Bronchial Asthma

A Case Presentation
 Introduction
Asthma is a chronic lung disease
that affects a person's airways and
makes it difficult to breathe. The
airways are the breathing “tubes” that
are inside of your lungs. These are
called bronchial tubes.
 When a person has asthma he
experiences airway inflammation
(reddening and swelling of the inside
of the airways), airway constriction
or bronchospasms (tightening of the
muscles around the airways) and
excessive mucous production of the
mucous cells along the airways.
 During an asthma flare-up, a
person may experience: coughing,
wheezing, shortness of breath, chest
pain, chest tightness (DOB). It may
feel as if you are breathing through a
straw or someone was sitting on
your chest.
 Traditionally, doctors have divided
asthma into two general categories,
Extrinsic (allergic) asthma and
Intrinsic (non-allergic) asthma,
depending upon the types of stimuli
that trigger attacks.
Extrinsic Asthma

In Extrinsic Asthma, an "allergen" or an

"antigen" is a foreign particle which enters the
body. Our immune system over-reacts to these
often harmless items, forming "antibodies"
which are normally used to attack viruses or
bacteria. Mast cells release these antibodies as
well as other chemicals to defend the body.
Extrinsic Asthma

Extrinsic asthma is caused by this type of

immune system response to inhaled allergens
such as pollen, animal dander or dust mite
particles. It was found early this century that
some asthmatics had an immediate skin
reaction such as swelling or redness, when an
allergen was injected just under the skin.
Extrinsic Asthma

This reaction is described as "Atopic" and so

extrinsic asthma is also called Atopic or "Allergic"
asthma. People with allergic asthma and their
families frequently have other allergy-related
problems such as hay fever, rhinitis, skin rashes,
hives, eczema and so on. Allergic asthma usually
responds quite well to the use of inhaled steroids
as these suppress the immune system, particularly
in the lungs where the reaction is creating havoc.
Intrinsic Asthma

Intrinsic Asthma is caused by anything except an

allergy. It may be caused by inhalation of chemicals
such as cigarette smoke or cleaning agents, taking
aspirin, a chest infection, stress, laughter, exercise, cold
air, food preservatives or a myriad of other factors.
Antibodies are not produced and even when skin tested
to various antigens shows a reaction, these substances
do not lead to an asthma attack. The cause may be an
irritation to the nerves or muscles in the airways.
Intrinsic Asthma

Asthmatics' airways are unusually sensitive or "hyper-

reactive" and the asthma presents itself in the usual
manner of constricted smooth muscle, airway
inflammation and increased mucus production.
Treatment of intrinsic asthma is not easy as it may not be
known what triggers the asthma in the first place and
therefore avoiding triggers can be impossible. Avoidance
of things with strong odors such as perfume or cleaning
agents may be possible at home and smokes inside and
outside homes.
 There are a lot of triggers of asthma episodes; it can
be induced by the environment, physiological,
psychological and physical stress.
The common allergen triggers include; dust mites (tiny
bugs that live in dust), cockroaches (small indoor pests),
mold (a type of fungus), and pollen (from flowers, trees,
grass, and weeds). While the common animal triggers
include; cats, dogs, and horses – people with asthma can
be sensitive to their dander, urine, and saliva. Rabbits,
hamsters, and guinea pigs can also be the cause of
asthma symptoms because of their urine. Viruses are also
common allergen triggers to induce an asthma attack
and with the presence of cough and colds.
 People who have asthma should
try to avoid the triggers that can
cause asthma flare-ups. They can also
manage and control their asthma by
taking medications; it can be a long
term or short term med.
 Nursing Health History

