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Group 7 Ablay-Andrade-Batario-Berbano- Bibera-Borja-Borres-Burns- Cabañero-Corsiga-Custodio- Cuyegkeng Case Presentation

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Case PresentationGroup 7 Ablay-Andrade-Batario-BerbanoBibera-Borja-Borres-BurnsCabaero-Corsiga-CustodioCuyegkeng

BRONCHIAL ASTHMA IN ACUTE EXACERBATION CHRONIC OBSTRUCTIVE PULMONARY DISEASE

INTRODUCTION

INTRODUCTIONCOPD, or chronic obstructive pulmonary disease, is a progressive disease that makes it hard to breathe. "Progressive" means the disease gets worse over time. COPD can cause coughing that produces large amounts of mucus, wheezing, shortness of breath, chest tightness, and other symptoms. Cigarette smoking is the leading cause of COPD. Most people who have COPD smoke or used to smoke. Most cases of COPD occur as a result of long-term exposure to lung irritants that damage the lungs and the airways.

Breathing in secondhand smoke, air pollution, and chemical fumes or dust from the environment or workplace also can contribute to COPD. (Secondhand smoke is smoke in the air from other people smoking.) In rare cases, a genetic condition called alpha-1 antitrypsin deficiency may play a role in causing COPD. People who have this condition have low levels of alpha-1 antitrypsin (AAT)-a protein made in the liver.

Having a low level of the AAT protein can lead to lung damage and COPD if you're exposed to smoke or other lung irritants. If you have this condition and smoke, COPD can worsen very quickly. COPD develops slowly. Symptoms often worsen over time and can limit your ability to do routine activities. Severe COPD may prevent you from doing even basic activities like walking, cooking, or taking care of yourself.

Most of the time, COPD is diagnosed in middleaged or older people. The disease isn't passed from person to personyou can't catch it from someone else. COPD has no cure yet, and doctors don't know how to reverse the damage to the airways and lungs. However, treatments and lifestyle changes can help you feel better, stay more active, and slow the progress of the disease.

CHRONIC BRONCHITIS Lung damage and inflammation in the large airways results in chronic bronchitis. Chronic bronchitis is defined in clinical terms as a cough with sputum production on most days for 3 months of a year, for 2 consecutive years. In the airways of the lung, the hallmark of chronic bronchitis is an increased number (hyperplasia) and increased size (hypertrophy) of the goblet cells and mucous glands of the airway.

As a result, there is more mucus than usual in the airways, contributing to narrowing of the airways and causing a cough with sputum. Microscopically there is infiltration of the airway walls with inflammatory cells. Inflammation is followed by scarring and remodeling that thickens the walls and also results in narrowing of the airways. As chronic bronchitis progresses, there is squamous metaplasia (an abnormal change in the tissue lining the inside of the airway) and fibrosis (further thickening and scarring of the airway wall). The consequence of these changes is a limitation of airflow.

Patients with advanced COPD that have primarily chronic bronchitis rather than emphysema were commonly referred to as blue bloaters because of the bluish color of the skin and lips (cyanosis) seen in them. The hypoxia and fluid retention leads to them being called Blue Bloaters.

EMPHYSEMA Emphysema is a chronic obstructive pulmonary disease (COPD, as it is otherwise known, formerly termed a chronic obstructive lung disease). It is often caused by exposure to toxic chemicals, including long-term exposure to tobacco smoke. Emphysema is characterized by loss of elasticity (increased pulmonary compliance) of the lung tissue caused by destruction of structures feeding the alveoli, owing to the action of alpha 1 antitrypsin deficiency.

This causes the small airways to collapse during forced exhalation, as alveolar collapsibility has decreased. As a result, airflow is impeded and air becomes trapped in the lungs, in the same way as other obstructive lung diseases. Symptoms include shortness of breath on exertion, and an expanded chest. However, the constriction of air passages isnt always immediately deadly, and treatment is available.

ASTHMA

Asthma is a chronic lung disease that inflames and narrows the airways. Asthma causes recurring periods of wheezing, chest tightness, shortness of breath, and coughing. The coughing often occurs at night or early in the morning. Asthma affects people of all ages, but it most often starts in childhood.

