Saint Gabriel College Case Analysis

Published on June 2016 | Categories: Documents | Downloads: 72 | Comments: 0 | Views: 363
of 17
Download PDF   Embed   Report

a case presentation about bronchial asthma

Comments

Content

Saint Gabriel College Old Buswang, Kalibo, Aklan

In Partial Fulfillment of the Requirements in Intensive Nursing Practice “Case Analysis”

“BRONCHIAL ASTHMA in ACUTE EXACERBATION”

Submitted to:

Mr. Elizalde M. Baldueza R.N. MAN Instructor

Submitted by: Leader: Members: Detuya, Allyson Faith Inolino, Philip Andrew Iray, Denoel Martin, Jessica D. Sabido, Katherine Anne Resterio, Mary Joy P.

Table of Contents

I. II.

Introduction Statement of Objectives A. General Objectives B. Specific Objectives

III. IV. V.

Biographical Data Chief Complaint Health History A. Present Illness B. Past health History C. Family History D. Educational History E. Occupational History F. Obstetric History G. Social History H. Dietary History

VI. VII.

Growth and Development Physical Assessment

VIII. Laboratory exam IX. X. XI. XII. Anatomy and Physiology Pathophysiology Drug Study Nursing Care Plan

XIII. Prognosis/ rehabilitation phase

INTRODUCTION

The main function of the respiratory system is to move air into the lungs so that oxygen can enter the body and carbon dioxide can be inhaled. Several pulmonary disorders can affect the airways. Their pathophysiology differs but these diseases are characterized by limited airflow. Airflow is limited when air walls are thickened, airway lumen is obstructed by secretions, increasing resistance, and smooth muscle of the airways is activated, causing bronchoconstriction. Limited airflow increases the work of breathing and residual volume of the lungs as air is trapped behind narrowed or collapsed airways. Asthma is a chronic inflammatory respiratory disorder that causes recurrent episodes of wheezing, breathlessness, chest tightness and cough, especially at night or in the early morning. These asthma episodes are associated with airflow limitation or obstruction that is reversible either spontaneously or with treatment. Bronchial asthma is usually intrinsic (no cause can be demonstrated), but is occasionally caused by a specific allergy (such as allergy to mold, dander, dust). This case study is a thorough learning about Bronchial Asthma, which contains a study about the normal physiology of the respiratory system, pathological physiology of the disease, a thorough assessment of the patient with said illness, applied nursing care plans to patients having this kind or disease. (http://www.scribd.com/doc/27330007/BRONCHIAL-ASTHMA-)

Concerning Bronchial Asthma as one of the disorders of respiratory system. We had decided to make it as the center of our case study for the first shifting. Through the help of Andagao RHU Nurses.We had able to come up with an interview to a 52 year old male of Andagao, Kalibo, Aklan with the diagnosis of Bronchial Asthma in Acute Exacerbation. Conditions affecting the lower respiratory tract like Bronchial Asthma are serious and often life threatening if proper interventions are not yet addressed. The patient requires care from nurses with the accurate assessment and clinical management skills as well as an understanding of the impact of the disorder on the patient’s quality of life and ability to carry out usual activities of daily living. Therefore, nurses must have an adequate knowledge and skills regarding the pathophysiology of the disease/ illnesses of the patient to ease their pain, to implement effective breathing strategies and to evaluate the effectiveness of these strategies, regardless of any setting.

OBJECTIVES

General Objectives At the end of the shifting, we the BSN IV B of Saint Gabriel College assigned at Kalibo RHU 2 under the service of Mrs. Diane Regalado will be ableto acquire knowledge, right skills and desirable attitudes in conducting case study to our patient with the problem in respiration. Specific Objectives Knowledge:      Skills:    Attitude:    To Develop rapport to the patient To gain trust and cooperation To established interpersonal relationship with the members of the health care team To assess the health status based on health history of the patient. To perform physical assessment accurately. To formulate appropriate care plan according to the priority needs of the patient. To Define bronchial Asthma To obtain information about the history of the past and the present illness. To discuss anatomy, physiology and Pathophysiology of bronchial asthma. To discuss nursing care plan and drug study. To provide health teachings to our patient.

