Republic of the Philippines

NUEVA ECIJA UNIVERSITY OF SCIENCE

Cabanatuan City, Nueva Ecija, Philippines
AND TECHNOLOGY
ISO 9001:2015 CERTIFIED
Case 7

Mr. T is a 40-year-old recreational athlete with a medical history significant for asthma, for which he has
been using an albuterol rescue inhaler approximately 3 times per week for the past year. During this
time, he has also been waking up with asthma symptoms approximately twice a month, and has had
three unscheduled asthma visits for mild flares. Mr. T has asthma that is not well controlled.

As a result of these symptoms, spirometry was performed revealing a forced expiratory volume in the
first second (FEV1) of 78% predicted. Mr. T then was prescribed treatment with a low-dose
corticosteroid, fluticasone 44 mcg at two puffs twice per day. However, he remained symptomatic and
continued to use his rescue inhaler 3 times per week. Therefore, he was switched to a combination
inhaled steroid and long-acting beta-agonist (LABA) (fluticasone propionate 250 mcg and salmeterol 50
mcg, one puff twice a day) by his primary care doctor.

Initial pulmonary assessment  Even with this step up in his medication, Mr. T continued to be
symptomatic and require rescue inhaler use. Therefore, he was referred to a pulmonologist, who
performed the initial work-up shown here:

Spirometry, pre-albuterol: FEV1 79%, post-albuterol: 12% improvement

Methacholine challenge: PC20: 1.0 mg/mL

Chest X-ray: Within normal limits

Continued pulmonary assessment  His dose of inhaled corticosteroid (ICS) and LABA was increased to
fluticasone 500 mcg/salmeterol 50 mcg, one puff twice daily. However, he continued to have symptoms
and returned to the pulmonologist for further work-up, shown here:

Chest computed tomography (CT): Normal lung parenchyma with no scarring or bronchiectasis

Sinus CT: Mild mucosal thickening

Complete blood count (CBC): Within normal limits, white blood cells (WBC) 10.0 K/mcL, 3% eosinophils

Immunoglobulin E (IgE): 25 IU/mL

Allergy-skin test: Positive for dust, trees

Exhaled NO: Fractional exhaled nitric oxide (FeNO) 53 parts per billion (pbb)

Assessment for comorbidities contributing to asthma symptoms  After this work-up, tiotropium was
added to his medication regimen. However, he remained symptomatic and had two more flares over the
next 3 months. He was assessed for comorbid conditions that might be affecting his symptoms, and
results showed:

Esophagram/barium swallow: Negative

Esophageal manometry: Negative

Esophageal impedance: Within normal limits

 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE
Cabanatuan City, Nueva Ecija, Philippines
AND TECHNOLOGY
ISO 9001:2015 CERTIFIED
ECG: Within normal limits

Genetic testing: Negative for cystic fibrosis, alpha1 anti-trypsin deficiency

The ear, nose, and throat specialist to whom he was referred recommended only nasal inhaled steroids
for his mild sinus disease and noted that he had a normal vocal cord evaluation.

Following this extensive work-up that transpired over the course of a year, Mr. T continued to have
symptoms. He returned to the pulmonologist to discuss further treatment options for his refractory
asthma.
 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE
Cabanatuan City, Nueva Ecija, Philippines
AND TECHNOLOGY
ISO 9001:2015 CERTIFIED
Nursing Diagnosis: Ineffective Airway Clearance

