Case Abstract

This is the case of 6 month baby boy patient admitted at OSMUN

2/23/10 with a chief complaint of DOB. Initial Vital Signs: RR: 68
HR: 155 T: 38.0 ˚C immediately given 90% O2 Sat (6 LPM in Mask),
Upon admitting, CBC, X- Chest X-ray APL, ABG, PE Done, Diagnosis of
pt is Asthma.

Learning Objectives
-To describe the nature of the disease process of Asthma
-to identify medication/treatment given
-to analyze the pathophysiology of the disease
-to determine the plan of care given
-to identify the anatomy and physiology of the involve system
-to interpret the laboratory results
-to analyze the diagnostic procedure given
BIOGRAPHIC DATA:
NAME: Baby boy S. A.
AGE: 6 months GENDER: Male
ADDRESS: Muntinlupa City
DATE OF BIRTH: July 25, 2009 PLACE OF BIRTH: OSMUN
ADMITTING DIAGNOSIS / IMPRESSION: Asthma

NURSING HISTORY:
MAJOR CONCERN: Difficulty of breathing

HISTORY OF MAJOR CONCERN: 2 days PTA the patient experienced productive

cough and vomiting and was given ambroxol with no consultation. 4 hours PTA the
patient experienced difficulty of breathing and increase respiratory rate and fever. Upon
admission, the patient was immediately given oxygen. The patient is transferred from ER
to pedia ward .
 CURRENT HEALTH STATUS:

I: PHYSIOLOGIC MODE

A: REST
According to the grandmother, her grandchild usually wakes up at 7 am and sleeps around
11pm. The infant usually sleeps 2-3 hours in the afternoon and sleeps 5 hours at night until morning.

B: Activity
Due to the child illness, the infant is restricted to do strenuous activity such as crawling for
hours, tickling him and etc.

C: NUTRITIONAL METABOLIC PATTERN

According to the grandmother, the infant is are usually introduced in solid food such as
Cerelac, Rice and Soya , mixed vegetables. He usually consumes 1-2 small plates per day. The
infant usually drinks 6 oz of milk for about 3-4 bottles a day. Restricted from eating crackers.
Their source of water supply is Wilkins. Medication used cefuroxime, hydrocortisone and
salbutamol.

D: ELIMINATION PATTERN
a. Bladder
The infant usually consumes 2-3 diapers, 180 cc/day, aromatic, and yellowish in color

b. Bowel
The infant usually consumes 2 diapers a day with urine. The consistency is soft and
yellowish to brown color.

E: FLUID ELECTROLYTES
The infant has good skin turgor, no K, Ca, Na supplements but the infant is taking
immunozinc vitamins

F: OXYGENATION AND CIRCULATION

The infant is experiencing productive cough, the infant’s grandfather has a history of
asthma. The infant is experiencing difficulty in breathing with wheezes

G: SKIN INTEGRITY
 The infant has green spot in his left upper, his skin temperature is warm to touch and
smooth

Growth and Development

Month Motor Fine motor Socialization Play

Development Development and
Language
0-1 Largely Keeps hands Enjoys
reflex fisted; able watching face
to follow of primary
object to caregiver,
midline listening to
soothing
sounds
2 Holds head Has a social Makes Enjoys bright-
up when smile cooing colored
prone sounds; mobiles
differentiates
cry
3 Holds head Follows Laughs out Spends time
and chest up object past loud looking at
when prone midline hands or uses
them as toy
during the
month
4 Grasp, Needs space
stepping, to turn
tonic neck
reflex are
fading
5 Turn front to Handles
back; no rattles well
longer has
head lag
when pulled
up right;
bears partial
weight on
 feet when
held upright
6 Turn both Uses palmar May say Enjoys
ways; moro grasp vowel bathtub toys,
reflex fading sounds rubber ring
for teething
(oh oh)

Freud Psychoanalytical theory

Infant (6 months)

 Oral stage

-The patient explores the world by using mouth via breastfeeding and pacifiers
for enjoyment or relief of tension, as well as for nourishment.

Erickson’s theory of Psychosocial Development

 Trust vs. Mistrust

- The patient learns to love and be loved, whose discomforts safely removed
to view the world as a safe place. He becomes fearful and suspicious of the
world and also to the strangers.

Piaget’s Theory of Cognitive Development

 Sensory Motor stage

- The patient can recognize his parents, that a parent remains the same person
whether dressed in a robe or pants and a T-shirt

- The patient learns he is a separate entity from objects.