It was the 25th of March 2010 in the Out Patient

Department in Mother Seton Hospital when we
have the make-up duty of our group under Mrs.
Sheila Tretasco, RN. Our chosen patient was
Gubert Hans De Guzman, 10 months old, 14
pounds in weight and with a chief complaint of
difficulty of breathing and cough and colds for 1
week. With a temperature of 36.6 degrees Celsius,
the physician ordered to give Salbutamol 5ml x 2
w/in 20 minutes time interval.
 During the interview the mother said that Hans
experienced asthma for 1 week with cough and
colds intermittently and abundant secretions. She
also stated that Hans’ father is a smoker and her
brother (Hans’ uncle) has chronic asthma. The nurse
asked the mother to describe the place where they
lived; she said that they reside along the road with
various vehicles passing. She also added that they
own 2 cats. The nurse also observed slight wheezing
as he breath, slightly cyanotic face and extremities.
Mother often fed Hans with milk aside from
breastfeeding.
Drug Study
Name Dosage Route Nursing Indications Adverse Special
Measures Reaction Consideration

Ventol 5ml 2x Nasal Proper health To prevent tremor, Use cautiously

in a day (INHAL teaching for exercise- nervousness, in pts with CV
ATION) administration induced dizziness, disorders( includ
specially if bronchospasm insomnia, ing coronary
doctor orders headache, insufficiency
for specific To prevent or tachycardia, and
intervals for treat palpitations, hypertension),
each dose bronchospasm hypertension, hyperthyroidism
pt with drying and , DM and those
reversible
irritation of unusually
obstructive
nose and responsive to
airway
disease throat, adrenergics
heartburn,
N/V,
hypokalemia,
weight loss,
muscle
cramps,
bronchospasm
 ANATOMY AND
PHYSIOLOGY OF THE
RESPIRATORY SYSTEM
RESPIRATION- act of breathing
• Inhaling (inspiration)
– taking in oxygen
– is initiated by the diaphragm and supported by the
external intercostal muscles. Normal resting
respirations are 10 to 18 breaths per minute, with a
time period of 2 seconds. During vigorous inhalation
(at rates exceeding 35 breaths per minute), or in
approaching respiratory failure, accessory muscles of
respiration are recruited for support. These consist of
sternocleidomastoid, platysma, and the scalene
muscles of the neck.
RESPIRATION- act of breathing
• Inhaling (inspiration)
– When the diaphragm contracts, the ribcage expands
and the contents of the abdomen are moved
downward. This results in a larger thoracic volume
and negative (suction) pressure (with respect to
atmospheric pressure) inside the thorax. As the
pressure in the chest falls, air moves into the
conducting zone. Here, the air is filtered, warmed,
and humidified as it flows to the lungs.
• Exhaling (expiration)
– giving off carbon dioxide
– generally a passive process; however, active or forced
exhalation is achieved by the abdominal and the
internal intercostal muscles. During this process air is
forced or exhaled out.
 Functions of the Respiratory System

1. BREATHING or ventilation
2. EXTERNAL RESPIRATION - which is the
exchange of gases (oxygen and carbon
dioxide) between inhaled air and the blood.
3. INTERNAL RESPIRATION - which is the
exchange of gases between the blood and
tissue fluids.
4. CELLULAR RESPIRATION
 Other Functions
• REGULATION OF BLOOD pH - which
occurs in coordination with the kidneys,
and as a
• DEFENSE AGAINST MICROBES
• CONTROL OF BODY TEMPERATURE - due
to loss of evaporate during expiration
 Organs of Respiration

The upper respiratory tract includes the:

