CASE STUDY /Bronchial Asthma

CASE STUDY



Medical Diagnosis: Bronchial Asthma


Allergy: non

Temp: ْ C Pulse: 80 beat\minute BP: / mmgh RR: rate\minute

Past History (Reason for admission):
A 60 year old male patient, complain of shortness of breathing and abdomen distention from 3 days that accrue after drink milk before 1 day from admission and during the night the patient complain of SOB and cyanosis, not # or $ and not associated with any thing.
The patient referred emergency room and take oxygen by mask for 3 hour’s after that he transferred to medical ward.

Present complain:
Subjective Data:
Pt said “I drink milk before 4 days after that my abdomen was distend".
Pt said "before 2 years the same case was accrue after milk drinking".
Pt said "I complain of this case (asthma) from child period".
Pt said "I smoke 1 packet per 3 days but in the past 3 packet per day".
Pt said "in the past I work truck driver for transfer asphalt and debris that cause increase my disease and lead to stop this work".
Pt said "before 2 days I breathe difficulty and my skin become blue, I referred the hospital and take oxygen for 2 hour’s after that I return to my hose”.
Pt said "I'm feel good when sit as this (Sitting high)"
Pt said "before 1 day the attack return, I referred this hospital and take oxygen for 2 hour’s after that I enter this ward".
When I ask the patient about his feel about this state he said "that’s usual thing I expert about my state, I’m feel good".
Pt said "no DM put I complain from weakness in the heart muscles and lung fibrosis".
Objective Data:
H.R - Temp: ْ C - B.P / - R.R
Low salt diet.
Cough: productive - 3-4 \min - Sputum: thick - yellow to weight color.
Fatigue patient and spend more time on the bed.
During walk the patient become tired and breathes difficulty.
Physical examination:
§ Conscious and oriented patient.
§ Skin:
· Pale and cyanosis in the extremity.
· Temperature: normal.
· Texture: roughness.
· Mobility and turgor: easy and speed with which it returns into place.
· Moisture: dryness.
§ Abnormal sound: distinct wheeze and crackles.
§ No tender area.
§ Clubbing and cyanosis finger à hypoxia.
§ Percussion à lung: Hyper resonance (asthma) + abdomen: resonance (air accumulation)
§ Barrel-shaped chest.
§ Patient use accessories muscle and he breathe difficulty.
§ Respiratory expansion \ Tactile fremitus \ Voice sound: not detected.
§ ECG and x-ray not detected.







Lap Results / Diagnostic tests:

Type Results Normal range Nursing consideration
WBC
RBC
HB
PLT
Na
K
Urea
Glucose
TG
\
17.1
169*10^3\
136.5
6.44
17.3
9 5-10*10^3\mm3
3.8-5.8*10^6\mm3
11-16.5 gm\dl
150-500*10^3\mm3
135-148 meq\L
3.5-5.3 meq\L
1.7-8.3 mmol\L
4.2-6.4 mmol\L

Medication
1- Lasix -furosemide- (40 mg tab 1×1)
Drug classes
Loop diuretic
Therapeutic actions
Inhibits the reabsorption of sodium and chloride from the proximal and distal renal tubules and the loop of Henle, leading to a sodium-rich diuresis.
Adverse effects
• CNS: Dizziness, vertigo, paresthesias, xanthopsia, weakness, headache, drowsiness, fatigue, blurred vision, tinnitus, irreversible hearing loss
• GI: Nausea, anorexia, vomiting, oral and gastric irritation, constipation; diarrhea, acute pancreatitis, jaundice
• CV: Orthostatic hypotension, volume depletion, cardiac arrhythmias, thrombophlebitis
• Hematologic: Leukopenia, anemia, thrombocytopenia, fluid and electrolyte imbalances
• GU: Polyuria, nocturia, glycosuria, urinary bladder spasm
• Dermatologic: Photosensitivity, rash, pruritus, urticaria, purpura, exfoliative dermatitis, erythema multiforme
• Other: Muscle cramps and muscle spasms
Nursing Considerations
Assessment
• History: Allergy to furosemide, sulfonamides, tartrazine; electrolyte depletion anuria, severe renal failure; hepatic coma; SLE; gout; diabetes mellitus; lactation
• Physical: Skin color, lesions, edema; orientation, reflexes, hearing; pulses, baseline ECG, BP, orthostatic BP, perfusion; R, pattern, adventitious sounds; liver evaluation, bowel sounds; urinary output patterns; CBC, serum electrolytes (including calcium), blood sugar, liver and renal function tests, uric acid, urinalysis
Implementation
• Administer with food or milk to prevent GI upset.
• Reduce dosage if given with other antihypertensives; readjust dosages gradually as BP responds.
• Give early in the day so that increased urination will not disturb sleep.
• Avoid IV use if oral use is at all possible.