Kohlberg’s theory of Moral Development

 Prereligious Stage

- The patient learn when he do certain action, parents give affection and
approval.
 - Sometimes scolded and labeled the behavior ‘bad”

PHYSICAL EXAMINATION

Date performed: 02/27/10 No. of Hospital Days: 4 days

1.1 Weight: 8.8 kg Length: 71cm

1.2 Vital Signs:
Temperature: 38.0˚C CR: 140 RR:68
1.3 When applicable
Head circumference: 46cm
Abdominal circumference: 50cm
Chest circumference: 52cm

H: REGIONAL EXAMINATION

2.1 Hair: Distribution: well distributed Appearance: black Texture: coarse and silky
2.2 Skin: Color: Fair
2.3 Head: Size: normal Shape: normocephalic
Fontanelles: Anterior open posterior closed
2.4 Face: Symmetry: symmetrical
2.5 Eyes: Color (Optic disk & conjunctiva): pinkish (conjunctiva)
Pupil Response: reactive to light
2.6 Ears: Symmetry: symmetrical Discharges/growth: no discharges

2.7 Nose: condition of mucosa:dry Discharges/growth: no discharges

2.8 Mouth & Pharynx

Lips : color /smoothness: pale, crack lips
Tongue : lesions/condition of mucosa: no lesions, pinkish
Teeth : looseness/presence of cavity: none
Mucous membrane : color: pinkish
Gums : color: pinkish

2.9 Neck: Symmetry: symmetrical

Lymph nodes: no lymph nodes present
2.10 Chest walls (Anterior and posterior)
Symmetry: asymmetrical, R chest wall is larger than L
 Breath sounds: presence of wheezes
2.11 Breast and Axillary areas:
Symmetry: asymmetrical Retraction: (+) retraction
Discharge: no discharges Lymph nodes: none
2.12 Heart: Rhythm: S1S2, regular
Intensity: normal (+2)
Extra Sounds / beats: no extra sounds Murmurs: none
2.13 Abdomen:
General Contour: globular and rounded, soft Tenderness: no tenderness
Bowel Sounds: presence of bowel sounds
2.14 Genitals:
Growth: descended testes Discharges: none
2.15 Anus and Rectum: patent

2.16 Extremities:
Extremities (-) edema
ROM: full range of motion
OTHER SOURCES

1. Laboratory Examination.
 Examination Done Results Reference values

ABG(Arterial Blood Gas) – 2/23/10

determine the effectiveness
of ventilation and acid base 7.360 7.350-7.450
31.2
status 35-45 mmHg
171.9 80-100 mmHg
Ph 22-26 mmol/L
PaCO2 17.2
HCO3 -7.3 80-100%
Base excess
99.4% SET UP
O2 Sat %  A/C
 Face mask
 SIMV
 T-Piece
SET  BIPAP
 Room air
40% FIO2  CPAP
 Nasal
 CMV/IMV
Cannula
 MV Support
 Ambu
Bagging

Complete Blood
Count(CBC) -

125 - 160 g/L

Hemoglobin 107 0.38 - 0.50 %
Hematocrit 0.32 5 - 10 10^g/L
WBC Count 9.92 0.00 - 0.01 %
Stab 0 0.40 - 0.60 %
Neutrophile 0.62 0.01 - 0.01 %
Eosiniphile 0.01 0.00 - 0.01 %
Basophile 0.00 0.20 - 0.40 %
Lymphocyte 0.28 0.02 - 0.08 %
Monocyte 0.09 5 - 15 10^4/L
Reculocyte 0.06 4.5 - 5.5 10^12/L
RBC Count 3.74 150 - 350 10^g/L
Platelet Count
Blood Typing O+ 2 - 4 mins
Bleeding time 338 7 - 15 mins
Clotting

Chest X-ray (pending result)

ANATOMY AND PHYSIOLOGY OF THE LUNGS
The left and right lung

The two lungs, which fill most of the thorax, are each enclosed within a double membrane
known as the pleura. The right lung is the larger, being divided into three lobes, while the left is divided
into two lobes. The lobes are further divided into bronchopulmonary segments, each of which has a
segmental bronchus.

The bronchi and bronchioles

The trachea branches off into the two main tubes of the lungs – the right and left bronchi. Within
the lungs the bronchi branch again, forming secondary and tertiary bronchi, then smaller bronchioles,
and finally terminal bronchioles. At the end of the terminal bronchioles are the alveoli.

