A Case Study on Bronchial Asthma

In partial fulfillment of the course requirement for Advance Psyho-Pathophysiology

Presented to the Faculty of Cebu Normal University College of Nursing Graduate studies

Submitted by: Justin Craig Bulawan Delfin, B.S.N, R.N.

TABLE OF CONTENTS

I. Introduction II. Objectives III. Nursing Assessment 1.2 1.3

1.3.1 1.3.2 2. 3. 1. Personal History 1.1 Patients Profile Family and Individual Information, Social & Health History Level of Growth and Development Normal Development at a Particular Stage The Ill Person at a Particular Stage Diagnostic Results Present Profile of Functional Health Patterns 3.1 Health Perception / Health Management Pattern 3.2 Nutritional-Metabolic Patterns 3.3 Elimination Pattern 3.4 Activity / Exercise Patterns 3.5 Cognitive / Perceptual Pattern 3.6 Rest / Sleep Pattern 3.7 Self-Perceptual Patterns 3.8 Role Relationship Pattern 3.9 Sexuality-Reproductive Pattern 3.10 Coping-Stress Tolerance Pattern 3.11 Value-Belief System 4. Normal Anatomy and Physiology of the Organ/System Affected 5. Pathophysiology and Rationale 5.1 Schematic Drawing of Pathophysiology of the disease 5.2 Discussion of Disease Process 5.3 Comparative Chart of Classical Signs and Symptoms and the Actual Manifestation IV. Nursing Intervention 1. Care Guide of Patient with Disease Condition 2. Physical Assessment 3. Actual Patient Care 3.1 NCP 3.2 BLM 3.3 DTR 3.4 SOAPIE Charting 3.5 Health Teaching Plan V. Evaluation and Recommendation Prognosis Recommendation VI. Evaluation and Implication of this Case Study Nursing Practice Nursing Education Nursing Research VII. Bibliography

I. Introduction

Asthma (from the Greek , sthma, "panting") is the common chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm. Symptoms include wheezing, coughing, chest tightness, and shortness of breath. Asthma is clinically classified according to the frequency of symptoms, forced expiratory volume in 1 second (FEV1), and peak expiratory flow rate. Asthma may also be classified as atopic (extrinsic) or non-atopic (intrinsic). It is thought to be caused by a combination of genetic and environmental factors. Treatment of acute symptoms is usually with an inhaled short-acting beta-2 agonist (such as salbutamol). Symptoms can be prevented by avoiding triggers, such as allergens and irritants, and by inhaling corticosteroids. Leukotriene antagonists are less effective than corticosteroids and thus less preferred. Its diagnosis is usually made based on the pattern of symptoms and/or response to therapy over time. The prevalence of asthma has increased significantly since the 1970s. As of 2010, 300 million people were affected worldwide. In 2009 asthma caused 250,000 deaths globally. Despite this, with proper control of asthma with step down therapy, prognosis is generally good. Asthma is defined by the Global Initiative for Asthma as "a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role. The chronic inflammation is associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness and coughing particularly at night or in the early morning. These episodes are usually associated with widespread, but variable airflow obstruction within the lung that is often reversible either spontaneously or with treatment". Asthma is clinically classified according to the frequency of symptoms, forced expiratory volume in 1 second (FEV1), and peak expiratory flow rate. Asthma may also be classified as atopic (extrinsic) or non-atopic (intrinsic), based on whether symptoms are precipitated by allergens (atopic) or not (non-atopic). While asthma is classified based on severity, at the moment there is no clear method for classifying different subgroups of asthma beyond this system.Finding ways to identify subgroups that respond well to different types of treatments is a current critical goal of asthma research. Although asthma is a chronic obstructive condition, it is not considered as a part of chronic obstructive pulmonary disease as this term refers specifically to combinations of disease that are irreversible such as bronchiectasis, chronic bronchitis, and emphysema. Unlike these diseases, the airway obstruction in asthma is usually reversible; however, if left untreated, the chronic inflammation from asthma can lead the lungs to become irreversibly obstructed due to airway remodeling. In contrast to emphysema, asthma affects the bronchi, not the alveoli.

II. Objectives General Objectives: After 2 days of rendering holistic nursing care, the nurse will be able to develop And improve his knowledge, attitude, and skills in the care of a patient with Bronchial Asthma Nurse Centered: After 2 days of rendering holistic nursing care, the Nurse will be able to:

1. Establish rapport with the patient 2. Present a thorough nursing assessment of the patient with Bronchial Asthma using
the IPPA

3. Review:
the anatomy and physiology of the CNS and respiratory system normal level of growth and development of patient and the ill patient at particular age

4. Impart health teaching regarding Bronchial Asthma as to its:

o o o o clinical signs and symptoms predisposing and precipitating factors management

5. Trace the pathophysiology of Bronchial Asthma 6. Develop a comprehensive nursing care plan for the patient 7. Utilize the nursing process in caring patients with Bronchial Asthma
Patient Centered: After 2 days of student nurse client interaction, the patient and family will be able to:

1. Establish a trusting relationship with the student nurse 2. Identify the clinical signs and symptoms of Bronchial Asthma 3. Verbalize feelings and concerns 4. Take appropriate measures for the management of symptoms

5. Follow specific treatment regimen ordered or taught 6. demonstrate beginning skills in the management of Bronchial Asthma

III. Nursing Assessment 1. Personal History 1.1 Patients Profile Name: Mrs. M.L.B.A Age: 54 y .o Civil Status: Married Religion: Roman Catholic Date of Admission: March 19, 2012 Room No.: Bed 7 OPD Ward Chief Complaint: Dyspnea, Weakness Impression: Bronchial Asthma In Acute Exacerbation R/I Pleural Effusion Final Diagnosis: Acute Asthma Physician: Dr. Jasmin Olorvida 1.2 Family and Individual Information Mrs. M.L.B. is 54 years old, married from Barangayl Poblacion, Talisay City, Cebu admitted for the the 2nd time in Talisay District Hospital due to complaints of Dyspnea, and General Body Weakness. She is a Hypotensive, BP of 80/60, temperature of 37C, respiration of 30 bpm, pulse rate of 112bpm on initial assessment. She is given Hydrocortisone 100mg IVTT every 8 hours, Salbutamol nebulization alternate with saulbutamol + Ipratropium 1 nebule every 6 hours, Azithromycin 500 mg 1 tab OD x 3 days (done), Cefuroxime 750 mg IVTT every hours, and Paracetamol 500 mg 1 tab every 4 hours Per Orem PRN. He is non-diabetic and and a known asthmatic. The patient is not allergic to any food or medications but under hypoallergenic diet with aspiration precaution. She is a non smoker.She is an occasional alcoholic beverage drinker but already quit way back 20 years ago. She has history of hypertension in the family. She is very hardworking according to his Husband. He has previous hospitalization. Sex: Female Hospital No: 10 08 - 58

