynx

Larynx

Trachea

Bronchi

Bronchiol
e

Alveoli

Alveolus
Lungs
Nose
 Primary structure of the respiratory tract
 External nares with cilia or hair – traps larger particles that may enter
the respiratory tract
 Nasal cavity – allows the air to enter into the main portion of
respiratory tract when inhaling

Division of Nasal Cavity

1. superior nasal conchae
2. middle nasal conchae
3. inferior nasal conchae

• If nasal hair falls to trap particles, then the particles will adhere along
mucous membrane along the nasal cavity which is made up of two
cells – goblet cells and ciliated cells.

Paranasal Sinus
 Not part of a nose
 Lined with mucus membrane
 If inflamed, sinusitis (mucus tends to lower the sinus)

Pharynx
 The throat, passageway of both the digestive and respiratory systems
 Receives air from the nasal cavity and air, food and H2O from the
mouth.

The Three Portions of the Pharynx:

1. Nasopharynx – where air enters coming from the nose.
2. Oropharynx – joins the oral cavity and contains the palatine and
lingual tonsils.
3. Laryngopharynx – opens into the larynx and the esophagus.

Larynx
 Guarded by epiglottis
 Closes as we swallow the food
 The epiglottis will cover the passageway so that no food particle
will enter the airway.
 • Whenever we talk, the air leaves the respiratory tract, the larynx
opens and the vocal chords will vibrate so as the time we talk, the
food will trap the larynx which causes choking.

Structures of Larynx:
 1 pair along the inferior portion – true vocal chords (vibrates as
we talk).
 1 pair along the superior portion – false vocal chords but with
the help of lower vocal chords that larynx closes (does not
vibrate).

• Voice depends on air that passes along the vocal chords.

• The larynx opens when exhaling.

Trachea
 Made up of rings of cartilage (15-20 rings).
 Its length depends on the individual’s height.

From the Trachea

Right Bronchus Left Bronchus

3 Secondary Bronchi 2 Secondary Bronchi

(segmental bronchi) (segmental bronchi)

 Primary Bronchi
• Responsible for
bringing the air
to the right and
left lung.

• Right Lung is divided into 3 lobes

(each lobe is supplied with specific
secondary bronchi)

 Tertiary Bronchi
• Branches of
secondary bronchi

 Terminal Bronchiole
• Connected to alveolar
duct which is connected to
alveolus
 • Primary, Secondary, Tertiary Bronchi
 Made up of epithelial cells (combination of goblet cells and
ciliated cells)

Bronchi – there is the presence of cartilage in the vessels

Bronchiole – there are no cartilage in the vessels

Lungs
 Principal organ for respiration

Mediastinum – divides the lung into left and right lung

1. Right Lung – 3 lobes (superior, middle, inferior)
2. Left Lubg – 2 lobes (superior, inferior)

Pleura – external membrane covering the lungs

Diaphragm – large dome of skeletal muscles that separate the thoracic

cavity from the abdominal cavity.

Physiology of the Respiratory System

Ventilation
 Breathing mechanism
 Process of moving air into and out of the lungs

Two Processes:
1. Inspiration (Inhalation) – movement of air into the lungs
2. Expiration (Exhalation) – movement of air out of the lungs

• Air moves from an area of higher pressure to an area of lower

pressure.
• Pressure in the lungs decreases as the volume of the lungs increases
and vice versa.

Pulmonary Volumes and Capacities

  Spirometry is the process of measuring volumes of air that
move into and out of the respiratory system.
 Spirometer – measures respiratory volume.

Pulmonary Volumes:
1. Tidal Volume – volumes of air inspired or expired during quiet
breathing
2. Inspiratory Reserve Volume – amount of air that can be inspired
forcefully after inspiration of normal tidal volume.
3. Expiratory Reserve Volume – amount of air that can be expired
forcefully after expiration of normal tidal volume.
4. Residual Volume – the volume of air still remaining in the respiratory
passages and lungs after a maximum expiration.

Gas Exchange
 The respiratory membranes are thin and have a large surface
area that facilitates gas exchange.
 The components of the respiratory membrane include a film of
H2O, the walls of the alveolus, and the capillary and an interstitial
space.
 The rate of diffusion depends on the thickness of the respiratory
membrane and the partial pressure of the gases in the alveoli and the
blood.