The airways are tubes that carry air into and out of your lungs. People who have asthma have inflamed airways. This makes the airways swollen and very sensitive. They tend to react strongly to certain substances that are breathed in. When the airways react, the muscles around them tighten. This causes the airways to narrow, and less air flows to your lungs. The swelling also can worsen, making the airways even narrower. Cells in the airways may make more mucus than normal. Mucus is a sticky, thick liquid that can further narrow your airways.

When your asthma symptoms become worse than usual, it's called an asthma attack. In a severe asthma attack, the airways can close so much that your vital organs do not get enough oxygen. People can die from severe asthma attacks. Asthma is treated with two kinds of medicines: quick-relief medicines to stop asthma symptoms and long-term control medicines to prevent symptoms.

NURSING THEORIES

VIRGINIA HENDERSON

NURSING THEORIESVirginia Henderson Henderson defined nursing in functional terms. She stated, The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery that he would perform unaided if he had the necessary strength, will or knowledge.

And to do this in such a way as to help him gain independence as rapidly as possible. Person (Patient) Henderson viewed the patient as an individual who requires assistance to achieve health and independence or peaceful death. The mind and body are inseparable. The patient and his or her family are viewed as a unit.

3 levels comprising the nurse patient relationship 1. nurse as a substitute for the patient 2. nurse as a helper to the patient 3. nurse as a partner with the patient

Henderson identified 14 basic needs of the patient, which comprise the components of nursing care. These include the following needs: 1. Breathe normally 2. Eat and drink adequately 3. Eliminate body wastes 4. Move and maintain desirable postures

5. Sleep and rest 6. Select suitable clothesdress and undress 7. Maintain body temperature within normal range by adjusting clothing and modifying the environment 8. Keep the body clean and well groomed and protect the integument 9. Avoid dangers in the environment and avoid injuring others

11. Worship according to ones faith 12. Work in such a way that there is a sense of accomplishment 13. Play or participate in various forms of recreation 14. Learn, discover, or satisfy the curiosity that leads to normal development and health and use the available health facilities

PERSONAL DATA

PERSONAL DATAMr. R.B, a 50-year-old Filipino, male. He was born Roman Catholic on August 13, 1959 and resides in Mamatid, Cabuyao Laguna. His wife died four years ago and now, hes living with his 3 children. He earned his income being a tricycle driver. Mr. R.B was admitted to the hospital last June 29, 2010 because he experienced difficulty of breathing and was diagnosed of having COPD under the management of Dr. Cuadra

HISTORY

NURSING HISTORYSources of History - Mr. R.B. - daughter of Mr. R.B. (unfortunately she only knows a few about her fathers illness and medications). Reasons for Seeking Care A few hours prior to admission, the patient experienced dyspnea accompanied with a productive cough.

Present Health or History of Present illness Three days prior to admission (June 25, 2010), Mr. R.B has been having an on and off productive cough. Then a few hours before he was admitted (June 28, 2010), he suffered from difficulty of breathing that is why his relatives rushed him at the ER of Calamba Doctors Hospital and admitted to our institution. Patient manifested productive cough greenish in color, with nasal canula connected to oxygen tank at 2-3 liter per minute as ordered.

His initial vital signs were: BP = 160/100 mmHg RR = 36 cpm PR = 138 bpm Temp = 36.5 C Diagnostic exams included Chest X-ray, CBC, BUN, NA, K, Urinalysis, ABG.

Past Health History Patient was known to be asthmatic since childhood. His usual attacks are precipitated by dust or smoke inhalation. He has maintenance medication of Ventolin. During his teenage years, He worked as a farmer and was exposed to fertilizers and other different chemicals used for the crops. According to him, he often sweats himself in the field and doesnt bother to change his clothes which he concluded as the source of his Pneumonia. No accidents or injuries are noted.

At 20 years old, he worked as a Construction worker. He also worked in a Textile factory and worked as a tricycle driver. During those days, he was diagnosed with PTB. He had suffered dyspnea and had hemoptysis. According to him, he had his shots of Streptomycin in their health center. Nebulization was done for about 3 times but offered no relief of the said condition

Last year, he suffered from difficulty of breathing and he was admitted in Calamba Medical Center with a diagnosis of COPD At year 2010 of January, patient seeks consultation and was then admitted in Calamba Doctors Hospital and diagnosed him COPD. Complaining of DOB accompanied by greenish phlegm. Patient also started to complain of easy fatigability. Patient was also unable to sleep at night associated with wheezes, chest pain.