History of Present Illness Upon in the Emergency in Talisay District Hospital patient had bad onset of undocumented fever with chills, Dyspnea and General Body Weakness. She then selfmedicated with Paracetamol which afforded temporary relief. Two days prior to admission, persistence of dyspnea was present but nevers sought consultation in a mentality that it would only reside. His family then requested the patient to be consulted at Talisay District Hospital. 1.3 Level of Growth and Development 1.3.1 Normal development at particular stage: A. Physiological Changes: Major physiological changes occur between 40 and 65 years of age. The most visible changes are graying of the hair, wrinkling of the skin, and thickening of the waist. Balding commonly begins during the middle years, but it may also occur in young adult males. Decreases in hearing and visual acuity are often noted during this period. B. Mental Changes: Changes in the cognitive function of the middle adults are rare except with illness or trauma. The middle adult can learn new skills and information. Some middle adults enter educational or vocational programs to prepare themselves for entering the job market or changing jobs. C. Emotional Changes The emotional changes in the middle adult may involve expected events, such as children moving away from home, or unexpected events, such as marital separation or the death of a close friend. These changes may result in stress that can affect the middle adults overall level of health. Nurses should assess the major life changes occurring in the middle adult and the impact that the changes have on that persons state of health. Nursing assessment should also include individual psychosocial factors such as coping mechanisms and sources of social support.

D. Sexual Changes: The onset of climacteric can affect the sexual health of the middle adult. It is caused by decreased levels of androgens. Throughout this period and thereafter, a man is still capable of producing fertile sperm and fathering a child. However, penile erection is less firm, ejaculation is less frequent, and the refractory period is longer. Other factors influencing sexuality during this period include work stress, diminished health of one or both partners, and the use of prescription medications like antihypertensive agents, with side effects that may influence sexual desire or functioning. E. Social Changes According to Erik Erikssons developmental theory, the primary developmental task of the middle years is to achieve generativity. Generativity is the willingness to care for and guide others. Middle adults can achieve generativity with their own children or the children of close friends or through guidance in social interactions with the next generation. If middle adults fail to achieve generativity, stagnation occurs. This is shown by excessive concerns with themselves or destructive behavior toward their children and the community. Career changes may occur by choice or as a result of changes in the workplace or society. In technological advances, middle adults are forced to seek new jobs. Such changes, particularly when unanticipated, may result in stress that can affect health, family relationships, self-concept and other dimensions.

1.3.2 The Ill Person at particular stage: Acute and chronic illnesses may affect roles and responsibilities assumed by the middle adult. Strained family relationships, modifications in family activities, increased health care tasks; increased financial stress, the need for housing adaptation, social isolation, medical concerns, and grieving may all result from chronic illness. The degree of disability and the clients perception of both illness and the disability determine the extent to which lifestyle changes will occur. A few examples of the problems experienced by clients who develop debilitating chronic illness during adulthood include role reversal, changes in sexual behavior, and alterations in self-image. Along with the current health status of the chronically ill middle adult, the nurse must assess the knowledge base of both the client and family. This assessment should include the medical course of illness and the prognosis for the client, the coping mechanisms of the client and family, adherence to treatment and rehabilitation regimens, and the need for community and social services, along with appropriate referrals. (Patricia A. Potter and Anne Griffin Perry: Fundamentals of Nursing 5th edition volume 1 and 2 copyright 2001 by Mosby page 235-241, 549,655)

2. Diagnostic Results X- Ray Result As of 3 20 - 2012 RESULT: Both Lungs are hyperaeted with falttening of both hemidiaphrams. There are inhomogenous and fibronodular densities seen in both lung field. Comparative study with previous film dated 4 5- 2010 shows no significant change seen. IMPRESSION: - HYPERAETION OF BOTH LUNGS. -CHRONIC INFLAMMATORY PROCESS IN BOTH LUNG FIELD

Diagnostic Test Urinalysis (Macroscopic) Color Appearance Specific Gravity PH Protein Glucose Urinalysis (Microscopic) RBC WBC Epithelial cells Mucus threads Bacteria Crystals

Normal Value

Result

Significance

Yellow Cloudy 1.010 7.41 (-) (-)

Yellow (clear) Clear 1.030 6.0 -/+ Negative

Normal Normal Slightly Concentrated Slightly Acidic Trace Normal

2.4 12 -15 Moderate Few Moderate A.Urates Moderate

Diagnostic Test HEMATOLOGY WBC HCT Platelet POLY Lymph

Normal Values

Result

N.V 5 10 x 109 / L N.V = M = 0.4 0.5

8.0 x 109 /L .44 232,500 /umm .91 .09

3. Present Profile of Functional Health Pattern 3.1 Health Perception / Health Management Pattern Mr.Alipong, her son,spoke for the patient. According to him, the patients condition or health is not good because it is unlikely for the patient to experience this kind of illness. Mr. Cerna loves to eat healthy foods especially vegetables but not taking supplements. She is often stressed and overworked on chores on the house. Mr Aliponga stated that she is not well managed in terms of health that she only minds it if symptoms occur. 3.2 Nutritional-Metabolic Patterns Mrs. MLBA stated that she really like to eat vegetables. She drinks 8 to 10 glasses of water a day. She also like to eat sweats ang salty foods. Often times she eat meat but mostly fish is her favorite. She also like drinking coffee when is feeling drowse. She doest eat that much rice. She eats mostly 3 times a day and rarely go on snacks. 3.3 Elimination Pattern Mrs. MLBA as observed has normal bowel movement. In her interview she stated that she has a regular bowel movement everyday. She said she rarely had a day when she doest excrete. But when she was admitted, she hardly had a time when she had her last bowel movement. Also, Mrs. MLBA has increased urinary output but in normal condition. Also she sweats a lot especially when her asthma attacks.

3.4 Activity-Exercise Pattern Mrs. MLBA in her interview stated that in her prime, she was athletic but during her marital years, she was not as active as before. She spends her time looking out for her family and the house. Now, she spends her spare time cooking ang lloking out for her grand children. She spends time early morning to walk a couple of blocks on their neighbor and talk then goes back to the house and managing it.

