COLLEGE OF HEALTH SCIENCES

Case study on

Asthma

Name of the students:

1- Hiba Saleem Al-Alawi. 1910329

2- Suha Juma Al-Khaldi 1910295
3- Hafsa Hamed AL-Balushi 1910445

Name of the instructor:

Date of submission :

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CASE STUDY FORMAT
Formatting Guidelines

Margins: all sides 1 inch

Spacing: 1.5 inches
All headings and subheadings bold
Font type and size: Calibri 12

INTRODUCTION OF THE CASE

 It tells about the background of the case study(from where you took the case,why you
choose the case)
 It mentions about the description of the disease
 Statistics pertaining to the incidence of the disease globally and locally
 Latest trends and studies available about the disease and its management.

NURSING HEALTH ASSESSMENT

Demographic Profile

Age 1 yr., 4 months.

Date of Birth 08/05/2022
Gender Male
Civil Status Single
Religion Muslim
Occupation -
Address Al-Swaqe
Nationality Omani
Date Admitted 03/10/2023
Admitting Diagnosis Asthma

Chief Complaint
Asthma on prophylaxis

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History of Present Illness

Baby present to the A&E with history of cough and runny nose since the past day. While
the day of admission the baby comes with increase work of breathing, less activity, and
reduce oral intake. On examination the baby was tachypneic, with chest retraction,
distress, thick chest secretions, afebrile, mild dehydration, and chest wheezing.

History of Past Illness

All 1-year childhood immunization are taken, admitted previously in the hospital for
coughing, SOB, and tachypnea. The child diagnosed with asthma in February 2022, kept
in fluticasone inhaler (1puff BID) and salbutamol PRN. Child has allergy to pollutant.

Family Health History

Identifies genetic predisposition and environmental influences. Should also include at

least 3 generations, usually past generations.
S. No Name of Age/sex Occupation Relation to Education Health
family family status
members member
1 Salah 34 Policeman Father Educated Healthy
2 Amina 29 Teacher Mather Educated Asthma
3 Sara 8 Student Sister Student Healthy

Social History
(includes diet, activity and exercise; sleep and rest; cigarette use; substance use)

Psychological Data

Occupation
_

Review of Systems
In this section, the subjective data obtained from the client during the interview
are presented following the systems approach.

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Physical Assessment

 Use the head-to-toe approach

Doctor examine ears, nose, throat, eyes, skin, chest, and lungs during a physical
examination to check for asthma or allergies:
1- General Appearance:
T RR P BP SPO2 Wt(Kg)
37.4C 62 161/min 108/72 95% 9.4kg
breath/min mmHg

2- General Appearance:
● The child appears pale, ill, and exhausted despite being well-groomed, wearing
clean clothes, and having his hair combed.

3- Head & Neck:

● The rounded head, normal cephalic and symmetrical facial structures, evenly
distributed hair, clean scalp, and shining, well-textured hair are all characteristics
of the head.
● (Eyes): The iris is round and flat, and the pupils are black and equal in size.

● (Nose): Itchy, runny nose.

● (Ears): His facial skin color matches the symmetry of his auricles.

● (Mouth): The client's lips are rugged, symmetrical, and consistently pink. The
enamels are not discolored in any way. There is no gum retractions, and the gums
are pink in color. decreased consumption by mouth.
● Neck is normal; there is no edema or restriction in its range of motion. There are
no noticeable pulsations in the carotid arteries, the thyroid gland is palpable and
there is no swelling, and the client's lymph nodes are not palpable.

4- Respiratory & Cardiac:

● Both sides of the chest have equal symmetry and retraction. The youngster
displayed signs of tachypnea, increased work of breathing, and the utilization of
auxiliary macules. Conducting breath sounds audible during auscultation
(wheezing).
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 ● Cardiac findings, S1, S2 are normal, no murmur.

5- Abdomen:
● Abdomen is soft, no tender, no masses or organometallic. Hypoactive sound heard
on auscultation. No obvious sign of hernia.

6- Musculoskeletal (Back & Extremities):

● No abnormal curvature of spine, no muscle spasm or tenderness. Child can
maintain ROM, able to perform ADL’s
● No edema or superficial varicosities, no muscle atrophy and No deformities or
swelling, joints move smoothly.
● The extremities are symmetrical in size and length.

7- Genitourinary:
● The child had circumcision immediately after birth. Have no problem in the
genital area, he voids 5 times a day the color of urine is yellow, clear, there is no
sign of UTI.

8- Neurological examination:
● Cranial nerve I (Olfactory): The child recognized the smell of perfume.

● Cranial nerve II (Optic nerve.): A child's person's pupils contract when exposed
to light.
● Cranial nerve III, IV, VI (Oculomotor nerve, Trochlear nerve, Abduces nerve):
Child able to following light in all six cardinal directions with complete
symmetric eye movements.
● Cranial nerve V (Trigeminal nerve.): Child is able to feel light touch in the
maxillary and mandibular areas.
● Cranial nerve VII (Facial nerve.): The child can raise his eyebrows, smile, and
display teeth.
● Cranial nerve VIII (Vestibulocochlear nerve): The child could hear my soft voice
and picked up on the medicine's flavor.