• nose
-together with the cilia, it receives the air inhaled firsthand
and filters it.
• nasal cavity
-humidifies and makes the inhaled air warm
• frontal and maxillary sinus
-makes the sound produced more even and clear.
-decreases pressure
-functions to keep the cranium lightweight
 Organs of Respiration
• larynx
-is also called the voice box. The vocal cords stretch
across the larynx and vibrate when the air passes
through them. This vibration produces various
sounds.
-it has several folds of elastic connective tissue called
the vocal cords. They extend from the posterior end
of the pharynx to the end of larynx. When air passes
through the larynx, these cords vibrate and produce
sound.
 Organs of Respiration
• trachea
-is also called the windpipe. The trachea are held
open with the help of C-shaped cartilagenous rings.
The open ends of the rings are towards the
oesophagus also known as the foodpipe. The
trachea is situated in front of the oesophagus. The
cartilages keep the larynx and trachea from
collapsing even when there is no air in them. The
trachea then branch into two main branches called
bronchi.
The lower respiratory tract includes:
• lungs
-are a pair of cone-shaped organs made up of spongy,
pinkish-gray tissue.
-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.
• alveoli
-contains capillaries wherein gas exchange happens
through diffusion. Carbon dioxide is excreted and oxygen is
taken up by the rbc's and dissolved into the plasma.
• Bronchi
-is also supported by the cartilagenous rings. The bronchus
then branches into several bronchioles. The bronchioles
progressively lose the cartilages as they become narrower.
The bronchioles end as fine tubules called the alveolar ducts.
-lined with ciliated epithelial cells and secretory cells (goblet
cells). These secrete mucus which moistens the air as it
passes through the repiratory tract and also trap any fine
particles of dust or bacteria that have escaped the hairs of
the nasal cavity. The cilia beat with an upward motion such
that the foreign particles along with the mucus is sent to the
base of the buccal cavity from where it may be either
swallowed or coughed out.
Pathway of Inhaled Air
Air enters the NOSTRILS

NASAL CAVITY: it is filtered by the fine

hair and warms the air through its rich
supply of blood vessels

air then enters the

PHARYNX

LARYNX

TRACHEA
 BRONCHUS

BRONCHIOLES

ALVEOLAR DUCTS

ALVEOLI: wherein gas exchange happens.

Composition of the Air we breathe

• Nitrogen - 78%
• Oxygen - 21%
• Carbon dioxide - 0.03 - 0.04%
• Hydrogen - traces
• Noble gases - traces
 Signs and Symptoms of Asthma

Emergent signs
• Severe wheezing while breathing both in and out
• Breathing very fast
• Getting short of breath while or having difficulty
talking
• A feeling of impending doom or panic
• Profuse sweating
• Inability to perform PEFR
• Color changes in fingertips
 Classic Signs and Symptoms of Worsening Asthma

As asthma worsens, the airways narrow, become

inflamed, and fill with mucus.

Patients may experience the following symptoms:

• Chest tightness
• Chronic cough
• Shortness of breath
• Wheezing
 Early warning signs of worsening asthma:

• Increased night time cough

• Cough or wheezing with physical activity
• Tiredness with activities that you normally could
complete easily
• Decreases in your peak expiratory flow rate (PEFR)
• Restless sleep or waking up tired
• Worsening allergy symptoms like persistent runny
nose, dark circles under your eyes or itchy,
inflamed skin
Etiology and Symptomatology
Ineffective airway clearance r/t increased
bronchial secretions

Increased bronchial secretions

Bronchial Irritation

Bronchial Spasm and edema

Constriction of airways

Severe coughing

Ineffective airway clearance

  
Ineffective breathing pattern r/t respiratory muscle spasm

Respiratory muscle spasm

Unpredictable occurrence of muscular

constriction

Episodes of chest tightness and difficulty of

breathing

Ineffective breathing pattern

Risk for Sleep Deprivation r/t prolonged discomfort : chronic coughing and shortness of breath

During sleep: Excessive coughing and shortness of breath

occurs chronically

exhaustion and fatigue

Anxiety and disturbance

Sleep Deprivation
 Predisposing factors precipitating factors
-Age (10 months old) - Atmospheric pollutants (smoke
&perfume)
- Uncle has chronic asthma - Foods (milk)
- allergens (cat pets)

Immune Response ( interferons are produced)