3.5 Cognitive-Perceptual Patterns The patients hearing at present is not that good. He can hear but with a loud clear voice. He uses reading glasses. According to her daughter, Mrs. MLBA has a very good handwriting skills and able to read. She has a very calm voice and is understandable. She responds to verbal cues accurately but often time s forgetful on specific events. 3.6 Sleep-Rest Pattern The patients sleep is from 7 in the evening until 4 in the morning. According to her daughter, the patient loves to talk and do something. The patient is not taking any medication for sleep, but he always reads the novena booklet every night just to sleep. Now, he sleeps for the whole day, feeling very weak, only awakens in the middle of the day or night for his medications and other nursing interventions. 3.7 Self-Perception Pattern The patients family is very much concerned about her wellness and state. In an interview with her daughter, she stated that she is not that mindful about her physical appearance because she is already aged. But is concerned more about the family being there with her. She also feels lonely and in times, feeling depressed.

3.8 Role Relationship Pattern The patients family came from the province so she has close family ties. Her family is often time changing shifts. In my interview, the patients seemed to be important to the family as she is very well taken cared of. She is also married but her husband wasnt

present that it needed to take care of the house while the family was away. She also has close family ties whit the grand children and her sons and daughters. 3.9 Sexuality-Reproductive Pattern The patients sexual functioning is good in her prime. In fact, she had many children, some of which was not present at the time. Mrs. MLBA stated her reproductive years if far over but still has time to make love with her husband. 3.10 Coping-Stress Management Pattern The patients have good judgment and decision making skills. She very well instructs her family on their chores at home. In the ward, where the environment is not that conducive for healing, she takes time to clean the area and arrange the things so that its more stress free. 3.11 Value-Belief System Mrs. MLBA is a very religious person. He finds strength in God and from her family. Whenever she is with them she is very much contented, they go to church to hear mass every Sundays and other holy days of obligation. They are not active members of any religious organization.

4. Normal Anatomy and Physiology of Respiratory System Respiratory system The respiratory system is the anatomical system of an organism that introduces respiratory gases to the interior and performs gas exchange. In humans and other mammals, the anatomical features of the respiratory system include airways, lungs, and the respiratory muscles. Molecules of oxygen and carbon dioxide are passively exchanged, by diffusion, between the gaseous external environment and the blood. This exchange process occurs in the alveolar region of the lungs. Other animals, such as insects, have respiratory systems with very simple anatomical features, and in amphibians even the skin plays a vital role in gas exchange. Plants also have respiratory systems but the directionality of gas exchange can be opposite to that in animals. The respiratory system in plants also includes anatomical features such as holes on the undersides of leaves known as stomata. Ventilation In respiratory physiology, ventilation (or ventilation rate) is the rate at which gas enters or leaves the lung. It is categorized under the following definitions: Measurement Minute ventilation Equation tidal volume * respiratory rate tidal volume - dead space) * respiratory rate Description the total volume of gas entering the lungs per minute.
the volume of gas per unit time that reaches the alveoli, the respiratory portions of the lungs where gas exchange occurs. the volume of gas per unit time that does not reach these respiratory portions, but instead remains in the airways (trachea, bronchi, etc.).

Alveolar ventilation

Dead space ventilation

dead space * respiratory rate

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. This section is

especially sensitive during infancy, and the neurons can be destroyed if the infant is dropped and/or shaken violently. The result can be death due to "shaken baby syndrome". Inhalation 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. Pectoral muscles and latissimus dorsi are also accessory muscles. 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 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. During inhalation the diaphragm contracts. Exhalation 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.[10] 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. 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 other 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 acidbase balance of the body is maintained as part of homeostasis. If proper ventilation is not maintained, two opposing conditions could occur: respiratory acidosis, a life threatening condition, and respiratory alkalosis. Upon inhalation, gas exchange occurs at the alveoli, the tiny sacs which are the basic functional component of the lungs. 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) close 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. This whole mechanism of gas exchange is carried by the simple phenomenon of pressure difference. When the air pressure is high inside the lungs, the air from lungs flow out. When the air pressure is low inside, then air flows into the lungs. Non-respiratory functions: Lung defense mechanisms Airway epithelial cells can secrete a variety of molecules that aid in lung defense. Secretory immunoglobulins (IgA), collectins (including Surfactant A and D), defensins and other peptides and proteases, reactive oxygen species, and reactive nitrogen species are all generated by airway epithelial cells. These secretions can act directly as antimicrobials to help keep the airway free of infection. Airway epithelial cells also secrete a variety of chemokines and cytokines that recruit the traditional immune cells and others to site of infections.

Metabolic and endocrine functions of the lungs In addition to their functions in gas exchange, the lungs have a number of metabolic functions. They manufacture surfactant for local use, as noted above. They also contain a fibrinolytic system that lyses clots in the pulmonary vessels. They release a variety of substances that enter the systemic arterial blood and they remove other substances from

the systemic venous blood that reach them via the pulmonary artery. Prostaglandins are removed from the circulation, but they are also synthesized in the lungs and released into the blood when lung tissue is stretched. The lungs also activate one hormone; the physiologically inactive decapeptide angiotensin I is converted to the pressor, aldosteronestimulating octapeptide angiotensin II in the pulmonary circulation. The reaction occurs in other tissues as well, but it is particularly prominent in the lungs. Large amounts of the angiotensin-converting enzyme responsible for this activation are located on the surface of the endothelial cells of the pulmonary capillaries. The converting enzyme also inactivates bradykinin. Circulation time through the pulmonary capillaries is less than 1 s, yet 70% of the angiotensin I reaching the lungs is converted to angiotensin II in a single trip through the capillaries. Four other peptidases have been identified on the surface of the pulmonary endothelial cells. Vocalization The movement of gas through the larynx, pharynx and mouth allows humans to speak, or phonate. Vocalization, or singing, in birds occurs via the syrinx, an organ located at the base of the trachea. The vibration of air flowing across the larynx (vocal cords), in humans, and the syrinx, in birds, results in sound. Because of this, gas movement is extremely vital for communication purposes. Temperature control Panting in dogs and some other animals provides a means of controlling body temperature. This physiological response is used as a cooling mechanism.

5. Pathphysiology and Rationale 5.1 Schematic Drawing of Pathophysiology of the disease

Environmental Risk Factors (Predisposing Factors)

INFLAMMATION! !

