St. Anne College Lucena Inc.

Diversion Road G- Gulang Lucena City

In Partial Fulfillment for Academic Requirements In Related Learning !"erience A Case of BAIAE

Pre"ared #y$ Joy Rachel D. Tabernilla BSN III-A

Presented to$ Shiela Galang, R.N.

%uly& '()(

TABLE I.

! C NTENTS

*+% C,I- S............................... ' a. General *#/ectives #. S"ecific *#/ectives II. PA,I 0, PR*FIL .....................' a. +iogra"1ical data of t1e "atient #. Clinical data of t1e "atient 2IS,*R3.................................' a. 0ursing 2istory i. C1ief Com"lain ii. Admitting Diagnosis iii. P1ysical !amination iv. Final Diagnosis #. Present 2ealt1 2istory i. '4 1ours recall of events ii. Signs and sym"toms e!"erienced #y t1e "atient c. Past 2ealt1 2istory i. 2os"itali5ations ii. Surgical 6anagements iii. Allergies ). Foods '. Drugs iv. *t1ers d. Family 2ealt1 +ac7ground i. 2ealt1 tree 08,RI,I*0.............................4 a. '4 1ours food recall #. Regular9Routine diet c. Inta7e and out"ut d. -ices and 1a#its DIS AS 0,I,3.......................4 a. Definition #. tiology c. Anatomy of t1e organ involved 6A0AG 6 0,........................: a. 0ursing 6anagement #. P1armacologic 6anagement LA+*RA,*R3..........................; a. +lood analysis PA,2*P23SI*L*G3.....................< 08RSI0G CAR PLA0 Disc1arge Plan.......................<

III.

I-.

-.

-I.

-II. -III. I=. =.

I.

BJECTI"ES a. GENERAL BJECTI"ES# In t1e lig1t of 7no>ledge& t1e main goal of t1e study is to develo" s7ills& 7no>ledge and rig1t attitude a#out t1e case ast1ma. ,1roug1 t1is& >e could #e a#le to s1are it >it1 our fello> students. b. S$ECI!IC BJECTI"ES#

,o define t1e case and its effects to 1uman #ody. ,o en1anced our 7no>ledge and learning regarding t1e disease identity. ,o 1ave a com"lete details or #ac7ground a#out t1e "atients "rofile and nutritional status. ,o revie> t1e anatomy and "1ysiology of t1e client& s"ecifically t1e lungs. ,o develo" s7ills regarding t1e care of "atient >it1 a""endicitis ast1ma and its managements.

II.

$ATIENT $R !ILE a. Biogra%hical &a'a of 'he %a'ien' 0ame$ R.A.C. Age$ 4?years old Gender$ Female Date of +irt1$ *cto#er '<& )@:4 Civil Status$ 6arried 0ationality$ Fili"ino Address$ Aa#allero Su#d. & Lucena City Religion$ Roman Cat1olic ducational Attainment$ College Graduate *ccu"ation$ P0+ b. Clinical &a'a of 'he %a'ien' Diagnosis$ +A r9o sinusitis C1ief Com"lain$ D*+ Diet$ 1y"oallergenic diet Room$ Sa""1ire 0SB Attending P1ysician$ Angelito r>in Reyes& 6.D. Date and ,ime of Admission$ %uly :& '()( at '$?<"m Case C$ 4:':4; 6em#ers1i"$ P6 -alucare ,y"e of admission$ 0e> 2os"ital$ St. Anne General 2os"ital

III.

(IST R) a. N*rsing (is'ory i. Chief Co+%lain# D*+ ii. A&+i''ing Diagnosis# +A r9o sinusitis iii. $hysical E,a+ina'ion# G 0 RAL ASS S6 0,$ conscious and co1erent coo"erative

>it1 "in7is1 con/unctiva >it1 dry "in7is1 li"s >it1 none "roductive coug1 >it1 symmetrical c1est e!"ansion >it1 "in7is1 nail #eds

i-. !inal Diagnosis# +AIA & 8R,I b. $resen' (eal'h (is'ory i. ./ ho*rs Recall of E-en's ,1e nig1t #efore t1e admission& t1e "atient >it1 1er family 1ad dinner toget1er& 1ad "lenty of ice cream after. ,1e ne!t morning& s1e 1ad feel difficulty of #reat1ing& colds and non-"roductive coug1 yet s1e >ent to 1er >or7 at P0+. During >or7& s1e 1ad 1eadac1e. S1e t1en ta7e Seretide one to relief 1er feelings. ,1en fe> 1ours after 1ad severe difficulty of #reat1ing 1ence consuted at SAG2I. ii. Signs an& sy+%'o+s e,%erience& by 'he %a'ien' 0on "roductive coug1 Colds 2eadac1e D*+

