I.

INTRODUCTION:
According to the latest WHO data published in may 2014 Asthma Deaths in
the Philippines reached 12,342 or 2.37% of total deaths. The age adjusted Death
Rate is 21.20 per 100,000 of population ranks Philippines #9 in the world, but this
may not be epidemiologically accurate, since there are many etiologies and other
factors involve.
The main function of the respiratory system is to move airinto the lungs so
that oxygen can enter the body and carbondioxide can be exhaled. Several
pulmonary disorders can affect the airways. Their pathophysiology differs but these
diseasesare characterized by limited airflow. Airflow is limited whenair walls are
thickened, airway lumen is obstructed bysecretions, increasing resistance, and
smooth muscle of theairways 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.
Bronchial Asthma is a chronic inflammatory disease of the airway that causes
airway hyper responsiveness, mucosal edema and mucus production. Commonly
caused by physical and chemical irritants such as food, pollens, dust mites,
cockroaches, smoke, animal dander, temperature changes, respiratory infection
activity and stress. Allergic reaction in the airway can cause immediate reaction,
with obstruction occurring and it can precipitate late bronchial obstruction reaction
several hours after exposure. Mast cell release of histamine and leukotrienes that
result to diffuse obstructive and restrictive airway disease because of triad of
inflammation,

bronchoconstriction

and

increase

mucus

production.

Common

symptom is coughing in the absence of respiratory infection especially at night.

Status asthmaticusis a state where in a child displays distress despite vigorous
treatment measure; it is an emergency that can lead to respiratory failure and
death if left untreated.
Asthmausually begins in childhood or adolescence, but it also mayfirst appear
during adult years. While the symptoms may besimilar, certain important aspects of

asthma are different inchildren and adults. Children born to families with history
ofallergies or asthma are more likely to have asthma. Children wholive in urban
areas, where there is a higher incidence of airpollution, or live in a home that has
high levels of dust mites or cigarette smoke, are also at a higher risk for
asthma.Infants born prematurely or who suffer lung damage shortly afterbirth are
also more likely to have asthma. (Lemone, 2012).
Bronchial asthma is the more correct name for the commonform of asthma.
The term 'bronchial' is used to differentiate itfrom 'cardiac' asthma, which is a
separate condition that iscaused by heart failure. Although the two types of asthma
havesimilar symptoms, including wheezing (a whistling sound in thechest) and
shortness of breath, they have quite different causes (respiratory-lung, 2012).
Bronchial asthma is usually intrinsic (no cause can bedemonstrated), but is
occasionally caused by a specific allergy(such as allergy to mold, dander, dust). This
case study is athorough learning about Bronchial Asthma, which contains a
studyabout the normal physiology of the respiratory system,pathological physiology
of the disease, a thorough assessment ofthe patient with said illness, applied
nursing care plans topatients having this kind or disease, and discharge planning
toa patient to limit the recurrence of the attack or if not propermanagement and
care to be given during the time of asthma attack

II.PATIENT DATABASE
Demographics
Our patients name is M.X. She is 3 years old. She liveS in 273 Blk. 19
Brgy.Addition Hills, Welfare Vine, Talamban, Cebu City. They are Roman
Catholic. Her doctor is Dr.Black. She was admitted 3:00 am, July 12,
2009. She wasdiagnosed of Bronchial Asthma with Acute Exacerbation.
1.Gordons Functional Health Pattern
a.Health Perception-Health ManagementShe is a very active and playful
child. She doesnthave any allergies on any foods.
b.Nutritional-MetabolicShe doesnt have any special diet but she is
takingCeleen for her vitamin. At home, as verbalized by themother, she
can eat all of the food served. She didnthave difficulty of swallowing, and
started solid foodas the main composition of the food of the patient.
c.Elimination PatternShe did not experience any decrease in defecating
ordifficulty of urinating. Her bowel elimination pattern is once a day even
during her stays at the hospital.Her way of breathing is better than she is
at home,and she could go to comfort room with assistance ofmother (with
IV), read books, and eat all food served.
d.Activity-Exercise PatternOur patient loves to play bahay - bahayan and
running.She independently wears her dress but with assistancefrom her
mother. She can go to the bathroom, whenevershe wants to urinate and
defecate but her mother stillwashes her anus after defecating. She goes
schoolingin prep-school and playing or socializing, talking,mingling with
her classmates.
e.Sleep-Rest PatternShe experience difficulty of sleeping while admittedin
the hospital. Before her admission, she sleeps asearly as 10 in the
evening and wakes at 8 in themorning. During her hospitalization, she
sleeps at 10and wakes at 8 in the morning. She also sleeps onehour in
the afternoon. During night when her asthmaattacks, she cant breathe
normally usually having ahard time of breathing so her sleep during night
isdisturbed during her hospitalization period.

