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Liceo de Cagayan University College Of Nursing NCM501-205 Related Learning Experience Case Presentation Bronchial Asthma in Acute Exacerbation January 26, 2011 Group B6 Clinical Instructor Mr. Andy Roy Salabas RN, MN

Overview of the Case Pneumonia is an inflammation of the lungs usually caused by infection with bacteria, viruses, fungi or other organism. Pneumonitis is a more general term that describes an inflammatory process in the lung tissue that may predispose a patient to or a place at risk of microbial invasion. Spread by infected respiratory droplets thru person-person contact. According to UNICEF, Pneumonia rank as the number 5 top most leading cause of death in the Philippines and it comprises 1, 521, 912 persons being affected.(www.UNICEF.org-infobycountry-Philippines) Pneumonia is a particular concern for older adults and people with chronic illnesses or impaired immune systems, but it also can strike young, healthy people. Worldwide, it's a leading cause of death in children, many of them younger than a year old.

There are more than 50 kinds of pneumonia ranging in seriousness from mild to life-threatening. Although signs and symptoms vary, many cases of pneumonia develop suddenly, with chest pain, fever, chills, cough and shortness of breath. Infection often follows a cold or the flu, but it also can be associated with other illnesses or occur on its own. We choose patient X our client because the other patients we chose for this study unfortunately died and the group didn’t give care to the patient for the first choice due to her few days of staying.

Objective of the Study The objective of the study is to bestow quality-nursing care to assigned patient, utilizing the knowledge based on the nursing process and critical thinking skills. This care study aims to guide the student nurses in providing client-centered nursing care while applying critical thinking in all phases of nursing care from assessment to evaluation. Also, awareness and knowledge of the patient’s disease condition and its corresponding pathophysiology is vital in providing suitable intervention to the client. Thus, with accurate application of physical assessment, actual and potential health problems are being detected and resolved through the nursing care plan.

After completing the care for the patient with Pneumonia the student nurses will be able to: ,[object Object]

Obtain a complete health data that can be used in the follow-up care.

Impart health teachings about necessary information pertaining to the disease condition.

Understand the course and essence of the chosen care study.

Add up additional knowledge and understanding in the Nursing profession,[object Object]

PATIENT PROFILE Name: Patient X Age: 73 years old Address: Lugait, Misamis Oriental Gender: Male Civil Status: Married Date of Birth: September 3, 1983 Place of Birth: Cagayan de Oro City Religion: Roman Catholic Nationality: Filipino Occupation: Farmer Educational Attainment: Grade 6 Height: 5’2” Name of Hospital: SabalHospital Weight: 65 kgs.

Date of Admission: January 13, 2011 Time Admitted: 9:10 pm Chief Complaint: Cough and Shortness of Breath Admitting Physician: Dr. Arthur Tan Admitting Diagnosis: Bronchial Asthma in Acute Exacerbation Income: 2,500/month Temperature: 36.2 C Pulse: 64 bpm Respiration Rate: 28 cpm Blood Pressure: 110/70 mmHg

HEALTH HISTORY The informant mentioned that both families had no history of asthma. He also mentioned that his mother side had hypertension. Patient X is known to be asthmatic since he was 10 years old. At age of 59, patient was admitted for the first time in Bega, LugaitMisamis Oriental for 15 days due to over fatigue. He is maintaining medications such as cetirizine 10 mg, salbutamol 500mg, doxofylline 400 g, methyl prednisolone 4 g. A known smoker, he is able to consumed two packs of cigarette a day. He also consumed alcohol almost thrice a week. For the past 6 months, our patient was able to experience these conditions: ,[object Object]

Productive cough – Occurred on January 10, 2011,[object Object]

DEVELOPMENTAL DATA A.ErikErikson’s Psychosocial Development Theory Erik Erickson envisioned life as a sequence of levels of achievement. Each stage signals a task that must be achieved. He believed that the greater that task achievement, the healthier the personality of the person. Failure to achieve a task influences the person’s ability to achieve the next task. Stages of Erikson’s Psychosocial Theory are as follows:  Infancy Birth – 18 months Trust vs. Mistrust Early Childhood 18 months – 3 years Autonomy vs. Shame & Doubt  Late Childhood 3 – 5 years Initiative vs. Guilt School Age 6 – 12 years Industry vs. Inferiority Adolescence 12 – 20 years Identity vs. Role Confusion Young Adulthood18 – 25 years Intimacy vs. Isolation Adulthood 25 – 65 years Generativityvs. Stagnation Maturity 65 years to death Integrity vs. Despair

Basing on this theory, our patient belongs to maturity. The development task at this time is ego integrity versus despair. People who attain ego integrity view life with a sense of wholeness and derive satisfaction from past accomplishments. They view death as an acceptable completion of life. According to Erikson (1963), people who develop integrity accept “one’s one and only life cycle”. By contrast, people who despair often believe they have made poor choices during life and wish they could live life over.