Airway HyperResponsivenesss

Airflow Limitation

Precipitants Symptoms: wheezing, shortness of breath, chest tightness and coughing, and use of accessory muscle

5.2 Discussion of the Disease Process Asthma is caused by environmental and genetic factors. These factors influence how severe asthma is and how well it responds to medication. The interaction is complex and not fully understood. Studying the prevalence of asthma and related diseases such as eczema and hay fever have yielded important clues about some key risk factors. The strongest risk factor for developing asthma is a history of atopic disease; this increases one's risk of hay fever by up to 5 and the risk of asthma by 34. In children between the ages of 314, a positive skin test for allergies and an increase in immunoglobulin E increases the chance of having asthma. In adults, the more allergens one reacts positively to in a skin test, the higher the odds of having asthma. Because much allergic asthma is associated with sensitivity to indoor allergens and because Western styles of housing favor greater exposure to indoor allergens, much attention has focused on increased exposure to these allergens in infancy and early childhood as a primary cause of the rise in asthma. Primary prevention studies aimed at the aggressive reduction of airborne allergens in a home with infants have shown mixed findings. Strict reduction of dust mite allergens, for example, reduces the risk of allergic sensitization to dust mites, and modestly reduces the risk of developing asthma up until the age of 8 years old.However, studies also showed that the effects of exposure to cat and dog allergens worked in the converse fashion; exposure during the first year of life was found to reduce the risk of allergic sensitization and of developing asthma later in life. The inconsistency of this data has inspired research into other facets of Western society and their impact upon the prevalence of asthma. One subject that appears to show a strong correlation is the development of asthma and obesity. In the United Kingdom and United States, the rise in asthma prevalence has echoed an almost epidemic rise in the prevalence of obesity. In Taiwan, symptoms of allergies and airway hyper-reactivity increased in correlation with each 20% increase in body-mass index.] Several factors associated with obesity may play a role in the pathogenesis of asthma, including decreased respiratory function due to a buildup of adipose tissue (fat) and the fact that adipose tissue leads to a pro-inflammatory state, which has been associated with non-eosinophilic asthma. Asthma has been associated with ChurgStrauss syndrome, and individuals with immunologically mediated urticaria may also experience systemic symptoms with

generalized urticaria, rhino-conjunctivitis, orolaryngeal and gastrointestinal symptoms, asthma, and, at worst, anaphylaxis. Additionally, adult-onset asthma has been associated with periocular xanthogranulomas. Exacerbation Some individuals will have stable asthma for weeks or months and then suddenly develop an episode of acute asthma. Different asthmatic individuals react differently to various factors.However, most individuals can develop severe exacerbation of asthma from several triggering agents. Home factors that can lead to exacerbation include dust, house mites, animal dander (especially cat and dog hair), cockroach allergens and molds at any given home.Perfumes are a common cause of acute attacks in females and children. Both virus and bacterial infections of the upper respiratory tract infection can worsen asthma.

5.3

Comparative Chart of classical Signs and Symptoms and the actual manifestations Signs and Sysmptoms:

Classical Wheezing Shortness of Breath Chest Tightness Coughing Usage of Addition muscles

Actual Wheezing Slight Shortness of Breath Negative Slight Cough Present

IV. Nursing Interventions 1. Care guide of the patient with the disease condition Document diagnosis and assessment of asthma severity and level of asthma control Moderate to severe asthma or a poor level of asthma control can be assumed for patients who: Spirometry is preferred for diagnostic testing and should be used for both diagnosis and assessment of severity. Most adults and children over seven years old can perform spirometry. When diagnosing asthma, Peak Expiratory Flow (PEF) Measurement is not a substitute for spirometry. When spirometry has been performed, the results should be documented in the patients medical record and/or the print out of results attached. Consider referral to a respiratory laboratory for spirometry if you are unable to perform it in your practice. Review the patients use of, and access to, asthma related medication and devices To achieve the best possible asthma control with the lowest effective medication dose and minimum side effects, use of asthma related medications and devices should be regularly reviewed. Long-term adjustment of asthma maintenance medication needs to be tailored to each patients individual condition. Step down of medications should generally be considered 612 weeks after good control has been achieved. The step down of medications can be monitored by the frequency of symptoms, the use of reliever medication and objective measurement of lung function (preferably by spirometry). have symptoms on most days, OR use regular preventer medications, OR use a bronchodilator at least 3 times per week, OR have experienced acute exacerbations leading to hospital admission or attendance

Provide a written asthma action plan (or documented alternative if the patient is unable to use a written action plan) Severe or life threatening asthma attacks are more likely to occur in patients with inadequate medical supervision. An individualised written asthma action plan should be developed so that a person with asthma can recognise deterioration and respond appropriately. Action plans can be based on symptoms and/or peak flow measurements. Provide asthma self management education Studies have shown that asthma self-management education will provide people with asthma with the knowledge and skills to better control their asthma, resulting in fewer emergency attendances at the doctor or hospital. Review the written or documented asthma action plan The final requirement before you can complete the Asthma Cycle of Care is that you review the patients asthma control and ongoing management as well as their written asthma action plan. This involves a complete review of asthma symptoms, lung function and response to treatment, medications and dosages and peak flow measurements (if appropriate). Alternative asthma care using MBS Chronic Disease Management items The Chronic Disease Management (CDM) items provide an alternative funding mechanism to the SIPs for providing best practice care of patients with chronic conditions, including patients with asthma. For patients with asthma alone a GP should choose to use either GP managed care through the CDM items (GP Management PlanGPMP), or provide an Asthma Cycle of Care, but not both services for the same patient as the work involved in both services overlaps (these items should not both be claimed in the same twelve months). For patients with asthma and complex needs requiring care from a multidisciplinary team, a GP may provide team-based care using the CDM items (for most patients this means a GPMP and a Team Care ArrangementsTCA), and the

Asthma Cycle of Care. A CDM review item and an Asthma Cycle of Care should not be claimed within three months of each other as the work involved overlaps.