f. Sexuality-Reproductive Pattern

g.Cognitive-PerceptualShe neither has hearing difficulties nor eye

problems.She has a good memory for learning activities inschool like
problem solving and her mother makesdecisions for her during
medications, treatments, etc.and she also learns easily.
h.Self Perception Self ConceptShes feeling better every time she is
asked how shefeels. Her illness makes her feel worthless becauseshe
cannot do anything. She is very anxious every timeher asthma attacks.
i.Role relationshipShe lives with her family and depends on her parentsfor
her needs. She misses her siblings and likes totalk about them. In their
house she can easily expresswhat she wants or needs but during her
hospitalizationtime her parents didnt knew what are the needs thatshe
wanted or needed because of her condition.
j.Coping Stress ToleranceShe always wants her mother to be beside her
becauseshe provides all that she needs and she cries whenevershe cant
get something that she wants. She always wanted to go home right away
but because of thedoctors order they cant go home right away, so
theonly thing she can do is to cry.
k.RecreationalOur patient is a very playful child, she loves toexplore and
play with her friends almost everyday,usually playing for 2 hours. She
does also running asher favorite sport but now that she has Asthma,
hermother forbids her to run and play at the dusty places.
l.Value and BeliefsThey are Roman Catholic. She verbalized that she
knowsGod loves her and He will wash her illness away sothat she can go
home. The parents react patiently totheir daughters needs, and they
supported all whattheir child needs

Health History
a. Past and Present HistoryHistory of Present Illness
The patients past history of illness was said to be in thefathers side.
The patient was diagnosed with bronchial asthma since 2008given
Salbutamol nebulization as necessary.
2 days prior to admission, the patient experienced nonproductive
cough, watery nasal discharge, and (-) fever,and decreases in appetite.
1 day prior to admission, the patient experienceddifficulty of breathing,
excessively vomit once and 3 dosesgiven Salbutamol at Tunasan Health
Center every 4 hours.
Few hours prior to admission, they went to Ospital ngMuntinlupa for
consultation, the patient experiencedpersistence of difficulty of breathing.
She is a fully immunized child, complete BCG, DPT, OPV, andHepa B
immunization.
When she reached 1 year of age, she disregards to drinkmilk but
instead she started to eat solid foods like rice,etc.

I.

ANATOMY AND PHYSIOLOGY

Respiratory System
Main function- supplies oxygen to the blood while removing
carbon dioxide.
>The respiratory system organs oversee the gas exchanges
that occur between the blood and the external environment.
Using blood as the transporting fluid, the cardiovascular system
organs transport respiratory gases between the lungs and the
tissue cells.

