Saint Gabriel College Old Buswang, Kalibo, Aklan in Partial
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Saint Gabriel College Old Buswang, Kalibo, Aklan In Partial Fulfillment of the Requirements in Intensive Nursing Practice “Case Analysis” “BRONCHIAL ASTHMA in ACUTE EXACERBATION” Submitted to: Mr. Elizalde M. Baldueza R.N. MAN Instructor Submitted by: Leader: Resterio, Mary Joy P. Members: Detuya, Allyson Faith Inolino, Philip Andrew Iray, Denoel Martin, Jessica D. Sabido, Katherine Anne Table of Contents I. Introduction II. Statement of Objectives A. General Objectives B. Specific Objectives III. Biographical Data IV. Chief Complaint V. Health History A. Present Illness B. Past health History C. Family History D. Educational History E. Occupational History F. Obstetric History G. Social History H. Dietary History VI. Growth and Development VII. Physical Assessment VIII. Laboratory exam IX. Anatomy and Physiology X. Pathophysiology XI. Drug Study XII. Nursing Care Plan XIII. Prognosis/ rehabilitation phase INTRODUCTION The main function of the respiratory system is to move air into the lungs so that oxygen can enter the body and carbon dioxide can be inhaled. Several pulmonary disorders can affect the airways. Their pathophysiology differs but these diseases are characterized by limited airflow. Airflow is limited when air walls are thickened, airway lumen is obstructed by secretions, increasing resistance, and smooth muscle of the airways is activated, causing bronchoconstriction. Limited airflow increases the work of breathing and residual volume of the lungs as air is trapped behind narrowed or collapsed airways. Asthma is a chronic inflammatory respiratory disorder that causes recurrent episodes of wheezing, breathlessness, chest tightness and cough, especially at night or in the early morning. These asthma episodes are associated with airflow limitation or obstruction that is reversible either spontaneously or with treatment. Bronchial asthma is usually intrinsic (no cause can be demonstrated), but is occasionally caused by a specific allergy (such as allergy to mold, dander, dust). This case study is a thorough learning about Bronchial Asthma, which contains a study about the normal physiology of the respiratory system, pathological physiology of the disease, a thorough assessment of the patient with said illness, applied nursing care plans to patients having this kind or disease. (http://www.scribd.com/doc/27330007/BRONCHIAL-ASTHMA-) Concerning Bronchial Asthma as one of the disorders of respiratory system. We had decided to make it as the center of our case study for the first shifting. Through the help of Andagao RHU Nurses.We had able to come up with an interview to a 52 year old male of Andagao, Kalibo, Aklan with the diagnosis of Bronchial Asthma in Acute Exacerbation. Conditions affecting the lower respiratory tract like Bronchial Asthma are serious and often life threatening if proper interventions are not yet addressed. The patient requires care from nurses with the accurate assessment and clinical management skills as well as an understanding of the impact of the disorder on the patient’s quality of life and ability to carry out usual activities of daily living. Therefore, nurses must have an adequate knowledge and skills regarding the pathophysiology of the disease/ illnesses of the patient to ease their pain, to implement effective breathing strategies and to evaluate the effectiveness of these strategies, regardless of any setting. OBJECTIVES General Objectives At the end of the shifting, we the BSN IV B of Saint Gabriel College assigned at Kalibo RHU 2 under the service of Mrs. Diane Regalado will be ableto acquire knowledge, right skills and desirable attitudes in conducting case study to our patient with the problem in respiration. Specific Objectives Knowledge: To Define bronchial Asthma To obtain information about the history of the past and the present illness. To discuss anatomy, physiology and Pathophysiology of bronchial asthma. To discuss nursing care plan and drug study. To provide health teachings to our patient. Skills: To assess the health status based on health history of the patient. To perform physical assessment accurately. To formulate appropriate care plan according to the priority needs of the patient. Attitude: To Develop rapport to the patient To gain trust and cooperation To established interpersonal relationship with the members of the health care team DEMOGRAPHIC DATA Name: Mr. L. B. R. Age: 52years old Address: Barangay Masing, Andagao, Kalibo, Aklan Birth Date:January 10,1962 Birth Place:Andagao, Kalibo, Aklan Civil Status:Married Religion:Roman Catholic Occupation:None Date of Admission:July 5, 2013 Date of Interview:November 22, 2013 Date of discharge:July 9. 