In all there are about 25 divisions between the trachea and the alveoli, with the structure of the
tubes changing progressively from the trachea to the terminal bronchioles.

The structure of the first 7 divisions has:

 a wall comprising cartilage and smooth muscle
 an epithelial lining with cilia and mucus-secreting goblet cells
 Endocrine cells.
The next 16—18 divisions have:
 no cartilage
 a progressively thinner muscular layer
 a single layer of ciliated cells
 few goblet cells
 granulated Clara cells that produce a surfactant-like substance

The alveoli

The alveolar sacs are made up of groups of alveoli at the end of the terminal bronchioles. Each
lung contains approximately 300 million alveoli, giving a total surface area of 40—80m2. The
epithelial lining of the alveoli consists mainly of type 1 pneumocytes which provide a thin layer for gas
exchange. They are connected to type II pneumocytes (from which they are derived) by tight junctions.
These tight junctions limit the fluid movement in and out of the alveoli. Although more numerous than
the type I pneumocytes, type II pneumocytes cover less epithelium. They contain vacuoles that produce
the pulmonary surfactant. The alveoli also contain macrophages which contribute towards the defence
mechanisms of the lungs.

Pulmonary vasculature

Deoxygenated blood from the heart is carried to the lungs via the pulmonary artery, which
divides with the bronchi and bronchioles. At the level of the bronchioles, the pulmonary arterioles have
very thin walls. The alveoli are served by a diffuse network of capillaries which provides a large
surface area of approx. 30m2 for gaseous exchange. Oxygenated blood from the capillary network
passes into pulmonary venules which join forming the pulmonary veins.
 Another bronchiole circulatory system arises from the descending aorta, where the bronchial
arteries supply oxygenated blood to the tissues of the lung, and bronchial veins drain into the
pulmonary veins.

Lymphatic system of the lungs

Lymphatic channels are closed vessels that are located between the alveolar cells and the
endothelium of the pulmonary arterioles. Resembling capillaries, the ends of these vessels usually lie
within the interstitial spaces and have walls of only one endothelial cell. This allows for the diffusion of
fluid and large particles. The lymph carries proteins, lipids, dead cells and foreign particles away from
the interstitial spaces, hence playing a major role in defending the lungs from disease.

Nerve supply to the lungs

Parasympathetic and sympathetic nerve supplies from a plexus at the nerve root, with branches
that accompany the pulmonary arteries and bronchioles.

Physiology of the lungs

Contraction and relaxation of the muscles of the chest and the diaphragm are responsible for
inspiration and expiration. When air is inhaled, the diaphragm contracts and flattens and the intercostal
muscles between the ribs contract, pulling the ribcage upwards and outwards. During exhalation, the
intercostals muscles and the diaphragm relax, pulling the ribcage down and contracting the lungs. This
reduces the volume of the chest and forces the air out of the lungs.

The respiratory centre, located in the brain stem, controls breathing. Although breathing is an
involuntary process, the depth and rate of breathing can be altered voluntarily.

Oxygen from inhaled air passes through the alveoli into the bloodstream. The blood is then
taken to the left side of the heart via the pulmonary veins, and from here it is pumped around the body.
Deoxygenated blood, which returns from the body to the right side of the heart, is pumped back to the
lungs via the pulmonary arteries. Carbon dioxide passes from the capillaries which surround the
alveoli, into the alveolar spaces, and is breathed out.

2. Related Studies – readings on the condition/diagnosis of the patient.

a. Definition
b. Pathophysiology (in paradigm)
 PATHOPHYSIOLOGY OF ASTHMA

NONMODIFIABLE
MODIFIABLE
- HEREDITARY
- ALLERGENS
(dust, fur from - 6 months
animals, etc.)
- SUDDEN
CHANGE OF
TEMP.

