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Prepared by: Airen L. Jamago LTI- Male Department SKIN - warm, slightly dry, hair evenly distributed HEAD - symmetric skull, no flaking of scalp, no lesions and tenderness EYES - no redness and discharges, sclera white and clear, pupils reactive to light and accommodation NOSE AND SINUSES - nasal septum straight, not perforated, no discharged, NGT present THORAX AND LUNGS - thorax is symmetric, chest expansion is decrease due to muscle weakness, bony prominences are marked, there is loss of subcutaneous tissue, no tenderness, wheezes audible upon auscultation UPPER EXTREMITIES - decorticate position, arms are unable to abduct and adduct NAILS - convex in curvature, rough, with slightly delayed capillary refill III. PATIENT HISTORY RTA Sep. 26,2011 Known to have asthma and DM RMH Oct. 5,2011 PATIENT X Ward Oct. 24,2011 • Dec. 7,2011 semi- conscious, unable to speak and follows command, quadriphlegic, on NGT and diaper • Shortness of breath---low O2 sat.--tracheostomy tube ( Jan. 12, 2013) • VS stable with seldom episodes of desaturation STIMULI inflammation bronchospasm Airway hyperresponsiveness Asthma symptoms STIMULI (allergen, irritant, virus, cold air, exercise etc.) Activation of Inflammatory cells Migration into airways and activation of more inflammatory cells Airway hyperresponsiveness Airway obstruction Asthma symptoms Frequent cough, especially at night Losing your breath easily or shortness of breath Feeling very tired or weak when exercising Wheezing or coughing after exercise Feeling tired, easily upset, grouchy, or moody Decreases or changes in lung function as measured on a peak flow meter Signs of a cold or allergies (sneezing, runny nose, cough, nasal congestion, sore throat, and headache) Trouble sleeping Severe wheezing when breathing both in and out Coughing that won't stop Very rapid breathing Chest pain or pressure Tightened neck and chest muscles, called retractions Difficulty talking Feelings of anxiety or panic Pale, sweaty face Blue lips or fingernails Identify and minimize contact with asthma triggers. Understand and take medications as prescribed. Monitor asthma to recognize signs when it is getting worse. Know what to do when asthma gets worse. Assist him to relax as much as possible. Administer oxygen via nasal cannula to ease breathing and to increase arterial oxygen saturation during an acute asthma attack. Adjust oxygen according to the patient’s vital functions and ABG measurements. Administer drugs and I.V. fluids as ordered. Combat dehydration with I.V. fluids until the patient can tolerate oral fluids, which will help loosen secretions. Encourage the patient to express his fears and concerns about his illness. Encourage the patient to identify and comply with care measures and activities that promote relaxation. Decreased ability to exercise and take part in other activities Lack of sleep due to night time symptoms Permanent changes in the function of the lungs Persistent cough Trouble breathing that requires breathing assistance (ventilator) DEATH 1. Ineffective airway clearance related to mucus 2. 3. 4. 5. accumulation. Impaired Gas Exchange related to altered oxygen supply, obstruction of airways by secretions, bronchospasm. Ineffective breathing pattern related to decreased lung expansion. Hyperthermia related to underlying infection in the lungs. Impaired nutrition less than body requirements related to inadequate intake. ASSESSMENT Subjective: N/A Objective: -(+)wheezing -Tachypnia bilateral -(+) secretions characterized by: thick, greenish in color, approx. amount 5-8cc q suctioning -Frequent coughing NURSING DIAGNOSIS Ineffective Airway Clearance related to accumulation of mucus. OBJECTIVES After 12 hrs. of nursing intervention the patient will be able to expel secretions effectively. After 3-5 days of nursing intervention the patient will maintain clear airway. NURSING INTERVENTION 1. Position with the head of the bed elevated, head aligned properly in straight position. 2. Change position frequently. 