c. $as' (eal'h (is'ory i. (os%i'ali0a'ions# %anuary '((@ D 6t. Carmel E Ast1ma 3ear '((< E t>ice& ast1ma ii. S*rgical 1anage+en's$ none iii. Allergies ). Allergy- stress& insects& dusts '. Drugs$ no 7no>n allergies &. !a+ily (eal'h Bac2gro*n&

-ast1ma

- 1eart "ro#lem

y/o

ast1ma

ast1ma

L G 0D$ - 6ale - female - "atient

- Deceased

- alive and >ell

I".

N3TRITI N a. ./ ho*r foo& recall '4 1ours "rior to admission "atient 1ad ta7en t1e follo>ing foods$ DinnerE rice& meat - ice cream +rea7fast- rice& fis1 Lunc1- rice >it1 c1ic7en inasal ,1e "atient daily consum"tion >as more on car#o1ydrates& some "rotein >it1 some fats. b. Reg*lar4Ro*'ine &ie' Patient regular diet >as more on meats or "rocessed foods. c. In'a2e an& o*'%*' ,1e "atient daily inta7e of fluids >as a#out ) to ' liters >it1 t1e corres"onding normal out"ut. &. "ices an& habi's

,1e "atient 1ad sedentary lifestyle. +ecause of 1er >or7& s1e >as used to do a lot of t1ings at 1ome.

".

Disease En'i'y

a. Defini'ion

Ast1ma is a common c1ronic inflammatory disease of t1e air>ays c1aracteri5ed #y varia#le and recurring sym"toms& airflo> o#struction& and #ronc1os"asm. Sym"toms include >1ee5ing& coug1& c1est tig1tness& and s1ortness of #reat1.
5

b. E'iology

Common triggers of ast1ma can #e classified as follo>s $

A. Allergens FIndividual s"ecificG

i *utdoor allergens H Pollens - from grass I trees H 6olds - of some fungi ii Indoor Allergens H 2ouse dust mites H Dander For fla7esG -from t1e s7in& 1air or feat1ers of >arm #looded "ets Fdogs& cats& #irds& rodents& etc.G H 6olds -1ar#oured in -acuum cleaners& Air-con- ditioners& 2umidifiers. H Insects -Coc7roac1 iii Food Allergens Rarely cause an ast1ma attac7. ,1oug1 some of foodstuffs may cause allergic manifestations in some "eo"le. it is not >ise to #and allergy "roducing foods in general for an ast1matic. Avoid t1ose s"ecific foods >1ic1 evo7es an ast1ma9allergy attac7 >it1in fe> minutes or 1ours after inta7e. Commonly allergy-"roducing foods are$ H +eef& Pra>n& 2ils1a and some ot1er fis1es& sea-foods& duc7 egg& some vegeta#les& nuts& etc. H Food additives& e.g. meta#isul"1ite& tartra5ine.

+. Irritants F6ore generali5edG

i ,o#acco smo7e ii Jood smo7e iii Strong odours& "erfumes and s"rays& cosmetics& "aints& coo7ing Fes"ecially >it1 s"icesG iv Air-"ollutants - Smo7e and to!ic gases from automo#iles and factories.

C. 8""er res"iratory tract infection - viral infections& common cold D. !ercise - strenuous "1ysical activities. . Certain Drugs - e.g. #-#loc7ers Feven eye dro"sG& As"irin& 0SAIDS etc. F. C1anges in season& >eat1er and tem"erature- An ast1ma attac7 is li7ely if tem"erature lo>ers for B(C or more t1an t1e "revious day. G. Stress i. motion - e.g. Laug1ing& So##ing& 6ental de"ression