Pediatric respiratory anatomy

Differences between Pediatric and Adult Airway

More rostral larynx
Relatively larger tongue
Angled vocal cords- Infants vocal cords have more angled attachment to trachea, whereas
adult vocal cords are more perpendicular
Differently shaped epiglottis- Adult epiglottis broader, axis parallel to trachea; Infant
epiglottis ohmega () shaped and angled away from axis of trachea
Funneled shaped larynx-narrowest part of pediatric airway is cricoid cartilage; narrowest
part of infants larynx is the undeveloped cricoid cartilage, whereas in the adult it is the
glottis opening (vocal cord)

Divisions of the respiratory tract

A. Structural
a. Upper respiratory tract( nose larynx)
b. Lower respiratory tract (bronchi- alveoli)
Because gas exchanges with the blood happen only in the alveoli, the
other respiratory system structures are really just conducting
passageways that allow air to reach the lungs. They also have important
jobs namely, to purify, humidify, and warm incoming air.
Upper respiratory tract
Nose
a. External

 External nares or nostrils- where air enters during breathing.

b. Internal
Nasal septum- divides the interior nasal cavity.
Olfactory receptors- located in the mucosa in the slit like superior part of
the nasal cavity, just beneath the ethmoid bone.
Respiratory mucosa- the
rest of the mucosa lining the
nasal cavity; Rests on a rich
network of thin walled veins
that warms the air as it flows
past. Moistens the air and
traps incoming bacteria and
other debris by the sticky
mucus produced by the
mucosas
gland
and
lysozyme enzymes in the mucus destroys bacteria chemically.
Conchae- greatly increase the surface area of the mucosa exposed to the
air. It also increase the air turbulence in the nasal cavity.
Palate- separates the nasal cavity from the oral cavity.
o Hard palate- anteriorly, where the palate is supported by bone.
o Soft palarte- the unsupported posterior part.
Paranasal sinuses(frontal, maxillary, ethmoidal and sphenoidal)
lighten the skull, and they act as resonance chambers for speech.
Nasolacrimal ducts- drains tears from the eyes, also empty into the nasal
cavities.
Pharynx
The pharynx is a muscular passageway also known as the throat. Common
passage way for food and air. It is continuous with the nasal cavity anteriorly
via the posterior nasal aperture. Air enters the superior portion, the
nasopharynx, from the nasal cavity and then descends through the oropharynx
and laryngopharynx to enter the larynx. The pharyngeal, palatine, and the
lingual tonsils are found in the pharynx.
Larynx or voice box
Larynx composed of hyoid bone and a series of cartilages
Single: thyroid, cricoid, epiglottis
Paired: arytenoids, corniculates, and cuneiform
It routes air and food into the proper channels and plays a
role in speech. It is formed by rigid hyaline cartilages and a
spoon flap of elastic cartilage, the epiglottis.
Thyroid cartilage- The largest of the hyaline cartilages,
which protrudes anteriorly and is commonly known as the
Adams apple.
Epiglottis - protects the superior opening of the larynx.
When we swallow food or fluids, the larynx is pulled upward
and the epiglottis tips, forming a lid over the larynx. The
food is now rerouted to the esophagus.
Vocal cords- Part of the mucous membrane of the larynx, which vibrate with
expelled air. This ability of the vocal folds to vibrate allows us to speak.
Glottis- The slit like passageway between the vocal folds.
Laryngeal folds consist of:

Paired aryepiglottic folds extend from epiglottis posteriorly to superior surface

of arytenoids
Paired vestibular folds (false vocal cords) extend from thyroid cartilage
posteriorly to superior surface of arytenoids
Paired vocal folds (true vocal cords) extend from posterior surface of thyroid
plate to anterior part of arytenoids
Interarytenoid fold bridging the arytenoid cartilages
Thyrohyoid fold extend from hyoid bone to thyroid cartilage