Control of Respiration
 The respiratory center in the medulla oblongata and the pons
stimulates the muscles of inspiration to contract. When stimulation of
the muscles of inspiration stops, expiration occurs passively.
 During labored breathing, the muscles of inspiration are
stimulated to a greater degree and the muscles of expiration are also
stimulated to increase expiration.
 CO2 is the major chemical regulator of respiration. An increase in
CO2 or decrease in pH of the blood can directly stimulate
chemoreceptors in the medulla oblongata causing a greater rate and
depth of respiration.
 Low blood levels of O2 can stimulate chemoreceptors in the
carotid and aortic bodies, which stimulate the respiratory center.
Input from higher brain cenyers and from proprioceptors stimulates the
respiration during exercise.
 LABORATORY EXAMINATION

URINALYSIS
November 15, 2007
Actual Results Normal Results Analysis
Color Yellow Straw – Amber Normal
Character Slighly. Turbid Clear Normal
pH 5.0 4.6 – 6.5 Normal
Specific Gravity 1.030 1.002 – 1.030 Normal
Albumin Trace Negative Normal
Sugar Negative Negative Normal
MICROSCOPIC EXAMINATION
WBC/hpf 1-2hpf 0 – 5hpf Normal
RBC/hpf 0-2hpf 0 – 4hpf Normal
Epithelial Cells positive Negative Infection
Bacteria negative Negative Normal
Mucus thread positive positive Normal
Rationale: It’s a routine procedure for patients undergoing hospital admission. It is
useful indicator of a healthy or disease state.

HEMATOLOGY REPORT
November 14, 2007
Actual Results Normal Results Analysis
WBC 10.8 x 10^9/L 3.5 – 10.0 Infection
Lymph # 0.9 x 10^9/L 1.2 – 3.2 Infection
Mid # 0.7 x 10^9/L 0.3 – 0.8 Normal
Gram # 9.2 x 10^9/L 1.2 – 6.8 Infection
Lymph % 8.7% 17.0 – 48.0 Infection
Mid % 6.6% 3.0 – 11.0 Normal
Gran % 84.7% 43.0 – 76.0 Infection
Hgb 145 g/L 110 – 165 Normal
RBC 4.28 x 10^12/L 3.8 – 5.8 Normal
Hct 47.2 % 35.0 – 50.0 Normal
MCV 110.5 fL 82.0 – 97.0 Macrocytic Anemia
 MCH 33.8 pg 26.5 – 33.5 Macrocytic Anemia
MCHC 307 g/L 315 – 350 Macrocytic Anemia
RDW-CV 15.0% 11.5 – 14.5 Anemia
RDW-SD 58.0% 35.0 – 56.0 Anemia
PLT 237 x 10^9/L 150 – 390 Normal
MPV 9.9 fL 6.5 – 11.0 Normal
PDW 15.7 15.0 – 17.0 Normal
PCT 0.234% 0.108 - 0.282 Normal
Rationale: This is the basic screening test; give valuable diagnostic information about
the hematologic and other body systems, prognosis, response to treatment, and recovery.

X-RAY and ULTRASOUND REPORT

CXR (PA) 11/ 06/ 07

Fibrohazard densities are noted the upper lobes. Heart is enlarged. Aorta is
Atherosclerotic. Diaphragm is depressed and flattened. The rest of he specialized
structures are unremovable.
Impression:
PTB, upper lobes
Pulmonary Emphysema
Atherosclerotic Aorta
Normal heart size

Dr.M.Tobias (Radiologist)

CXR II PA 11/ 17/ 07

Follow up examination done 11/ 17/ 07 as compared to the study taken dated 11/
06/ 07 showed no interval change in the previous findings of upper lobe PTB with
bullous changes, both lung bases, pulmonary emphysema and calcified aorta. The rest of
the chest structures remain unchanged in status.

Dr. Imelda Turingan (Radiologist)

 DRUG STUDY
ACETAMINOPHEN (PARACETAMOL)

Classification:
Analgesic/Antipyretic
Dosage:
500 mg p.o.
Action:
• Resembles salicylates in the manner which it produces
analgesia and antipyretics
• Reduces fever by direct action in the hypothalamus
Indication:
• Used to relieve mild to moderate pain fro headaches,
muscle aches, sore throats, toothaches and to reduce fever
• Analgesic (pain reliever)
• Antipyretics (fever reducer)
Contraindication:
• Patients with cardiac or pulmonary disease are more
susceptible to toxic effects of acetaminophen
Nx. Responsibilities:
• Administer tablets whole or crushed with fluids
• Administer this drug with no combination of another
acetaminophen to avoid toxic reactions