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ANATOMY AND PHYSIOLOGY
With the picture explain the anatomy and physiology make it brief and focused
on the organ affected by the disease

COMPARISON OF BOOK PICTURE AND PATIENT PICTURE

DEFINITION: A chronic inflammatory illness of the lungs' airways is asthma. It is

typified by reversible airflow obstruction, easily triggered bronchospasms, and
variable and recurrent symptoms. Breathing difficulties, coughing fits, chest
tightness, and wheezing fits are among the symptoms. These could happen a
couple times a day or a couple times a week. Asthma symptoms can vary from
person to person and can worsen at night or after exercise.

CAUSES
BOOK PICTURE PATIENT PICTURE
1- Family history. If you have a parent
with asthma, you are three to six times 1. Allergies.
more likely to develop asthma than 2. Viral respiratory infections.
someone who does not have a parent
with asthma.
2- Allergies.
3- Viral respiratory infections.
4- Occupational exposures.
5- Smoking.
6- Air Pollution.
7- Obesity.

SIGNS AND SYMPTOMS

1- Wheezing, coughing and chest 1. cough and runny nose
tightness becoming severe and constant. 2. increased work of breathing
2- Being too breathless to eat, speak or 3. less activity
sleep. 4. reduced oral intake
3- Breathing faster. 5. tchypnic, with chest retraction
4- Fast heartbeat. 6. mild dehydarted
5- Drowsiness, confusion, exhaustion or 7. wheeze
dizziness.
6- Blue lips or fingers.
7- Fainting.

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 DIAGNOSTIC TEST
1- Spirometry. 1. UREA
2- Spirometry with bronchodilator tests. 2. LFT (LIVER FUNCTION TESTS)
3- Bronchoprovocation tests. 3. BLOOD GAS PANEL (POC) ARTERIAL
4- Peak expiratory flow (PEF) tests. 4. RFT (RENAL FUNCTION TESTS)
5- Fractional exhaled nitric oxide (FeNO) 5. BONE PROFILE
tests. 6. MAGNESIUM (Mg)
6- Allergy skin or blood tests. 7. CRP (C REACTIVE PROTEIN)

MEDICAL MANAGEMENT (INCLUDES TREATMENT/IV FLUIDS/MENTION ALL THE

DRUGS AND DOSE ONLY)
The mainstay of asthma treatment is
long-term asthma control drugs, which 1. Potassiurn Chloride Injection
are typically taken on a daily basis. These 20Mmol/10MI (4 Mmol-STAT -
drugs reduce your risk of having an 1Days).
asthma attack and help you manage your 2. Amoxyclav Injection
asthma on a daily basis. Among the many 600Mg/1Vial( 270 Mg- TID -7 Days).
kinds of long-term control drugs are: 3. methylPREDNISolone sodium succ
corticosteroid inhalation. Injection 40Mg/1MI (9.5 Mg - 6H - 4
Days).
These are the most common long-term 4. EPINEPHrine Injection
control medications for asthma. These
1Mg/1MIAmection-500Mg/1Vial (1
anti-inflammatory drugs include:
Mg - STAT - 1 Days).
5. Salbutamol Solution 5Mg/1MI (2.5
1- Fluticasone (Flovent HFA).
Mg - 2H - 3 Days).
2- Budesonide (Pulmicort Flexhaler).
3- Beclomethasone (Qvar RediHaler).
4-Ciclesonide (Alvesco, Omnaris) .
5-Mometasone (Asmanex HFA).

SURGICAL MANAGEMENT (TYPE OF SURGERY/DATE PERFORMED/PRE-OP HISTORY

INTRA-OP HISTORY AND POST-OP)

One way to treat severe asthma is with

bronchial thermoplasty. It's a means of
clearing your throat. The process involves Not done.
using low heat to contract the smooth
muscles in your lungs, which tighten
during an asthma attack and cause
difficulty breathing.

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 HEALTH EDUCATION
1. Education — Acquiring knowledge to
identify and manage asthma symptoms is
crucial, and having an action plan can 1- It's important to work closely with a
help you handle symptoms promptly. healthcare professional to manage your
2. Tracking asthma over time — To child's asthma. They can provide a
effectively treat asthma, monitor your personalized treatment plan, including
child's symptoms, triggers, and lung medications and lifestyle modifications.
function over time, including exercise, 2. Avoid triggers like allergens, tobacco
cold weather, and allergen exposure. smoke, and pollution.
3. Asthma diary — Doctors may 3. Encourage regular physical activity and
recommend keeping a daily diary to track teach your child proper inhaler
symptoms, medications, and treatment techniques.
start times for children with uncontrolled 4. Remember, every child's asthma is
symptoms or new treatments. unique, so it's best to consult with a
4- Measuring lung function — Spirometry healthcare professional for specific
measures lung function in children, with guidance.
lower results due to asthma. Children
typically reach six years old, requiring
high cooperation and a tight seal on a
mouthpiece. Spirometry measures lung
function in children, with lower results
due to asthma. Children typically reach
six years old, requiring high cooperation
and a tight seal on a mouthpiece.
5. Action plan – An action plan for asthma
is a document created by a physician,
outlining symptoms, treatment, and
emergency measures. It helps determine
when to consult a doctor, adjust
medication, and seek medical attention.
Individual action plans may evolve over
time.
6. When to call for emergency help—
Understanding when to seek emergency
medical attention is crucial, especially
when prescription drugs fail to alleviate
asthma symptoms, as severe attacks can
be fatal if not treated promptly.
7. Managing asthma triggers — Asthma
symptoms can be triggered by various
factors, and controlling them requires