Increase secretions Bronchial Irritation

(bronchial goblet cells)
(50% in asthmatic) Bronchial spasm and edema

Asthma episodes with cough and colds

NURSING CARE
PLANS
 Assessment NSG Rationale Planning Intervention Rationale Evaluation
Diagnosis
Ineffective Increased After 4 hours of -Position the pt in high -proper After 4 hours of
Subjective: airway bronchial intervention, back rest or upright positioning intervention,
- mother clearance r/t secretions the client will: position lessens the the client :
stated “1 week increased cause -maintain difficulty of -is able to
na may bronchial blockage that normal breathing maintain
asthma si secretions gets massive, respiration as - assess the secretions. - the normal
Hans at may therefore evidenced by Document its amount, characteristics of respiration as
abo at sipon making it absence of color and odor. the secretion may evidenced by
pa” difficult and dyspnea and indicate certain absence of
- “kada ineffective wet crackles condition of the dyspnea and
inaatake siya for the pt to - be able to pt that maybe wet crackles
nagrarum clear airway sustain normal diagnosed by the -is able to
paghangus respiration rate doctor sustain normal
niya” of 40-50 bpm -do oronasopharyngeal - to remove the respiration rate
-“ may kaiba -maintain suctioning limited to 5- bronchial of 44 bpm
pa pating abo absence of 10 second duration. secretions and -is able to
asin sipon” bronchial clear the airway maintain
Objective: secretionss of the pt absence of
Age: 10 -medicate by following -to relieve bronchial
months the doctor’s order: dyspnea and secretions
Wt: 14 pounds bronchodilators allow the
T: 36.6 bronchioles to
RR: 35 return to its
With cough function as the
and colds drug takes effect
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

2. Ineffective After 4 hours of - Put the client in an After 4 hours of

Subjective Data: breathing patterns r/t nursing intervention upright position as his nursing intervention
- An episode begins respiratory muscle Patient will: mother held him the:
with a dry cough, often spasm. - Feel comfortable in a - Administered metered - Child can now
at night. 3. Risk for sleep sitting or standing dose inhalers (ventolin) breathe easily.
- DOB deprivation r/t to position rather than - Encouraged mother to - mother is taught and
Objective Data: prolonged lying down. continue to drink fluids about the diet and
- Cyanosis present discomfort: chronic - Be relieve of dob and by asking about favorite factors that might
-Initial wheezing coughing in shortness asthma attacks beverages but avoiding trigger asthma
audible of breath. After 4 hours of milk. - instructed mother to
- Age: 10 months nursing intervention seek immediate help
- Wt: 14 pounds Patient’s mother will: if asthma not relieved
- T: 36.6 - Show willingness to at home
- RR: 35 listen and learn
- With cough and colds teachings to avoid
allergen by
environmental control.
Instructing parents the
side effects and cautions
of the drugs.
- Skin testing and
hyposensitization to
identify allergens.
DISCHARGE PLAN
 Medication exercise Treatment Health Teaching Out patient Diet Spirituali
ty
Ventolin 5ml 2x a day Allow the pt Medications Advice the Follow-up Avoid those Advice
Action: to prevent to walk with such as parent of the pt check up on foods that parent to
exercise-induced support and bronchodilators to continue March 29, causes pray and
bronchospasm play but and anti- medications as 2010 allergy teach the
To prevent or treat give rest to inflammatory prescribed by More fruits pt on
bronchospasm pt with avoid getting Mild tolerable doctor and how to
reversible obstructive too tired activities Teach how to vegetables talk to
airway disease administer that could God and
Adverse reaction: medications such make the ask for
tremor, nervousness, as the nebulizer immune help
dizziness, insomnia, Advice parents to system fight
headache, tachycardia, keep pt away foreign
palpitations, from allergens or bodies that
hypertension, drying anything that could be the
and irritation of nose triggers asthma causes of
and throat, heartburn, the asthma
N and V, hypokalemia,
weight loss, muscle
cramps, bronchospasm