PREDNISONE

Classification:
Corticosteroids
Dosage:
30 mg OD p.o.
Action:
 • It works to treat other conditions by reducing swelling and
by changing the way the immune system works
• Has anti-inflammatory properties
Indication:
• Treatment of allergic and inflammatory conditions
Contraindication:
• Systemic fungal infections
Nx. Responsibilities:
• Administer after meals or with snack to reduce gastric
irritation
• Do not stop abruptly with long term therapy. Reduce only
dosage by scheduled decrements to prevent withdrawal
symptom and to permit adrenals to recover from drug-
induced partial atrophy
• Avoid alcohol and caffeine, it may contribute to steroiduker
development

DUAVENT

Classification:
Anti-asthmatic
Dosage:
Neb q 4°
Action:
• Relaxes smooth muscles of bronchi and bronchioles and
reducing formation of cGMP which is a mediator of
bronchous tuctus
Indication:
• Management of Bronchial asthma
• COPD
Contraindication:
• Hypertrophic Obstructive Cardiomyopathy
• Tachyarrythmia
Nx. Responsibilities:
• Do not administer after meals
• Do chest physiotherapy after nebulization

ANSIMAR

Classification:
Anti-asthmatic
Dosage:
400mg ½ tab BID
Action:
 • Reduces constriction of bronchioles and edema in bronchial
mucosa
Indication:
• Bronchial Asthma
• Chronic Bronchitis
Contraindication:
• Hypersensitivity to Drug
Nx. Responsibilities:
• Assess patient as to vital signs and history of asthma

ALDAZIDE

Classification:
Diuretics
Dosage:
1 tab OD
Action:
• Spinorolactone promotes dieresis in patients with edema
• It acts by competitive inhibition of aldosterone
Indication:
• Essential hypertension
• Edema
• Nephrotic syndrome
Contraindication:
• Acute renal insufficiency
• Anuria
• Hyperkalemia
Nx. Responsibilities:
• Measure I&O
• Administer with meals
• Monitor for symptoms of Hyponatremia

LEVOFLOXACIN
Classification:
Anti-infectives (antibiotics)-fluoroquinolones
Dosage:
500mg 1tab OD p.o.
Action:
• It works by eliminating bacteria that cause infections
• Inhibits bacterial replication
Indication:
• Used to treat infections such as pneumonia and asthma
 • Treatment of maxillary sinusitis caused by strains of
streptococcus pneumoniae
Contraindication:
• Used cautiously in patients with seizure disorders
• Hypersensitive to antibiotics
Nx. Responsibilities:
• Take tablets with fluids
• Administer it continuously even if patient gets well. Do not
stop taking it without talking to your doctor
• Avoid NSAIDS while taking levofloxacin if possible
• Administer once a day with meals
TIOTROPIUM BROMIDE (SPIRIVA)

Classification:
Bronchodilators
Dosage:
18 mg 1 cap for oral inhalation OD
Action:
• Has an anticholinergic effect for Muscarinic Receptors
Indication:
• Used for treatment of breathing problems in patients with
COPD. It is a maintenance bronchodilator and helps to
keep narrowed airways open
Contraindication:
• Hypersensitive to atropine
• Hypersensitive to spiriva
Nx. Responsibilities:
• Use this to maintain treatment for COPD and not to treat
sudden episodes of breathing problems (Bronchospasm)
• Capsules are not for ingestion
• Watch out for sensitivity
• Note for allergic reactions (itching and rash)
 NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

S: Medyo Ineffective airway At the end of 30  Elevated head  To take Goal met. The
nahihirapan akong clearance r/t minutes, the patient of bed and advantage of patient maintained a
huminga eh” as retained mucus will maintain changed gravity patent airway as
verbalized by the secretions airway patency. position every decreasing manifested by a
patient. two hours. pressure on respiratory rate of
diaphragm and 20 cpm, absence of
O: *nonproductive enhancing cough and wheezes.
cough drainage and
*wheezes ventilation.
*difficulty
vocalizing  Encouraged  To mobilize
*changes in deep breathing secretions.
respiratory rate and coughing
and rhythm exercises.
*wide-eyed and
restlessness  Encouraged pt.  To liquefy
to increase fluid secretions.
RR: 28 cpm intake to at
least 2, 500 ml
per day

 Provided  To loosen
supplemental secretions.
humidification
(nebulization)
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
S: “Nahihirapan Ineffective At the end of 30  Elevated head  To promote Goal met. The
akong huminga” as breathing pattern r/t minutes, the patient of bed as physiological patient was able to
verbalized by the respiratory muscle will establish a appropriate ease of establish a normal
patient. fatigue. normal and maximal and effective
effective respiratory inspiration. respiratory pattern
O: RR: 28 cpm pattern. as manifested by a
 Encourage  To assist client respiratory rate of
*Use of accessory slower and in taking 20 cpm, absence of
muscles to deeper control of the nasal flaring and use
breathe. respirations. situation of accessory
*nasal flaring (breathing is muscles to breathe.
considered to
be the best
bronchodilator)

 Encourage  To limit use of

adequate rest energy and
periods. avoid fatigue.
To provide
comfort.

