Case Analysis / Study

CASE ANALYSIS DEFINITION : 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.

PATHOPHYSIOLOGY / ETIOLOGY

Bronchial Asthma triggers may include: •

Tobacco smoke

•

Infections such as colds, flu, or pneumonia

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Allergens such as food, pollen, mold, dust mites, and pet dander

•

Exercise

•

Air pollution and toxins

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Weather, especially extreme changes in temperature

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Drugs (such as aspirin, NSAID, and beta-blockers)

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Food additives (such as MSG)

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Emotional stress and anxiety

•

Singing, laughing, or crying

•

Smoking, perfumes, or sprays

•

Acid reflux

These factors that contribute to trigger bronchial asthma causes “AIRWAY INFLAMMATION”! HOW? •

The linings of our bronchi consists of 2 layers.

•

The first layer is the epithelial cells lining in which it is a hexagonal shape cells that alows them to packed together.

•

When triggering factors invades the epithelial cell lining, your oversensitive immune system activates antibodies such as IgE,mast cells and WBCs’ to protect us from perceived threats.

•

But the result is actually inflammed airways causing an increased mucus production between compartments of epithelial cell linings, thus resulting to mucus producing goblet cells.

•

This mucus producing goblet cells will now flow to the second layer of the bronchi which is the brochial smooth muscle, triggering the release of cytokines and eventually causing bronchospasm and symptoms of bronchial asthma that make it harder for us to breathe.

WHAT WILL HAPPEN TO THE LINING OF YOUR BRONCHI AFTER AN AIRWAY INFLAMMATION?

♥ It will become edematous, epithelial cell linings becomes injured, impaired mucociliary function, increased airway responsiveness and airway limitation.

This process will lead to “BRONCHIAL ASTHMA”. If bronchial asthma was left untreated or being treated but with repeated exposure to the triggering factors, COMPLICATIONS OCCUR: These are the complications: ♥ Status asthmaticus ♥ Respiratory failure ♥ Pneumonia ♥ Atelectasis CLINICAL MANIFESTATIONS:

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).

Patient being treated but with repeated exposure to triggering factors, “EXCACERBATIONS OCCUR”. Signs & symptoms of excacerbations includes: ➢ Cough with or without mucus ➢ Generalized wheezing (the sound of airflow through narrowed airways) ➢ Generalized chest tightness

➢ Dyspnea & Tachycardia ➢ Expiration requires effort and becomes prolonged ➢ Diaphoresis & fatigue ➢ Widened pulse pressure ➢ Hypoxemia & central cyanosis ➢ Respiratory failure DIAGNOSTIC TEST: TEST

1. Hematology (Complete Blood Count)

CLINICAL SIGNIFICANCE

Reveals elevated levels of WBC ( eosinophils to rule out infection or inflammation

2. Pulse oximetry

Reveals hypoxemia during acute attack

3. Arterial Blood Gas

Reveals normal PaCO2 which is an impending sign of respiratory distress because CO2 level can never be normal with brochial asthma

4. Spirometry

Provides a means for measuring: ✔ FVC (Forced vital capacity) ✔ FEV 1.0 (Forced expiratory volume in one second) ✔ PEV (Peak expiratory flow) ✔ IRC (Inspiratory reserve capacity)

✔ Tidal volume ✔ Expiratory reserve 5. Inhalation Challenge Test

Measures the level of airway responsiveness using methacholine (a cholinergic agonist), histamine or exposure to non pharmacologic agent such as cold air

6. Peak Flow Meter

Measures the highest volume of air flow during a forced expiration

TREATMENT & MANAGEMENT: The expert panel of the National Asthma Education and Prevention Program (NAEPP) has developed measures to control triggering factors contributing to bronchial asthma: 1. Education of the patient and family regarding measures used in avoiding exposure to irritants and allergens that are known to induce or trigger an attack. 2. Relaxation technique and controlled breathing often help to allay the panic and anxiety that aggravate breathing difficulties. 3. Injection of selected antigen (based on skin test) to stimulate the production of IgG antibodies that block the IgE response. 4. A course allergen immunotherapy is typically 3 to 5 years duration. 5. Pharmacologic treatment is used to prevent or treat reversible airway obstruction and airway hyperresponsiveness caused by inflammatory process: ○ Bronchodilators

○ Anti – inflammatory

2 General Categories

A. Quick Relief Medication (short – acting) ☺ Beta2 – adrenergic agonists – albuterol (salbutamol) ☺ Anti – cholinergic agents – Ipratropium ☺ Systemic cortocosteroids

B. Long Term Medication ☺ Anti – inflammatory agents – corticosteroids, sodium cromolyn, nedocrom, salmeterol, formoterol and albuterol sustained released ☺ Long acting bronchodilators – theophylline, methylxathine ☺ Leukotriene modifiers – zileuton, zafirlukast and montelukast

NURSING MANAGEMENT: The nurse assesses the patient’s respiratory status by monitoring the severity of symptoms, breath sounds, peak flow, pulse oximetry and vital signs. The nurse generally performs the following tasks: ♂ Obtains a history of allergic reactions to medications before administering medications. ♂ Identifies medications the patient is currently taking.

♂ Administers medications as prescribed and monitors the patient’s responses to those medications. An antibiotic may be prescribed if the patient has an underlying respiratory infections. ♂ Adminiters fluids if the patient is dehydrated.

REFERENCES:

A.Reading Materials: ☼ 2007 Lippincott’s Nursing Drug Guide by Amy M. Karch ☼ Brunner & Suddarth’s Textbook of Medical – Surgical Nursing Eleventh Edition by Suzanne C. Smeltzer, Brenda G. Bare, Janice L. Hinkle, Kerry H. Cheever ☼ Pathophysiology : Concepts of altered health state Seventh Edition by Carol Mattson Porth

☼ Nursing Care Plans : Nursing Diagnosis & Intervention Sixth Edition by Gulanick and Myers ☼ Nursing Diagnosis : Reference Manual Sixth Edition by Sparks & Taylor

B.Online Website sources: ☼

http://nursingcrib.com/nursing-care-planbrochial-asthma/

☼ http://asthma.about.com/od/asthmabasic1/a/ pathophysiology.htm