2. Physical Assessment The client with mild to moderate asthma may have no manifestations between asthma attacks. During an acute cycle episode the most common manifestation is an audible wheeze and increased respiratory rate. The wheeze is louder than on exhalation. When inflammation occurs with asthma, coughing may increase. The Client may use accessory muscle to help breathe during an attack. Observe for muscle retraction at the sternum, the suprasternal notch, and between the ribs. The client with long standing, severe asthma may have a barrel chest, caused by airtrapping. The Anteroposterior (AP) diameter (diameter between the front and the back of the chest) increases with air trapping, giving the chest a rounded rather than oval shape. The normal chest is nearly twice as wide as it is thick. In the client with severe, chronic asthma, the AP diameter may equal or exceed the lateral diameter. Air trapping also increases the space between ribs. Along with an audible wheeze, the breathing cycle is longer and requires more effort. The client may be unable to complete a sentence of more than five words between breaths. Examine the oral mucosa and nail beds for cyanosis. Pulse oximeter shows poor oxygen saturation related to the degree of dyspnea. Other indicators of hypoxemia include changes in the level of consciousness and tachycardia.

VI. Evaluation and Recommendation Prognosis of Patient based on Nursing Assessment and Rationale The clients temperature and pulse rate are within normal range. Malaise is present and it could still indicate infection due to its disease process and has a decrease respiratory rate that shows sign of respiratory distress as a result of the disease. Patient still exhibits Brudzinkis sign, nuchal rigidity still present, absence of visual acuity, patient has lesser reaction to any stimuli. The prognosis was poor, but there is still hope as long as the significant others would just follow the medical procedures instructed, can be able to provide good nutrition, can be able to support each need and wants of the patient and can supply needed medications for the disease.

Recommendation to Promote Early Recovery and Rehabilitation The student nurse was able to encourage the significant others to follow each and every medical advise and that they should have faith and hope in the healing process. The student nurse encourages them to provide good nutritious foods and provide all the medications needed.

VI. Evaluation and Implication of this Case Study 1.1 Nursing Practice In caring for the patient with Tb Meningitis, this case study reflects a thorough nursing care guide and intervention. The care includes education, treatment plan, prevention of complication and lifestyle modification. The student nurse was able to apply all the knowledge and information she has gained and skills to render holistic care to the client. The student nurse was able to answer some questions of the significant others and gave information regarding the conditions. The nursing implication of this study therefore aims to help nurses in planning care for clients with

Tb Meningitis. A holistic approach in the care of the client would yield a better progress in the promotion of the health of client. 1.2 Nursing Education This case study would serve as an experience and hands-on practice in the field for the student nurses. This case study not only required research of the case but holistic implementation and care as well. This case study could serve as a reference guide to other student and future student nurses to achieve information and learning experience. 1.3 Nursing Research This case study contains thorough information about Tb Meningitis. It includes both dependent and independent nursing actions and more. This study could support current information and data in written literature to show their effectiveness in caring for a patient with Tb Meningitis.

VI. Referral and Follow-up Mr. Cerna, Francisco was getting well at present, according to the nurses notes written on his chart and according to his significant others. So, therefore Mr. Cerna was responding to the medical and nursing interventions given to him. He should be given further interventions and attention for a complete recovery. He should be constantly monitored with the spread of infection in his meninges and prevent existence of complications.

VII. Bibliography Patricia A. Potter and Anne Griffin Perry: Fundamentals of Nursing 5th edition volume 1 and 2 copyright 2001 by Mosby. Suzanne C. Smeltzer, Brenda G. Bare, Brunner and Suddarth: Textbook of Medical Surgical Nursing Volume 1 and 2 10th edition Copyright 2004 by Lippincott Williams and Wilkins Joyce M. Black and Jane Hokanson Hawks: Medical Surgical Nursing Clinical Management for Positive Outcomes Volume 1 and 2 6th edition copyright 2004 by Elsevier Saunders

Professional Guide to Pathophysiology 2nd edition by Lippincott Williams and Wilkins Medical Surgical Nursing 4th edition by Ignatavicius and Workmann Mosbys Diagnostic and Laboratory Test Reference by Pagana copyright 1992 Marilynn E. Doenges, Mary Frances Moorhouse and Alice C. Geissler-Murr: Nursing Care Plans Guidelines for individualizing Patient Care 6th edition copyright 2002 by F.A Davis Company http://www.umm.edu (University of Maryland Medical Center) http://knowyouask.info/?qqq=tbmeningitis (google) http://www.healthline.com http://www.webmd.com http://www.emedicine.com/emerg/topic309.htm

SOAPIE #1 S Taas man iyang hilanat, init gud kaayo siya. As verbalized by significant other. O received patient unresponsive, sleeping; with IVF D5LR 1L at 40gtts/min infusing well at

left hand: with Salem sump attached at left nostril; non-ambulatory; febrile, temperature at 38.4 degrees Celsius; warm, flushed skin; skin pallor noted; capillary refill 4seconds; increased pulse rate 147beats per minute; increased respiratory rate 35 breaths per minute; blood pressure 160/90; facial grimace and resistance noted upon blood pressure taking; fatigued, exhausted appearance. A Altered Thermoregulation: Fever related to bacterial infection P To manifest a decrease in temperature from 38.4 degrees Celsius to 36.5-37.5degrees Celsius. I monitored vital signs; recorded/monitored all sources of fluid loss such as urine, vomitus; wrapped extremities with bath towels; promoted client safety(maintained patent airway, side rails up); maintained bed rest; provided/encouraged high calorie diet (total parenteral nutrition); performed tepid sponge bath & taught significant others; administered replacement fluids and/or regulated IVF; administered analgesic per doctors order. E Patients temperature lowered down, from 38.4 degrees Celsius to 37.1degrees Celsius. sweating noted, capillary refill 2 seconds, respiratory rate 100 breaths per minute, pulse rate 120 beats per minute, blood pressure 110/90.

SOAPIE #2 S Hangtud karon kay wa pa man gihapon siya kalibang. As verbalized by significant other. O Received patient unresponsive, incoherent; with IVF D5LR at 30gtts/min infusing well at

left arm; non ambulatory; with Salem sump attached at left nostril; patient kept on NPO status; abdominal distention noted 46cm; fatigue and exhaustion noted; flatulence noted; irritable; insufficient physical activity BP 110/90 Celsius A Altered Elimination Pattern: Constipation related to insufficient fluid intake (NPO status) P To regain normal function of bowel movement I auscultated abdomen for presence, location and characteristic of bowel sounds; encouraged a balanced fiber and bulk in diet (if not on npo); promoted adequate fluid intake, including high-fiber fruitjuices, suggested drinking or sips of warm fluids; regulated IVF; encouraged activity (passive ROM exercises) within limits; administered stool softeners as ordered; provided a comfortable environment; assisted in positioning of patient to sides. E Patient able to pass a little amount of wet stool. RR 20 breaths per minute PR 110 beats per minute T 37.6 degrees