Trachea
Fairly rigid because its walls are reinforced with C-shaped rings of hyaline
cartilage. These rings serve a double purpose. The open parts of the rings
about the esophagus and allow it to expand when we swallow a large piece of
food. The solid portion support the trachea walls and keep it patent, or open, in
spite of the pressure changes that occur during breathing.
Divides into main bronchi.
Main bronchi
The right and the left are formed by the division of the trachea. Each main
bronchus runs obliquely before it plunges into the medial depression of the lung
on its own side.
The right main bronchus is wider, shorter, and straighter than the left. It is the
more common site for an inhaled foreign object to become lodged.
By the time incoming air reaches the bronchi, it is warm, cleansed of most
impurities, and well humidified.
Lungs
They occupy the entire thoracic cavity except for the most central area, the
mediastinum, which houses the heart, the great blood vessels, bronchi,
esophagus, and other organs.
Apex-the narrow superior portion of each lung is just deep to the clavicle.
Base- The broad lung area resting on the diaphragm.
Each lung is divided into lobes by fissures; the left lung has two lobes, and the
right lung has three.
The surface of each lung is covered with a visceral Serosa called the pulmonary,
or visceral pleura, and the walls of the thoracic cavity are lined by the parietal
pleura.
Pleural fluid- produced by the pleural membranes ; a slippery serous secretion
which allows the lungs to glide easily over the thorax wall during breathing
movements and causes the two pleural layers to cling together.
Has 3 types of alveolar cells:
o Pneumocytes 1: simple squamous
Very effective in gas exchange
o Pneumocytes 2: cuboidal
Produces surfactants prevents lung collapse and promotes lung
recoil
o Pneumocytes 3: machrophages
Ingests foreign matter and act as defense mechanism

Bronchioles
After the primary bronchi enter the lungs, they subdivided into smaller
branches, finally ending in the smallest of the conducting passageways, the

bronchioles. Because of these branching passageways, the network formed is

often referred as the respiratory tree. The terminal bronchioles lead into the
respiratory zone structures which eventually terminate into the alveoli.
Alveoli
The alveoli are the final branchings of the respiratory tree and act as the
primary gas exchange units of the lung. The gas-blood barrier between the
alveolar space and the pulmonary capillaries is extremely thin, allowing for
rapid gas exchange. To reach the blood, oxygen must diffuse through the
alveolar epithelium, a thin interstitial space, and the capillary endothelium; CO2
follows the reverse course to reach the alveoli. The final line of defense for the
respiratory tract is found in the alveoli. Macrophages also known as dust cells
wander in and out of the alveoli picking up bacteria, carbon particles, and other
debris. Most of the alveolar walls contain cuboidal cells which produce a lipid
molecule called the surfactant. It coats the gas-exposed alveolar surfaces and
lowers surface tension of the film of water lining the each alveolar sac so that
they do not collapse between each breath.

FUNCTIONS OF THE RESPIRATORY SYSTEM

The major function of the respiratory system is to supply the body with oxygen and
to dispose of carbon dioxide. To do this, at least four distinct events, collectively
called respiration, must occur:
Pulmonary ventilation: Air must move into and out of the lungs so that the
gases in the air sacs are continuously refreshed. Commonly called breathing.
External respiration: gas exchange occurs between the pulmonary blood and
alveoli.
Respiratory gas transport: oxygen and carbon dioxide are transported to and
from the lungs and tissue cells via the bloodstream
Internal Respiration: gas exchange occurs at systemic capillaries between
the blood and tissue cells.
Control
Ventilation occurs under the control of the autonomic nervous system from parts of
the brain stem, the medulla oblongata and the pons. This area of the brain forms the
respiration regulatory center, a series of interconnected brain cells within the lower and
middle brain stem which coordinate respiratory movements. The sections are the
pneumotaxic center, the apneustic center, and the dorsal and ventral respiratory groups.
-

Inspiration
Inhalation 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.
Under normal conditions, the diaphragm is the primary driver of inhalation. 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.
During forced inhalation, as when taking a deep breath, the external intercostal
muscles and accessory muscles aid in further expanding the thoracic cavity.