RELEASE OF IgE BY B-
LYMPHOCYTES

IgE + MAST
CELLS

DAMAGE TO MAST
CELLS

RELAESE OF CHEMICAL MEDIATORS

SUCH AS HISTAMINE, BRADYKININ,
PROSTAGLANDIN, SEROTONIN,
LEUKOTRIENES

BRONCHOSPASMS

- BRONCHOCON
STRICTION

- EDEMA OF
MUCUS
MEMBRANE

- HYPERSECRETI
ON OF MUCUS

- NARROWING
OF AIRWAYS

SIGN AND
SYMPTOMS
 VASODILATI EXHAUSTI
ON ON

SLOW, SHALLOWING RESPIRATION

(HYPOVENTILATION)

RETENTION OF
CO2
HYPOTENSIO BLOOD
CONGESTIO - INCREASE
N CAPILLARY HYPOXI RESPIRATO
PREMIABILITY A RY
VENTILATIO
- ESCAPE OF
N
SHOC COLLOIDS
K

EDEM DECREASE BLOOD

A VOLUME

ASTHM
A
 Drug Study
Name of Drug
(genericof
Name and brand Classification Dosage/ Route Mechanism of Indication Nursing
Drug
name) Classification Dosage/ Route
Frequency Mechanism of Action
Action Indication Nursing
Responsibility
(generic and Frequency Responsibility
brand name)
Hydrocortisone Anti-inflammatory 40mg IV Decreases Used in the -Assess affected
Immunosuppressant Q6 inflammation, mainly management of prior to and daily
Cefuroxime Antiinfective 300mg IV Semisynthetic second Infectiony caused by -Determine history
by stabilizing wide variety of during therapy.
generation cephalosporin susceptible organisms of hypersensitivity
Antibiotic leukocyte lysosomal allergic/ -Note degree of
antibiotic with structure in the lower reaction to
membrane; suppress immunologic inflammation and
Second similar to that of the respiratory tract, cephalosporines ,
immune response, reaction. pruritus.
generation penicillin. penicillin and
stimulates bone . -Notify physician
cephalospirin Resistance against beta- history of allergy,
marrow; and influences or other health
lactamase-producing strains particularly to
protein, fat and care provider for
exceeds that of first drugs, before
carbohydrate symptoms of
generation cephalosporin. therapy is
metabolism infection
Preferentially binds to one or initiated.
develop.
more of the penicilin-binding
-Monitor for
proteins(PBP)located on cell
manifestation of
walls of susceptible hypersensitivity.
organisms. Discontinue drug
This inhibits third and final and report their
stage of bacterial cell wall appearance
synthesis thus killing the promptly.
bacterium.Partial cross-
allerginity between other -
beta-lactain antibiotics and
cephalosporin has been
reported.
 Name of Drug
(generic and brand Classification Dosage/ Route Mechanism of Indication Nursing
name) Frequency Action Responsibility

Salbutamol(Combivent Salbutamol . The Management of -Ensure that the

Nebule) sulfate 2cc +2cc NSS Inhalation, oral combination of reversible nebulizer mask
pratropium and bronchospasms fits the user face
Q1
albuterol is used associated with properly and that
to prevent obstructive nebulized
wheezing airway disease solution does not
difficulty bronchial asthma escape into the
breathing chest eyes .
tightness and
-CPT to
coughing.
immobilize
secretions

-Evaluate
therapeutic
response
-
Name of Drug Classification Dosage/ Route Mechanism of Indication Nursing
(generic and Frequency Action Responsibility
brand name)

Paracetamol Non narcotic Q4 Oral -The preparation -Monitor for

Analgesics PRN The mechanism is indicated in signs and
of action is diseases symptoms of
Antipyretics related to manifesting with hepatotoxicity,
depression of the pain and fever, even with
prostaglandin headache, moderate
synthesis by toothache, mild acetaminophen
inhibition of the and moderate doses especially
specific cell postoperative and in individuals
cyclooxygenase injury pain, high with poor
and depression of temperature, nutrition.
the infectious
thermoregulatory diseases and
center in the chills.
medulla
oblongata. -Can be given to
children after
vaccinations to
prevent post-
immunization
pyrexia
(high temp.) : is
often included in
cough, cold and
flu remedies.
 NURSING CARE PLANS
Problems and Nursing
Cues Diagnosis Objective Intervention Rationale Evaluation