1.3 Level of Growth and Development 1.3.1 Normal Growth and Development at particular stage Middle Adulthood (40 - 65 years old) These are the years of stability and consolidation. Physical Development

Appearance- Hair begins to thin, gray hair appears. Wrinkles occur due to poor skin turgor, decreased moisture and loss of subcutaneous fat. Fat deposits in the abdominal area. Musculoskeletal System Decreased bulk of skeletal muscle at about age 60. Decrease in height of about 1 inch due to thinning of the intervertebral disks. Calcium losses from the bones become common among postmenopausal women. Cardiovascular System Blood vessels lose elasticity and become thicker. Sensory Perception Loss of accommodation causes decreased visual acuity for near vision (presbyopia). Decreased auditory acuity for high- frequency sounds particularly in men (presbycussis). Diminished taste sensations. Metabolism Weight gain due to slowed metabolism. Gastrointestinal System Constipation due to decreased tone of large intestine. Urinary System Decreased glomerular filtration rate due to actual loss of nephrons. Sexuality Menopause (menstruation ceases) occurs in women between ages 40 and 55, average of 47 years. Climacterium (andropause) occurs in men due to decrease of androgen levels. Men lose ability to reproduce. This occurs between 70 to 90 years. Cognitive Development Cognitive and intellectual ability change very little. Cognitive processes involve reaction time, memory, perception, learning, problem solving and creativity. The middleaged adult can reflect on the past and current experience and can imagine, anticipate, plan and hope. Psychosocial Development The developmental task of the middle-aged adult is Generativity vs. Stagnation. (Erikson). Generativity is the concern for establishing and guiding the next generation. The person becomes more altruistic, and concepts of service to others and love and compassion gain prominence. The person becomes more engaged with civic and social works, he/she may experience midlife crisis between the ages of 35 to 45, the deadline decade. This occurs when the individual recognizes that he has reached the halfway mark of life. Moral Development The middle aged adult can move beyond the conventional level to the postconventional level (Kohlberg). In conventional level of moral development, action is taken to please another and gain approval. Right behavior is obeying law and following the rules. In post conventional level of moral development, standard of behavior is based on adhering to laws that protect the welfare and rights of others. Universal moral principles are internalized. Person respects other humans and believes that relationships are based on mutual trust. Spiritual Development

In the middle age, the person tends to be less dogmatic about religious beliefs, and religion may offer more comfort than before. The person often relies on spiritual beliefs to help him deal with illness, death and tragedy. 1.3.2 The Ill Person at Particular Stage of Patient Illness brings about changes in both the involved individual and in the family. The changes vary depending on the nature, severity, and duration of the illness, attitudes associated with the illness by the client and others, the financial demands, the lifestyle changes incurred, adjustments to usual roles, and so on. An Ill client may experience behavioral and emotional changes, changes in self-concept and body image and lifestyle changes. Behavioral and emotional changes associated with short-term illness are generally mild and short lived. The individual, for example, may become irritable and lack the energy and desire to interact in the usual fashion with the family members or friends. More acute responses are likely with severe, life threatening, chronic, or disabling illness. Anxiety, fear, anger, withdrawal, denial, a sense of hopelessness, and feeling of powerlessness are all common responses to severe or disabling illness. Ill individuals are also vulnerable to loss of autonomy, the state of being independent and self-directed without outside control. Family interactions may change so that the client may no longer be involved in making family decisions or even decisions about their own health care. With the condition of the patient brought by her illness, there is a mild loss of autonomy experienced by the patient. This is manifested through the patients temporarily dependence to her significant others when it comes to weakness and dehydration due to frequent urination. Other responses of a person undergoing illness at her particular age group like anxiety, fear, anger, withdrawal, denial and a sense of hopelessness is not assessed well due to her aphastic condition which set a barrier in communicating with the patient.

4.1 NORMAL ANATOMY AND PHYSIOLOGY OF CNS & RESPIRATORY SYSTEM

The meninges, three membranes enveloping the brain and spinal cord, are predominantly for protection. The pia mater and astrocytes together form the membrane part of the bloodbrain barrier. The arachnoid, a thin layer of connective tissue, extends from the top of each gyrus to the top of the adjacent gyrus; it does not extend into the sulci and fissures. The space between this layer and the pia mater is known as the subarachnoid space. Cerebrospinal fluid flows through this space. The cranial dura mater is a tough, nonstretchable vascular membrane with two layers. The outer dura mater is actually the membrane (periosteum) of the cranial bones. The inner dura mater forms the plates that separate the two cerebral hemispheres (falx cerebri), the cerebrum and the brain stem and cerebellum (tentorium cerebelli), and the cerebellar hemispheres(faly cerebelli). The tentorium cerebelli is a landmark term that is often used by clinicians to separate parts of the brain; it is often referred to as tentorium. Supratentorial refers to the cerebrum and all the structures superior to the tentorium cerebelli; infratentorial refers to structures inferior to the tentorium cerebelli the brain stem and the cerebellum. Brain space that often fill the blood

after head trauma include the potential space (the subdural space) between the inner dura mater and the arachnoid and the epidural space between the dura mater and the periosteum. The meninges anchor the spinal cord. The pia mater, which closely surrounds the spinal cord, continues from the tip of the conus as a thread-like structure (the filum terminale) to the end of the vertebral column, where it is anchored into the ligament on the posterior side of the coccyx. The denticulate ligaments extend laterally from the pia mater to the dura mater to suspend the spinal cord from the dura mater.