DEMOGRAPHIC DATA

Name: Mr. L. B. R. Age: 52years old Address: Barangay Masing, Andagao, Kalibo, Aklan Birth Date:January 10,1962 Birth Place:Andagao, Kalibo, Aklan Civil Status:Married Religion:Roman Catholic Occupation:None Date of Admission:July 5, 2013 Date of Interview:November 22, 2013 Date of discharge:July 9. 2013 Chief Complaint:Difficulty of breathing Diagnose:Bronchial Asthma in Acute Exacerbation Attending Physician:Dr. V.

PRESENT OF MEDICAL HISTORY Two days prior to admission, Patient L.B.R. experienced difficulty of breathing. He take medicine ( salbutamol tablet 500mg) thinking that it will relief. After medication he take a rest but his feeling is not yet good. After that day the patient still having a difficulty of breathing and the patient cannot tolerate already. His wife decided to bring her husband L.R to the mission hospital. On July 5,2013 he was admitted at around 7:00pm accompanied by his wife in mission hospital. He was examined by Dr. Valencia and was diagnosed with bronchial Asthma in Acute exacerbation. He was discharge on July 9. 2013 PAST MEDICAL HISTORY According to the mother of MR. L.B.R his immunizations is completed. He doesn’t have any experience of injuries or any surgical operations in the past. According to Mr. L.B.R he inherited his asthma from his grandfather and to his father. He stated that when he was a child, he uses nebulizer whenever he has an asthma attack. His 1st admission to the hospital because of asthma was when he was 11years old.

FAMILY HISTORY Mr. L.B. R. is the second child of Mr. R. R. and Mrs. J. R. His father stated that he has a history of asthma and his wife has a history of hypertension.

EDUCATIONAL BACKGROUND Mr. L.B.R finished his primary school atAndagao elementary school and his secondary school at ASU Kalibo, but he did not finished his studies due to financial problem. OCCUPATIONAL HISTORY Mr. L.B.R is a Tricycle Driver for 3years but he stopped driving due to his condition when he was admitted to the hospital.

PERSONAL AND SOCIAL HISTORY According to Mr. L.B. R. he is aware of proper hygiene. According to him he takes a bath once a day and brushes his teeth three times a day particularly after eating his breakfast. He has a good personal interaction with his family, friends, cousins, and neighbors. He started to smoke and drink liquor when he was 11 years old, and having night out with all his friends.

ENVIRONMENTAL HISTORY The house of Mr. L.B.R was located along the coastal highway. According to him every time when he smell dander of the chicken he experience difficulty of breathing. He always exposed to dust because of the nature of his work because he is a tricycle driver and he also smokes. Every morning he goes to the beach (Lambingan beach) to inhale fresh air and to relax.

IMMUNIZATION BCG DPT MEASLES OPV HEPA-B 1 dose 3 doses 1 dose 3 doses 3 doses

24 HOURS DIETARY RECALL

July 4, 2013

Breakfast   1 ½ bowl of porridge 1 glass of water (250 ml)

Lunch   1 cup of rice 1 slice of fish (sinabawangbangus)

Snack  1 pack of biscuit (sky flakes) 1 glass of juice (250 ml)

Dinner    1 cup of rice 1 pc. fried chiken 2 glass of water (500 ml)



Growth and Development
A. Infancy: Trust vs. Mistrust ( 0-12months ) On this stage according to the patient he was left alone to cry and even when to stop crying. His mother breastfed him when he was hungry. According to the patient he was given a soft food like porridge. And at the age of 6 months old his sister stated that his tooth came out, crawled at 8 months. Then the rest of the year was followed by the growth and development.