B.SigmundFreud’s Psychosexual Development Theory The psychosexual stages of Sigmund Freud are five different developmental periods during which the individual seeks pleasure from different areas of the body associated with sexual feelings. Our patient falls under Genital Stage of Freud’s theory. It is the fifth and last stage of psychosexual development, the genital stage, from puberty onwards. It actually continues until development stops. This stage represents the major portion of life, and the basic task for the individual is the detachment from the parents. It is also the time when the individual tries to come in terms with unresolved residues of the early childhood. These stages are as follows: Oral Birth to 1 yearAnal 2 – 3 yearsPhallic 4 – 5 yearsLatency 6 – 12 yearsGenital 13 – Up

C.RobertHavighurst’s Developmental Task Theory A developmental task is a task which arises at or about a certain period in the life of an individual. Havighurst has identified six major age periods: infancy and early childhood (0-5 years), middle childhood (6-12 years), adolescence (13-18 years), early adulthood (19-29 years), middle adulthood (30-60 years), and later maturity (61+). Basing on Havighurst’s Theory, our patient belongs in the later maturity stage.

D. Jean Piaget’s Cognitive Theory of Development Cognitive development refers to how a person perceives, thinks, and gains understanding of his or her world through the interaction and influence of genetic and learning factors. This is divided into five major phases: Sensorimotor Phase Birth to 2 yearsPre-conceptual Phase 2 – 3 yearsIntuitive Thought Phase 4 – 6 yearsConcrete Operations Phase 7 – 11 yearsFormal Operational Phase 12 – adulthood

Basing on this theory, our patient belongs to the Formal operational stage. Changes in the cognitive structures occur as a person ages. It is believed that progressive loss of neurons occurs, decreased of blood flow in the brain, the meninges appear to thicken, and brain metabolism slows. In older adults, changes in cognitive abilities are more often a difference in speed than in ability. Overall the older adult maintains intelligence, problem solving, judgment, creativity, and other well – practiced cognitive skills. Intellectual loss generally reflects a disease process such as atherosclerosis, which causes the blood vessels to narrow and diminishes perfusion of nutrients to the brain. Most older adults do not experience cognitive impairments.

Older people need additional time for learning, largely because of the problem of retrieving information. Motivation is also important. It is suggested that the older person should remain mentally active to maintain cognitive ability at the highest possible level. Lifelong mental activity, particularly verbal activity, helps the older person retain a high level of cognitive function and may help maintain long-term memory. Cognitive impairment that interferes with normal life is not considered part of normal aging.

MEDICAL MANAGEMENT A. Medical Orders with Rationale

ANATOMY AND PHYSIOLOGY The respiratory system is an integrated network of organs and tubes that coordinates the exchange of oxygen and carbon dioxide between an organism and its environment. Harmony is seen in the fact that the respiratory system in animals involves the consumption of oxygen and contribution of carbon dioxide to the environment, while in plants the respiratory system involves the consumption of carbon dioxide and contribution of oxygen to the environment. In humans, air enters the nose or mouth and travels down different tubes to the lungs, where gas exchange takes place. The diaphragm pulls air in and pushes it out. However, there are many different respiratory systems found across various organisms, including amphibians, many of which can breathe through their skin.

In mammals, including humans, the respiratory system begins with the nose and mouth; air enters the oral and nasal cavities, which combine to form the pharynx, which becomes the trachea. Air then travels down the various tubes to the lungs. Respiratory muscles mediate the movement of air into and out of the body. The alveolar system of the lungs functions in the passive exchange of molecules of oxygen and carbon dioxide, by diffusion, between the gaseous environment and the blood. Thus, the respiratory system facilitates oxygenation of the blood with a concomitant removal of carbon dioxide and other gaseous metabolic wastes from the circulation. The system also helps to maintain the acid-base balance of the body through the efficient removal of carbon dioxide from the blood.