Assessment Nursing Outcome Planning Implementation Evaluation

Diagnosis identification
Subjective: Ineffective After 12 hours -To maintain Independent: The goal was met.
“Nahihirapa airway of nursing airway -Assess respiratory rate, depth After 12 hours of
n po ako clearance interventions, patency. and rhythm. nursing
huminga at related to the patient Rationale: Changes in the interventions,
kapag presence of will be able to -Lungs will be respiratory rate and rhythm the patient
umubo ako secretions expel clear of any may indicate an early sign of maintained a
may as secretions adventitious impending respiratory distress. patent airway and
kasamang evidenced effectively and sounds upon demonstrated
plema” by rapid, maintain auscultation. -Asses changes in vital signs. signs of reduction
as verbalized shallow airway Rationale: Tachycardia and of air way
by the client. breathing, patency. -Patient will hypertension occur when secretions.
nasal flaring demonstrate increase of breathing.
Objective: and correct
-coughing abnormal coughing -Auscultate the lungs for
-rapid, lung sounds. deep presence of normal or
shallow breathing adventitious lung sounds.
breathing techniques. (wheezes and rhonchi)
-wheezes in Rationale: Wheezes suggest
both lungs partial obstruction or
-nasal flaring resistance. While rhonchi  may
-appears indicate retained secretions in
weak and the lungs.
restless
-Encourage deep breathing and
VS: coughing exercises.
Temp: 36.8 Rationale: Helps loosen and
°C expectorate excess secretions
BP: 130/90 out of the lungs.
mmHg
HR - 110 -Assess the effectiveness of
bpm cough.
RR - 40 cpm Rationale: Coughing is
a  natural way to clear the
throat and breathing passage
of foreign particles, irritants,
and mucus.

-Place in fowlers or orthopneic

position.
Rationale: to facilitate
breathing and lung expansion.
Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE
Cabanatuan City, Nueva Ecija, Philippines
AND TECHNOLOGY
ISO 9001:2015 CERTIFIED
-Keep environment allergen
free.
Ratioanale:To prevent allergic
reactions.

-Suction airway as needed.

Rationale: To retained
secretions alter the ventilatory
response, thus reducing
oxygen, leading to hypoxemia.

-Monitor Arterial Blood Gasses

(ABG).
Rationale: Increase PaCO2 and
Decreased PaCO2 are signs of
respiratory failure.

Dependent:
-Administer Supplemental
oxygen as ordered.
Rationale: Oxygen therapy
corrects  hypoxemia, which can
be caused by retained
respiratory secretions.
 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE
Cabanatuan City, Nueva Ecija, Philippines
AND TECHNOLOGY
ISO 9001:2015 CERTIFIED

Nursing Diagnosis: Ineffective Breathing Pattern

 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE
Cabanatuan City, Nueva Ecija, Philippines
AND TECHNOLOGY
ISO 9001:2015 CERTIFIED

Nursing Diagnosis: Fatigue

ASSESSMENT NURSING OUTCOME PLANNING IMPLEMENTATION EVALUATION

DIAGNOSIS IDENTIFICATION
Subjective: Fatigue related After 8 hours of Short term: -Monitor and record After 8 hours of
“I feel weak and to physical nursing  Patient will vital signs nursing
tired after exertion to interventions, the verbalize Rationale:For baseline interventions,
asthma attacks” maintain Patient will be understandin data to identify
the patient
as verbalized by adequate able to g on health changes  that allows exhibit
the patient. ventilation as demonstrate teachings immediate action to decreased
-inability to evidenced by decreased fatigue given to minimize thefatigue as
return to usual verbalization of as evidenced by improve occurrence of fatigue evidenced by
routine/level of lack of energy less restlessness, sense of verbalization of
physical activity and inability to verbalization of energy - Monitor breath increase energy
maintain usual improve energy  Patient will sounds. level and
routines level and report Rationale: Hypoxemia increased ability
Objective: increase ability to improve and hypoxia increases to perform
-lethargic perform usual sense of sense of fatigue, usual activities.
-breathlessness activities. energy impairs ability to The goal was
-cool clammy function. met.
skin
-appears weak Long Term: -Assess the patient’s
-drowsy  Within 2 days ability to perform
-restlessness of nursing activities of daily living
interventions, Rationale: Fatigue can
VS: the patient limit the person’s
Temp: 36.8 °C will be able to ability to participate in
BP: 130/90 fully perform self care
mmHg ADLs and
HR - 110 bpm participate in -Provide environment
RR - 40 cpm desired conducive to relief of
activities. fatigue
Rationale:Temperatur
e and level of humidity
can affect exhaustion

Discuss with the

patient the need for
activity. Plan activity
schedule with the
patient for periods
when he has the most
energy.
Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE
Cabanatuan City, Nueva Ecija, Philippines
AND TECHNOLOGY
ISO 9001:2015 CERTIFIED
Rationale: Prevents
overexertion and
allows tolerance for
some activity within
ability.

Alternate activity with

rest periods
Rationale: Prevents
excessive fatigue

Encourage nutritional
intake/use of
supplements as
appropriate
Rationale :Necessary
to meet energy needs
for activity