B. Toddlerhood: Autonomy vs. Shame and Doubt ( 12months- 3 years old) The patient’s sister stated that he started to walk at the age of 1 ½ year old. And he stated that at the age of 3 his stop breast feeding. And the first word that the patient stated was “ta-ta” and “na-na”. When he was about 3 years old he was toilet trained by his mother, at that age he was able to socialized and played with other kids.

C. Preschooler: Initiative vs. Guilt (4-6 years old) Normally, most children of this stage are being prepared or groomed for proper education. His sister said that his brother had an interest in his study when he entered Day care and kinder years at the age of six at Andagao Elementary School. Mr. L.B.R is fond of playing toy cars with his cousins and eating sweets like lollipop and at this stage also, Mr. L.B.R feared of being left alone at bed time. Like any other kids, he loved playing with his friends and cousin.

D. School Age: Industry vs. Inferiority (6-12 years old) L.B.R started his elementary education at the age of 6 at Andagao Elementary School. At the age of 10 he started to drink alcohol with his friends and cousins. Even if L.B.R has asthma, he still helps his sister in doing household chores.

E. Adolescence: Identity vs. Role Confusion (12-18 years old) Mr. L.B.R was in 2nd year High School when he was 14 years old. But he did not finish his studies because of financial problem. And at the age of 12 years old, Mr. L.B.R experienced asthma attack so they decided to admit him in the hospital.

F. Early Adulthood: Intimacy and Isolation (20-40 yrs old) According to him he did not finish his studies because of financial problem. He said he started to work at this stage as a tricycle driver. He got married at the age of 25 yrs. Old and has 2 children.

G.

Middle adulthood: Generativity vs. Stagnation (40-62 yrs. Old)

At this stage Mr. L. B. R. stopped driving because of his condition .His family decided to stop his work as a tricycle driver, he only depend for the money that his daughter send him from Saudi for their monthly income.

Physical Assessment

General Appearance Mr. L.B.R is sitting on chair wearing white t-shirt and green short during interview. He is cooperative during our conversation. He is restless and experiencing back pain. Hair is not fixed and medium body built. Integumentary System  No lesion noted  Skin is warm to touch Head  55cm. in diameter  Able to smile and frown  Dry black hair, no flaking and no any dandruff seen upon inspection. Eyes     Ears  Ears are symmetrical in shape  Able to hear voice whisper from 2 feet away  Earwax is present upon inspection using penlight. Nose  Nasal flaring noted. Mouth and Throat      Neck  No lymph nodes upon palpitation  Can rotate neck from left to right at 90% Lungs and Thorax  Anterior thorax, the apices of the lungs extends for 4-5cm above clavicle upon inspiration.  Using of accessory muscles upon inhaling  Wheezing sound was heard upon auscultation  Abnormal chest expansion when breathing  Tachypnea Teeth are yellowish, tongue & gums are pinkish in color Able to lift tongue with tongue depressor Tonsils are not inflamed Ability to purse lips Symmetry in contour PERLLA Able to blink rapidly and raise eyebrows rapidly Sclera is white stained with reddish color, conjunctiva is pink in color. Able to follow light upward, downward and from side to side

 RR of 33 bpm Cardiovascular  Heart sound is heard in all landmarks  Capillary refill after 2 seconds  Cardiac rate of 96 bpm Breast  The client refused to be inspected but he stated that there is no dimpling and lymph nodes in the breast.  74cm in diameter Abdomen  Size is medium, shape is oval. Musculoskeletal  Not able to twist from side to side because of back pain  Can move fingers in both hands  Can move toes on the feet Genital/ Rectum and Anus  Mr. L.B.R refused to examine but he stated that he urinate 4 times a day and it depends to his fluid intake. And he defecates every morning. He also stated that there is no any lesion found in his genital and rectum.

ANATOMY AND PHYSIOLOGY

The upper respiratory tract consists of the nose, sinuses, pharynx, larynx, trachea, and epiglottis.