Expiration
Exhalation is 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. The lungs have a natural elasticity: as they recoil from the stretch of
inhalation, air flows back out until the pressures in the chest and the atmosphere reach
equilibrium.
During forced exhalation, as when blowing out a candle, expiratory muscles including
the abdominal muscles and internal intercostal muscles, generate abdominal and thoracic
pressure, which forces air out of the lungs.
Inspiration
Expiration

Circulation
The right side of the heart pumps blood from the right ventricle
through the pulmonary semilunar valve into the pulmonary trunk. The
trunk branches into right and left pulmonary arteries to the pulmonary
blood vessels. The vessels generally accompany the airways and also
undergo numerous branchings. Once the gas exchange process is
complete in the pulmonary capillaries, blood is returned to the left side
of the heart through four pulmonary veins, two from each side. The
pulmonary circulation has a very low resistance, due to the short
distance within the lungs, compared to the systemic circulation, and for
this reason, all the pressures within the pulmonary blood vessels are
normally low as compared to the pressure of the systemic circulation
loop.
Gas exchange
The major function of the respiratory system is gas exchange
between the external environment and an organism's circulatory system. In humans and
mammals, this exchange facilitates oxygenation of the blood with a concomitant removal of
carbon dioxide and other gaseous metabolic wastes from the circulation. As gas exchange
occurs, the acid-base balance of the body is maintained as part of homeostasis. If proper
ventilation is not maintained, two opposing conditions could occur: 1) respiratory acidosis, a
life threatening condition, and 2) respiratory alkalosis
Upon inhalation, gas exchange occurs at the alveoli, the tiny sacs which are the basic
functional component of the lungs. It occurs by simple diffusion through the respiratory
membrane. The alveolar walls are extremely thin (approx. 0.2 micrometres). These walls
are composed of a single layer of epithelial cells (type I and type II epithelial cells) in close
proximity to the pulmonary capillaries which are composed of a single layer of endothelial
cells. The close proximity of these two cell types allows permeability to gases and, hence,
gas exchange.

Oxygen is transported in the blood in two ways. Most attach to hemoglobin molecules to
form oxyhemoglobin. The other amount of oxygen is carried and dissolved in plasma.
Most carbon dioxide is transported in plasma as the bicarbonate ion, which plays a very
important role in the blood buffer system. A smaller amount of Carbon dioxide is carried
inside the RBCs bound to hemoglobin at a different site than oxygen does, and so it
doesnt interfere in any way with oxygen transport. Before carbon dioxide can diffuse out
of the blood into the alveoli, it must first be released from its bicarbonate ion form. For
this to occur, bicarbonate ions must enter the RBC where they combine with hydrogen
ion to form carbonic acid. Carbonic acid quickly splits to form water and carbon dioxide,
which diffuses from the blood and enters

NAME OF TEST
Complete Blood Count(July
12,2009- 6:59 am)
Purpose: CBC is ordered
toaid in the detection
ofanemias; hydration
status;and as part of
routinehospital admission
test. Thedifferential WBC
isnecessary for
determiningthe type of
infection

Medical Management:

NORMAL VALUE

RESULTS

SIGNIFICANCE

RBC: 4-6 x 10/L

4.28

Hct: 0.37- 0.47

0.36

Hgb: 110- 160 gm/L

111

WBC: 5-10 x 10 /L

11.3

Lymphocytes:0.25-0.35

0.25

Segmenters: 0.50-0.65

0.74

Eosinophil: 0.01-0.06

0.01

Increased segmenters
(mature neutrophils)
reflect a bacteria
linfection since thisare
the bodys firstline of
defense against acute
bacteria linvasion.
Lymphocytes are
decreased during early
acute bacteria linfection
and only increase late in
bacterial infections but
continue to function
during the chronic
phase

Quick relief medications

- Short acting beta 2 agonist
- Anticholinergics
- Systemic corcosteroids
Long term medications
- Corticosteroids
- Antiallergic medications
- NSAIDS
- Long acting beta 2 agonist
- Leukotriene modifiers
- Long acting bronchodilators
For status asthmaticus
- Continuous nebulization with an inhaled beta 2 adrenergic agonist and IV
corticosteroids maybe necessary to reduce symptoms
- Oxygen at 30%-40% concentration; if greater than 40% use venture mask
- Oxygen levels may only be increase if it is determined that the child is not
acidotic
- IV at D5 45% saline
- Use cough suppressants with caution