Anatomy In humans and other mammals, the respiratory system can be conveniently divided into an upper respiratory tract (or "conducting zone") and a lower respiratory tract ("respiratory zone"). Air entering the nose moves through the body in the following order: ,[object Object]

Pharynx (naso-, oro-, laryngo-)

Alveoli (site of gas exchange) ,[object Object]

Lower respiratory tract/respiratory zone The trachea leads down to the chest, where it divides into the right and left "main stem" bronchi. The subdivisions of the bronchus are: Primary, secondary, and tertiary divisions (first, second, and third levels). In total, the bronchi divide 16 times into even smaller bronchioles. The bronchioles lead to the respiratory zone of the lungs, which consists of respiratory bronchioles, alveolar ducts, and the alveoli, the multi-lobulated sacs in which most of the gas exchange occurs.

Physiology: Ventilation Ventilation of the lungs in humans is carried out by the muscles of respiration, which include intercostal muscles. Control Ventilation is controlled by the autonomic nervous system. The breathing regulatory center is in the medulla oblongata and the pons, parts of the brain stem containing a series of interconnected neurons that coordinate respiratory movements. The sections are the pneumotaxic center, the apneustic center, and the dorsal and ventral respiratory groups (CRISP 2007). This section of the brain is especially sensitive during infancy, and the neurons can be destroyed if the infant is dropped or shaken violently. The result can be early death due to "shaken baby syndrome" (SIPH 2006).

Inhalation Inhalation is driven primarily by the diaphragm with help from the intercostal muscles. When the diaphragm contracts, the ribcage expands and the contents of the abdomen are moved downward. The expansion of the ribs results in a greater chest volume, which in turn causes a decrease in intrathoracic pressure, according to Boyle’s Law. When the pressure inside the lungs is lower than the atmospheric pressure outside the body, air moves into the respiratory tract in an attempt to equalize the pressures. At rest, normal respiration is about 10 to 18 breaths per minute, with each inhalation lasting about 2 seconds. Rates of breathing can increase during exercise, fever, or illness. During vigorous inhalation (at rates exceeding 35 breaths per minute), or when approaching respiratory failure, other accessory muscles are recruited for support. During forced inhalation, as when taking a deep breath, the external intercostal muscles and accessory muscles further expand the thoracic cavity and more air moves into the lungs at a greater velocity.

Exhalation Exhalation is generally a passive process, however, active, or "forced," exhalation can be achieved with the help of the abdominal and the internal intercostal muscles. The lungs have a natural elasticity; following the stretch of an inhalation, the lungs recoil and air flows back out until the pressures in the chest and the atmosphere reach equilibrium. The flow of air during exhalation can be compared to that of an inflated but released balloon recoiling to force air out. At the end of both inhalation and exhalation, the pressure in the lungs equals that of the atmosphere. During forced exhalation, as when blowing out a candle, the abdominal muscles and internal intercostal muscles generate extra abdominal and thoracic pressure, which forces air out of the lungs with greater volume and with greater velocity.

Gas exchange The major function of the respiratory system is gas exchange. As gas exchange occurs in humans, the acid-base balance of the body is maintained as a component of homeostasis. In the absence of proper ventilation, two conditions could occur: 1)respiratory acidosis, a life threatening condition caused by a deficiency of ventilation, or 2)respiratory alkalosis, caused by an excess of ventilation, or hyperventilation. The actual gas exchange occurs at the alveoli, the basic functional component of the lungs. The alveolar walls are extremely thin (approx. 0.2 micrometers), and are permeable to gases. Pulmonary capillaries line the alveoli; the walls of these capillaries are also thin enough to permit gas exchange.

NURSING DIAGNOSIS: Infection, risk for [spread] Risk factors may include Inadequate primary defenses (decreased ciliary action, stasis of respiratory secretions) Inadequate secondary defenses (presence of existing infection, immunosuppression), chronic disease, malnutrition ] Possibly evidenced by [Not applicable; presence of signs and symptoms establishes an actual diagnosis.] DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Infection Status (NOC) Achieve timely resolution of current infection without complications. Knowledge: Infection Control (NOC) Identify interventions to prevent/reduce risk/spread of/secondary infection.

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