The lower respiratory tract consists of the bronchi, bronchioles and the lungs. The major function of the respiratory system is to deliver oxygen to arterial blood and remove carbon dioxide from venous blood, a process known as gas exchange.

The normal gas exchange depends on three processes: • Ventilation- is movement of gases from the atmosphere into and out of the lungs. This is accomplished through the mechanical acts of inspiration and expiration. • Difffusion- is a movement of inhaled gases in the alveoli and across the alveolar capillary membrane. • Perfusion- is movement of oxygenated blood from the lungs to the tissues.

Control of gas exchange- involves neural and chemical process The neural system, composed of three parts located in the pons, medulla and spinal cord, coordinates respiratory rhythm and regulates the depth of respirations. The chemical processes perform several vital functions such as: • Regulating alveolar ventilation by maintaining normal blood gas tension

• Guarding against hypercapnia (excessive CO2 in the blood) as well as hypoxia (reduced tissue oxygenation caused by decreased aterial oxygen (PaO2) inhibits ventilation. • Helping to maintain respirations (though peripheral chemoreceptors) when hypoxia occurs. SPECIFIC PARTS Different portions of the lungs consist of the following: • Trachea- is a tube that connects the pharynx or larynx to the lungs, allowing the passage of air; it commences at the larynx, level with the fifth cervical vertebra, and bifurcates into the primary bronchi at the vertebral level of T4/T5. • Bronchi- are passages of airways in the respiratory tract that conduct air into the lungs; divides into two main bronchi (also mainstem bronchi), the left and the right, at the level of the sterna angle at the anatomical point known as the carina. • Bronchioles- are the first airway branches approximately 1mm or less in diameter with walls consist of ciliated cuboidal epithelium and a layer of smooth muscle that no longer contain cartilage; they are branches of the bronchi and terminate by entering the circular sacs called alveoli. • Alveoli- are anatomical structures found in the lung parenchyma as dead ends of the respiratory tree that have the form of a hollow cavity which outcrop from either alveolar sacs or alveolar ducts ; they are both sites of gas exchange with the blood as well.

PATHOPHYSIOLOGY

Predisposing Factors

Precipitating Factors

-Family history -Age (52)y.o -gender (M)

-Exposure to animal dander -Nature of work (tricycle driver) -Exposure to chemical sprays like perfumes -smoking

Exposure to different allergens

Entry of the allergen in the body

Release of immunoglobulin E (IgE) Release of different chemical Mediators

Mast cell Degranulation

Release of different inflammatory chemical mediators

Leukotriene

Prostaglandin

Release of eosinophils

Opening of the mucosal intracellular junction Inflammatory process

Histamine, Bradykinin and other inflammatory mediator

Mucus production Mucosal Edema More release of other inflammatory mediators Decrease ciliary function Mucus hyper secretion

Increase Vascular Permeability Bronchoconstricti on Epithelial damage

Increased airway Responsiveness

AIRWAY OBSTRUCTION

DIAGNOSTIC TEST

Chest X-Ray-is an imaging test that uses small amounts of radiation to produce pictures of the organs, tissues, and bones of the body. When focused on the chest, it can help spot abnormalities or diseases of the airways, blood vessels, bones, heart, and lungs. Purpose: To visualize if there is a spot in the lungs. Nursing Responsibility:  Check that the patient has emptied the bladder before the test commences.  Check to see if a female patient is, or could be pregnant. Exposure of the unborn fetus to X-rays can be damaging to the child.  After the test, the patient should be returned to their normal activities if these have been disturbed, i.e. eating and drinking, as quickly as possible.  Whilst most contrast medium allergies are instantaneous, nurses should be aware of possible longer-term reactions over the next few hours or days, and observe patients accordingly.

RADIOLOGY

Name: Mr. L. B. R. Address: Andagao, Kalibo, Aklan Examination: Chest X-ray

Age: 52 yrs old Sex: Male Attending Physician: Dr. F.A .P

Report        Chest PA shows a hyper inflated lung. Fibroexudative infiltrates are noted at the upper lungs. Cardiac shadow isnot enlarged transversely. Tracheal air column is at the midline. Diaphragm is low set. Costophrenic angles are intact. Osseors and soft tissue structures are unremarkable.