Nursing Management

Interventions during acute asthma attacks

- Assess airway patency
- Administer humidified oxygen
- Administer quick relief medication
- Continuous monitoring of respiratory function, pulse oximeter, and color; be
alert to decreased wheezing or a silent chest
- Initiate an IV line and prepare to correct hydration, acidosis and or electrolyte
imbalances
- Prepare child for chest radiograph
- Prepare to obtain samples for determining arterial blood gas and serum
electrolyte levels
Chest physiotherapy
Allergen control
Home care measures
- Instruct the family on measures to eliminate allergens
- Avoid extremes of temperature
- Avoid exposure to individuals with URTI
- Instruct how to identify early signs of asthma attack
- Encourage adequate rest and balance diet
- Instruct on the importance of adequate fluid intake
- Assist to develop an exercise program
- Encourage to cough effectively
- Encourage parent to keep immunization up to date
- Inform other person of existing asthma condition

DISCHARGE PLAN
MEDICATION
Instructed the SO to let the patient continue taking the following medications:
Cefuroxime (Tergecef) 20 mg/ml drops; 1.2 ml 2x/day x 4 days or until
consumed
Montelukast 4mg (Sinjulair/Kastair) chew tab; 1 tablet at bedtime x 1 month
Nasatapp syrup 2.5 ml 3x /day
Ambrolex 15mg/5ml; 2.5ml 3x /day
Salbutamol (Ventolin) 1 nebule every 12 hrs
Instructed SO to let the patient take medication at the right dosage, right time, right
route and right frequency
Informed patients SO about the indication, contraindications and adverse effect of
the medication
ENVIRONMENT
Encouraged SO to maintain a clean, therapeutic and peaceful environment at home
Encouraged to have well ventilated environment
Encouraged to maintain a safe home free from any healthy hazards such as sharp
objects, chemicals and matches
Advised not to leave patient alone and to keep watch at all times
Encouraged SO to keep away the allergens that can trigger the patients allergy like
pollens, dust, animal dander & etc.
TREATMENT
Instructed patients SO to have follow-up check-ups with physician
Encouraged patients SO to fully participate in continuing treatment at home
HEALTH TEACHINGS
Encouraged SO to give child a good sleeping time and adequate nutrition
Reminded SO to always assess patient needs
Encouraged SO to do chest tapping to facilitate mobilization of secretions
Encouraged SO to change patients position regularly to facilitate drainage and
mobilization of secretions
Instructed SO to observe proper hygiene such as bathing the baby daily to keep the
baby from infection
Instructed SO to keep the child always clean and dry
Advised SO to give toys that are big for the mouth so that the patient may not be
able to swallow these
Instructed SO to do hand washing before and after contact with patient
Instructed SO not to take the patient to crowded places to prevent risk of having
infection
Instructed SO to give medications at the right route, dose and time
OBSERVABLE SIGNS & SYMPTOMS
Advised to go to the physician if the following signs and symptoms of pneumonia are
observed.
fever

 chills
cough
unusually rapid breathing
breathing with grunting or wheezing sounds
labored breathing that makes a childs rib muscles retract (when muscles under the rib
cage or between ribs draw inward with each breath)
vomiting
chest pain
abdominal pain
decreased activity
loss of appetite (in older children) or poor feeding (in infants)
in extreme cases, bluish or gray color of the lips and fingernails
DIETS
Reminded SO to serve the food mentioned to the patient.:
Advised to follow the right vitamin C and multivitamin supplements to be
taken
Encouraged oral fluids
Encouraged to eat green leafy vegetables such as kamungay,
kangkong, and pechay
Encouraged to eat high calorie or carbohydrates foods such as rice, bread,
and root crops to provide adequate energy and to improve nutrition
SPIRITUALITY
Encouraged SO to continue praying to God and to attend mass every Sundays and
other days
Encouraged to keep and uphold pre-existing family values such as close family ties,
respect and love