4.2 SCHEMATIC DRAWING OF PATHOPHYSIOLOGY OF DISEASE AND ITS EFFECTS

Diabetes Mellitus Alcoholism Chemical Irritation Drug Allergies

Unvaccinated from BCG since birth Household contact of people with TB HIV Infection Immunosuppression

DROPLET INHALATION

SIGNS AND SYMPTOMS: Fever, malaise & chills Headache, vomiting, papilledema & irritability Nuchal rigidity Photophonia, diplopia & vision problems Kernigs sign Brudzinkis sign Opisthotonos Delirium, deep stupor & coma

NURSING MANAGEMENT: Maintain patent airway Explain pathophysiology of illness Prevent injury Perform range of motion exercises Maintain body temperature within normal limits Observe aseptic technique in handling the patient

MEDICAL MANAGEMENT: Anti TB drugs Systemic steroids Antibiotics

OPTIMUM LEVEL OF FUNCTIONING

4.4 Classical and Clinical signs and symptoms Classical Symptoms Clinical Symptoms Fever, Malaise & Chills Fever, Malaise & Chills Cues:

Rationale Manifested Resulting from infection and

-Temp:38.4degrees Celsius -droopy eyes -warm to touch, flushed skin -pale lips, dry mucosa Headache, Vomiting, Papilledema & Irritability Headache & irritability Cues: -Facial grimace upon TSB -fatigued / exhausted Nuchal rigidity Cues: -patient unable to move neck due to stiffness -facial grimace upon movement of neck Photophobia Cues: -patient closed his eyes when inspected with a penlight Kernigs sign Cues: -As the clients legs were flexed at the hip, brought the knee to a 90-degree angle and attempts to extend the knee. The client experienced pain and spasm (facial grimace) of the hamstring muscle when the leg was straightened Brudzinkis sign Cues: - As the clients head and neck were flexed onto the chest, there was a flexion of the hips and knees response. Not Manifested

inflammation

Manifested Resulting from increased intracranial pressure Manifested A stiff neck and soreness is manifested, particularly when the neck is flexed.

Nuchal rigidity(meningeal irritation)

Photophobia, Diplopia & other vision problems

Manifested Resulting from cranial nerve irritation

Kernigs Sign

Manifested As the clients legs were flexed at the hip, brought the knee to a 90-degree angle and attempts to extend the knee. The client experienced pain and spasm (facial grimace) of the hamstring muscle when the leg was straightened. Manifested As the clients head and neck were flexed onto the chest, there was a flexion of the hips and knees response. Not Manifested

Brudzinkis sign

Opisthotonos (a spasm in which the back and extremities arch backward so that the body rests on the head and heels) Delirium, Deep stupor, and coma

Delirium, deep stupor

Manifested As a result from increased intracranial pressure and cerebral edema.

2.1 Brunswick Lens Model Name of Patient: Mr. Cerna, Francisco Date: May 22, 2007 Chief Complaints: fever, back pain

Age: 55 y.o Sex: Male BRUNSWICK LENS MODEL

Diagnosis: TB Meningitis Physician: Dr. Aurora Vibar

Measures to: a.) relieve back pain -provide a quiet and calm environment, well ventilated room, cluster nursing interventions -provide comfort measures (backrubs massages) -suggest ways of minimizing pain, firm mattress -proper body mechanics (side-lying), use pillows for support -instruct use of relaxation techniques (focused breathing) (deep breathing, music) -encourage divertional activities (TV, radio, talking) -monitor constantly vital signs -administer analgesics as indicated -instruct patients significant others to avoid straining the patient with activities b.) regain a pattern or normal function of bowel movement B. Altered Elimination Pattern: Constipation -note color, odor, consistency & frequency of stool Cues: -insufficient physical activity -auscultate abdomen for presence, location & characteristic of -abdominal discomfort bowel sounds -flatulence/ flatus -encourage a balanced fiber and bulk in diet -headache, -fatigue -promote adequate fluid intake, including high-fiber fruit juices, -insufficient fluid intake suggest drinking warm fluids -abdominal distention (bloated) -encourage activity (minimal) within limits -straining with defecation -provide a comfortable environment -patient on NPO status 1.Altered Comfort:backpain -administer stool softeners as ordered related to prolonged inactivity c.) maintain body temperature within normal limits 2.Altered Elimination Pattern: -monitor BP, heart rate, respiratory rate constantly constipation related to insufficient -monitor all sources of fluid loss such as urine,vomitus, diarrhea C. Altered Thermoregulation: Hyperthermia -wrap extremities with bath towels Cues: -increase in body temperature 38.4C fluid intake -flushed appearance, skin is warm to touch 3.Altered Thermoregulation: fever -promote client safety (maintain patent airway, side rails up) -maintain bed rest, provide high-caloric diet/ parenteral nutrition -increased respiratory rate 30bpm, increased pulse rate 160bpm, related to bacterial infection -perform tepid sponge bath, encourage intake of fluids blood pressure of 160/90, seen patient covered with a warmer, seen -administer replacement fluids, administer patient lying on bed, looks fatigued, weak, -patient complained of analgesics as ordered headache, -lips are pale, droopy eyes A. Altered Comfort: back pain Cues: O- sudden movement L lower back area D- 10 seconds C- gnawing pain A- sudden movements R-analgesics and proper positioning T- analgesic as ordered by physician -facial grimace noted upon movement, seen patient having a hard time moving about his bed -irritable, restless, -rated pain scale as 5 (1 is lowest and 10 highest)

Objectives: After 8hours of student nurse-client of student nurse-client Interaction, the client will be able to: the client will be able to gain

Goal: After 2 days interaction,

1 .apply measures to relieve pain level of functioning. 2. regain normal bowel function 3. participate in activities 2.4 Health Teaching Plan Objectives General objective: After 2 days of student nurseclient/ SO interaction, the patient/ SO will be able to gain adequate knowledge, attitude and skills in the care of a patient with meningitis. Specific objectives: After 45 minutes of student nurse-client/ SO interaction, the patient/ SO will be able to: 1.define meningitis 1.1 TB meningitis Contents Methodology

optimum

Evaluation

Meningitis- inflammation of the covering of the brain and spinal cord, usually as a result of bacterial or viral infection. TB meningitis- rare form of meningitis that happens when tuberculosis bacteria (Mycobacterium tuberculosis) invade the membranes and fluid surrounding the brain and spinal cord. Causes- almost always a complication of bacteremia. Its causative agent is Mycobacterium tuberculosis (causative agent for PTB). Other infections: Brain abscess allergies Otitis media chemical irritation Craniotomy Sinusitis Myelitis Penetrating head wound

Informal lecture / discussion

2.identify causes of TB meningitis

Informal lecture / discussion

3.identify signs and symptoms of

S/S: -fever, chills &malaise resulting from infection

Informal lecture / discussion

TB meningitis

and inflammation -headache, vomiting and rarely, papilledema(inflammation and edema of the optic nerve) from increased ICP -nuchal rigidity -exaggerated deep tendon reflexes -photophobia, diplopia and other vision problems from cranial nerve irritation -delirium, deep stupor and coma from increased ICP -positive Brudzinkis and Kernigs sign -opisthotonos(spasm in which the back and extremities arch backward so that the body rests on the head and heels.) -increased ICP -hydrocephalus -cerebral infarction -encephalitis -endocarditis -brain abscess -seizure -shock -coma -death Promotion of health: - patient should be kept on bed rest to prevent increases in ICP -fever reduction to decrease metabolic demands that may increase ICP -monitor fluid balance, maintain adequate fluid intake to avoid dehydration, but avoid fluid overload because of the danger of cerebral edema. -watch for adverse reactions to the I.V antibiotic & other drugs. To avoid infiltration and phlebitis, check the I.V site often, and change the site according to facility policy. -position the patient carefully to prevent joint stiffness and neck pain. Turn him often according to a planned positioning schedule. Assist with ROM exercises. -maintain adequate nutrition and elimination. It may be necessary to provide small, frequent meals or to Informal lecture / discussion