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recognizing and avoiding these triggers.
8. Frequent check-ups with the doctor —
Regular doctor visits are essential for
children with asthma, assessing
symptoms frequency, severity, and
exacerbations to evaluate the
effectiveness of their asthma treatment.

DISCHARGE PLAN
Upon discharge, every asthmatic patient
needs to have a well-defined plan of
follow-up. After your child leaves the
hospital, they will likely still have asthma
symptoms, so when they get home,
follow the doctor's instructions to help
them recover at home. The cough will Not for discharge.
gradually clear up in seven to fourteen
days. It could take a week for eating and
sleeping to return to normal. A follow-up
appointment with your doctor should be
made. May require you to take time off
work in order to care for your child.

DRUG STUDY(WRITE ALL THE DRUGS)

Name of Dosage/ Mechanis Indications Adverse Nursing

the drug route/ m of Reactions Responsibilities
frequency action

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Nursing diagnosis: priorities and write 5 NCP

Nursing care plan 1:

Assessment Nursing Goals Interventions Rationale Evaluation
diagnosis
Subjective Ineffective Short term Independent: Independent: Short term
Data: breathing goal: 1-Auscultate 1-Wheezing is a goal was met,
Mother state pattern After 4 hours lung fields. common after 4 hours
“my child related to of nursing 2-Position the finding with of nursing
having a sever increase interventions child upright. asthma interventions
cough with thick the child will 3-Suction patients. the child was
runny nose mucus in display an secretions as 2-To promote able to display
since the chest effective necessary. lung expansion an effective
yesterday.” as breathing 4- Evaluate and make the breathing
“My child evidence pattern skin color, air flow easier. pattern
breathing is too by the evidenced by temperature, 3- To clear evidenced by
fast.” child signs absent of and capillary blockage in absent of
“He looks so and thick mucus refill. airway. thick mucus
tired.” symptoms secretion. 5-Eleminate 4.Lack of secretion.
Objective Data: . Long term excess clothing oxygen can Long term
-Tachypnea goal: and cover. cause cyanosis. goal was met,
-Cough After 2 days Dependent: 5- To decrease after 2 days of
-Chest of nursing 6-Administer warmth and nursing
Wheezing intervention salbutamol increase intervention
-Nasal flaring the child will medication evaporative the child was
-Use of achieve 2.5Mg cooling. able to
accessory normal 7-Coordinate Dependent: achieve
muscles breathing as with 6- normal
-Distress evidence a respiratory Bronchodilator breathing as
-Fever respiratory therapist for s are helpful to evidence a
rate and chest facilitate respiratory
rhythm physiotherapy. respiration. rate and
within 7-To mobilize rhythm within
normal secretions from normal limits.
limits. smaller airway
that cannot be

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 eliminated by
means of
coughing or
suctioning.

Nursing care plan 2:

Assessment Nursing Goals Interventions Rationale Evaluation
diagnosis
Subjective 3-Imbalanced Short term: Independent: Independen Short term:
data: Nutrition: -Assess vital t: Goal met,
less than After 12 hours signs. -To check after 4hrs of
His mother body Patient current nursing
said “My child requirements demonstrates -Assess BMI health intervention
refuse to eat related to increased and BMR and status. the client
any things”. anorexia as appetite. Plan high energy family be
evidence by diet. -To check able to
Objective poor weight. and verbalize
data: -Auscultate improve understandin
 Poor Long term: bowel sounds nutritional g of causative
muscle After 1-week and Insert Ryle's status. factors when
tone. patient tube. known and
 Pale. maintains/reg -To check necessary of
 Weak. ains desired -Encourage rest bowel interventions.
 Weight body weight. period before movement.
loss. and after meals And tube
 Fatigue. and Execute For gastric Long term:
 Inability physical gavage. Goal met,
exercise. after 12
to feed.
-It increases hours The
 Wt
Dependent : total caloric patient 's
9.4kg
intake and appetite
 Tem:37.
-Administer For fitness increased and
4c nutritional of body. after 1 week
 BP:108/ supplementary he gain
72 drug. Dependent: weight
(Omega-3 fatty
acids (0.7 -To Provide
GRAMS -TID) adequate
nutrients.

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CONCLUSION
Present here new information and experiences gained or learned, patient’s condition at
the time of discharge

REFERENCES (APA style)

ADD BOOK REFERNCES

1. MEDICAL-SURGICAL
2. PHARMACOLOGY
3. ANATOMY AND PHYSIOLOGY
4. JOURNAL REFERNCES

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