Patient History at the ICU Patient sensorium is unpredictable and the GCS is only 9 then the next day is 15. After several minutes the patient was intubated, size of ET tube is 7.5 lip level is 21, and continuous ambubagging was done prior the patient was connected to mechanical ventilator with the setting of FIO2 100%, TV -450 RR is 22, he has Nasogastric tube

and after several minutes Foley Catheter is inserted connected to urine bag with a minimal Urine Output, on Physical Restrains. Patient is full pulses 94 beats per minute, pulse oximeter O2 Saturation 98%. After 9 days, patient was extubated and placed O2 face mask at 10LPM as ordered and the next day he was transferred to medical ward with same medications and with nasal canula connected to oxygen tank at 5-6LPM and with Indwelling Foley Catheter.

Family History He is not Hypertensive and Diabetic but his brother is only known for this disease. Psychosocial History The patient is a widow and has 3 children. His neighbors are friendly and helpful. He is a high school graduate and work as a Tricycle driver. He is a not an alcohol drinker and only an occasional smoker. Whenever the patient has problems, he is usually supported by his children and relatives. Everytime he gets hospitalized when he is having an asthma attack, his family is worried about what might happen to him and also with the expenses that they will have. Work and money was considered as primary stressor and his ways of coping are laughing and spending time with peers.

PHYSICAL ASSESSMENT

PHYSICAL ASSESSMENTIntegumentary Mr. RBs skin is cold when touched, cyanotic, has no edema, no signs of dehydration, scar on the left foot. Nail convex curvature, smooth in texture, capillary refill is not normal. Hair is dark brown with some gray in color, shiny and equally distributed.Head and Neck Skull is rounded, smooth contour, absence of nodules or masses. Facial gestures are symmetric. Has sunken eyeballs. Eyebrows are symmetrically aligned.

Eyelashes are equally distributed and curled slightly outward. Eyelids has no discharge, discoloration, closes symmetrically. There is no visible sclera above corneas, sclera appears white, the conjunctiva is pink in color, and both eyes are coordinated. Ears color are same with the facial skin, the auricle is aligned with other canthus of the eye, they are firm and not tender. His hearing is tested by asking questions and he response to his normal voice. The external nose are symmetric and straight there are no discharge, and has flaring, uniform in color, not tender and there are no lesions.

Air movement is restricted in both nares and he has nasal canula. His lips are dry, slightly pink in color. Teeth are incomplete, tongue is pink in color, slightly rough, there is no lesions, no tenderness and it moves freely. Muscles neck are equal in size, head centered with smooth movements with no discomfort. Thorax/ Lungs/ Heart - thorax is barrel, it is decreased in vibratory sensation, asymmetric thoracic expansion and he has abnormal breathing pattern, his respiratory rate is 32 breaths per minute and his lips are pursed.

His left lung has dubbing sounds when it is auscultated and palpated. He has persistent cough which is productive; green in color. Heart rate is 105 beats per minute and irregular. Abdomen - abdomen is soft, free of tenderness, no pain on light palpation. Peripheral Vascular - pulses equal in both arms, pulses equal in both legs. No edema present.

Musculoskeletal - normal spinal curves. No joint deformities, tenderness, full active range of motion in all joints. Muscle strength equal bilaterally, there are no contractures, tremors. Neurologic - facial expressions appropriate. Speech is not clear, he has husky voice. He has muscle strength to hold and grasp things. He is non alcoholic, feels pain on his head part.

NURSING ASSESSMENT 14 Fundamental Needs

Nursing Assessment (14 fundamental needs)Breathe normally During admission, his RR=20 and his chief complain is DOB. ICU Days, he is intubation because of DOB and the result of pulse oximetry is 38- 40%. Post ICU, he is negative in DOB but there is still oxygen

Eat and Drink adequately his usual eating pattern is 5 meals a day with meriendas. magana naman akong kumain as stated Eliminate body waste Before hospitalization, his usual BM is every morning.now, when he is in the hospital he did not bowel for 3 days.

hndi pa ako dumudumi ilang araw na as stated. On July 2,there is an insertion of foley cathether because of uncontrolled urination.he had bladder training on July 8 and because theres an urge of urination it was removed on July 9 early AM.his urinary frequency in now normal.

Move and Maintain desirable posture He works as a tricycle driver and did not usually participate in activities like exercise because he has asthma. madali ako hapuin- as stated. Sleep and Rest ICU days, he has difficulty of sleeping and resting because of severe productive cough. But after intubation, he slept and rest well.