2013 Chief Complaint:Difficulty of breathing Diagnose:Bronchial Asthma in Acute Exacerbation Attending Physician:Dr. V. PRESENT OF MEDICAL HISTORY Two days prior to admission, Patient L.B.R. experienced difficulty of breathing. He take medicine ( salbutamol tablet 500mg) thinking that it will relief. After medication he take a rest but his feeling is not yet good. After that day the patient still having a difficulty of breathing and the patient cannot tolerate already. His wife decided to bring her husband L.R to the mission hospital. On July 5,2013 he was admitted at around 7:00pm accompanied by his wife in mission hospital. He was examined by Dr. Valencia and was diagnosed with bronchial Asthma in Acute exacerbation. He was discharge on July 9. 2013 PAST MEDICAL HISTORY According to the mother of MR. L.B.R his immunizations is completed. He doesn’t have any experience of injuries or any surgical operations in the past. According to Mr. L.B.R he inherited his asthma from his grandfather and to his father. He stated that when he was a child, he uses nebulizer whenever he has an asthma attack. His 1st admission to the hospital because of asthma was when he was 11years old. FAMILY HISTORY Mr. L.B. R. is the second child of Mr. R. R. and Mrs. J. R. His father stated that he has a history of asthma and his wife has a history of hypertension. EDUCATIONAL BACKGROUND Mr. L.B.R finished his primary school atAndagao elementary school and his secondary school at ASU Kalibo, but he did not finished his studies due to financial problem. OCCUPATIONAL HISTORY Mr. L.B.R is a Tricycle Driver for 3years but he stopped driving due to his condition when he was admitted to the hospital. PERSONAL AND SOCIAL HISTORY According to Mr. L.B. R. he is aware of proper hygiene. According to him he takes a bath once a day and brushes his teeth three times a day particularly after eating his breakfast. He has a good personal interaction with his family, friends, cousins, and neighbors. He started to smoke and drink liquor when he was 11 years old, and having night out with all his friends. ENVIRONMENTAL HISTORY The house of Mr. L.B.R was located along the coastal highway. According to him every time when he smell dander of the chicken he experience difficulty of breathing. He always exposed to dust because of the nature of his work because he is a tricycle driver and he also smokes. Every morning he goes to the beach (Lambingan beach) to inhale fresh air and to relax. IMMUNIZATION BCG 1 dose DPT 3 doses MEASLES 1 dose OPV 3 doses HEPA-B 3 doses 24 HOURS DIETARY RECALL July 4, 2013 Breakfast Lunch Snack Dinner 1 ½ bowl 1 cup of rice 1 pack of 1 cup of of porridge 1 slice of fish biscuit rice (sinabawangbangus) (sky 1 pc. fried 1 glass of flakes) chiken water (250 1 glass of 2 glass of ml) juice (250 water ml) (500 ml) Growth and Development A. Infancy: Trust vs. Mistrust ( 0-12months ) On this stage according to the patient he was left alone to cry and even when to stop crying. His mother breastfed him when he was hungry. According to the patient he was given a soft food like porridge. And at the age of 6 months old his sister stated that his tooth came out, crawled at 8 months. Then the rest of the year was followed by the growth and development. B. Toddlerhood: Autonomy vs. Shame and Doubt ( 12months- 3 years old) The patient’s sister stated that he started to walk at the age of 1 ½ year old. And he stated that at the age of 3 his stop breast feeding. And the first word that the patient stated was “ta-ta” and “na-na”. When he was about 3 years old he was toilet trained by his mother, at that age he was able to socialized and played with other kids. C. Preschooler: Initiative vs. Guilt (4-6 years old) Normally, most children of this stage are being prepared or groomed for proper education. His sister said that his brother had an interest in his study when he entered Day care and kinder years at the age of six at Andagao Elementary School. Mr. L.B.R is fond of playing toy cars with his cousins and eating sweets like lollipop and at this stage also, Mr. L.B.R feared of being left alone at bed time. Like any other kids, he loved playing with his friends and cousin. D. School Age: Industry vs. Inferiority (6-12 years old) L.B.R started his elementary education at the age of 6 at Andagao Elementary School. At the age of 10 he started to drink alcohol with his friends and cousins. Even if L.B.R has asthma, he still helps his sister in doing household chores. E. Adolescence: Identity vs. Role Confusion (12-18 years old) Mr. L.B.R was in 2nd year High School when he was 14 years old. But he did not finish his studies because of financial problem. And at the age of 12 years old, Mr.