S= Ineffective After 2 hours of Independent: After 2 hours of

- “Nahihirapan Airway nursing -Auscultate breath nursing
huminga ang apo Clearance intervention the sounds intervention the
ko” as verbalized related to patient will show - Some degree of patient show sign
-Monitor RR every 2 hrs bronchospasms
by the pt’s increased signs improve airway
grandmother production of improving is present w/ clearance
secretions airway clearance obstruction in
O= airway
- Nasal flaring -chest physiotherapy - To immobilize
- (+) intercostals Rationale: (CPT) after nebulisation. secretions
and subcostal Inability to clear
retraction secretions or - To deacrease the
-Increased fluid intake,
- Difficulty of obstruction from viscosity of
the respiratory provide warm or tepid
breathing secretions,
tract to maintain liquids w/ SAP,
- Tachypnea facilitating
a clear airway expectorant,
- RR: 68 breathes using warm
per minute liquids may
- With wheezing Dependent: decrease
sound heard at the -Administer bronchospasm
right lung field
- with productive
bronchodilators as - To decrease
cough note with prescribed brochospasm
whitish phlegm
amount of 2 cc -suctioning if needed as - To clear
ordered secretion
 NURSING CARE PLANS
Problems and Nursing
Cues Diagnosis Objective Intervention Rationale Evaluation

Subjective:
“ hinahabol niya ang Ineffective After 2 hours of Independent:
kanyang hininga” as Breathing Pattern nursing -Auscultate the chest -To Evaluate the After 2 hrs of
verbalized by the Related to intervention the presence or character nursing
grandmother constriction of patient will of Breath sounds/ intervention the
bronchi, establish a normal secretion. patient was able
effective -Evaluate cough presence -Indicating possible to demonstrated
respiratory System. of secretion obstruction improved
Objective: ventilations and
- Use of Rationale: -chest physiotherapy after -helps to aid oxygen tissues
accessory Inspiration nebulization. immobilization of and absence of
muscle while and/or expiration secretions. symptoms of
breathing
that does not -position the patient in a -to enhance lung respiratory
- DOB
- (+) IC and SC provide adequate sitting position expansion distress.
retraction ventilation.
- RR=68 Dependent:
-Administer oxygen at -management of
lowest concentration and underlying pulmonary
prescribed respiratory condition, respiratory
medication. distress or cyanosis.
-decrease
brochospasm
-administer conbivent
nebulizer as ordered
 NURSING CARE PLAN
Problems and Nursing
Cues Diagnosis Objective Intervention Rationale Evaluation

Independent:
Subjective: Hyperthermia After 30 mins of -monitor Temperature -provide baseline data After 3 hours of
“nilalagnat ang apo related to increased nursing intervention - teach the grandmother to -heat loss by nursing
The client will intervention the
ko”as verbalized by metabolic rate apply TSB conduction
decrease client decrease
the grandmother temperature from
temperature from
38.0 C to 37.0-37.3 38.0 to 37.0 C
Objective: Rationale: C -increase fluid intake -to prevent
-febrile dehydration
-T: 38.0 ˚C Body temperature
-warm to touch elevated above
-flushed skin normal range Dependent:
-tachypnea -administer paracetamol -anti-pyretics
as ordered decreases body
temperature.
 NURSING CARE PLAN
Problems and Nursing Diagnosis Plan of care Intervention Rationale Evaluation
Cues
Objective: Activity intolerance After 8 hours of Independent: After 8 hours of
related to nursing intervention nursing intervention
-Dyspnea - Monitor VS -to provide baseline
deprivation the patient will the patient
data
-use of accessory oxygenation demonstrate a demonstrate a
muscles when decrease in -To prevent decrease in
physiological signs -adjust activities physiological signs
breathing overexertion
Rationale: of intolerance -plan care to of intolerance
-(+) retractions -to reduce fatigue
carefully balance
Insufficient
-tachypnea rest periods with
physiological energy
activities
endure or complete
required or desired Dependent:
daily activities -maintenance of
-Provide/monitor adequate
response to oxygenation
supplemental oxygen
and medication
 NURSING CARE PLAN
Problems and Nursing Plan of care Intervention Rationale Evaluation
Cues Diagnosis

Objective: Risk for infection After 8 hours of Independent >To assess causative After 8 hours of
related to poor nursing intervention, factors nursing intervention,
-overcrowded ward -Note risk factors
immune system. the client will the demonstrate
for occurrence of
-incomplete demonstrate techniques to
infection
immunization techniques to promote safe
promote safe -Note signs & environment
environment symptoms of
Rationale: At
infection >To reduce risk
increased risk for
factors
being invaded by -Monitor client’s
pathogenic visitor for
organisms. respiratory illness

-Proper
handwashing

-Proper waste >To prevent

disposal infection
 OLIVAREZ COLLEGE
Dr. A. Santos Avenue, Sucat Road
Parañaque City

NCAR
(Nursing Care Analysis Record)

Prepared By:
GROUP IV
GROUPS V
GROUP VI