PATIENTS BACKGROUND

Name: Elyza C. Lawag

Address: Hawan Grande, Virac, Catanduanes
Age: 2 y/o
Birthday: August 28, 2014
Civil Status: Single
Sex: Female
Religion: Catholic
Nationality: Filipino
Chief Complaint: 4 days PTC, cough and colds, fever
Tentative Diagnosis: T/C Bronchial Asthma
Final Diagnosis: T/C Bronchial Asthma
Consulting Doctor: Abigail A. Valeza, RN, M.D.
Present Health History: (+) cough and colds, (+) fever
 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, hyper secretion of mucus, and mucosal edema.

The symptoms of bronchial asthma includes:

a feeling of tightness in the chest;
difficulty in breathing or shortness of breath;
wheezing; and
coughing (particularly at night).

Asthma triggers may include:

Tobacco smoke
Infections such as colds, flu, or pneumonia
Allergens such as food, pollen, mold, dust mites, and pet dander
Exercise
Air pollution and toxins
Weather, especially extreme changes in temperature
Drugs (such as aspirin, NSAID, and beta-blockers)
Food additives (such as MSG)
Emotional stress and anxiety
Singing, laughing, or crying
Smoking, perfumes, or sprays
Acid reflux
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Ineffective Bronchial asth Patient will Auscultate breath Some degree of After 3 days of nursing
4 days PTC, (+) Airway ma is a chronic maintain/im sounds. Note bronchospasm is interventions, the
cough and colds, Clearance r/t inflammatory prove airway adventitious breath present with patient was able to
(+) fever increased disease of clearance sounds like obstructions in demonstrate behaviors
production of the airways, AEB wheezes, crackles airway and mayor to improve airway
Objective: secretions associated with absence of and rhonchi. may not be clearance.
(+) wheezing on recurrent, signs of manifested in
all lung fields reversible respiratory adventitious breath Client will be able to
airway distress sounds. identify and avoid
obstruction potential allergens or
with Elevate head of Elevation of the stimuli that could
intermittent the bed, have bed facilitates trigger asthma attack
episodes of patient lean on respiratory function and be able to handle
wheezing and over bed table or by use of gravity. symptoms if recurrence
dyspnea. Bron sit on edge of the comes, prompt follow
chial bed. up checkup and to
hypersensitivit always bring or have
y is caused by Keep Precipitators of the prescribed
various environmental allergic type of medication is on hand
stimuli, which pollution to a respiratory in case asthma occurs.
innervate the minimum like reactions that can
vagus nerve dust, smoke and trigger or
and beta- feather pillows, exacerbate onset of
adrenergic according to acute episode.
receptor cells individual
of the airways, situation.
leading to
bronchial smo Encourage or Provides patient
oth muscle assist with with some means to
constriction, abdominal or cope with or
hyper secretion pursed lip control dyspnea
of mucus, and breathing and reduce air
mucosal exercises. tapping.
edema.
Assist with Coughing is most
measures to effective in an
improve upright position
effectiveness of after chest
cough effort. percussion.

Increased fluid Hydration helps

intake to 3000 ml/ decrease the
day. Provide warm viscosity of
or tepid liquids. secretions,
facilitating
expectoration.
Using warm liquids
may decrease
bronchospasm.