c. Ana'o+y of 'he organ in-ol-e&

,1e function of t1e res"iratory system is to give us a surface area for e!c1anging gases #et>een t1e air and our circulating #lood. It moves t1at air to and from t1e surfaces of t1e lungs >1ile it "rotects t1e lungs from de1ydration& tem"erature c1anges and un>elcome "at1ogens. It also "lays a "art in ma7ing sounds suc1 as tal7ing& singing& ot1er nonver#al sounds and >or7s >it1 t1e central nervous system for t1e a#ility to smell. 3%%er Res%ira'ory ,1e u""er res"iratory system consists of t1e nostrils Fe!ternal naresG& nasal cavity& nasal vesti#ule& nasal se"tum& #ot1 1ard and soft "alate& naso"1aryn!& "1aryn!& laryn! and trac1ea. Jit1in t1e nostrils& course 1airs "rotect us from dust& insects and sand. ,1e 1ard "alate serves to se"arate t1e oral and nasal cavities. ,1ere is a "rotective mucous mem#rane t1at lines t1e naval cavities and ot1er "arts of t1e res"iratory tract. It is secreted over t1e e!"osed surfaces and t1en t1e cilia s>ee"s t1at mucus and any microorganisms or de#ris to t1e "1aryn!& so it is s>allo>ed and t1en destroyed in stomac1 acids Lo5er Res%ira'ory ,1e trac1ea #ranc1es off into >1at is 7no>n as t1e #ronc1i Fmore commonly called #ronc1ial tu#esG. ,1ese t>o main #ronc1i 1ave #ranc1es forming t1e #ronc1ial tree. J1ere it enters t1e lung& t1ere is t1en secondary #ronc1i. In eac1 lung& t1e secondary #ronc1i divides into tertiary #ronc1i and in turn t1ese divide re"eatedly into smaller #ronc1ioles. ,1e #ronc1ioles control t1e ratio of resistance to airflo> and distri#ution of air in our lungs. ,1e #ronc1ioles o"en into t1e alveolar ducts. Alveolar sacs are at t1e end of t1e ducts. ,1ese sacs are c1am#ers t1at are connected to several individual alveoli& >1ic1 ma7es u" t1e e!c1ange surface of t1e lungs. The L*ngs ,1e 1uman res"iratory system 1as t>o lungs& >1ic1 contain lo#es se"arated #y dee" fissures. Sur"risingly& t1e rig1t lung 1as t1ree lo#es >1ile t1e left one 1as only t>o lo#es. ,1e lungs are made u" of elastic fi#ers t1at gives it t1e a#ility to 1andle large c1anges in air volume. ,1e "leural cavity is >1ere t1e lungs are located. ,1e dia"1ragm is t1e muscle t1at ma7es u" t1e floor of t1e t1oracic cavity and "lays a ma/or role in t1e "ressure and volume of air moving in and out of t1e lungs.

"I. 1ANAGE1ENT a. N*rsing 1anage+en'

,1e main focus of nursing management is to actively assess t1e air >ay and t1e "atient res"onse to treatment. ,1e immediate nursing care of "atient >it1 ast1ma de"ends on t1e severity of t1e sym"toms. A calm a""roac1 is an im"ortant as"ect of care es"ecially for an!ious client and oneKs family.

L ,1is requires a "artners1i" #et>een t1e "atient and t1e 1ealt1 care "roviders to determine t1e desire outcome and to formulate a "lan >1ic1 includeM L L L L t1e "ur"ose and action of eac1 medication trigger to avoid and 1o> to do so >1en to see7 assistance t1e nature of ast1ma as c1ronic inflammatory disease

b. $har+acologic 1anage+en'

2ydrocortisone FP1armacortG )((mg t1ru I- q < 1ours ! B doses A0S,F-G Aertin B((mg ) ca" +ID Seretide '?( mg9'? mg ' "uffs +IDFgargle after useG Rise7 '( mg9ta# ) ta# *D Celco!! )((mg9ca" ) ca" +ID C1or"1eniramine maleate ) ta# ,ID

"II. Labora'ory

a. Bloo& analysis

(e+a'ology 678- 79, .7:7;.#<<%+= S$ECI!ICATI N 2ematocrit 2emoglo#in J+C Platelet RES3LTS (.B( )( )(.B 4)B
N R1AL RANGE

INTER$RETATI N Nanemia& 1emodilution Nanemia& fluid retention Ninfection& tissue necrosis N IDA

F (.B;-(.4? F E )'-)? g9dL ?-)(=)(O@9L )?(-4(( ! )(Og9dL

3rinalysis 678-78, .7:7 ; :.%+= TEST Glucose Leu7ocyte Pus cells "it1elial cells +acteria RES3LT PPPP P )(-)?91"f 6any Fe> N R1AL RANGE INTER$ETATI N 0egative D6& cus1ingKs syndrome 0egative (-'91"f "yoria Fe> none Renal disease

>-ray 678-79, .7:7= Clear lung fields. 0ormal 1eart s1ado>. Dia"1ragm osseous stractures& soft tissues are intact. Im"ression$ ssentially normal c1est findings.