Select suitable clothes- dress and undress before hospitalization, he wears his usual comfy clothes. Now, he is wearing a standard gown for patient. Maintain body temperature before he did not change clothes even if it is wet. Now, hes been hospitalized he wears socks and uses blanket whenever he feels cold.

Keep the body clean and well groomed and protect the integument. before he takes a bath regularly. Now, he needs assistance on going to CR. He had sponge bath every morning with the assistance of the nurse and relatives. Avoid dangers in the environment and avoid injuring others he doesnt know where he got TB. And he is

aware that might infect his family. Communicate with others in expressing emotions, needs, fears/ opinions he is the bread winner of his family and his childrens family. ICU days, he cant talk because of intubation. after extubation, he can talk and express feelings even though his voice is husky

Worship according to ones faith he is Roman Catholic and believes in God but he doesnt always pray and goes to church. Play or Participate in various forms of recreation he doesnt have vices and recreational activities. Now, he is in the hospital he watches TV, sleeps, and sometimes makes joke with his family to eliminate his boredom.

Learn, Discover or Satisfy the curiosity that leads to normal development and Health and use the available Health Facilities. he is aware and understands his illness. He gave information about the history of his illness and he complies on therapeutic regimen but due financial problem, his family sometimes

DRUG STUDIESDRUG NAME CLASSIFICATION & ACTION Miscellaneous respiratory tract drugs Mucolytic that reduces the viscosity of pulmonary secretions by splitting disulfide linkages between mucoprotein molecular complexes. INDICATION ADVERSE REACTION / SIDE EFFECTS CNS: fever, drowsiness, gait disturbances CV: tachycardia, hypotension, hypertension, flushing, chest tightness GI: stomatitis, nausea, vomiting RESPI: bronchospasm, dyspnea, cough SKIN: rash, diaphoresis OTHER: chills CONTRAINDICATI ON Contraindicated to patients with hypersensitive to drug. Use cautiously in elderly patients with severe respiratory insufficiency. Use I.V. formulation in patients with asthma or history of bronchospasm. NURSING CONSIDERATION - drug smells strongly of sulfur. Mixing oral form with juice or cola improves its taste - drug delivered to nasogastric tube maybe diluted with water. - monitor cough type and frequency - monitor patient for bronchospasm, specially if he has asthma - facial erythema may occur within 30-60 mins. Of start of IV infusion and usually resolves without stopping infusion.

ACETYLCYSTEIN E (fluimucil) Dosages: Inhalation solution: 10%, 20% I.V. injection: 20% solution (200mg/ml)

- for abnormal viscid thickened mucous secretions

DRUG STUDIES

DRUG NAME

CLASSIFICATION & ACTION Mucolytic It enhances pulmonary surfactant production and stimulates ciliary activity. These actions result in improved mucus flow and transport (mucociliary clearance). Enhancement of fluid secretion and mucociliary clearance facilitates expectoration and eases cough.

INDICATION

ADVERSE REACTION / SIDE EFFECTS Mild upper gastrointestinal side effects (primarily pyrosis, dyspepsia, and occasionally nausea, vomiting) have been reported, principally following parenteral administration. Allergic reactions have occurred rarely, primarily skin rashes. There have been extremely rare case reports of severe acute anaphylactictype reactions but their relationship to ambroxol is uncertain. Some of these patients have also shown allergic reactions to other substances.

CONTRAINDICATIO N should not be used in patients known to be hypersensitive to ambroxol or other components of the formulation.

NURSING CONSIDERATION -should be taken with food - monitor S/SX of aspiration of excess secretions and bronchospasms, if occurred notify physician - have suction apparatus immediately available. - tell the patient or family to report any difficulty clearing the airway or any other repi distress.

AMBROXOL (Mucosolvan) Dosage: Tablet: 75mg, 30 mg, 50mg Mucosolvan Liquid 30 mg, 60ml

acute and chronic bronchopulmonary diseases associated with abnormal mucus secretion and impaired mucus transport.

DRUG NAME

CLASSIFICATION & ACTION Antiasthmatic Bronchodilator its mechanism of action is related to the inhibition of phosphodiesterase activities, resulting in bronchodilating effects.

INDICATION

DOXOFYLLINE (ansimar) Dosage: Tab Adult 1 tab bid-tid. Syr Childn >12 yr 10 mL once-tid,