 Administer 
oxygen at
lowest
concentration
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
S: “Nanghihina ako Fatigue r/t increased At the end the shift,  Encouraged  Periods of rest Goal partially met.
saka pakiramdam physical exertion the patient will adequate rest provide comfort The patient was able
ko lagi akong and sleep report improved periods. to the patient. to report some
pagod” as deprivation. sense of energy. improvement in his
verbalized by the  Provided  To avoid sense of energy.
patient. environment exhaustion.
conducive to
O: *restlessness relief of fatigue.

 Instruct in  To decrease
methods to fatigue.
conserve
energy

 Assist with self  To minimize

care needs tiredness

 Discuss  To provide
routines to information on
promote restful how to promote
sleep. relaxation
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
S: “Tatlong araw na Constipation r/t At the end the shift,  Encouraged to  To promote soft Goal met. The
ako dito hindi pa irregular defecation the patient will increase fluid or moist stool. patient was able to
ako tumatae.” As habits. establish normal intake at least manifest
verbalized by the pattern of bowel 2500ml per improvement in
patient. functioning. day. bowel functioning,
“Tumae ako ng
O:*distended  Instructed  To improve konti kaninang
abdomen patient to eat consistency of umaga” as
*hypoactive balanced fiber stool and verbalized by the
bowel and bulk in diet. facilitate patient.
sounds passage through
*bowel sounds - the colon.
2
 Encouraged  To stimulate
activity or contraction of
exercise within the intestines.
the limits of
individual
ability.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
S: “Hindi ako Disturbed sleep At the end of the  Arrange care to  To minimize the Goal partially met
nakakatulog mabuti pattern r/t shift, the patient provide for disturbance the “Nakatulog naman
dito, minsan excessive will be able to uninterrupted client is ako ng 3 oras at
maingay sa labas, stimulation, noise identify periods of rest. Do experiencing. hindi masyadong
minsan yung and interruptions techniques to as much care as magulo ang paligid
pagpasok ng mga for therapeutics promote and possible without ko.” as verbalized
nurses” as and monitoring. improve sleep waking client. by the patient.
verbalized by the and rest and to
patient. be able to  Provide quiet
manifest environment and  To assist client
O: *frequent increased sense comfort measures establish optimal
yawning of well being. in preparation for sleep rest pattern.
*presence of eye sleep (fixing bed
bags linens etc.)
*increasing
irritability  Explain necessity
of disturbances  To familiarize the
done by the nurses patient that it is a
(VS monitoring, part of care.
meds)

 Recommended mid  For increase

morning nap. adequate rest and
to compensate for
the loss of sleep.

 Explore other sleep  To assist client to

aids (warm bath, have a restful
 PATHOPHYSIOLOGY of BRONCHIAL ASTHMA
Predisposing Factors: Etiology: Precipitating Factors:
- age - unknown milk before sleep. - allergies
- gender (female) bedtime) - irritants
- history of allergies - smoking
- pollution

Stimulation of B-lymphocytes

Differentiation into plasma cells

Production of IgE antibodies

Attach to mast cells and

basophils in bronchial walls

Release of chemical mediators

Inflammatory Response Stimulation of Adrenergic Receptors

Decrease cyclic adenosine monophosphate (CAMP)

Swelling of membranes Increase mucus Bronchospasm
lining the airways production
 A
Increase workload of breathing Increase Chemical Mediators
(prolonged expiration)

Circulatory Obstruction
Cough Wheezing
A Dyspnea
Bronchoconstriction
Hyperventilition

Labored breathing/ use of Tachycardia Fatigue Uneven Lung aeration

accessory muscles

Incomplete Emptying of
Increase Respiratory Alveoli
work demand Hypoventilation

Trapping of Air
Compensatory CO2 Retention
Mechanism Failed
Hyperinflation of
Respiratory Hypercapnia Hypoxemia Alveoli
Acidosis
Respiratory Failure
Increase Chest
Diameter

B Cyanosis Decrease LOC Chest Tightness

 B
Impaired gas exchange

Hypoxemia

Decrease Tissue Perfusion

Cellular Ischemia

Tissue Necrosis

Hypoxia

Vital Organs Failure/ Death

DEATH