"III.

$a'ho%hysiology

!"osure to allergens

Colds& stress

s9s!$ coug1& colds

Inflammation of t1e air>ay

Do#& non-"roductive coug1

Increase constriction of t1e smoot1 muscle

2y"ersecretion of mucus in t1e #ronc1ial tree

Causing mucosal edema

10

dys"nea

I>. Discharge $lan 1- medication instructed to t1e "atient to ta7e at 1ome$ Antamin ) ta# B! a day for ? days Sereride '?(mg9'?mg& ' "uffs '! a day Fgargle after useG Aertin B((mg9ca" '! a day for ? days 8ltrami! )gm9ta# ) ta# '! a day Celco!! )((mg9ca" ) ca" if in "ain Prednisone ) ta# '! a day for ; days after meal E- nvironment or e!ercise suited for t1e management and "revention of ast1ma li7e$ Provision of t1era"eutic environment Avoidance of t1ings9materials t1at could aggravate condition T- treatment t1at may develo" a >ell resistance fot t1e management of ast1ma$ ,a7ing t1e necessary drug for ast1ma li7e anti1istamins I nasal decongestants (- 1ealt1 teac1ings for t1e "revention I care of "atient >it1 ast1ma$ Action of medications Jays to avoid I "revent ast1ma attac7 0ature I cause of ast1ma - *PD ncouraged "atient to 1ave 1er follo> u" c1ec7 u" on %uly )?& '()( D St. Anne Clinic D- diet Avoidance of food t1at could aggravate ast1ma li7e allergens& foofs suc1 as s1rim"s or cra# and ot1ers.

11

0ame of Patient$ Carrasco& Rut1 C. Attending P1ysician$ Dr. . Reyes DATE4TI1E (;9(@9K)( ;am

Age$ 4? Se!$ F Room$ Sa""1ire RE1AR?S

Qreceived sitting on c1air >it1 ongoing I-F of P0SS ) L ! R-* D )?(cc level& inserted D rig1t metacar"al vein& infusing >ell Qno redness I s>elling noted on I- insertion site Qconscious I co1erent Q-9S ta7en I recorded Q0PI esta#lis1ed t1roug1out t1e s1ift SQ S0a1i1ira"an a7ong 1uminga&T as ver#ali5ed #y t1e "atient. *Qdys"nea Qc1est tig1tness Qnon-"roductive coug1 QD*+ AQ Ineffective air>ay clearance r9t #ronc1ostriction& increased mucus "roduction I res"iratory infection as evidence #y D*+& colds& dys"nea I non"roductive coug1. PQ After < 1ours of nursing intervention t1e "atient >ill maintain or im"rove air>ay clearance as evidence #y a#sence of signs of res"iratory distress. IQencouraged ver#ali5ation of feelings Qroutine assessment done Qadequately 1ydrate t1e "atient Qteac1 I encourage t1e use of dia"1ragmatic #reat1ing and coug1ing e!ercises Q instruct to avoid #ronc1ial irritants suc1 as cigarette& smo7e& aerosols& e!tremes of tem"erature I fumes Q teac1 early signs of infection t1at are to #e re"orted to t1e clinician immediately Qadminister medication as ordered Q At t1e end of < 1ours nursing interventions& "atient ver#ali5ed& So7 na ang "ag1inga 7o& 1indi na a7o na1i1ira"anT. Qneeds attended Qseen at frequent intervals Qendorsed

12

0ame of Patient$ ,alay& 6arieta Attending P1ysician$ Dr. . Reyes DATE4TI1E (;9)49K)( ;am