3. Keep patient environment free from source of allergens, such as dust, powder, smoke. RATIONALE -Proper positioning facilitate effective passage of air through the lungs and provide good aeration of lung segments. - Changing of position aids in mobilization of secretions that may ease expectoration of secretions. -Precipitators of allergic type of respiratory reactions that can trigger or exacerbate onset of acute episode. EVALUATION Goal met. -Patient maintained a patent airway and demonstrated signs of reduction in respiratory secretions. -Displayed decreasing amount of secretions. 4. Provide chestphysiothera py BID for 5 days as indicated by treatment. 5. Nebulize with pulmicort |+ atrovent every 6 hrs. as ordered. 6.Administer mucolytics 10 ml x 7 days as ordered CPT helps in mobilization of secretions -Nebulization may be used to open constricted airways and liquefy secretions. -Facilitates liquefaction and removal of secretions ASSESSMENT Subjective: NA Objective: -with slightly delayed capillary refill (4 secs.) -episodes of frequent desaturation approx. 2-4x/ shift -(+) clubbing of fingernails NURSING DIAGNOSIS OBJECTIVES Impaired Gas Exchange related to altered oxygen supply, obstruction of airways by secretion, bronchospasm. After 12 hrs of nursing intervention the patient will be free from episodes of desaturation as manifested by oxygen saturation of 95100%. After 3-5 days of nursing intervention the patient will demonstrate improved ventilation and adequate oxygenation of tissues as evidenced by normal respiratory rate (20bpm), and good breathing NURSING INTERVENTION 1.Provide adequate rest. RATIONALE -To decrease oxygen demand. 2.Keep environment free of allergen. -To prevent irritation of bronchial walls. 3.Administer oxygen as ordered. -To increase oxygen of the patient. 4. Nebulize the patient as ordered. -To promote bronchodilation. 5. Administer meds. As ordered -To promote curative aspect EVALUATION GOAL MET. Patient is free from desaturation episode as manifested by O2 sat. of 99%. ASSESSMENT NURSING DIAGNOSIS OBJECTIVES Subjective: NA Ineffective Breathing Pattern related to airway constriction secondary to bronchial asthma After 12 hrs. of nursing intervention the patient will demonstrate breathing in normal rate, depth & rhythm. Objective: -(+) dyspnea -shortness of breath -increased work of breathing, use of accessory muscles -(+) nasal flaring -decrease O2 sat. After 3-5 days of nursing intervention the patient will experience no cyanosis, dyspnea and normal range O2 saturation. NURSING INTERVENTION 1. Maintain a clear airway, suction PRN, CPT as indicated. 2. Elevate the head and help change the position. 3.Nebulize with pulmicort |+ atrovent, administer mucolytics as ordered 4. Collaboration -Provide supplemental oxygen RATIONALE -Helps in mobilization of secretions. -Changing of position aids in mobilization of secretions that may ease expectoration of secretions. -Nebulization may be used to open constricted airways & liquefy secretions as well as the mucolytics. -maximize breath and reduce labor EVALUATION GOAL MET. Demonstrated normal breathing, no cyanosis and dypnea, and normal O2 saturation. Asthma is a chronic inflammation of the bronchial tubes (airways) that causes swelling and narrowing (constriction) of the airways. The bronchial narrowing is usually either totally or at least partially reversible with treatments. The most common chronic illness in children, affecting one in every 15. It involves only the bronchial tubes and usually does not affect the air sacs or the lung tissue. The narrowing that occurs in asthma is caused by three major factors: inflammation, bronchospasm, and hyperreactivity. Allergy can play a role in some, but not all, asthma patients. Many factors can precipitate asthma attacks and they are classified as either allergens or irritants. Symptoms include shortness of breath, wheezing, cough, and chest tightness.It is usually diagnosed based on the presence of wheezing and confirmed with breathing tests. Chest X-rays are usually normal in asthma patients. Avoiding precipitating factors is important in the management of asthma. Medications can be used to reverse or prevent bronchospasm in patients with asthma.