4.enumerate complications of TB meningitis/ meningitis

5.discuss ways on prevention of complications and promotion of health on a patient with TB meningitis

Informal lecture / discussion

supplement meals with nasogastric tube or parenteral feedings. To prevent constipation and minimize the risk of increased ICP resulting from straining at stool. -ensure patients comfort. Provide mouth care regularly. -provide reassurance and support 6.discuss ways to prevent development of meningitis (transmission) Prevention: -the proper medical treatment of chronic sinusitis or other chronic infections -follow strict sterile technique when treating patients with head wounds or skull fractures -wear a tight face mask when entering the patients room -handle tubings carefully, not to touch contaminated area, wear gloves in handling body fluids of patient and wash hands after -daily supplements or vitamins would help in prevention of illnesses. Informal lecture / discussion

7.show willingness of interaction

Source: Medical Surgical Nursing 4th edition by Ignatavicius and Workmann pp. 904-907

3. Actual Patient Care 3.1 NCP NURSING CARE PLAN

Needs/ Problems/ Cues Subjective: A.Maglisod kog ginhawa as verbalized by the patient. Objective: Use of accessory muscle. Abnormal breath sounds. V/S taken as follows: T: 37.3 P: 82 R: 25 BP: 110/80

Nursing Diagnosis

Scientific Basis

Objectives of Care After 3 days of nursing interventions, the patient will demonstrate behaviors to improve airway clearance.

Nursing Actions

Rationale

Evaluation

Ineffective airway clearance related to increased production of secretions

Bronchial asthma is a chronic inflammatory disease of the airways, associated with recurrent, reversible airway obstruction with intermittent episodes of wheezing and dyspnea. Bronchial hypersensitivity is caused by various stimuli, which innervate the vagus nerve and beta adrenergic receptor cells of the airways, leading to bronchial smooth muscle constriction, hypersecretion of mucus, and mucosal edema.

Independent: Auscultate breath sounds. Note adventitious breath sounds like wheezes, crackles and rhonchi. Elevate head of the bed, have patient lean on overbed table or sit on edge of the bed. Keep environmental pollution to a minimum like dust, smoke and feather pillows, according to individual situation. Encourage or assist with abdominal or pursed lip breathing exercises. Assist with measures to improve effectiveness of cough effort.

Some degree of bronchospasm is present with obstructions in airway and may or may not be manifested in adventitious breath sounds. Elevation of the bed facilitates respiratory function by use of gravity. Precipitators of allergic type of respiratory reactions that can trigger or exacerbate onset of acute episode. Provides patient with some means to cope with or control dyspnea and reduce air tapping. Coughing is most effective in an upright position after chest percussion.

After 3 days of nursing interventions, the patient was able to demonstrate behaviors to improve airway clearance.

Increased fluid intake to 3000 ml/ day. Provide warm or tepid liquids.

Source: Ignatavicus Medical Surgical 8th edition pp. 585

3.2 DTR Drug/ Dose/ Frequency/ Route Classification & Mechanism of action

Drug Therapeutic Record Side/ Adverse Effects/ Contraindication & Indication Side Effects and Adverse Reactions Nervousness Restlessness Tremor Headache Insomnia Chest pain Palpitations Angina Arrhythmias Hypertension Nausea and vomiting Hyperglycemia Hypokalemia Contraindications Hypersensitivity to adrenergic amines Hypersensitivity to fluorocarbons Indications To control and prevent reversible airway obstruction caused by asthma or chronic obstructive pulmonary disorder (COPD) Principles of Care Treatment Evaluation

Salbutamol Nebulization ( albuterol) 1 nebule q 4 hours

It relieves nasal congestion and reversible bronchospasm by relaxing the smooth muscles of the bronchioles. The relief from nasal congestion and bronchospasm is made possible by the following mechanism that takes place when Salbutamol is administered. First, it binds to the beta2-adrenergic receptors in the airway of the smooth muscle which then leads to the activation of the adenyl cyclase and increased levels of cyclic- 35adenosine monophosphate (cAMP). When cAMP increases, kinases are activated.

Cardiac disease including coronary insufficiency, a history of stroke, coronary artery disease and cardiac arrhythmias Hypertension Hyperthyroidism Diabetes Glaucoma Geriatric patients older individuals are at higher risk for adverse reactions and may require lower dosage Pregnancy especially near term Lactation Children less than 2 years of age because safety of its use has not been established Excess inhaler use which may lead to tolerance and paradoxical bronchospasm

Assess lung sounds, PR and BP before drug administration and during peak of medication. Observe fore paradoxical spasm and withhold medication and notify physician if condition occurs. Administer PO medications with meals to minimize gastric irritation. Extended-release tablet should be swallowed-whole. It should not be crushed or chewed. If administering medication through inhalation, allow at least 1 minute between inhalation of aerosol medication. Advise the patient to rinse mouth with water after each inhalation to minimize dry mouth.

Kinases inhibit the phosphorylation of myosin and decrease intracellular calcium. Decreased in intracellular calcium will result to the relaxation of the smooth muscle airways.

Quick relief for bronchospasm

Inform the patient that Albuterol may cause an unusual or bad taste.

Paracetamol 500 mg q4 PO PRN

Classification: Anti pyretic, non opioid analgesic Mechanism of action: Inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever, primarily in the CNS

Side effects: -hepatic failure -hepatotoxicity -renal failure -rash, urticaria Indications: -relief of moderate to severe pain, toothache, peripheral nerve infections with the common cold or fever. -relief of fever Contraindications: hypersensitivity

advise patient to take medicine exactly as directed and not to take more than recommended dose -advise patient to avoid alcohol -instruct patient to consult a health care provider if discomfort or fever is not relieved by routine doses. -use liquid for children

administer with a full glass of water -may be taken with food or an empty stomach -take vital signs before and after giving the medication