2- Aldactone -spironolactone- (50 mg 1×2 PO)
Drug classes
Potassium-sparing diuretic
Aldosterone antagonist
Therapeutic actions
Competitively blocks the effects of aldosterone in the renal tubule, causing loss of sodium and water and retention of potassium.
Adverse effects
• CNS: Dizziness, headache, drowsiness, fatigue, ataxia, confusion
• GI: Cramping, diarrhea, dry mouth, thirst
• Hematologic: Hyperkalemia, hyponatremia
• GU: Impotence, irregular menses, amenorrhea, postmenopausal bleeding
• Dermatologic: Rash, urticaria
• Other: Carcinogenic in animals, deepening of the voice, hirsutism, gynecomastia
Nursing Considerations
Assessment
• History: Allergy to spironolactone, hyperkalemia, renal disease, pregnancy, lactation
• Physical: Skin color, lesions, edema; orientation, reflexes, muscle strength; P, baseline ECG, BP; R, pattern, adventitious sounds; liver evaluation, bowel sounds; urinary output patterns, menstrual cycle; CBC, serum electrolytes, renal function tests, urinalysis
Implementation
• Mark calendars of edema outpatients as reminders of alternative day or 3- to 5-d/wk therapy.
• Give daily doses early so that increased urination does not interfere with sleep.
• Make suspension as follows: tablets may be pulverized and given in cherry syrup for young children. This suspension is stable for 1 mo if refrigerated.
• Measure and record regular weight to monitor mobilization of edema fluid.
• Avoid giving food rich in potassium.
• Arrange for regular evaluation of serum electrolytes, BUN.

3- Prednisone - prednisone- (5m 2×1 PO)
Drug classes
Corticosteroid (intermediate acting)
Glucocorticoid
Hormone
Therapeutic actions
Enters target cells and binds to intracellular corticosteroid receptors, thereby initiating many complex reactions that are responsible for its anti-inflammatory and immunosuppressive effects.
Adverse effects
• CNS: Vertigo, headache, paresthesias, insomnia, convulsions, psychosis, cataracts, increased intraocular pressure, glaucoma (long-term therapy)
• GI: Peptic or esophageal ulcer, pancreatitis, abdominal distention, nausea, vomiting, increased appetite, weight gain (long-term therapy)
• CV: Hypotension, shock, hypertension and CHF secondary to fluid retention, thromboembolism, thrombophlebitis, fat embolism, cardiac arrhythmias
• MS: Muscle weakness, steroid myopathy, loss of muscle mass, osteoporosis, spontaneous fractures (long-term therapy)
• Hypersensitivity: Hypersensitivity or anaphylactoid reactions
• Endocrine: Amenorrhea, irregular menses, growth retardation, decreased carbohydrate tolerance, diabetes mellitus, cushingoid state (long-term effect), increased blood sugar, increased serum cholesterol, decreased T3 and T4 levels, HPA suppression with systemic therapy longer than 5 d
• Electrolyte imbalance: Na+ and fluid retention, hypokalemia, hypocalcemia
• Other: Immunosuppression, aggravation, or masking of infections; impaired wound healing; thin, fragile skin; petechiae, ecchymoses, purpura, striae; subcutaneous fat atrophy
Nursing Considerations
Assessment
• History: Infections; kidney or liver disease, hypothyroidism, ulcerative colitis with impending perforation, diverticulitis, active or latent peptic ulcer, inflammatory bowel disease, CHF, hypertension, thromboembolic disorders, osteoporosis, convulsive disorders, diabetes mellitus; hepatic disease; lactation
• Physical: Weight, T, reflexes and grip strength, affect and orientation, P, BP, peripheral perfusion, prominence of superficial veins, R, adventitious sounds, serum electrolytes, blood glucose
Implementation
• Administer once-a-day doses before 9 AM to mimic normal peak corticosteroid blood levels.
• Increase dosage when patient is subject to stress.
• Taper doses when discontinuing high-dose or long-term therapy.
• Do not give live virus vaccines with immunosuppressive doses of corticosteroids.
Drug-specific teaching points
• Do not stop taking the drug without consulting your health care provider.
• Avoid exposure to infections.
• Report unusual weight gain, swelling of the extremities, muscle weakness, black or tarry stools, fever, prolonged sore throat, colds or other infections, worsening of the disorder for which the drug is being taken.
Diagnosis:
Ineffective Airway Clearance related to, R\T increased mucous production, tenacious secretions and bronchospasm AMB my observation (wheeze and crackles sound).
Activity Intolerance R\T inadequate oxygenation for activities AMB my observation (fatigue patient and SOB with walking)
Planning and interventions
1- Goal: Facilitating Effective Airway Clearance.
Objectives: the patient will able to:
Assume comfortable position that facilitates increased air exchange during my shift.
Demonstrate effective coughing during my shift.
Relate strategies to decrease tenacious secretions during my shift.
Interventions:
Instruct the client on the proper method of controlled coughing (Uncontrolled coughing is tiring and ineffective, leading to frustration).
a. Breathe deeply and slowly while sitting up as high as possible (Sitting high shifts the abdominal organs away from the lungs, enabling greater expansion).
b. Use diaphragmatic breathing (Diaphragmatic breathing reduces the respiratory rate and increases alveolar ventilation).
c. Take a second breath, hold, and cough from the chest (not from the back of the mouth or throat) using two short, forceful coughs (Increasing the volume of air in lungs promotes expulsion of secretions).
d. Hold the breath for 3 to 5 seconds and then slowly exhale as much as possible through the mouth. (Increasing the volume of air in lungs promotes expulsion of secretions)
Teach the client measures to reduce the viscosity of secretions (Thick secretions are difficult to expectorate and can cause mucus plugs).
e. Maintain adequate hydration: increase fluid intake.
f. Maintain adequate humidity of inspired air.
g. Avoid environmental stimulants.
Auscultate the lungs before and after treatment (This assessment helps evaluate the effectiveness of the treatment).
Encourage and provide good mouth care (Good oral hygiene promotes a sense of well-being and prevents mouth odor).