Age$ ?? Room$ BBB RE1AR?S

Se!$ F

Qreceived sitting on c1air >it1 ongoing I-F of P0SS ) L ! R-* D :?(cc level& inserted D rig1t metacar"al vein& infusing >ell Qno redness I s>elling noted on I- insertion site Qconscious I co1erent Qafe#rile Q-9S ta7en I recorded Q0PI esta#lis1ed t1roug1out t1e s1ift SQ S6edyo na1i1ilo a7o&T as ver#ali5ed #y t1e "atient. *Qslig1t >ea7 I "ale in a""earance Qirrita#le Q>it1 com"lain of di55iness AQ Ris7 for in/ury related to develo"mental aging. PQ At t1e end of < 1ours nursing intervention& t1e "atient ver#ali5ed good t1era"eutic regimen I seen free from in/ury. IQencouraged ver#ali5ation of feelings Qroutine assessment done Q"rovide safety measures to avoid in/ury Qencouraged to use rela!ation tec1nique QProvide t1era"eutic environment Qencouraged significant ot1ers to >atc1 out "atient carefully Qinstruct oatient to eat nutritious foods I drin7 "lenty of fluids Qadminister medication as ordered Q After < 1ours nursing interventions& "atient seen comforta#ly slee"ingI free from in/ury. Qneeds attended Qseen at frequent intervals Qendorsed

13

0ame of Patient$ *cfemia& ugenia Attending P1ysician$ Dr. Guinto& Dr. 3a" DATE4TI1E (;9)?9K)( ;am RE1AR?S

Age$ ?; Se!$ F Room$ merald

Qreceived lying on #ed >it1 ongoing I-F of D?06 ) L ! :(gtt9mins D )((cc level& inserted D left metacar"al vein& infusing >ell Qno redness I s>elling noted on I- insertion site Qconscious I co1erent Q>it1 foley cat1eter draining #onto yello> urine& scanty in amount Q>it1 e"idural cat1ter& intact in "lace Qafe#rile Q-9S ta7en I recorded Q0PI esta#lis1ed t1roug1out t1e s1ift SQ SSumasa7it na ang o"era 7o&T as ver#ali5ed #y t1e "atient. *Qslig1t >ea7 in a""earance Q>it1 facial mas7 Q>it1 surgical dressing on rig1t u""er quadrant of a#domen& dry I intact Q>it1 "ain scale of :9)( AQ Alteration in comfort& "ain secondary to "ost surgical "rocedure done. PQ At t1e end of < 1ours nursing intervention& t1e "atient re"ort lessen "ain. IQencouraged ver#ali5ation of feelings Qroutine assessment done Q"rovide safety measures to avoid in/ury Qencouraged to use rela!ation tec1nique QProvide t1era"eutic environment Qim"art 1ealt1 teac1ings$ a. "ro"er "ositioning #. "ro"er >ound care c. im"ortance of adequate rest "eriods d. strict ad1erence to treatment regimen Qa#ove I-F consume I follo>ed #y D?LRS ) L ! < 1ours Qadminister medication as ordered Q After < 1ours nursing interventions& "atient >as a#le to ver#ali5ed less "ain as evidence #y latest "ain scale of 49)(. Qneeds attended Qseen at frequent intervals Qendorsed

14

0ame of Patient$ *cfemia& ugenia Attending P1ysician$ Dr. Guinto& Dr. 3a" DATE4TI1E (;9):9K)( ;am RE1AR?S

Age$ ?; Se!$ F Room$ merald

Qreceived sitting on c1air >it1 ongoing I-F of D?LRS ) L ! R-* D B:(cc level& inserted D left metacar"al vein& infusing >ell Qno redness I s>elling noted on I- insertion site Qconscious I co1erent Qafe#rile Q-9S ta7en I recorded Q0PI esta#lis1ed t1roug1out t1e s1ift SQ S*7 na naman ang "a7iramdam 7o& 7a1it sa ta1i 7o&T as ver#ali5ed #y t1e "atient. *Qdisru"ted s7in layers Q>ound area >arm to touc1 Q>it1 surgical dressing on rig1t u""er quadrant of a#domen& dry I intact AQ Im"aired s7in integrity related to disru"ted s7in layers secondary to "ost surgical "rocedure. PQ At t1e end of < 1ours nursing intervention& t1e "atient "artici"oate in treatment and "revention of com"lications. IQencouraged ver#ali5ation of feelings Qassess9ins"ect incision site for redness& s>elling or signs of evisceration Q7ee" t1e incision site clean I dry& carefully c1ange dressing Qim"art 1ealt1 teac1ings$ a. su""ort t1e surgical site >1en moving #. im"ortance of "ro"er >ound care c. ta7e foods ric1 in vitamin C& "roteins I minerals d. strict ad1erence to treatment regimen Qadminister medication as ordered Q After < 1ours nursing interventions& "atient 1ad com"lied >it1 t1e teac1ings I do actions. Qneeds attended Qseen at frequent intervals Qendorsed

15