IMPRESSION: PTB with Pneumonia and Pulmonary Hyperinflation Bilateral

Sputum Exam-is a test of secretions from the lungs and bronchi (tubes that carry air to the lung) to look for bacteria that cause infection. Purpose: To determine if the patient is positive in tuberculosis. How to Prepare for the Test Drinking a lot of water and other fluids the night before the test may help to get the sample.

SPECIAL PROCEDURE

Nebulization- is the process of medication administration via inhalation. It utilizes a nebulizer which transports medications to the lungs by means of mist inhalation.

Purpose: To loosen the secretions.

Nursing Responsibility       Check doctor’s orders for the medication, prepare thereafter Place the medication in the nebulizer while adding the amount of saline solution ordered. Attach the nebulizer to the compressed gas source Attach the connecting tubes and mouthpiece to the nebulizer Turn the machine on (notice the mist produced by the nebulizer) Offer the nebulizer to the patient, offer assistance until he is able to perform proper inhalation (if unable to hold the nebulizer [pediatric/geriatric/special cases], replace the mouthpiece with mask

Rehabilitation Phase

 Advise the patient to avoid allergens that can trigger to his conditions such as pollens, molds, dust, mites,spray(perfumes) and pets like dogs and cats.  Instruct the patient to avoid strenuous activities.  Advise the patient to position in high fowler’s position to prevent difficulty of breathing.  Encourage the patient for deep breathing exercise to promote lung expansion.  Instruct the patient to increase fluid intake to prevent dehydration.  Encourage the patient to eat nutritious foods to boost his immune system.  Advise the patient to use mask in going to pollutant area.

PROGNOSIS The prognosis of the patient with Bronchial Asthma in Acute Exacerbation is good because after 2 days we had conducted a home visit to our patient and we tried to ask him regarding his condition. According to him he can do the things that he can’t do and he is no longer suffering from asthma attack. He scales his present condition 3 out of 10. He is able to sleep well now unlike before we interviewed the patient. Aside from this, he said that during morning time there is no manifestations of difficulty of breathing noted because he comply all the home medications prescribed by his physician like salbutamol/ albuterol 4mg per orem TID, salmiflo 125mcg nasal administration TID, combivent 2.5 ml nasal administration every 4 hours. As we auscultate his upper left and right quadrant lungs, decrease in tactile fremitus and decrease in wheezing sounds has noted.

CONCLUSION We the BSN IV-B student assigned at Kalibo RHU II will be able to acquire desired knowledge, right skills, and good attitudes in conducting a case study about respiratory problem to a patient experiencing difficulty of breathing, with the impression of Bronchial Asthma in Acute Exacerbation. Bronchial Asthma in Acute Exacerbation is somewhat a difficult kind of respiratory disease because we have learn that a person suffering from an attack cannot breathe easily or severe complications from the course of the disease could occur like a shock. When this happens, the support and skill of a professional nurse and even a student nurse are essential to the patient and to his family by giving them proper health teachings on how to manage respiratory problem by using effective strategies like deep breathing exercises, and avoid allergens that can trigger his condition. Aside the knowledge and information that we had gathered for our continuous learning in nursing practice, we have learned also that in gathering data in an interview, we need to develop effective verbal and non- verbal communications skills. We must not only focus on the topic to be discussed but we need to establish first a rapport to the patient and his family for us to gather more information about our case study. We should be responsible and flexible so that we can make proper interventions on the part of the patient’s condition in own little ways and for to become critical, competent and productive nurse in the future.

Sponsor Documents

Or use your account on DocShare.tips

Hide

Forgot your password?

Or register your new account on DocShare.tips

Hide

Lost your password? Please enter your email address. You will receive a link to create a new password.

Back to log-in

Close