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2- Goal: Promoting tissue perfusion
Objectives: the patient will able to:
Demonstrate methods of effective coughing, breathing, and conserving energy during my shift.
Identify a realistic activity level to achieve or maintain.
Intervention:
Explain activities and factors that increase oxygen demand.
a. Smoking.
b. Extremes in temperature.
c. Excessive weight.
d. Stress
* (Smoking, extremes in temperature and stress cause vasoconstriction, which increases cardiac workload and oxygen requirements. Excess weight increases peripheral resistance, which also increases cardiac workload)
Provide the client with ideas for conserving energy (Excessive energy expenditure can be prevented by pacing activities and allowing sufficient time to recuperate between activities.).
e. Pace activities throughout the day.
f. Schedule adequate rest periods.
g. Alternate easy and hard tasks throughout the day.
Gradually increase the client’s daily activities as tolerance increases.
Teach the client effective breathing techniques,
Teach the importance of supporting arm weight (When arms are not supported, the respiratory muscles are required to perform dual roles: increase respirations, and stabilize the chest wall in support of arm weight and activity).
Maintain supplemental oxygen therapy, as needed (Supplemental oxygen increases circulating oxygen levels and improves activity tolerance).
After activity, assess for abnormal responses to increased activity (ntolerance to activity can be assessed by evaluating cardiac, circulatory, and respiratory status)
h. Decreased pulse rateb.
i. Decreased or unchanged systolic blood pressure
j. Excessively increased or decreased respiratory rate
k. Failure of pulse to return to near resting rate within 3 minutes after activity
l. Confusion, vertigo, uncoordinated movements
Plan adequate rest periods according to the client’s daily schedule (Rest periods allow the body a period of low energy expenditure, increasing activity tolerance) .
Assess for problems associated with eating (Identification of barriers to proper nutrition can prevent or reduce malnutrition.)
m. Breathing competing with eatingb.
n. Abdominal gas
o. Grocery shopping
p. Meal preparation
Teach strategies to increase nutritional status
q. Eat a diet high in lipid/proteins and low in carbohydrates (CHO digestion produces more carbon dioxide. Protein is essential for healing).
r. Have a large fluid intake (This reduces viscosity of secretions and choking sensations).
s. Avoid milk, chocolates, and other foods that increase viscosity of saliva. (Secretions that can be expectorated will lessen anorexia.).
t. Avoid dry and hot foods (These will irritate throat and stimulate coughing).
Patient Education/Health Maintenance
Environmental Control Advise patients on the following environmental modifications to reduce symptoms
Use nonallergic materials for bedding (pillows, blankets).
Keep clothing in a closet with door shut.
Avoid stuffed animals and other dust collectors.
Use synthetic pillows that can be washed and replaced frequently; bed linens should be washed in hot water.
Damp-dust daily and wear a mask while doing it.
Eliminate upholstered furniture, shag carpets, and draperies.
Avoid smoking and smoke-filled areas.
Avoid rapid changes in temperature.
Avoid mold growth by using a fungicide in bathrooms, damp basements, food storage areas, and garbage containers.
Keep windows closed during high pollen season.
Avoid outdoor activities when high pollen/pollutants are in the air.







Evaluation

Goal met:
Patient approximately response to teach and verbalize good feeling.
Patient use comfortable position
Healthy oral mucous membranes.
Goal partial met:
Slightly decrease abnormal sound à need more time and the patient stay smoking.
Others goal not met:
Need more time to teaching and observation,

CASE STUDY /Bronchial Asthma

CASE STUDY

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